Usefulness of the SAGE score to predict elevated values of brachial-ankle pulse wave velocity in Japanese subjects with hypertension.

The score based on the office systolic blood pressure, age, fasting blood glucose level, and estimated glomerular filtration rate (SAGE score) has been proposed as a useful marker to identify elevated values of carotid-femoral pulse wave velocity (PWV). The present cross-sectional study was conducted to examine whether the SAGE score is also a useful marker to identify subjects with elevated brachial-ankle PWV values in Japanese subjects with hypertension. We measured the brachial-ankle PWV and calculated the SAGE score in a total of 1019 employees of a Japanese company with hypertension and 817 subjects with hypertension derived from a multicenter study cohort. The analyses in this study were based on data from these two study groups as well as on a composite population of the two (n = 1836). The receiver operating characteristic curve analysis showed that the area under the curve to identify subjects with brachial-ankle PWV values of ≥1800 cm/s was over 0.70 in each of the three study groups. Even after adjustments, a SAGE score ≥7 had a significant odds ratio for identifying subjects with brachial-ankle PWV values ≥1800 cm/s in the 1836 study subjects from the composite occupational and multicenter study cohort (odds ratio = 2.1, 95% confidence interval = 1.4-3.0, P < 0.01). Thus, in Japanese subjects with hypertension, the SAGE score may be a useful marker for identifying subjects with elevated brachial-ankle PWV values.

Prognostic impact of reducing myocardial ischemia identified using ECG-gated myocardial perfusion SPECT in Japanese patients with coronary artery disease: J-ACCESS 4 study.

AIM: Whether myocardial ischemia identified using myocardial perfusion imaging (MPI) can be an alternative target of coronary revascularization to reduce the incidence of cardiac events remains unclear. METHODS AND RESULTS: This multicenter, prospective cohort study aimed to clarify the prognostic impact of reducing myocardial ischemia. Among 494 registered patients with possible or definite coronary artery disease (CAD), 298 underwent initial pharmacological stress 99mTc-tetrofosmin MPI before, and eight months after revascularization or medical therapy, and were followed up for at least one year. Among these, 114 with at least 5% ischemia at initial MPI were investigated. The primary endpoints were cardiac death, non-fatal myocardial infarction and hospitalization for heart failure. Ischemia was reduced ≥5% in 92 patients. Coronary revascularization reduced ischemia (n = 89) more effectively than medical therapy (n = 25). Post-stress cardiac function also improved after coronary revascularization. Ejection fraction significantly improved at stress (61.0% ±â€¯10.7% vs. 65.4% ±â€¯11.3%; p < 0.001) but not at rest (67.1% ±â€¯11.3% vs. 68.3% ±â€¯11.6%; p = 0.144), among patients who underwent revascularization. Rates of coronary revascularization and cardiac events among the 114 patients were significantly higher (13.6%, p = 0.035) and lower (1.1% p = 0.0053), respectively, in patients with, than without ≥5% ischemia reduction. Moreover, patients with complete resolution of ischemia at the time of the second MPI had a significantly better prognosis. CONCLUSIONS: Reducing ischemia by ≥5% and the complete resolution of ischemia could improve the prognosis of patients with stable CAD.

Brachial artery diameter as a marker for cardiovascular risk assessment: FMD-J study.

BACKGROUND AND AIMS: Baseline brachial artery (BBA) diameter has been reported to be a potential confounding factor of flow-mediated vasodilation (FMD). The purpose of this study was to evaluate the relationships between BBA diameter and cardiovascular risk factors and compare the diagnostic accuracy of BBA diameter in subjects without cardiovascular risk factors and patients with cardiovascular disease (CVD) with that of FMD. METHODS: We measured BBA diameter and FMD in 5695 male subjects. In addition, we retrospectively investigated the incidence of cardiovascular events using another population sample consisting of 440 male subjects, to compare the accuracy of BBA diameter with that of FMD in predicting cardiovascular events. RESULTS: BBA diameter and FMD significantly correlated with age, body mass index, systolic blood pressure, diastolic blood pressure, triglycerides, high-density lipoprotein cholesterol, and glucose as well as Framingham risk score. The prevalence of cardiovascular risk factors and CVD increased with the increase in BBA diameter and FMD. Area under the curve (AUC) value of the receiver operating characteristic (ROC) curve for BBA diameter to diagnose subjects without cardiovascular risk factors (0.59 vs. 0.62, p = 0.001) or patients with CVD (0.58 vs. 0.64, p < 0.001) was significantly lower than that for FMD. In the retrospective study, the AUC value of the ROC curve for BBA diameter to predict first major cardiovascular events was significantly lower than that of FMD (0.50 vs. 0.62, p = 0.03). CONCLUSIONS: In men, BBA diameter was inferior to FMD for assessment of cardiovascular risk.

