Prognostic stratification of patients with vasospastic angina: a comprehensive clinical risk score developed by the Japanese Coronary Spasm Association.

OBJECTIVES: The present study aimed to develop a comprehensive clinical risk score for vasospastic angina (VSA) patients. BACKGROUND: Previous studies demonstrated various prognostic factors of future adverse events in VSA patients. However, to apply these prognostic factors in clinical practice, the assessment of their accumulation in individual patients is important. METHODS: The patient database of the multicenter registry study by the Japanese Coronary Spasm Association (JCSA) (n = 1,429; median 66 years; median follow-up 32 months) was utilized for score derivation. RESULTS: Multivariable Cox proportional hazard model selected 7 predictors of major adverse cardiac events (MACE). The integer score was assigned to each predictors proportional to their respective adjusted hazard ratio; history of out-of-hospital cardiac arrest (4 points), smoking, angina at rest alone, organic coronary stenosis, multivessel spasm (2 points each), ST-segment elevation during angina, and beta-blocker use (1 point each). According to the total score in individual patients, 3 risk strata were defined; low (score 0 to 2, n = 598), intermediate (score 3 to 5, n = 639) and high (score 6 or more, n = 192). The incidences of MACE in the low-, intermediate-, and high-risk patients were 2.5%, 7.0%, and 13.0%, respectively (p < 0.001). The Cox model for MACE between the 3 risk strata also showed prognostic utility of the scoring system in various clinical subgroups. The average prediction rate of the scoring system in the internal training and validation sets were 86.6% and 86.5%, respectively. CONCLUSIONS: We developed a novel scoring system, the JCSA risk score, which may provide the comprehensive risk assessment and prognostic stratification for VSA patients.

Clinical features of myocardial infarction in young Japanese patients.

Clinical features and outcomes of acute myocardial infarction (AMI) in the young have been poorly investigated. The aim of this study was to investigate the clinical features and hospital outcomes of AMI in young Japanese. We conducted a case-control study. A total of 53 consecutive AMI patients whose age was ≤ 45 years old were assigned to the young group and 106 AMI patients whose age was > 45 years old were assigned to the non-young group. We compared the clinical features and hospital outcomes between the two groups. Compared with the non-young group, the young group was associated with male sex, hyperlipidemia, current smoking, being overweight, single vessel disease, and Killip class I on admission. There were no differences in the length of hospital stay or major adverse cardiac events between the groups. However, mortality and ventricular rupture were slightly lower in the young. In conclusion, young AMI patients had clinical characteristics different to those of the non-young patients. Compared to non-young patients, modifiable risk factors such as smoking, hyperlipidemia, and being overweight were associated with young AMI patients.

Gender differences in the clinical characteristics and outcomes of patients with vasospastic angina--a report from the Japanese Coronary Spasm Association.

BACKGROUND: Accumulating evidence has demonstrated the gender differences in the clinical characteristics and outcomes of patients with ischemic heart disease. However, it remains to be elucidated whether it is also the case for vasospastic angina (VSA). METHODS AND RESULTS: We enrolled a total of 1,429 VSA patients (male/female, 1090/339; median age 66 years) in our nationwide multicenter registry by the Japanese Coronary Spasm Association. As compared with male patients, female patients were characterized by older age (median 69 vs. 66 years), lower incidence of smoking (20% vs. 72%) and less significant organic stenosis (9% vs. 16%) (all P=0.001). Multivariate analysis demonstrated that the predictors of major adverse cardiac events (MACE) were considerably different by genders; women were more associated with age and electrical abnormalities, whereas men with structural abnormalities. Overall 5-year MACE-free survival was comparable between both genders. However, when the patients were divided into 3 groups by age [young (<50 years), middle-aged (50-64 years) and elderly (≥65 years)], the survival was significantly lower in the young female group (young 82%, middle-aged 92%, elderly 96%, P<0.01), where a significant interaction was noted between age and smoking. In contrast, the survival was comparable among the 3 age groups of male patients. CONCLUSIONS: These results indicate that there are gender differences in the characteristics and outcomes of VSA patients, suggesting the importance of gender-specific management of the disorder.

