Deep vein thrombosis risk stratification.

Pulmonary thromboembolism (PTE) is a life-threatening disease which always presents in patients with deep vein thrombosis (DVT). There are few statements in guidelines regarding indications for anticoagulation based on the location of DVT. We investigated whether the relative risk of PTE depends on thrombus location and bleeding complications with anticoagulation therapy. Between January 1 and July 10, 2007, 461 patients underwent lower extremity venous ultrasound studies, and 129 patients were diagnosed as DVT (60 males, 66.9 ± 13.3 years). We retrospectively studied the incidence of PTE and bleeding complications associated with anticoagulation therapy. Average follow-up period was 536 ± 324 days. Above and below knee thrombosis was present in 60 and 69 patients, respectively. Warfarin was administered in 60 patients. Nine patients developed PTE. Multivariate analysis showed the absence of anticoagulation therapy and location of DVT (above knee) to be significantly correlated with onset of PTE (anticoagulation; P < 0.01, location; P = 0.02). However, the incidence of bleeding was not significantly different between above knee and below knee vein thrombosis (P = 0.72). In conclusion, below knee vein thrombosis carries a relatively low risk of PTE, but the incidence of bleeding complications does not depend on thrombosis location. This suggests that the indication of anticoagulation therapy should be based on DVT location.

A case of Takotsubo cardiomyopathy that was confirmed by cardiac catheterization at all three times of onset.

Takotsubo cardiomyopathy (TTC) is a cardiomyopathy associated with emotional and physiological stress which can be recurrent. We report a case of recurrent TTC (total 3 times) induced by emotional stress, which was diagnosed accurately by coronary angiography (CAG) and left ventriculography (LVG). A 77-year-old female was referred to our institute because of stomach ache, nausea, dizziness, and vomiting. She had developed TTC associated with emotional stress twice, and she took an angiotensin receptor blocker for preventing recurrence. She was admitted for treatment of electrolyte imbalance. After the admission, she suddenly suffered from chest pain with ST segment elevation in II, III, aVF, V3, V4, V5, and V6 leads in electrocardiography. Emergency CAG showed normal coronary arteries, while LVG revealed apical akinesia and basal hyperkinesia. These findings were compatible with TTC. Follow-up ultrasonic cardiogram showed left ventricular contractile normalization in a week. She was discharged in 22 days. A few cases of repeated recurrence have been reported, but they were not diagnosed by cardiac catheterization. In the present case, 3 episodes of TTC were all diagnosed in CAG and LVG. We suggest that antianxiety drugs have potential to prevent the recurrence of TTC in a case induced by emotional stress. .

Characteristics and trends of POBA in current DES Era.

The aim of this study is to clarify the characteristics and trends of POBA in current drug-eluting stent (DES) era. We examined retrospectively the cases of POBA performed in our institute during the years from 2008 to 2012. For control, bare metal stents (BMS) and DES implantation done in 2011 were analyzed. During the period, 85 cases of POBA, 63 BMS and 132 DES were identified. In the result, the rate of restenosis in POBA was significantly higher than BMS and DES (39.7, 14.9, 3.7%, POBA, BMS, DES, respectively, p < 0.001). We assumed three categories depending on the reasons for selecting POBA. (1) Stent delivery failure or expected difficulty of stent delivery due to calcification, etc. (n = 14), (2) intervention for in-stent restenosis or stent thrombosis (n = 34), (3) successful POBA applied to small vessels without complication (n = 14). According to it, category 1 showed significantly high probability of restenosis compared with others [(1) 10/14, 71.4%, (2) 12/34, 35.3%, 3; 2/14, 14.3%, p < 0.05]. In addition, category 3 showed nearly as good as BMS. Balloons used in POBA contained 32 non-compliant balloons and 14 scoring balloons, whereas 30 were semi-compliant balloons only. ACC/AHA lesion type B2/C was 85.7, 45.7 and 50.0%, and cases treated only with semi-compliant balloon were 57.1, 14.3, 92.9% (category (1), (2) and (3), respectively, both p < 0.05). Therefore, this fact shows that a case of small vessel of which diameter is less than 2.5 mm would have a favorable outcome with POBA when treated well only with semi-compliant balloon under the current DES era.

Six-month follow-up of takotsubo cardiomyopathy with I-123-beta-metyl-iodophenyl pentadecanoic acid and I-123-meta-iodobenzyl-guanidine myocardial scintigraphy.