Endothelial Function Is Impaired in Patients Receiving Antihypertensive Drug Treatment Regardless of Blood Pressure Level: FMD-J Study (Flow-Mediated Dilation Japan).

Hypertension is associated with endothelial dysfunction. Blood pressure significantly correlates with endothelial function in antihypertensive drug-naive subjects. The purpose of this study was to determine whether treatment status affects the relationship between blood pressure and endothelial function. We measured flow-mediated vasodilation (FMD) in 2297 subjects, including 1822 antihypertensive drug-naive subjects and 475 treated hypertensive patients. FMD significantly decreased in relation to increase in systolic blood pressure (8.2±3.1% in subjects with systolic blood pressure of <120 mm Hg, 7.5±2.8% for 120-129 mm Hg, 7.1±2.8% for 130-139 mm Hg, and 6.7±2.6% for ≥140 mm Hg; P<0.001). Systolic blood pressure was independently associated with FMD in untreated subjects. In contrast, there was no significant relationship between systolic blood pressure and FMD in treated hypertensive patients (4.6±3.1% in treated hypertensives with systolic blood pressure of <120 mm Hg, 4.8±2.7% for 120-129 mm Hg, 4.9±2.8% for 130-139 mm Hg, and 4.5±2.3% for ≥140 mm Hg; P=0.77). Propensity score matching analysis revealed that the prevalence of endothelial dysfunction defined as FMD of less than the division point for the lowest tertile, and the middle tertile of FMD was significantly higher in treated hypertensive patients than in untreated subjects in all systolic blood pressure categories. Endothelial function assessed by FMD was impaired regardless of the level of blood pressure achieved by antihypertensive drug treatment in hypertensive patients.

The role of vascular biomarkers for primary and secondary prevention. A position paper from the European Society of Cardiology Working Group on peripheral circulation: Endorsed by the Association for Research into Arterial Structure and Physiology (ARTERY) Society.

While risk scores are invaluable tools for adapted preventive strategies, a significant gap exists between predicted and actual event rates. Additional tools to further stratify the risk of patients at an individual level are biomarkers. A surrogate endpoint is a biomarker that is intended as a substitute for a clinical endpoint. In order to be considered as a surrogate endpoint of cardiovascular events, a biomarker should satisfy several criteria, such as proof of concept, prospective validation, incremental value, clinical utility, clinical outcomes, cost-effectiveness, ease of use, methodological consensus, and reference values. We scrutinized the role of peripheral (i.e. not related to coronary circulation) noninvasive vascular biomarkers for primary and secondary cardiovascular disease prevention. Most of the biomarkers examined fit within the concept of early vascular aging. Biomarkers that fulfill most of the criteria and, therefore, are close to being considered a clinical surrogate endpoint are carotid ultrasonography, ankle-brachial index and carotid-femoral pulse wave velocity; biomarkers that fulfill some, but not all of the criteria are brachial ankle pulse wave velocity, central haemodynamics/wave reflections and C-reactive protein; biomarkers that do no not at present fulfill essential criteria are flow-mediated dilation, endothelial peripheral arterial tonometry, oxidized LDL and dysfunctional HDL. Nevertheless, it is still unclear whether a specific vascular biomarker is overly superior. A prospective study in which all vascular biomarkers are measured is still lacking. In selected cases, the combined assessment of more than one biomarker may be required.

Usefulness of functional assessment in the treatment of patients with moderate angiographic paclitaxel-eluting stent restenosis.