Beta-blocker use is not associated with slow flow during rotational atherectomy.

OBJECTIVES: The purpose of this study was to investigate the association between beta-blocker use and slow flow during rotational atherectomy (RA). BACKGROUND: RA is often performed as part of percutaneous coronary interventions for the treatment of calcified lesions; however, the procedure can be complicated by slow flow. Previous reports suggested that the use of beta-blockers was associated with slow flow during RA. METHODS: A total of 186 patients who received RA were included, and 87 patients were on beta-blockers. The occurrence of slow flow was compared between the beta-blocker group (n = 87) and the non-beta-blocker group (n = 99). Multivariate logistic regression analysis was performed to investigate whether the use of beta-blockers was associated with slow flow. RESULTS: The occurrence of slow flow was not different between the beta-blocker group (29.9%) and the non-beta-blocker group (24.2%; P=.39). The use of beta-blockers was not significantly associated with slow flow (odds ratio, 0.75; 95% confidence interval, 0.34-1.68; P=.49) after controlling for all potential confounding factors. CONCLUSIONS: There was no definitive association between slow flow and the use of beta-blockers during RA. There is no need to discontinue beta-blockers in patients receiving RA.

Comparison of long-term clinical outcomes between sirolimus-eluting stents and paclitaxel-eluting stents following rotational atherectomy.

Rotational atherectomy (RA) can facilitate smooth stent delivery and stent expansion through lesion modification for a calcified coronary lesion. Several studies reported that sirolimus-eluting stent (SES) implantation following RA showed a lower rate of revascularization compared with bare-metal stents (BMS). However, there are limited data that compared the clinical outcomes between SES and paclitaxel-eluting stents (PES) after RA. We compared the long-term clinical outcomes of SES and PES following RA. Two hundred and thirty-three consecutive patients (SES n = 179, PES n = 54) who were treated with SES or PES following RA between 10th September 2004 and 13th April 2010 were investigated. Follow-up data for clinical outcomes were obtained in 91.4% of all subjects. The median follow-up period was 630 days (interquartile range, 300 to 1170 days) in the SES group, and 625 days (interquartile range, 285 to 900 days) in the PES group. Clinical outcomes including target lesion revascularization (TLR) (SES 4.9% versus PES 9.8%, P = 0.31), target vessel revascularization (TVR) (SES 6.8% versus PES 11.8%, P = 0.25), and major adverse cardiac events (MACE) (SES 14.8% versus PES 13.7%, P = 0.8) were not statistically different between the groups. The unadjusted cumulative event rates estimated by the Kaplan-Meier method and the log-rank test showed no significant differences between the two groups for time to event for TLR, cardiovascular death, all-cause death, or MACE. In conclusion, there was no significant difference in the long-term clinical outcomes between SES and PES following RA.

Clinical characteristics and long-term prognosis of vasospastic angina patients who survived out-of-hospital cardiac arrest: multicenter registry study of the Japanese Coronary Spasm Association.

BACKGROUND: Coronary artery spasm plays an important role in the pathogenesis of ischemic heart disease; however, its role in sudden cardiac death remains to be fully elucidated. We examined the clinical characteristics and outcomes of patients with vasospastic angina (VSA) in our nationwide multicenter registry by the Japanese Coronary Spasm Association. METHODS AND RESULTS: Between September 2007 and December 2008, 1429 patients with VSA (male/female, 1090/339; median, 66 years) were identified. They were characterized by a high prevalence of smoking and included 35 patients who survived out-of-hospital cardiac arrest (OHCA). The OHCA survivors, as compared with the remaining 1394 non-OHCA patients, were characterized by younger age (median, 58 versus 66 years; P<0.001) and higher incidence of left anterior descending coronary artery spasm (72% versus 53%, P<0.05). In the OHCA survivors, 14 patients underwent implantable cardioverter-defibrillator (ICD) implantation while intensively treated with calcium channel blockers. Survival rate free from major adverse cardiac events was significantly lower in the OHCA survivors compared with the non-OHCA patients (72% versus 92% at 5 years, P<0.001), including appropriate ICD shocks for ventricular fibrillation in 2 patients. Multivariable analysis revealed that OHCA events were significantly correlated with major adverse cardiac events (hazard ratio, 3.25; 95% confidence interval, 1.39 to 7.61; P<0.01). CONCLUSIONS: These results from the largest vasospastic angina cohort indicate that vasospasm patients who survived OHCA are high-risk population. Further studies are needed to determine whether implantable cardioverter-defibrillator therapy improves patient prognosis.

