Fatal myocardial infarction investigated using contrast-enhanced postmortem computed tomography: A case report.

Conventional autopsies are considered standard methods for clarifying cause of death. However, because of the increasing use of computed tomography, magnetic resonance imaging, and other diagnostic imaging techniques, autopsy imaging is now more frequently adopted to identify diseases with unknown causes and sudden deaths. A 84-year-old man was diagnosed with acute myocardial infarction using coronary angiography. After taking oral antiplatelet medication in the catheterization laboratory, the patient suddenly coughed violently, lost consciousness, and was diagnosed with cardiac arrest. Spontaneous circulation did not return after 50 min of cardiopulmonary resuscitation. To elucidate the cause of the cardiac arrest, we performed contrast-enhanced postmortem computed tomography (PMCT), which revealed cardiac tamponade due to cardiac rupture of the inferior myocardium. Our findings reaffirm the effectiveness of contrast-enhanced PMCT in the diagnosis of sudden death in the clinical setting.

Vasospastic Angina in a Young Woman: A Case Report.

Vasospastic angina (VSA) is a disease that causes myocardial ischemia due to transient vasoconstriction of the epicardial coronary arteries. This disease generally occurs in middle-aged and older adults, but there are also reports of it occurring in young people. We report a case of VSA in a woman in her 20's. Six months ago, a female patient in her 20s became aware of a strangling sensation in the chest that lasted for approximately 1-20 minutes at rest or during stress. She consulted her family doctor who prescribed nitroglycerin sublingual tablets, which were effective. She was a current smoker and had a history of bronchial asthma, with no family history of coronary artery disease. Resting electrocardiogram and echocardiography revealed no clear abnormalities. The patient was referred to our hospital for coronary angiography (CAG) and spasm provocation test (SPT), primarily to thoroughly examine her chest pain at rest. CAG revealed no significant stenosis. A subsequent SPT using acetylcholine demonstrated diffuse coronary spasm in the left anterior descending coronary artery (LAD). The coronary spasm resolved spontaneously, but the catheter was difficult to maneuver owing to the radial artery spasm at the puncture site; thus, nitroglycerin was administered, which alleviated the radial artery spasm. Another SPT was performed on the right coronary artery (RCA) and revealed no coronary spasm. Coronary microcirculatory function using a pressure wire in response to the peripheral infusion of adenosine triphosphate was assessed in the RCA and LAD, both of which were normal. The patient was discharged from the hospital on an oral calcium channel blocker (CCB). She continued to experience chest pain, but her chest symptoms improved with CCB medication and a change in her workplace. It must be kept in mind that coronary spasms can occur even in young women and should be one of the differentials of chest pain in such patients.

Recognition of Pulseless Ventricular Tachycardia Through the Second Analysis of Automated External Defibrillators, Leading to Successful Shock Delivery in a Patient With Dilated Cardiomyopathy: A Case Report.

The use of a defibrillator with a monitor is recommended for the shock indication algorithm for in-hospital cardiac arrest; however, it is likely that many medical facilities are still equipped only with automated external defibrillators (AEDs). We experienced a case of dilated cardiomyopathy (DCM) complicated by pulseless ventricular tachycardia (pVT) in which an AED was used, but shock was deemed unnecessary after the first analysis. We believe that this case is suggestive of resuscitating cardiac arrest, for which defibrillation is indicated and reported here. A 65-year-old man who had DCM and diabetic nephropathy was admitted to our institution because of worsening heart failure. In the hospital, he suddenly had syncope and was diagnosed with cardiac arrest. Thereafter, cardiopulmonary resuscitation (CPR) was performed using an AED, and the monitor on the AED showed pVT. The first analysis of the AED announced unnecessary shock delivery. The pads of the AED were pressed firmly against the chest wall while continuous high-quality CPR was administered for two minutes. The second analysis of the AED revealed the necessity of providing shock for shockable rhythm. The patient experienced the return of spontaneous circulation after shock delivery. We were reminded that there are some clinical cases in which AED shock is not indicated for pVT and that even in such cases, it is important to continue high-quality CPR without panicking.

Primary malignant pericardial mesothelioma with difficult antemortem diagnosis: A case report.

