Differential influence of lesion length on fractional flow reserve in intermediate coronary lesions between each coronary artery.

OBJECTIVES: This study evaluated whether the influence of lesion length on functional significance is similar between each target artery. BACKGROUND: In the presence of a similar moderate degree of stenosis, the fractional flow reserve (FFR) in the left anterior descending coronary artery (LAD) is more often <0.80 than in the other arteries. METHODS: A total of 221 lesions with intermediate stenosis on coronary angiography that underwent FFR measurement for the evaluation of myocardial ischemia were enrolled. Quantitative coronary angiographic analysis including percent diameter stenosis and lesion length was performed. The area under the receiver operating characteristics (ROC) curve was estimated for the best cutoff value as a predictor of FFR value of ≤0.80 for each coronary artery. RESULTS: Although lesion length was similar among the lesions with an FFR >0.80 at different locations, the mean lesion length was significantly longer for lesions in the right coronary artery (RCA) with an FFR ≤0.80 than for those in the LAD and left circumflex artery (13.4 ± 3.4 vs. 8.6 ± 3.1 vs. 12.0 ± 3.7 mm, p < .001). ROC analysis demonstrated that the optimal cutoff value of lesion length for predicting an FFR ≤0.80 was 10.0 mm in the LAD (0.56 area under the curve [AUC], 48% sensitivity, and 76% specificity), whereas 13.1 mm in the RCA (0.84 AUC, 67% sensitivity, and 93% specificity). CONCLUSIONS: The impact of lesion length on myocardial ischemia is different for each coronary artery. A longer lesion length is required in the RCA than in the LAD to achieve an FFR ≤0.80.

[Incidence and clinical outcome of contrast-induced nephropathy in the elderly patients].

BACKGROUND: Aging is an established risk factor for contrast-induced nephropathy (CIN). However, little information is available on the incidence and clinical outcome of CIN for the elderly patients in Japan. OBJECTIVES: We determined the incidence and clinical outcome of CIN in the Japanese elderly patient. METHODS: We studied 292 patients who had mild renal dysfunction (estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m(2)) at baseline and underwent coronary angiography. Patients were divided into two groups base on their age: the elderly group (age ≥ 75, n=108) and the control group (age<75, n=184). CIN was defined as a 25% increase in serum creatinine or an increase in serum creatinine by>0.5 mg/dl above the baseline value at or within 2 days post procedure. RESULTS: Patients in the elderly group had a higher incidence of CIN (14%) than those in the control group (9%). In patients who developed CIN, there was no significant difference between the two groups in baseline GFR and GFR on days 1, 2, 7 and 30 after the procedure. However, the relative increase in GFR above baseline on day 7 (-4.0 ± 6.1 vs -8.3 ± 8.0 ml/min P=0.096) and day 30 (1.5 ± 9.4 vs -10.1 ± 9.6 ml/min P=0.0017) in the elderly group was higher than that in the control group. Furthermore, death occurred in 3 patients in the elderly group (20%) whereas no patient died in the control group (P=0.092). CONCLUSION: Aging (age ≥ 75) is a risk factor for CIN in Japanese. CIN in the elderly patients may be associated with prolonged renal dysfunction and poor prognosis.

Preservation of myocardial viability within the risk area by intravenous nicorandil before primary coronary intervention in patients with acute myocardial infarction.

OBJECTIVE: To investigate the cardioprotective effect of intravenous nicorandil before primary percutaneous coronary intervention (PCI) on preservation of myocardial viability, we studied 199 consecutive patients with acute myocardial infarction. METHODS: Nicorandil was given intravenously on admission (before primary PCI). Echocardiography and technetium-99m tetrofosmin perfusion imaging were performed before and 1 month after primary PCI. Echocardiographic asynergic score before primary PCI was used to define the size of risk area, whereas the sum of scintigraphic defect grade before primary PCI was used to estimate myocardial viability within the area at risk. The change (before primary PCI and 1 month after primary PCI) in asynergic score and scintigraphic salvage index were calculated. RESULTS: Patients were divided into nicorandil (n=101) and control (n=98) groups. Although asynergic score before primary PCI was not different between the two groups (nicorandil=3.5+/-2.1 and control=3.9+/-1.5), myocardial viability was preserved in nicorandil group (defect score=11.0+/-4.0) than that in control group (defect score=14.0+/-4.7, P<0.0001). Multivariate analysis revealed that the presence of antegrade flow (P=0.015) and nicorandil (P<0.0001) were independently associated with preserved myocardial viability before primary PCI. Moreover, the greater reduction in asynergic score (66+/-41 vs. 49+/-23%, P=0.0006) and larger salvage index (65+/-25 vs. 53+/-26%, P=0.0015) were observed in nicorandil group compared with the control group. CONCLUSION: Intravenous administration of nicorandil before primary PCI preserved myocardial viability within the risk area, which leads to greater myocardial salvage and better functional recovery after primary PCI.

The effect of verapamil on the restoration of myocardial perfusion and functional recovery in patients with angiographic no-reflow after primary percutaneous coronary intervention.