A 69-year-old man with a history of transient chest pain was diagnosed takotsubo cardiomyopathy. In I-123-beta-metyl-iodophenyl pentadecanoic acid myocardial scintigraphy, decreased uptake of apex was seen in the acute phase, and it recovered in 3 months. In I-123-meta-iodobenzyl-guanidine myocardial scintigraphy, decreased uptake of apex persisted for 6 months, and there was a discrepancy between apical and total washout rate in the acute phase and after 3 months, which disappeared after 6 months. We speculate that the discrepancy of sympathetic innervation between the apical and basal region is the cause of the characteristic left ventricular apical akinesia of takotsubo cardiomyopathy.

Left cervical aortic arch associated with aortic aneurysm, aortic coarctation, and branch artery aneurysm--a case report and review.

Cervical aortic arch (CAA) is a rare congenital aortic anomaly. Although, in CAA, other cardiovascular abnormalities including aortic aneurysm and aortic coarctation are occasionally accompanied, coexistence of those 2 aortic abnormalities on the same patient is rare, and moreover, association of the aneurysm of branching artery has not been reported. The authors present here the first patient with CAA who had both an aneurysm and a coarctation in the aortic arch, and further, another aneurysm in the left subclavian artery. Clinical characteristics of CAA with either aortic aneurysm or aortic coarctation are reviewed.

A case of transient mid-ventricular akinesia (a variant form of Takotsubo cardiomyopathy) followed with I-123-beta-metyl-iodophenyl pentadecanoic acid and I-123-meta-iodobenzyl-guanidine myocardial scintigraphy.

A 67-year-old woman without history of heart disease was admitted with chest oppression. Her electrocardiogram (ECG) at the time of admission showed ST segment elevation in leads V2-V6. Cardiac ultrasound revealed severe hypokinesis in mid to apical portion of anterior wall. Emergent coronary angiography showed normal coronary arteries. Left ventriculography (LVG) revealed akinesis of mid portion of anterior and inferior wall with hyperkinesis of apex and basal portion of anterior and inferior wall. Cardiac ultrasound examination 3 months later revealed improvement in LV contraction without mid-ventricular akisesia. The LVG performed 6 months later showed no focal asynergy. In I-123-beta-metyl-iodophenyl pentadecanoic acid myocardial scintigraphy the discrepancy of uptake between apical and anterior and inferior wall of mid region (more uptake in apex) was reduced. Using I-123-meta-iodobenzyl-guanidine myocardial scintigraphy in acute phase, decreased uptake in the mid portion of anterior and inferior to lateral wall was seen in early and delayed images and that persisted through 6 months. As these findings resembled those of Takotsubo cardiomyopathy other than affected region, it is possible to say that basically they belong to same entity of disease but they are different in their phenotype.

Two cases of short QT interval.

BACKGROUND: The epidemiology of short QT interval remains unclear. We attempted to determine the incidence and clinical characteristics of short QT interval in a longitudinal cohort study. METHODS: A total of 19,153 subjects (7,525 male, 11,628 female) were enrolled in the study and all available electrocardiograms (ECGs) were investigated longitudinally from 1958 through 2003. We defined short QT interval as QTc of less than 350 ms. RESULTS: Of the 19,153 subjects, two met the criteria of short QT interval and allowed for prevalence and incidence estimates for short QT interval as 0.01% and 0.39/100,000 person-years, respectively. Both cases had neither a family history of sudden cardiac death, nor a history of drug use that might have affected for QT interval. Case 1 was a female with history of ischemic heart disease. Case 2 was a 60-year-old male who exhibited a short QT interval for the first time when he was 26 years of age. He had sick sinus syndrome as an underlying heart disease. CONCLUSIONS: Of the 19,153 subjects in this study, none were identified as having the short QT syndrome, with associated high risk of ventricular tachyarrhythmia, atrial fibrillation, and sudden death. Two subjects were identified as having QTc of less than 350 ms, and allowed prevalence and incidence estimates to be made of short QT interval. There observations were suggestive of clinical relationships between short QT interval and organic or electrophysiological heart disease.

Ventricular fibrillation in a patient with prominent j wave in the inferior and lateral electrocardiographic leads after gastrostomy.