Association of CD40 ligand levels in the culprit coronary arteries with subsequent prognosis of acute myocardial infarction.

OBJECTIVE: CD40 ligand (CD40L) plays a crucial role in atherogenesis and plaque destabilization. The purpose of this study was to clarify the association of CD40L levels in the culprit coronary arteries (CA) with the subsequent cardiovascular events in patients with acute myocardial infarction (AMI). METHODS: We enrolled 68 patients with AMI whose CA were treated using thrombectomy devices. Blood samples were collected from the peripheral veins (PV), the ascending aortae (AO) and CA. RESULTS: CD40L levels in the CA were significantly greater than those in the PV and AO. Statistical analyses revealed that CD40L levels in CA correlated positively with the corrected TIMI frame counts and maximal serum creatine kinase-MB in throughout clinical course, and inversely with myocardial blush grade and left ventricular ejection fraction 6 months after AMI. In logistic regression analyses, the group with high CD40L levels in CA was associated with an 8.58-fold increase in the odds of a cardiovascular event rate compared with the group with low CD40L levels. CONCLUSIONS: In patients with AMI, enhanced CD40L levels in CA might affect myocardial perfusion, myocardial damage, and subsequent cardiovascular events, and could be a predictive marker for the prognosis of AMI.

Circulating CD34+/133+ progenitor cells in patients with stable angina pectoris undergoing percutaneous coronary intervention.

BACKGROUND: This study explored the clinical significance of CD34(+)/133(+) circulating progenitor cell (CPC) counts in patients with stable angina pectoris (AP) who underwent percutaneous coronary intervention (PCI). METHODS AND RESULTS: Subjects comprised 52 patients with stable AP requiring PCI and 50 control patients without AP. In the AP group, blood samples were taken before and 20 min and 24 h after PCI to measure CPC counts by fluorescence-activated cell sorter analysis. The baseline number of CPCs was smaller in the AP group than in controls. In the AP group, body mass index (BMI) correlated positively with the baseline number of CPCs and was an independent predictor of CPC count in multivariate regression analysis. Other conventional risk factors, daily exercise activity and statin administration showed no association with CPC count. CPC counts remained unchanged within 24 h after PCI. CONCLUSIONS: CPC counts in patients with AP are influenced by BMI, but not by other coronary risk factors. CPC counts remain unchanged within 24 h after PCI.

Clinical features of early recurrent myocardial infarction.

Recurrence of myocardial infarction, especially when occurring early after the prior one, carries a significant morbidity and mortality rate. The aim of this study was to investigate the characteristics of patients who experienced recurrence under secondary prevention therapy. Case record review identified myocardial infarction patients who had a history of previous myocardial infarction within 5 years. Hospital chart records, initial laboratory data, medications, and type of infarction were reviewed. Patients were divided into two groups according to the interval of recurrence: an early group (recurrence within 1 year), and a late group (recurrence after more than 1 year). A total of 89 patients were included in the analysis; 40 patients in the early group, and 49 patients in the late group. Mean age in the early group and late groups was 67.3 +/- 11.9 and 59.4 +/- 8.9, respectively (P = 0.001). Mean body mass index in the early and late groups was 22.1 +/- 3.6 and 25.0 +/- 3.3, respectively (P < 0.001). There were fewer current smokers in the early group (7.5% vs 44.9%, P < 0.001) and more stent thrombosis (17.5% vs 2%, P = 0.02), as compared with the late group. The in-hospital mortality rate tended to be higher in the early group (7.5% vs 0%, P = 0.09). Multiple logistic regression revealed that smoking status (odds ratio [OR] 0.09, 95% confidence interval [CI] 0.02-0.49, P = 0.005), HDL cholesterol level (5 mg/dl increase: OR 1.34, 95% CI 1.04-1.74, P = 0.03), and stent thrombosis (OR 35.59, 95% CI 2.13-595.49, P = 0.01) had significant associations with early recurrence. Early recurrence of myocardial infarction was associated with stent thrombosis, a higher HDL cholesterol level, and a lower frequency of smoking. Early recurrence had a trend toward higher mortality than late recurrence.

