Questionnaire in patients with aborted sudden cardiac death due to coronary spasm in Japan.

OBJECTIVES: We investigated the medical or mechanical therapy, and the present knowledge of Japanese cardiologists about aborted sudden cardiac death (ASCD) due to coronary spasm. METHODS: A questionnaire was developed regarding the number of cases of ASCD, implantable cardioverter-defibrillator (ICD), and medical therapy in ASCD patients due to coronary spasm. The questionnaire was sent to the Japanese general institutions at random in 204 cardiology hospitals. RESULTS: The completed surveys were returned from 34 hospitals, giving a response rate of 16.7%. All SCD during the 5 years was observed in 5726 patients. SCD possibly due to coronary spasm was found in 808 patients (14.0%) and ASCD due to coronary spasm was observed in 169 patients (20.9%). In 169 patients with ASCD due to coronary spasm, one or two coronary vasodilators was administered in two-thirds of patients [113 patients (66.9%)], while more than 3 coronary vasodilators were found in 56 patients (33.1%). ICD was implanted in 117 patients with ASCD due to coronary spasm among these periods including 35 cases with subcutaneous ICD. Majority of cause of ASCD was ventricular fibrillation, whereas pulseless electrical activity was observed in 18 patients and complete atrioventricular block was recognized in 7 patients. Mean coronary vasodilator number in ASCD patients with ICD was significantly lower than that in those without ICD (2.1 ± 0.9 vs. 2.6 ± 1.0, p < 0.001). Although 16 institutions thought that the spasm provocation tests under the medications had some clinical usefulness of suppressing the next fatal arrhythmias, spasm provocation tests under the medication were performed in just 4 institutions. CONCLUSIONS: In the real world, there was no fundamental strategy for patients with ASCD due to coronary spasm. Each institution has each strategy for these patients. Cardiologists should have the same strategy and the same knowledge about ASCD patients due to coronary spasm in the future.

Development and validation of optimal cut-off value in inter-arm systolic blood pressure difference for prediction of cardiovascular events.

BACKGROUND: An inter-arm systolic blood pressure difference (IAD) is associated with cardiovascular disease. The aim of this study was to develop and validate the optimal cut-off value of IAD as a predictor of major adverse cardiac events in patients with arteriosclerosis risk factors. METHODS: From 2009 to 2014, 1076 patients who had at least one cardiovascular risk factor were included in the analysis. We defined 700 randomly selected patients as a development cohort to confirm that IAD was the predictor of cardiovascular events and to determine optimal cut-off value of IAD. Next, we validated outcomes in the remaining 376 patients as a validation cohort. The blood pressure (BP) of both arms measurements were done simultaneously using the ankle-brachial blood pressure index (ABI) form of automatic device. The primary endpoint was the cardiovascular event and secondary endpoint was the all-cause mortality. RESULTS: During a median period of 2.8 years, 143 patients reached the primary endpoint in the development cohort. In the multivariate Cox proportional hazards analysis, IAD was the strong predictor of cardiovascular events (hazard ratio: 1.03, 95% confidence interval: 1.01-1.05, p=0.005). The receiver operating characteristic curve revealed that 5mmHg was the optimal cut-off point of IAD to predict cardiovascular events (p<0.001). In the validation cohort, the presence of a large IAD (IAD ≥5mmHg) was significantly associated with the primary endpoint (p=0.021). CONCLUSIONS: IAD is significantly associated with future cardiovascular events in patients with arteriosclerosis risk factors. The optimal cut-off value of IAD is 5mmHg.

Left ventricular obstruction caused by a large hiatal hernia.

A 76-year-old man was admitted to our emergency department owing to chest pain, which started immediately after lunch. Although electrocardiogram revealed ST-segment elevation with hyperacute T-wave changes in the anterior lead tracings, emergency coronary angiography revealed normal coronary arteries. Echocardiography revealed left ventricular (LV) compression with left ventricular obstruction (LVO) caused by an echogenic mass. Computed tomography clearly revealed compression of both left atrial (LA) and LV by a large hiatal hernia. A large hiatal hernia can induce cardiac symptoms resulting from cardiac compression. This case highlights a possible association between chest pain and LVO caused by a hiatal hernia.

Five-year follow-up two-dimensional speckle tracking echocardiography in a juvenile with a double-chambered left ventricle.

Double-chambered left ventricle (DCLV) is a particularly rare congenital entity characterized by the presence of two ventricular cavities separated by an abnormal muscle band. An asymptomatic 15-year-old boy was referred to our hospital because of electrocardiographic (ECG) abnormalities. His initial transthoracic echocardiography (TTE) demonstrated a DCLV with mild left ventricular systolic dysfunction. During a 5-year follow-up period, he remained symptom free with no changes in ECG and conventional TTE findings. However, two-dimensional speckle tracking echocardiography revealed a subtle progressive deterioration of left ventricular systolic function during the 5-year follow-up.

Intravenous nicorandil for treatment of the urgent phase acute heart failure syndromes: A randomized, controlled trial.