BACKGROUND: Primary malignant pericardial mesothelioma (PMPM) is an extremely rare malignant tumor, and it is difficult to diagnose definitively before death. We present a case in which PMPM was diagnosed at autopsy. We consider this case to be highly suggestive and report it here. CASE SUMMARY: A 78-year-old male presented with transient loss of consciousness and falls. The transient loss of consciousness was considered to result from complications of diastolic dysfunction due to pericardial disease, fever with dehydration, and paroxysmal atrial fibrillation. Ultrasound cardiography (UCG) and computed tomography showed cardiac enlargement and high-density pericardial effusion. We considered pericardial disease to be the main pathogenesis of this case. Cardiac magnetic resonance imaging and gadolinium contrast-enhanced T1-weighted images showed thick staining inside and outside the pericardium. Pericardial biopsy was considered to establish a definitive diagnosis, but the patient and his family refused further treatment and examinations, and the patient was followed conservatively. We noticed a thickening of the pericardium and massive changes in the pericardium on UCG over time. We performed an autopsy 60 h after the patient died of pneumonia. Giemsa staining of the autopsy tissue showed an epithelial-like arrangement in the pericardial tumor, and immunostaining showed positive and negative factors for the diagnosis of PMPM. Based on these findings, the final diagnosis of PMPM was made. CONCLUSION: PMPM has a poor prognosis, and early diagnosis and treatment are important. The temporal echocardiographic findings may provide a clue for the diagnosis of PMPM.

Intracoronary Thrombogenicity in Patients with Vasospastic Angina: An Observation Using Coronary Angioscopy.

BACKGROUND: Despite significant interest in intracoronary thrombi in patients with vasospastic angina (VSA), the phenomenon remains unclarified. Therefore, we investigated a possible relationship using coronary angioscopy (CAS) in VSA patients. METHODS: Sixty patients with VSA, for whom we could assess the spastic segment using CAS, were retrospectively studied. An intracoronary thrombus on CAS was a white thrombus and an erosion-like red thrombus. We verified the clinical characteristics and lesional characteristics as they determined the risk of intracoronary thrombus formation. RESULTS: There were 18 (30%) patients with intracoronary thrombi. More of the patients with intracoronary thrombi were male, current smokers and had severe concomitant symptoms; however, no statistically significant difference was observed upon logistic regression analysis. There were 18 (26%) coronary arteries with intracoronary thrombi out of 70 coronary arteries recognised in the spastic segments. Furthermore, atherosclerotic changes and segmental spasms were significant factors responsible for such lesions. CONCLUSION: Intracoronary thrombi occurred in 30% of VSA patients and much attention should be paid to the intracoronary thrombogenicity of VSA patients.

Primary aldosteronism due to bilateral micronodular hyperplasia and concomitant subclinical Cushing's syndrome: A case report.

BACKGROUND: Adrenal incidentaloma (AI) has been frequently encountered in the clinical setting. It has been shown that primary aldosteronism (PA) or subclinical Cushing's syndrome (SCS) are the representative causative diseases of AI. However, the coexistence of PA and SCS has been reportedly observed. Recently, we encountered a case of AI, in which PA and SCS coexisted, confirmed by histopathological examinations after a laparoscopic adrenalectomy. We believe that there were some clinical implications in the diagnosis of the present case. CASE SUMMARY: A 58-year-old man presented with lower right abdominal pain with a blood pressure of 170/100 mmHg. A subsequent computed tomography scan revealed right ureterolithiasis, which was the cause of right abdominal pain, and right AI measuring 22 mm × 25 mm. After the disappearance of right abdominal pain, subsequent endocrinological examinations were performed. Aldosterone-related evaluations, including adrenal venous sampling, revealed the presence of bilateral PA. In addition, several cortisol-related evaluations showed the presence of SCS on the right adrenal adenoma. A laparoscopic right adrenalectomy was then performed. The histopathological examination of the resected right adrenal revealed the presence of a cortisol-producing adenoma, while CYP11B2 immunoreactivity was absent in this adenoma. However, in the adjacent non-neoplastic adrenal, multiple CYP11B2-positive adrenocortical micronodules were detected, showing the presence of aldosterone-producing adrenocortical micronodules. CONCLUSION: Careful clinical and pathological examination should be performed when a patient harboring AI presents with concomitant SCS and PA.

Coronary Microvascular Vasodilatory Function: Related Clinical Features and Differences According to the Different Coronary Arteries and Types of Coronary Spasm.

BACKGROUND: In the clinical setting; the microvascular vasodilatory function test (MVFT) with a pressure wire has been used in ischaemia patients with non-obstructive coronary arteries (INOCA), including vasospastic angina (VSA) and microvascular angina (MVA). The exact factors that affect the microvascular vasodilatory function (MVF) in such patients are still unknown. We aimed to identify the factors, including clinical parameters and lesion characteristics, affecting the MVF in such patients. METHODS: A total of 53 patients who underwent coronary angiography, spasm provocation tests (SPTs) and MVFTs were enrolled. In the MVFT, the coronary flow reserve (CFR) and index of microcirculatory resistance (IMR) were measured. Of the 53 patients, MVFT data in the left anterior descending coronary artery (LAD) were obtained from 49 patients, and the clinical parameters were checked in all of them. Based on the results of the SPT, coronary spasms were divided into focal spasm, diffuse spasm, and microvascular spasm (MVS). To assess the lesion characteristics influencing MVF, MVFT data were compared according to the types of coronary spasm and coronary vessels in 73 vessels of the 53 patients. RESULTS: In 49 patients who underwent the MVFT in the LAD, the IMR was higher in active smokers (n = 7) than in former smokers (n = 15) and never smokers (n = 27, p < 0.01). In the 73 coronary arteries in this study, the type of coronary spasm did not correlate with the CFR or IMR, whereas a higher IMR were more frequently observed in cases of focal spasm than in cases of diffuse spasm (p = 0.03). In addition, the IMR was higher in the right coronary artery (RCA) than in the LAD (p = 0.02). CONCLUSION: These results indicate that the smoking status affected the MVF in patients with INOCA, suggesting the possibility of improvement in the MVF by smoking cessation in such patients. In addition, in the assessment of MVF, it may be important to take into account which coronary artery or types of coronary spasm are being evaluated.