BACKGROUND: In recent years there has been a debate about the functional severity of restenosis of drug-eluting stents. The aim of the present study was to assess the functional severity of stenosis in patients with moderate angiographic restenosis after paclitaxel-eluting stents (PES) deployment. METHODS AND RESULTS: Forty-two patients with moderate angiographic restenosis at the in-stent segment and/or approximately 5mm from the stent edge were enrolled. For comparison, furthermore, 42 patients with de novo stenosis lesions matched for angiographic severity were assigned to the control group. Quantitative coronary angiography and functional assessment using fractional flow reserve (FFR) were performed. Although percent diameter stenosis was not significantly different between the 2 groups (PES group, 40.6±11.2%; de novo group, 40.6±9.0%, P=0.981), the functional severity of stenosis was significantly less in the PES group than in the de novo group (FFR: PES group, 0.86±0.07; de novo group, 0.79±0.10, P=0.002). CONCLUSIONS: FFR was preserved in patients with moderate angiographic restenosis after PES deployment, and the functional severity of restenosis is often limited. Therefore, revascularization should be performed with caution for patients with moderate angiographic restenosis after PES deployment.

Assessment of optimum stent deployment by stent boost imaging: comparison with intravascular ultrasound.

Stent boost (SB) imaging is an enhancement of the radiologic edge of the stent by digital management of regular X-ray images. The purpose of the present study was to validate SB imaging by comparison with the anatomical standard using intravascular ultrasound (IVUS). We investigated SB and IVUS after stent implantation in 68 arteries in 60 patients. Based on those findings, we added high-pressure dilatation in four patients and another stent implantation in four patients. We defined the SB criteria for adequate stent deployment as: complete stent expansion, stent minimum diameter ≥70% of reference diameter, and stent minimum diameter ≥2.0 mm; and IVUS criteria for adequate stent deployment as: minimal stent area ≥5.0 mm(2). If the reference vessel was <2.8 mm, adequate stent deployment was defined as minimum stent area ≥4.5 mm(2). IVUS findings indicated inadequate stent deployment in 21/72 observations (29%). Seven SB images showed inadequate stent expansion. SB predicted inadequate findings of IVUS with 100% specificity, 33% sensitivity, and 81% agreement. Although the sensitivity of SB image for adequate stent deployment is low, the specificity is sufficiently high for it to be the first-line for monitoring just after stent implantation in centers where IVUS is not used routinely.

[Bone and calcium update; diagnosis and therapy of bone metabolism disease update. Clinical assessment of atherosclerosis in aorta].

The purpose of clinical assessment of atherosclerosis in aorta is to detect early lesions that are associated with a substantial risk of cardiovascular disease, such as stroke, aortic aneurysm and dissection, and to develop a treatment strategy for reduction of the cardiovascular risk. The pulse wave velocity (PWV) and pulse wave analysis (augmentation index : AI) can reveal atherosclerotic functional vascular abnormalities. On the contrary, plain X-rays, ultrasound examination, computed tomography (CT) , and magnetic resonance imaging (MRI) can be employed to easily assess the severity of atherosclerotic vascular damage morphologically. In these examinations, only PWV, as an index of arterial stiffness, can detect early atherosclerotic change in aorta before organic change. So, considering the importance of detecting early lesion, PWV is the most useful examination of atherosclerosis in aorta.

[Usefulness of stress MPI for assessment of PCI indication--comparison with FFRmyo evaluation using pressure sensor wire].

PURPOSE: To examine the usefulness of percutaneous coronary intervention (PCI) indication assessment using stress myocardial perfusion imaging (St-MPI). BACKGROUND: The usefulness of myocardial fractional flow reserve (FFRmyo) using a pressure sensor wire for the assessment of PCI indication has been reported in recent years. However, we have frequently experienced discrepancies between results from FFRmyo and St-MPI. SUBJECTS AND METHODS: Forty-two patients with single-vessel disease with 75-90% (AHA classification) stenosis and chronic ischemic heart disease were enrolled in this study. We measured FFRmyo during coronary angiography (CAG), and determined that it was less than 0.75 in all cases. We separated the cases into groups based on the results of the St-MPI, which was carried out just prior to the CAG: 18 patients showing positive stress test (group P); and 24 patients showing negative stress test (group N). We selected PCI only for the group P. We tracked both groups for 4.4 +/-0.6 years and investigated the existence or non-existence of cardiac events therein. We carried out another St-MPI one year later on the group of cases without cardiac events. RESULTS: Although a fatal cardiac infarction occurred in 1 case in the group P, there were no occurrences of major cardiac events (cardiac death or fatal cardiac infarctions) in the group N. Minor cardiac events (new PCI, target lesion re-vascularization: TLR, coronary artery bypass surgery and heart failure) were detected in 8 cases (44%) in the group P and 3 cases (13%) in the group N, thus being a significantly high percentage in the group P (p<0.05). In group P patients without having restenosis at 1 year after PCI, VO2 was significantly improved as compared to that before PCI. However, no significant difference in VO2 before and after followup was observed in group N. CONCLUSION: Because the prognosis of patients with single-vessel stable ischemic heart disease is good, it can be inferred that the principal cardiac events therein are minor cardiac events. When we define minor cardiac event as endpoint, St-MPI can be a more beneficial test for the assessment of PCI indication than FFRmyo.