Plaque characteristics of the coronary segment proximal to the culprit lesion in stable and unstable patients.

BACKGROUND: Identifying vulnerable plaque is important for preventing an acute coronary event. The present study examined the relationship between the clinical presentation of coronary artery disease and the plaque characteristics of nonculprit segment assessed by virtual histology intravascular ultrasound (VH-IVUS). METHOD: We performed VH-IVUS analysis on nonculprit segments with < 50% diameter stenosis in 91 patients (48 acute coronary syndrome [ACS] patients, 43 stable angina [SA] patients). RESULTS: ACS patients showed significantly higher ratio of dense calcium (7.9% +/- 1.0% versus 5.0% +/- 0.9%, p = 0.03) and necrotic core plaque (13.7% +/- 1.1% versus 8.6% +/- 1.1%, p = 0.001) compared with SA patients. VH-IVUS-derived thin-cap fibroatheroma (VH-TCFA) was more frequently observed in ACS patients compared with SA patients (64.6% versus 35.7%, p = 0.006). Among ACS patients, plasma high sensitivity C-reactive protein (hs-CRP) levels were significantly higher in patients with VH-TCFA than in patients without VH-TCFA (7.9 +/- 2.6 mg/l versus 1.6 +/- 0.3 mg/l, p = 0.004). CONCLUSION: ACS patients presented higher prevalence of VH-TCFA in nonculprit segment. Presence of VH-TCFA was associated with an increased level of plasma hs-CRP in ACS patients.

Elevation of plasma placental growth factor in the patients with ischemic cardiomyopathy.

BACKGROUND: Placental growth factor (PlGF), which is a member of the vascular endothelial growth factor family, stimulates angiogenesis and collateral growth in ischemic tissues. In addition, PlGF has been known to be a useful biomarker of vascular inflammation. This study was undertaken to examine whether plasma PlGF levels were increased in patients with congestive heart failure (CHF). METHODS: Ninety-eight patients with systolic heart failure (ejection fraction <40%) and twenty control subjects were enrolled. The patients were divided into four subgroups according to the criteria of NYHA functional class. Plasma PlGF, tumor necrosis factor (TNF)-alpha, brain natriuretic peptide (BNP), norepinephrine, high-sensitive C-reactive protein (hs-CRP) were determined. RESULTS: In analysis of all the subjects, there was no significant difference in plasma PlGF levels among the subgroups of NYHA classes and the controls. In the ischemic cardiomyopathy (ICM) patients, however, plasma PlGF levels were significantly increased according to the severity of NYHA class; control: 8.9+/-0.5; NYHA I: 9.4+/-1.1, NYHA II: 9.7+/-1.9, NYHA III: 14.6+/-1.2, NYHA IV: 17.9+/-1.9 pg/ml (p=0.0006). Plasma PlGF levels correlated positively with BNP (r=0.53, p=0.0003) and hs-CRP (r=0.23, p=0.02) in the ICM patients, whereas there was not any correlation between plasma PlGF levels and other variable values in the non-ICM patients. CONCLUSIONS: In the ICM patients, plasma PlGF levels are increased according to the severity of heart failure. These results may indicate that augmented release of PlGF is involved in the pathogenesis of cardiomyopathy derived from chronic myocardial ischemia.

Daily exercise and bone marrow-derived CD34+/133+ cells after myocardial infarction treated by bare metal stent implantation.

