A Case of ST-elevated myocardial infarction resulting from obstructive intramural coronary amyloidosis.

A 49-year-old man presenting with ST-elevated myocardial infarction was brought to our emergency department with AL amyloidosis. Baseline coronary angiography showed no significant stenosis of the epicardial coronary arteries, however, coronary artery angiography in response to acetylcholine and coronary flow reserve in response to papaverine were abnormal, which suggested impairment of vascular endothelial function. Myocardial biopsy revealed amyloid deposition exclusively in intramural coronary arteries. Early amyloidosis without myocardial involvement can produce acute coronary syndrome through the combination of spastic epicardial coronary arteries and obstruction of the intramural coronary arteries. In the management of certain patients with acute coronary syndrome, the possibility of cardiac amyliodosis should be taken into consideration.

A one-year study of the antiatherosclerotic effect of the angiotensin-II receptor blocker losartan in hypertensive patients. A comparison with angiotension-converting enzyme inhibitors.

Angiotensin receptor blockers (ARB) have been emerging as drugs to treat atherosclerosis. The effectiveness of the ARB losartan at reducing atherosclerosis was compared with that of ACE inhibitors in hypertensive patients. A total of 50 patients with hypertension were divided into 3 groups: a control group receiving neither an ARB nor an ACE inhibitor (n = 14), a losartan group (n = 22) receiving 50 mg/day of losartan, and an ACE inhibitor group (n = 14) receiving either 5 mg/day of enalapril or 5 mg/day of imidapril. Atherosclerosis was evaluated based on the intima-media thickness (IMT) of the common carotid artery measured by B-mode ultrasound at baseline and after approximately 12 months of treatment. After the treatment, IMT significantly decreased with losartan (from 0.87 +/- 0.14 to 0.79 +/- 0.16 mm, P < 0.05) and with ACE inhibitor (from 0.81 +/- 0.14 to 0.74 +/- 0.11 mm, P < 0.05). The reduction was comparable between the two groups, -0.078 +/- 0.136 with losartan and -0.073 +/- 0.109 mm with ACE inhibitor, and the rate of the reduction was similar between the two drugs; -0.098 +/- 0.142 mm/year with losartan and (-0.076 +/- 0.118 mm/year) with ACE inhibitor. On the contrary, IMT did not change in the control group (from 0.90 +/- 0.20 to 0.95 +/- 0.26 mm) during the treatment period. Concomitant medication and coronary risk factors such as hyperlipidemia, diabetes mellitus, and smoking did not differ significantly among the groups. The antiatherosclerotic effect of losartan on the carotid artery was comparable to that of ACE-inhibitors, and less adverse effects, such as coughing that occurs with ACE inhibitors, were observed. Losartan appears to be a better alternative to ACE inhibitors for treating atherosclerosis in Japanese hypertensive patients.

A case of almost-exclusively atria-dominant cardiac amyloidosis related with hemodialysis.

We report a case of a 68-year-old man who had dialysis-related amyloidosis. The patient underwent neck surgery due to spondyloarthritis. Unfortunately he died after the surgery in sepsis. The preoperative routine echocardiography didn't suggest cardiac involvement of amyloidosis. However, the pathological findings in autopsy revealed severe amyloid depositions of both atria in contrast to the quite mild involvement of ventricles. We have experienced that the cardiac involvement of dialysis-related amyloidosis may be confined to atria almost sparing ventricles. Therefore, in patients with hemodialysis-related amyloidosis, even if echocardiogram doesn't suggest any ventricular amyloidosis, physicians should consider the possibility of atrial amyloidosis and should check the detail of atrial findings. If the A wave in the mitral filling pattern seems small or absent, physicians have to proceed transesophageal echocardiogram to detect intra atrial thrombus and consider anti-coagulation therapy to prevent thromboembolic complications of atrial amyloidosis.

A case of transient left ventricular ballooning with pheochromocytoma, supporting pathogenetic role of catecholamines in stress-induced cardiomyopathy or takotsubo cardiomyopathy.

We experienced a case with severe acute heart failure showing "takotsubo"-like left ventricular asynergy. Subsequently, he was found to have pheochromocytoma, and underwent emergent adrenalectomy, which almost completely reversed his cardiac function and symptoms. His clinical course, supports the pathogenetic role of catecholamines in "takotsubo cardiomyopathy".

A case of graft infection 10 years after ascending aorta replacement.

A 52-year-old man was admitted with anemia and slight fever, which he had for the last 2 months. He had undergone replacement of the ascending aorta for acute aortic dissection 10 years previously. Echocardiography demonstrated a flailing thin structure in the anterior wall of the ascending aorta corresponding to the proximal portion of the prosthetic graft. This abnormal echocardiographic finding led us to repeat blood cultivation. We finally detected Enterococcus facium and Staphylococcus epidermidis in his blood sample. We diagnosed this as a graft infection and prepared for surgical re-replacement of the infected graft. While he was waiting for the operation, an infectious aneurysm of a tibialis posterior artery ruptured and an emergency operation was done. Replacement of the infected ascending aorta graft was done thereafter. In surgery, 2-cm-long vegetation was found. It stuck to the graft wall near the former hole used for air removal in the first surgery. The patient recovered fully and left our hospital after 3 months of postoperative antibiotics therapy. This rare case of aortic graft infection long after the original replacement surgery suggests the importance of thorough echocardiographic investigation of prosthetic graft infection as a possible cause of fever of unknown origin.