[Assessment of regional myocardial systolic function in hypertensive left ventricular hypertrophy using harmonic myocardial strain imaging].

OBJECTIVES: Regional myocardial systolic function in hypertensive left ventricular hypertrophy was assessed using the newly developed myocardial strain imaging. METHODS: This study included 17 patients with hypertensive left ventricular hypertrophy (LVH group) and 22 normal subjects (N group). The transmural location of the strain peak value (StPP), and the strain peak value (StPV) in the end-systolic phase were measured at the posterior wall by myocardial strain imaging. Left ventricular mass index was simultaneously measured in both groups. RESULTS: StPV was significantly lower in the LVH group than the N group (1.00 +/- 0.36 vs 1.38 +/- 0.42, p < 0.01) and StPP was significantly moved to the epicardium side compared with the N group (31 +/- 10% vs 11 +/- 5%, p < 0.0001). StPV decreased and StPP increased with greater left ventricular mass index (r = -0.61, p < 0.0001; r = 0.72, p < 0.0001, respectively). CONCLUSIONS: Myocardial systolic impairment in hypertensive left ventricular hypertrophy may occur from the endocardium side, and the impairment may progress with increased left ventricular hypertrophy.

[Assessment of the time course of stunned myocardium with cardiac magnetic resonance imaging: a case report].

A 77-year-old woman with chest pain was admitted to our hospital for evaluation and treatment. Electrocardiography showed T-wave inversion in the I, aVL and V2-V6 leads. Emergency coronary angiography showed 75% stenosis in the left anterior descending artery. Left ventriculography demonstrated akinesis of the left ventricular apical region. Iodine-123-beta-methyl-p-iodophenyl-pentadecanoic acid radioactive isotope imaging showed an uptake defect in the apical region during the acute phase, but the defect disappeared 1 month later. Cine cardiac magnetic resonance (CMR) in the acute phase showed apical akinesis and hyperkinesis of the mid region, as observed by left ventriculography. Contrast magnetic resonance imaging with gadolinium showed no delayed hyperenhancement. One month later, cine CMR showed disappearance of the abnormal wall motion and contrast magnetic resonance imaging demonstrated no delayed hyperenhancement. CMR is useful to monitor changes in wall motion and wall thickening in the stunned myocardium.

[Assessment of therapeutic effect in acute myocardial infarction using early/delayed images of 123I-BMIPP myocardial scintigraphy].

This study was aimed at analyzing the discordance between the initial and late scintigraphic images in patients with acute myocardial infarction (AMI), and utilizing the data obtained for the treatment of AMI patients. Ninety-one patients with a history of the first episode of AMI were enrolled as subjects for this study. Emergency coronary angiography was performed in all the patients and left ventriculography (LVG) was carried out subsequently. 123I-BMIPP myocardial scintigraphy was performed to obtain initial images (BMi) and delayed images at 4 hours (BMd). Scintigraphy was performed a mean of 6 days after the onset of AMI in the patients. The subjects were classified into three groups according to the scintigraphic data. Quantitative gated single photon emission computed tomography (SPECT) with 99mTc-sestamibi (MIBI) was also conducted one month and 6 months later in all the patients. Discordance was observed in 51% of the patients. Left ventricular volume based on the quantitative gated SPECT (QGS) data at one month and 6 months after myocardial scintigraphy was significantly smaller in the washout group than in the other two groups. There was no significant change in LV volume measured at 6 months as compared to that measured at one month in the washout group. Significant increases in LVEDVI and LVESVI were observed over time in the no discordance group. In the fill-in group, the LV volume at one month was significantly higher than that in the washout group, but no significant change with time was observed. During the subacute stage of myocardial infarction, discordance is often seen between initial and late BMIPP-myocardial-scintigraphic images. The presence of such discordance, and analysis of its pattern, may be useful in predicting the cardiac function in these patients during the chronic phase of this disease.