BACKGROUND: The aims of the present study were to explore the mobilization of bone marrow-derived CD34(+)/133(+) cells in patients with acute myocardial infarction (AMI) and bare metal stent implantation who participated in daily exercise training, and associations with exercise capacity and restenosis. METHODS AND RESULTS: Participants comprised 23 Japanese men with AMI (Killip 1) who had been treated with a bare metal stent. All patients were advised to walk for 30-60 min/day, at least 4 times per week starting at 11 days after AMI, and were instructed to record the amount of time spent walking each day. At 10 days and then at 3 months after onset of AMI, symptom-limited cardiopulmonary exercise tests were performed and the number of CD34(+)/133(+) cells in the peripheral blood were measured by fluorescence-activated cell sorter analysis. At 3 months after AMI, the number of CD34(+)/133(+) cells and oxygen consumption at anaerobic threshold were higher in the high exercise group (ie, exercise duration >4 h/week) than the low exercise group (ie, exercise duration <2 h/week). At 3 months after AMI, the number of CD34(+)/133(+) cells significantly correlated with oxygen consumption at the anaerobic threshold (p=0.002). CONCLUSION: Moderate daily exercise of >4 h/week increases exercise capacity and the number of circulating CD34(+)/133(+) cells at 3 months after AMI.

Determinants of in-hospital death and rupture in patients with a Stanford B aortic dissection.

BACKGROUND: In Stanford B acute aortic dissection (AAD), medical treatment is the choice of therapy in the acute phase, however, a portion of patients experience complications caused by serious clinical outcomes including aortic rupture and abdominal visceral ischemia. The objective of this study was to determine the predictors of in-hospital events in an Asian cohort of Stanford type B AAD. METHODS AND RESULTS: Hospital records were queried to identify patients that met following criteria: (1) AAD presenting within 14 days of symptom onset; and (2) computed tomography (CT) confirmation of a dissected descending aorta not involving the ascending aorta. An in-hospital event was defined as death, rupture/impending rupture, or organ malperfusion. Patient characteristics, inflammatory markers, and CT findings were obtained from clinical case records and retrospectively analyzed. Two hundred and twenty patients with Stanford B AAD were identified. In-hospital events occurred in 15 patients (there were 8 deaths, and 5 patients need to undergo emergent surgery because of impending rupture or rupture, and 4 patients experienced organ malperfusion). In univariate logistic regression analysis, the non-thrombosed type (odds ratio (OR) 3.88, 95% confidence interval (CI) 1.20-12.61, p=0.02) and maximum aortic diameter measured by an initial CT (each having a 5 mm increment: OR 1.61, 95% CI 1.20-2.15, p=0.001) were significant predictors of in-hospital events. In multiple logistic regression analysis, the only significant predictor was maximum aortic diameter measured by an initial CT (each having a 5 mm increment: OR 1.41, 95% CI 1.04-1.92, p=0.03). CONCLUSION: The results identified a large maximum aortic diameter as the independent predictor of in-hospital events in Stanford type B AAD. The non-thrombosed type might also help differentiate high-risk patients.

Association of hyperadiponectinemia with severity of ventricular dysfunction in congestive heart failure.

BACKGROUND: Adiponectin, which is a collagen-like plasma protein produced by adipose tissue, has anti-atherogenic and anti-inflammatory effects. Plasma adiponectin levels in patients with congestive heart failure (CHF) were determined, as well as relationships between the plasma levels of adiponectin and other hormones. METHODS AND RESULTS: The study group comprised 90 patients with CHF and 20 control subjects, who were divided into 4 subgroups according to New York Heart Association (NYHA) functional class. Plasma levels of adiponectin, tumor necrosis factor (TNF)-alpha and brain natriuretic peptide (BNP) and cardiac hemodynamics were determined. Plasma adiponectin levels were significantly increased according to the severity of NYHA class in the patients with CHF; control: 6.2+/-1.0; NYHA I: 8.5+/-1.9, NYHA II: 12.0+/-2.2, NYHA III: 13.0+/-2.7, NYHA IV: 14.9+/-2.7 microg/ml (p=0.0008). Similarly, plasma BNP levels were significantly increased in accordance with the NYHA class. Plasma adiponectin levels correlated positively with BNP (r=0.40, p=0.0002) and TNF-alpha (r=0.49, p=0.0001), and correlated negatively with cardiac index (r=-0.27, p=0.05). In 24 of 46 patients in the NYHA III and IV subgroups, according to the prompt improvement in cardiac function, levels of both plasma adiponectin and BNP were significantly reduced (p<0.0001). CONCLUSION: Plasma adiponectin levels increased according to the severity of CHF and, moreover, they correlated with the plasma levels of BNP and TNF-alpha. These results indicate that augmented release of adiponectin is involved in the pathogenesis of CHF and further study is needed to elucidate its exact role.

