Assessment of lipophilic vs. hydrophilic statin therapy in acute myocardial infarction ­ ALPS-AMI study.

BACKGROUND: Statins reduce the incidence of cardiovascular events, but no randomized trial has investigated the best statins for secondary prevention. We compared the efficacy of hydrophilic pravastatin with that of lipophilic atorvastatin in patients with acute myocardial infarction (AMI). METHODS AND RESULTS: A prospective, multicenter study enrolled 508 patients (410 men; mean age, 66.0 ± 11.6 years) with AMI who were randomly assigned to atorvastatin (n=255) or pravastatin (n=253). The target control level of low-density lipoprotein cholesterol (LDL-C) was <100 mg/dl, and patients were followed for 2 years. The primary endpoint was the composite of death due to any cause, non-fatal myocardial infarction, non-fatal stroke, unstable angina or congestive heart failure requiring hospital admission, or any type of coronary revascularization. The primary endpoint occurred in 77 patients (30.4%) and in 80 patients (31.4%) in the pravastatin and atorvastatin groups, respectively (hazard ratio, 1.181; 95% confidence interval: 0.862-1.619; P=0.299), whereas greater reductions in serum total cholesterol and LDL-C were achieved in the atorvastatin group (P<0.001 for each). Changes in hemoglobin A1c, brain natriuretic peptide, and creatinine were not significant between the 2 regimens, and safety and treatment adherence were similar. CONCLUSIONS: On 2-year comparison of hydrophilic and lipophilic statins there was no significant difference in prevention of secondary cardiovascular outcome.

Endomyocardial biopsy in a patient with hemorrhagic pheochromocytoma presenting as inverted Takotsubo cardiomyopathy.

A 29-year-old female patient presented with shock and dyspnea due to heart failure and pulmonary edema. Echocardiography indicated excessive contraction limited to the left ventricular apex and akinesis of the basal and middle ventricle, which were confirmed by emergency left ventriculography. The finding was diagnostic of inverted Takotsubo cardiomyopathy. An abdominal computed tomography scan showed a tumor in the left adrenal gland with a central low-density area, and the plasma and urinary catecholamines were strikingly elevated. Taken together, these findings suggested the presence of a hemorrhagic pheochromocytoma. A myocardial biopsy in the very acute stage on the day of admission revealed neutrophilic infiltration and contraction-band necrosis, which was indistinguishable from the previously reported pathology in the acute phase of idiopathic Takotsubo cardiomyopathy without pheochromocytoma. The diagnosis of pheochromocytoma in this case was confirmed 7 weeks later by surgical removal of the left adrenal gland with massive hemorrhage at the center of the pheochromocytoma. The marked similarity of the endomyocardial pathology between this case and cases with idiopathic Takotsubo cardiomyopathy strongly points to catecholamine excess as a common causality for Takotsubo cardiomyopathy with or without pheochromocytoma.

Noninvasive evaluation of coronary endothelial function following sirolimus-eluting stent implantation by using positron emission tomography.

OBJECTIVE: Several invasive studies have reported delayed reendothelialization and endothelial dysfunction following sirolimus-eluting stent (SES) implantation. We evaluated the changes in coronary endothelial function following SES implantation by using a noninvasive method that involved positron emission tomography and cold pressor testing (CPT). METHODS: The study was conducted on 14 lesions on which percutaneous coronary intervention (PCI) was successively performed. The lesions were classified into 2 groups depending on the PCI performed: the conventional PCI group, in which 7 conventional PCIs (plain old balloon angioplasty or bare-metal stents) were performed, and the SES group, in which 7 SESs were implanted. Coronary endothelial function was defined as the percent increase in the myocardial blood flow (MBF) during CPT. RESULTS: The resting MBF in the segments distal to the PCI sites did not differ between the conventional PCI and SES groups; however, the MBF significantly decreased in the SES group during CPT. CONCLUSIONS: These data suggest that SES implantation induces coronary endothelial dysfunction in the segments distal to the PCI sites.

Patch-and-glue sutureless repair for blowout rupture after myocardial infarction: report of two cases.

A blowout cardiac rupture is sudden and dramatic. The most appropriate surgical repair remains controversial. We report our experience with blowout rupture treated by sutureless technique. The two cases were males aged 58 and 79 years respectively. Echocardiography confirmed the diagnosis of cardiac rupture. Resuscitation was continued in the operating suite, and the myocardial tear and necrotic area were covered with two sheets of fibrin tissue-adhesive collagen fleece and an equine pericardial patch secured to the heart surface with biologic glue with the aid of cardiopulmonary bypass. Both patients survived and were discharged from our hospital. One has been doing well for 15 months after surgery and the other remains breathing on his own but otherwise nonreactive for 20 months since. We have adopted a patch-and-glue sutureless technique instituting cardiopulmonary bypass for blowout rupture. Cardioplegic arrest was performed to achieve a bloodless surgical field and maximize glue function. All rupture sites should be covered with a properly large patch. This technique is simple, versatile, and considered to be associated with a favorable outcome.

Fatal acute pancreatitis with cystic formation in reactive systemic AA amyloidosis secondary to rheumatoid arthritis.