We describe the case of a 39-year-old man who experienced a ventricular fibrillation storm related to a prominent J wave in the inferior and lateral electrocardiographic leads on the day after gastrostomy. The J wave slowly decreased after amiodarone therapy (400 mg/day) was started, and ventricular fibrillation disappeared.

[Relationship between brain natriuretic peptide and coronary stenosis: influence of aging].

OBJECTIVES: The relationship between brain natriuretic peptide (BNP) and coronary stenosis, and the utility of BNP for the prediction of coronary stenosis were investigated. METHODS: This study included 100 consecutive patients (48 men, 52 women, mean age 65.8 +/- 9.9 years) who underwent elective cardiac catheterization for the diagnosis of coronary stenosis without other heart diseases (heart failure, valvular heart disease, cardiomyopathy, sick sinus syndrome), and E/A was recorded by echocardiography. The relationship between coronary stenosis, left ventricular ejection fraction by left ventriculography, left ventricular end-diastolic pressure, E/A, left ventricular stroke volume index by echocardiography and BNP were investigated. RESULTS: Thirty-nine patients revealed coronary stenosis > or = 75% (CS), and 6 patients had chronic total occlusion. In the CS(+) group, BNP and left ventricular end-diastolic pressure were elevated significantly (50.7 +/- 48.5 vs 22.1 +/- 21.6 pg/ml, p < 0.05; 9.2 +/- 5.3 vs 6.4 +/- 3.4 mmHg, p < 0.05). In logistic regression analysis, BNP and left ventricular end-diastolic pressure had significant correlations with CS(+), independent of age, systolic blood pressure, E/A and left ventricular ejection fraction (p = 0.007, p = 0.05, respectively). Prognostic values of BNP (> 20 pg/ml) for the diagnosis of CS(+) were sensitivity of 79%, and specificity of 61% (p < 0.005). In the CS(-) group, the patients showing BNP > 20 pg/ml were older than the patients showing BNP < or = 20 pg/ml (68.4 +/- 8.5 vs 60.0 +/- 9.4, p < 0.05). Therefore, the prognostic values were reduced (sensitivity 78%, specificity 82%, p < 0.005) in the younger group (age < 65, n = 42). Even in patients with coronary stenosis but without chronic total occlusion, both BNP and left ventricular end-diastolic pressure were elevated significantly compared with the patients without coronary stenosis (22.1 +/- 21.6 vs 44.0 +/- 43.2 pg/ml, p < 0.01; 6.4 +/- 3.4 vs 9.1 +/- 5.2 mmHg, p < 0.01). CONCLUSIONS: Plasma BNP levels are useful markers for detecting coronary stenosis, especially in younger patients.

[Clinical evaluation of the cause of left ventricular dysfunction in type 2 diabetes without significant cardiac disease].

OBJECTIVES: The relationship between left ventricular dysfunction and hypertension or proteinuria was evaluated in type 2 diabetic patients without significant cardiac disease to investigate the cause of diabetic cardiac dysfunction. METHODS: Twenty-one patients with type 2 diabetes mellitus (mean age 63.8 +/- 7.4 years) underwent left ventriculography and Doppler echocardiography to calculate the ejection fraction and E/A ratio (E/A). RESULTS: Thirteen patients had hypertension (61.9%) and six patients had proteinuria (28.6%). The E/A was 0.82 +/- 0.21 in all patients. The E/A in patients with hypertension or proteinuria was significantly less than in those without these diseases (0.74 +/- 0.18 vs 0.97 +/- 0.18, p = 0.011; 0.65 +/- 0.10 vs 0.89 +/- 0.20, p = 0.010, respectively). The ejection fraction was 73.3 +/- 7.2% in all patients. The ejection fraction in patients with proteinuria was significantly less than in those without proteinuria (67.6 +/- 10.0% vs 75.5 +/- 4.4%, p = 0.019), but there was no significant difference in ejection fraction between patients with and without hypertension. The duration of diabetes was significantly related to the ejection fraction (r = -0.436, p = 0.048) but not to the E/A. CONCLUSIONS: In patients with type 2 diabetes without significant cardiac disease, left ventricular diastolic function may be related to both hypertension and proteinuria and left ventricular systolic function may be related to proteinuria and duration of diabetes. Therefore, in addition to hypertension, complications of nephropathy or long duration of diabetes may be related to the cause of the diabetic cardiac dysfunction.