Successfully treated massive pulmonary thromboembolism and thrombus in the right atrium due to diffuse malignant lymphoma: a case report.

A 40-year-old man presented with massive pulmonary embolism related to diffuse large B cell lymphoma. His hemodynamic state worsened rapidly to shock after sudden onset of dyspnea. Echocardiography and thoracic computed tomography indicated pulmonary thromboembolism due to deep venous thromboembolism, associated with a mass in the anterior mediastinum and a 5 x 8 cm mass in the left pelvis compressing the left femoral vein. He underwent emergent surgery to remove a huge thrombus from the right atrium through the bilateral pulmonary arteries. Soon after this surgery, his hemodynamic state recovered and excision of the left cervical lymph node revealed diffuse large B cell lymphoma. Venous compression by the lymphoma mass had caused hemostasis and thrombus formation in the present case.

Close association of regional interleukin-6 levels in the infarct-related culprit coronary artery with restenosis in acute myocardial infarction.

BACKGROUND: The involvement of interleukin (IL)-6 in restenosis of the recanalized coronary artery after the percutaneous coronary intervention (PCI) was examined. METHODS AND RESULTS: There were 40 patients enrolled in the study who had acute myocardial infarction and whose infarct-related coronary arteries were treated by new thrombectomy devices and stenting. Blood samples were collected from the culprit coronary artery before and immediately after the maneuver of the PCI. Restenosis was defined as residual stenosis because it accounted for more than 50% at the follow-up coronary angiography. Plasma IL-6 levels in the infarct-related coronary artery were 12.8 and 13.2 pg/ml before and after the initial maneuver of the PCI, respectively, values that were significantly greater than that of 7.2 pg/ml in the peripheral vein (p<0.0001). The levels of IL-6 in the pre- and the post-stage of PCI were significantly greater in the patients with restenosis than those without restenosis. The plasma IL-6 levels in the post-stage of PCI had significant correlations with late loss and loss index. CONCLUSIONS: The present study findings indicate that plasma IL-6 levels in the culprit coronary artery at the post-stage of PCI are closely associated with the future restenosis of the revasculized coronary artery in acute myocardial infarction.

Exercise after heparin administration: new therapeutic program for patients with-option arteriosclerosis oblitrans.

BACKGROUND: A prospective study examined whether a combination of an exercise program and heparin administration improves the clinical symptoms of patients with arteriosclerosis obliterans (ASO) without an indication for surgical revascularization because of the lack of distal target vessels or other reasons such as high surgical risk or lack of a vein conduit from previous coronary artery bypass surgery. METHODS AND RESULTS: A total of 19 consecutive patients with symptomatic non-option ASO diagnosed by angiography were randomly assigned to 3 groups: heparin + exercise (walking for 60 min after heparin injection [3,000 units/day IV for 14 days], n = 6), heparin administration only (n = 6), and exercise only (n = 7). Plasma levels of hepatocyte growth factor (HGF) were serially measured before and after intravenous administration of heparin. Ankle brachial pressure index was measured and treadmill exercise test (2.5 km/h, 12% slope) was performed before the 2-week treatment, just after finishing treatment, and 12 weeks after beginning the treatment. Ophthalmic examinations, including visual acuity test, ocular fundoscopy and fluorescein angiographic fundus photography, were performed before and 12 weeks after the treatment program. In all patients, HGF levels increased more than 4-fold of the basal level at 30 min after heparin injection. Maximum walking time was significantly higher in the heparin + exercise group than in the other 2 groups (p < 0.05). There were no patients who showed pathological retinal angiogenesis. CONCLUSION: The combination of an exercise program and heparin administration improves the clinical symptoms of patients with non-option ASO.