OBJECTIVE: Angiographic thrombolysis in myocardial infarction (TIMI) flow grade < or = 2 after primary percutaneous coronary intervention (PCI), defined as angiographic no-reflow, predicts poor functional recovery in patients with acute myocardial infarction. We investigated the effect of verapamil on the restoration of myocardial perfusion and functional recovery in patients with angiographic no-reflow after PCI. METHODS: 99mTc tetrofosmin single photon emission computed tomographic (SPECT) imaging was performed (before, immediately after and 1 month after PCI) in 101 consecutive patients with acute myocardial infarction. The defect score was calculated as the sum of perfusion defect in a 13-segment model (scores of 3, complete defect to 0, normal perfusion). The asynergic score, defined as the number of asynergic segments, was assessed by echocardiography before and 1 month later. Multiple logistic regression analysis was performed to elucidate the effect of verapamil administration. RESULTS: Of 101 patients, 32 (31%) had angiographic no-reflow and were divided into two groups: 18 patients with verapamil (group 1) and 14 patients without verapamil (group 2). Sixty-nine patients had TIMI grade 3 reflow after PCI (group 3). The change in the defect score 1 month after PCI in group 1 was significantly larger than that in group 2 (P = 0.003). The asynergic score improved more at 1 month in group 1 compared to that in group 2 (P = 0.007). Moreover, logistic regression analysis revealed that TIMI grade reflow < or = 2 after PCI (P = 0.04, OR = 5.51), the defect score before PCI (P = 0.03, OR = 1.15), the asynergic score before PCI (P = 0.01, OR = 0.64) and the administration of verapamil (P = 0.002, OR = 22.4) were independently associated with successful myocardial reperfusion immediately after PCI. CONCLUSIONS: Intracoronary verapamil restored myocardial perfusion in patients with angiographic no-reflow after PCI and lead to better functional recovery after acute myocardial infarction.

Acute tubulointerstitial nephritis associated with autoimmune-related pancreatitis.

Various etiologic factors have been identified in tubulointerstitial nephritis (TIN), including allergic drug reaction, infection, and immune-mediated disease. Immune-mediated TIN without significant glomerular involvement has been reported to occur as a renal complication secondary to Sjögren's syndrome, lupus nephritis, and antitubular basement membrane antibody-related disease. We present a first case of acute TIN associated with autoimmune-related pancreatitis (AIP). A 64-year-old man was referred to our division from a surgeon for the close examination of renal dysfunction. The pancreatic and biliary imaging showed segmental narrowing of the pancreatic duct with localized swelling of the pancreatic head, suggesting the carcinoma of the pancreatic head at that time. However, the laboratory findings also showed renal dysfunction with high level of serum immunoglobulin G and hypocomplementemia. Renal biopsy was performed to investigate the etiology of the renal dysfunction. The renal biopsy specimen showed acute TIN. The patient had no drug history, which may cause TIN. Oral corticosteroid therapy improved the renal function as well as histological damage, the pancreatic imaging study, and the laboratory tests of pancreatic and hepatobiliary enzyme. Although the pancreatic biopsy has not performed in our patient, his clinical course confirmed us that AIP was the final diagnosis for his pancreatic lesion. Despite further examination, there was no evidence of other autoimmune-related diseases such as Sjögren's syndrome. To our knowledge, this is the first report of acute TIN associated with AIP. We suggest that AIP may be an etiologic factor in some cases of TIN.

Combined analysis of multislice computed tomography coronary angiography and stress-rest myocardial perfusion imaging in detecting patients with significant proximal coronary artery stenosis.

OBJECTIVE: Multislice computed tomography (MSCT) coronary angiography (CAG) is limited in detecting significant coronary artery stenosis because of its low specificity and positive predictive value. Stress-rest myocardial perfusion imaging (MPI) can detect myocardial ischemia. The aim of this study was to evaluate the diagnostic accuracy of detecting patients with proximal coronary artery disease for coronary intervention by combined analysis of MSCT-CAG and MPI. METHODS: MSCT-CAG, MPI, and CAG were performed in 125 patients with chest pain suggestive of coronary artery disease. A significant proximal coronary artery stenosis was defined as > or = 75% stenosis by MSCT and CAG. Myocardial ischemia was defined as reversible defect by MPI. Patients were defined as having coronary artery disease with a significant coronary stenosis by CAG. RESULTS: Seventy-four patients had a significant proximal coronary artery stenosis by MSCT. Of the 74 patients with a coronary artery stenosis by MSCT, 50 (67.6%) patients had a significant proximal coronary artery stenosis by CAG. In contrast, 50 (98.0%) of 51 patients without coronary artery stenosis by MSCT did not have coronary artery disease. In detecting patients with proximal coronary artery disease, combined analysis of MSCT and MPI showed a considerable improvement in specificity (94.6 vs. 67.6%, P = 0.0001) and positive predictive value (92.3 vs. 67.6%, P = 0.01) without significant changes in sensitivity (94.1 vs. 98.0%) and negative predictive value (95.9 vs. 98.0%) compared with MSCT alone. CONCLUSION: Combined analysis of MSCT-CAG and MPI can accurately detect patients with proximal coronary artery disease.

[Acute myocardial infarction due to late stent thrombosis seventeen months after stent implantation: a case report].

A 59-year-old man with acute myocardial infarction underwent successful stent implantation for proximal left anterior descending coronary artery occlusion. Antiplatelet therapy with 100 mg aspirin/day and 200 mg cilostazol/day was started after stenting and continued for 4 weeks. There was no cardiac event during the 1 year follow-up period. Follow-up coronary angiography at 12 months after stenting revealed no in-stent restenosis. The patient was admitted 17 months later due to sudden onset of severe chest pain. Electrocardiography revealed ST segment elevation in leads V1-V4. Emergency coronary angiography disclosed obstruction of the proximal left anterior descending coronary artery with thrombus. Intracoronary aspiration thrombectomy was successful. We describe a patient with acute myocardial infarction who had late stent thrombosis 17 months after stent implantation.