[Differential diagnosis in GERD and cardiovascular disease].

In substantial portion of patients referred to the coronary care unit (CCU) with a tentative diagnosis of acute coronary syndrome (ACS), gastro-esophageal diseases are the origins of their symptoms such as chest pain. The differential diagnosis is difficult and the coronary angiography (CAG) and the gastro-esophageal endoscopy are often required. We recently evaluated our 100 consecutive cases that underwent CAG as ACS. Among the 100 cases, 72 had significant organic coronary artery lesions, 5 had significant coronary vasospasms proved by the acetylcholine provocation, and the other 23 showed no detectable major coronary artery abnormality. Among the last 23 cases, gastro-esophageal endoscopy revealed the gastro-esophageal diseases such as reflux esophagitis in 7 cases. Those 7 cases with gastro-esophageal diseases had less coronary risk factors than the 77 cases with the coronary artery diseases. Gastro-esophageal diseases are the major differential diagnoses of ACS, especially in those with few coronary risk factors.

Common carotid intima-media thickness is correlated with myocardial flow reserve in patients with coronary artery disease: a useful non-invasive indicator of coronary atherosclerosis.

BACKGROUND: The common carotid intima-media thickness (IMT) is correlated with the angiographically determined coronary artery stenosis. However, their correlation is weak, which limits the clinical application of the IMT as a predictor of coronary artery stenosis. The IMT reflects diffuse early-phase atherosclerosis, whereas the angiographically determined coronary artery stenosis is a late-phase phenomenon. The latter is localized and rapidly progressive with plaque rupture and acute thrombosis. Instead of the angiographically determined coronary artery stenosis, we employed myocardial flow reserve (MFR) that reflects diffuse early-phase coronary atherosclerosis and impaired coronary vasodilatation function. We evaluated the relationship between the IMT and the MFR. METHODS: Twenty-three patients with angiographically diagnosed coronary artery disease (CAD) underwent B-mode ultrasound examination to measure their common carotid IMT and positron emission tomography (PET) with dipyridamole intervention to obtain their MFR. We also performed B-mode ultrasound examination in 21 patients with hypertension without CAD and in 15 control subjects. RESULTS: The common carotid IMT in patients with CAD was thickened (0.92+/-0.15 vs. 0.81+/-0.14 mm in patients with hypertension (P<0.05) and 0.69+/-0.13 mm in control subjects (P<0.01)). The IMT was inversely correlated with the MFR (r=0.51, P<0.01). The correlations between the MFR and most of the coronary risk factors (age, blood pressure, serum cholesterol level and triglyceride level, HbA1c level, smoking index) did not reach statistical significance. CONCLUSIONS: Thickened common carotid IMT is also an indicator of reduced MFR or early-phase coronary atherosclerosis.

[Coronary risk factor management in primary practice in Shibuya, Tokyo].

OBJECTIVES: Many large-scale clinical trials have confirmed that coronary risk factors such as hypertension, hyperlipidemia and diabetes mellitus predict a higher incidence of cardiovascular events and that control of these risk factors reduces the incidence. However, the actual management of such risk factors and the resultant improvement of the cardiovascular events in primary practice remains unclear. The Heart Care Network Shibuya, a voluntary study group of regional primary physicians, surveyed the management of coronary risk factors and the clinical outcomes. METHODS: Behavioral patterns of the coronary risk factor was investigated in the management and resultant changes of the risk factors in 209 outpatients (mean age 65.6 +/- 11.2 years) with more than one of hypertension, hyperlipidemia, diabetes mellitus or prior myocardial infarction for 1 year. RESULTS: Prescriptions of anti-hypertensive (from 1.3 +/- 0.8 to 1.4 +/- 0.8 drugs per patient) and antihyperlipidemia drugs (from 0.70 +/- 0.4 to 0.73 +/- 0.4 drugs per patient) did not significantly increase. Patient education for diet (93% to 97%, p = 0.077), exercise (69% to 81%, p < 0.05) and nonsmoking (66% to 86%, p < 0.05) significantly increased after 1 year. Blood pressure decreased from 142 +/- 16/81 +/- 10 to 138 +/- 78/78 +/- 9 mmHg (p < 0.05), serum total cholesterol level decreased from 215 +/- 39 to 203 +/- 39 mg/dl (p < 0.05). As a result, more patients attained the treatment goals recommended in the guidelines by the Japanese Society of Hypertension (34.6% to 46.8%) and Japan Atherosclerosis Society (40.2% to 49.5%), respectively. However, none of blood hemoglobin A1c level, body mass index or smokers significantly changed. CONCLUSIONS: Regional practitioners attempted to control all coronary risk factors. Hypertension and hyperlipidemia, which are relatively more dependent on the medical management, improved. In contrast, diabetes mellitus, obesity or smoking, which require life style changes, did not improve. The main issue in the risk factor management is how physicians act rather than specific actions.