Successfully treated triple valve infective endocarditis: a case report.

A 45-year-old woman presented with triple valve infective endocarditis and ventricular septal defect. There were vegetations on the tricuspid valve, pulmonary valve, and aortic valve. She had multiple complications such as nephrotic syndrome, severe anemia, congestive heart failure, and convulsion. Her general condition was extremely poor. Intensive medical therapy, such as blood transfusion, mechanical ventilation, and continuous venovenous hemofiltration, allowed her to tolerate surgery. Triple valve replacement and ventricular septal defect closure was successfully performed without major complication. She was ambulatory at the time of discharge.

Up-regulated synthesis of mature-type adrenomedullin in coronary circulation immediately after reperfusion in patients with anterior acute myocardial infarction.

OBJECTIVE: Levels of adrenomedullin (AM), a potent vasodilatory peptide, have been shown to increase in the early stage of acute myocardial infarction (AMI). The purpose of this study was to determine whether coronary sinus-aortic step-up of mature forms of AM is accelerated in patients with AMI after reperfusion. METHODS: The subjects were 29 consecutive patients with a first episode of anterior AMI and 10 normal controls. All patients with AMI underwent balloon reperfusion therapy within 24 h after symptom onset. Plasma levels of two molecular forms of AM (an active, mature form [AM-m] and an intermediate, inactive glycine-extended form [AM-Gly]) in the aorta and coronary sinus (CS) were measured by specific immunoradiometric assay after reperfusion. RESULTS: Plasma levels of AM-m and AM-Gly in the aorta and CS were higher in AMI patients than in controls. CS-aortic step-up of AM-m, which is an index of myocardial production of AM-m, was significantly greater in AMI patients than in controls (1.7 +/- 1.4 vs. 0.4 +/- 0.3 pmol/L, P < 0.01). However, there was no significant difference in CS-aortic step-up of AM-Gly (P = 0.30). AMI patients with left ventricular dysfunction (n = 10) had a significantly higher CS-aortic AM-m step-up than AMI patients without left ventricular dysfunction (n = 19). AM-m in the aorta and CS negatively correlated with the left ventricular ejection fraction (r = -0.50, r = -0.48, P < 0.01). CONCLUSIONS: Myocardial synthesis of AM-m is accelerated in patients with reperfused AMI, especially in patients with critical left ventricular dysfunction. Increased myocardial synthesis of active AM may protect against cardiac dysfunction, myocardial remodeling, or both after the onset of AMI.

Three episodes of inferior acute myocardial infarction due to thrombotic occlusion of the right coronary artery: a case report.

A 77-year-old female with two previous inferior myocardial infarctions was transferred to our medical center with a third inferior acute myocardial infarction. Coronary angiography revealed 99% stenosis with rich thrombus in the distal right coronary artery [Thrombolysis in Myocardial Infarction (TIMI) grade 2 flow]. The angiographic appearance of the right coronary artery was similar to the two previous myocardial infarctions. Coronary aspiration was performed and TIMI grade 3 flow was established. To confirm the presence of thrombus, intravascular ultrasound (IVUS) and coronary angioscopy were performed at pre-discharge. IVUS showed a thrombus-like low-density area at the mid right coronary artery. Red thrombi were observed in the same area using coronary angioscopy. Although warfarin had been prescribed for secondary prevention since the first acute myocardial infarction, both the second and third acute myocardial infarction occurred after cessation of warfarin. Patients with acute myocardial infarction due to thrombotic occlusion, confirmed by IVUS or angioscopy, might be good candidates for permanent warfarin therapy.