BACKGROUND: Vasodilators, such as nitroglycerin, have long been first-line treatments for acute heart failure syndromes (AHFS). Nicorandil is a vasodilator with dual potassium channel opening and nitrate properties. However, there are no randomized controlled studies of intravenous nicorandil safety and efficacy in the urgent phase AHFS. We examined the symptomatic, hemodynamic, and echocardiographic effects and safety, and 60-day clinical outcomes of intravenous nicorandil, in addition to standard therapy, in patients with AHFS in the urgent phase. METHODS: In this prospective, randomized controlled trial, 106 AHFS patients were randomized within one hour of arrival to receive either standard therapy (control group, n=56) or standard therapy plus simultaneous intravenous nicorandil (0.2 mg/kg bolus followed by 0.2 mg/kg/h for 24 h; nicorandil group, n=50). Outcomes were assessed at 60 days. RESULTS: Patients in the nicorandil group exhibited greater improvement of dyspnea as measured by change in a five-point Likert scale compared to those in the control group (after 1 h infusion: p=0.006, 6 h; p<0.001). The nicorandil group also showed significantly improved E/e', an estimate of left ventricular filling pressure, at 1 and 24 h ( p=0.001 and p=0.004, respectively). In addition, intravenous nicorandil therapy was safe and did not cause side effects such as excessive hypotension or reflex tachycardia. However, it did not reduce all-cause mortality and readmission rates at 60 days. CONCLUSIONS: Addition of intravenous nicorandil to standard therapy for urgent phase AHFS improved dyspnea and left ventricular diastolic function but not 60-day outcome.

Factor VII Tokushima: the first case of factor VII Cys22Gly with the development of myocardial infarction in the proband receiving recombinant factor VIIa replacement therapy.

An 81-year-old man was referred to our department because of suspected factor VII (FVII) deficiency. His FVII activity was under 1%, whereas the FVII activity levels of his son and granddaughter were 65 and 109%, respectively. The nucleotide at position 3886 of his FVII gene was homozygous for G. A single T to G substitution results in the replacement of wild-type Cys at residue 22 by Gly. His son was heterozygous for G and T at position 3886, whereas his granddaughter was homozygous for wild-type T. These results suggest that he was homozygous for FVII Cys22Gly. He underwent radiofrequency ablation (RFA) for hepatocellular carcinoma, receiving 20 µg/kg of recombinant FVIIa prior to RFA and 10 µg/kg of recombinant FVIIa twice after RFA. He showed no bleeding tendency; however, a myocardial infarction was diagnosed and percutaneous coronary intervention was performed.

Acute myocardial infarction in a patient with essential thrombocythemia who underwent successful stenting--a case report.

Essential thrombocythemia (ET) can cause systemic vascular thrombosis, but involvement of coronary arteries in the setting of ET is rare. This report describes a case of acute myocardial infarction (MI) in a patient with ET. A 67-year-old man with ET complained of severe acute chest pain. Emergent coronary angiography revealed subtotal thrombotic occlusion of the left main trunk (LMT) coronary artery. Coronary angioplasty and stenting were performed successfully. Coronary angiography 4 weeks later revealed no significant restenosis. The patient has done well after primary coronary stenting with the use of only an antiplatelet agent to treat the thrombocythemia.

Successful percutaneous coronary intervention for acute myocardial infarction caused by simultaneous occlusion of two major coronary arteries in patients with diabetes mellitus. A report of two cases.

Percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) is a common therapeutic method. Although two or more culprit lesions are rarely observed simultaneously in AMI patients, we present two cases of AMI caused by simultaneous occlusion of two major coronary arteries, the left anterior descending and right coronary arteries. In both cases, emergency PCI for the two major vessels was successful. Both patients had type 2 diabetes mellitus, which might have contributed to simultaneous occlusion of the two coronary arteries.

Does coronary artery stenting for acute myocardial infarction improve left ventricular overloading at the chronic stage?

In the present study, we evaluated whether stenting is useful for cardiac overloading, using ANP, BNP, and (99m)Tc-tetrofosmin myocardial scintigraphy. It has been reported that coronary artery stenting is useful for cardiac functions for acute myocardial infarction (AMI). The subjects were 110 patients with AMI successfully treated by direct angioplasty. These patients were subgrouped into two groups: the S group (underwent stenting; 54 patients) and the P group (underwent POBA alone; 56 patients). Extent scores reflecting decreased myocardial blood flow were calculated at myocardial areas showing a radioactivity count of less than (-)2 x standard deviations compared to the database of normal subjects.The ratio of extent scores to defect scores (extent/defect ratio) was compared between the P and S groups. Both ANP and BNP levels in the S group were lower than in the P group at the chronic stage (1 and 3 months after reperfusion therapy). Moreover, the end-diastolic volume index from the left ventriculography 3 months after reperfusion therapy was significantly larger in the P than the S group. The extent/defect ratio was significantly lower in the P group (2.8 +/- 0.2) than the S group (3.5 +/- 0.3), suggestive of a microcirculation disorder. These results suggest that cardiac overloading and left ventricular remodeling are decreased more by stenting than by POBA alone, probably because stenting prevents decreased myocardial blood flow around the infarct myocardium.