We report a patient with reactive systemic AA amyloidosis secondary to rheumatoid arthritis who showed fatal acute pancreatitis with a cystic formation in the pancreas head. The pancreatitis rapidly worsened despite intensive treatment and resulted in death. In this patient severe deposition of amyloid in the gastrointestinal tract was considered to play an important role in the pathogenesis of the acute pancreatitis. This is an unusual complication in patients with AA amyloidosis, but we should consider it as a possible diagnosis when patients with AA amyloidosis show recurrent or intractable pain in the upper abdomen.

Systematic analysis of risk factors for coronary heart disease in Japanese patients with type 2 diabetes: a matched case-control study.

AIM: To identify predictors of coronary heart disease (CHD) in Japanese patients with type 2 diabetes (T2DM). METHODS: A matched case-control study was performed using 800 patients with T2DM admitted for treatment of hyperglycemia from January 2002 to June 2010. Cases comprised 16 patients who had developed acute myocardial infarction and/or received a coronary artery bypass by June 2010, and controls comprised 48 age- and sex-matched patients without CHD events. The mean age, glycated hemoglobin (HbA1c), and body mass index (BMI) were 61.5 yrs, 9.7% and 24.4 kg/m(2), respectively. The relationship of baseline variables, including lipid values, HbA1c, BMI, blood pressure, fasting blood sugar, 2h-post-breakfast blood sugar, delta blood sugar(0-2h), urinary albumin excretion, estimated glomerular filtration rate and treatment modalities (insulin/sulfonylurea/biguanide), to CHD development was analyzed by conditional logistic regression analysis. RESULTS: Total cholesterol (TC) (OR 2.35, 95%CI 1.11-4.98, p=0.03), non-HDL-cholesterol (OR 3.07, 95%CI 1.33-7.10, p=0.009), LDL-cholesterol (OR 2.84, 95%CI 1.24-6.51, p=0.01), non-HDL-cholesterol/HDL-cholesterol (OR 2.07, 95%CI 1.10-3.90, p=0.02) and LDL-cholesterol/ HDL-cholesterol (OR 2.74, 95%CI 1.22-6.15, p=0.01) were significantly related to CHD. Fold risk increment per 1-SD increase in basal TC, non-HDL-cholesterol, LDL-cholesterol, non-HDL-cholesterol/HDL-cholesterol and LDL-cholesterol/HDL-cholesterol was 2.33, 2.89, 2.52, 2.37 and 2.60, respectively. Only non-HDL-cholesterol was an independent risk factor. From the receiver operating characteristic curve, 3.89 mmol/L non-HDL-C was the best cutoff value. None of the non-lipid variables were significantly related to CHD. CONCLUSION: Non-HDL-cholesterol was the most dominant predictor of the development of CHD in Japanese patients with T2DM.

Oculomotor Nerve Palsy following Cardiac Tamponade with Churg-Strauss Syndrome: A Case Report.

A 57-year-old man with a history of more than 10 years of bronchial asthma and chronic sinusitis complained of double vision which developed 18 days after cardiac tamponade with eosinophil-rich fluid (eosinophils 30%). He had oculomotor nerve palsy, and a blood test revealed eosinophilia (12,700/mm(3)) and elevation of both C-reactive protein and rheumatoid factor. He was diagnosed as having Churg-Strauss syndrome. His symptoms were relieved by corticosteroid therapy. Our case and previous cases in the literature revealed that oculomotor nerve palsy in Churg-Strauss syndrome is associated with pupil involvement and may be relieved by corticosteroid treatment.

Patch-and-glue repair in combination with or without direct suture for cardiac rupture after myocardial infarction.

OBJECTIVE: Left ventricular free-wall rupture is a catastrophic event after myocardial infarction. The most appropriate surgical management remains controversial. We have performed a patch-and-glue technique, with or without direct suture and using cardioplegic arrest, to treat postinfarction cardiac rupture. We describe our experiences over a 5-year period, and discuss the optimal surgical repair for each type of rupture. METHODS: Since 2002, we have managed 5 patients with cardiac rupture. Two patients had a blowout rupture, 2 were of the subacute type, and 1 experienced an oozing rupture. There were 3 men and 2 women, with an average age of 76.2 +/- 12.5 years. Echocardiography confirmed the diagnosis in all patients. Two patients underwent a patch-and-glue repair in combination with direct suture, one had an infarctectomy, and the others had a completely sutureless patch-and-glue treatment performed using cardioplegic arrest. RESULTS: All patients survived the initial treatment and were moved to the intensive care unit with complete hemostasis. The 2 patients who were treated in combination with direct suture died of brain death or cardiac failure (mortality rate 40%). The 3 patients who were treated with the patch-and-glue sutureless technique were discharged from our hospital, and are alive 15-27 months after the operation. Two are doing well, and the other is breathing on his own but remains nonreactive. CONCLUSION: We prefer the patch-and-glue sutureless technique even for a blowout rupture. We performed cardioplegic arrest to provide a bloodless surgical field and maximize adhesive function. The whole necrotic area should be covered with a large patch of appropriate size.