High-sensitivity C-reactive protein and left ventricular remodeling in patients with acute myocardial infarction.

Inflammatory cytokines are suspected to play an important role in the pathophysiology of left ventricular (LV) remodeling. We investigated whether high-sensitivity C-reactive protein (CRP) (hs-CRP) is a predictor for LV remodeling in patients with acute myocardial infarction (AMI) with successful reperfusion, and also whether such a situation can be avoided by the administration of angiotensin-converting enzyme inhibitors (ACEI) or angiotensin II receptor blockers (ARB). The subjects were 139 patients with an initial attack of anterior myocardial infarction successfully treated by reperfusion therapy. They were randomly divided into the following two groups: an angiotensin (AG) group (91 patients treated with ACEI/ARB) and a NON-AG group (48 patients not treated with ACEI/ARB). Levels of hs-CRP, creatine kinase, human atrial natriuretic polypeptide, brain natriuretic peptide (BNP), fasting blood glucose, serum lipids, fibrinogen, fibrin degradation product, prothromloin time, and activated partial thromboplastin time were measured immediately after 1, 2, 3, and 7 days, and 1 months after the onset of AMI. ACEI or ARB administration lowered hs-CRP levels and prevented the development of LV remodeling. Peak CRP levels significantly correlated with BNP levels during the acute stage (r = +0.54, P < 0.0001), end-diastolic volume index (r = +0.78, P < 0.0001), end-systolic volume index (r = +0.36, P = 0.0405), ejection fraction (r = -0.45, P = 0.0052), left ventricular end-diastolic diameter (r = +0.61, P < 0.0001), cardiac output (r = -0.52, P = 0.0005), cardiac index (r = -0.41, P = 0.0099), and systolic pulmonary arterial pressure (r = +0.48, P = 0.0017) 1 month after the onset of AMI in the NON-AG group but not in the AG group. Logistic multivariate analysis revealed that peak CRP alone was an independent risk factor for the development of LV remodeling in the NON-AG group (odds ratio = 1.79, P = 0.002). These results suggest that hs-CRP is a useful factor for predicting LV remodeling. Furthermore, ACEI or ARB administration to AMI patients showing increased hs-CRP levels during the early stage of the disease could prevent LV remodeling.

Acute myocardial infarction in a 35-year-old postpartum woman.

A 35-year-old postpartum woman was transferred to our emergency room because of severe precordial pain on the 49th day after delivery. Her ECG up on admission showed ST elevations in leads II, III, and aVF, and an emergency coronary angiography (CAG) demonstrated thrombosis in segment #1 and obstruction in segment #2 of the right coronary artery. Although percutaneous transluminal coronary angioplasty (PTCA) was performed immediately to dilate the stenotic and obstructive regions with balloons, it was not possible to achieve sufficient coronary blood flow TIMI grade 3 coronary blood flow was restored, however, through intracoronary thrombolysis. Three months after the onset of acute myocardial infarction (AMI), no significant stenosis was detected by CAG. However, a later CAG showed that the administration of acetylcholine induced spasm at the entrance and in segments # 2 and #4 of the right coronary artery. In our patient, the presence of both a vasospastic tendency and thrombophilia might have been a leading cause of the AMI, and this finding may be useful in determining future therapeutic tactics for postpartum AMI.

Echocardiographic Detection of Occult Cor Pulmonale During Exercise in Patients with Chronic Obstructive Pulmonary Disease.

We tested the ability of cycle ergometer exercise echocardiography to detect cases of occult cor pulmonale among 25 patients with chronic obstructive pulmonary disease (COPD). The M-mode echocardiographic ventricular septal motion, left ventricular shape determined by short-axis two-dimensional (2-D) echocardiography, and right and left ventricular pressure curves were recorded at rest and during exercise and were compared between patients. The ventricular septal motion was normal at rest in all of the patients. In nine patients (dip group), there was marked downward ventricular septal motion in early diastole during exercise, indicating distortion of the left ventricular shape. There were no distinct changes in the remaining 16 patients (non-dip group). At rest, the cardiac index was significantly lower, and right ventricular systolic and mean pulmonary artery pressures were significantly higher in the dip group than in the non-dip group. However, no significant difference was noted in the right ventricular end-diastolic pressure between the two groups at rest. The right ventricular systolic and end-diastolic pressures were greater during exercise in the dip group than in the non-dip group. In all of the patients in the dip group, the right ventricular pressure exceeded the left ventricular pressure only in early diastole, coinciding with the early diastolic dip of the ventricular septum, during exercise. In conclusion, occult cor pulmonale can be diagnosed accurately by the appearance of an early diastolic dip of the ventricular septum and distorted left ventricular shape during exercise in patients with COPD.