Clinical significance of prolonged chest pain in vasospastic angina.

BACKGROUND: Patients with vasospastic angina (VSA) sometimes experience prolonged chest symptoms. The clinical characteristics of these patients have not been clarified. AIM: To investigate the clinical characteristics of prolonged VSA patients. METHODS: This study included 167 patients with VSA diagnosed by spasm provocation tests (SPTs) using acetylcholine, which recorded the frequencies of positive reactions to a low dose of acetylcholine (L-ACh), total occlusion due to spasm (TOC), focal spasm, and the unavoidable use of nitroglycerin (unavoidable-NTG) during SPTs. The patients underwent a medical interview that investigated the maximum duration and frequency of chest symptoms as well as the frequencies of variant angina and other serious symptoms. The patients were divided into two groups based on the maximal duration: The short-duration group (< 15 min; n = 114) and the long-duration group (≥ 15 min; n = 53). They were also divided into two groups based on the frequency of chest symptoms: The low-frequency group (< 4/mo; n = 88) and the high-frequency group (≥ 4/mo; n = 79). RESULTS: The long-duration group showed higher frequencies of other serious symptoms (P < 0.001) and variant angina (P < 0.05) as well as higher frequencies of spasm induction by L-ACh (P < 0.05), TOC (P < 0.05), focal spasm (P < 0.01), and unavoidable-NTG (P < 0.01) than the short-duration group. These parameters did not differ significantly between the low-frequency and high-frequency groups. CONCLUSION: These findings suggest that patients with VSA who experience prolonged chest symptoms may have more severe characteristics of VSA.

Is Noncardiac Chest Pain Truly Noncardiac?

Many causes of noncardiac chest pain (NCCP) have been studied and gastroesophageal reflux disease is considered to be the major cause. However, studies have reported that treatment with a proton pump inhibitor does not effectively provide relief for NCCP-related symptoms, and these symptoms frequently recur. These findings suggest that patients with cardiac disease may be excluded completely from the NCCP group. Several examinations can be conducted to verify the presence of cardiac disease. Such examinations include the assessment of biochemical markers, rest and exercise electrocardiogram, echocardiography, cardiac computed tomography, stress myocardial perfusion imaging, cardiac magnetic resonance imaging, and coronary angiography (CAG). However, the presence of functional coronary artery diseases (CADs), such as vasospastic angina and/or microvascular angina, cannot be detected using these modalities. These functional CADs can be diagnosed by CAG with spasm-provocation testing and/or physiological coronary measurement. Thus, when a patient who is suspected of having NCCP takes a proton pump inhibitor and does not respond well, further examination-including assessment for possible functional CADs-may be needed.

Osteoprotegerin Prevents Development of Abdominal Aortic Aneurysms.

Abdominal aortic aneurysms (AAAs), which commonly occur among elderly individuals, are accompanied by a risk of rupture and subsequent high mortality. Establishment of medical therapies for the prevention of AAAs requires further understanding of the molecular pathogenesis of this condition. This report details the possible involvement of Osteoprotegerin (OPG) in the prevention of AAAs through inhibition of Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL). In CaCl2-induced AAA models, both internal and external diameters were significantly increased with destruction of elastic fibers in the media in Opg knockout (KO) mice, as compared to wild-type mice. Moreover, up-regulation of TRAIL expression was observed in the media by immunohistochemical analyses. Using a culture system, both the TRAIL-induced expression of matrix metalloproteinase-9 in smooth muscle cells (SMCs) and the chemoattractive effect of TRAIL on SMCs were inhibited by OPG. These data suggest that Opg may play a preventive role in the development of AAA through its antagonistic effect on Trail.

Is there any association between subcutaneous adipose tissue area and plasma total and high molecular weight adiponectin levels?

This study was conducted for the purpose of clarifying the correlations between the subcutaneous adipose tissue area and plasma total and high-molecular weight (HMW) adiponectin levels. The subjects of this study comprised 359 men and 142 women who underwent general health examinations from October 2005 to December 2006. The abdominal subcutaneous and visceral adipose tissue areas were measured using low-dose x-ray computed tomography. Total and HMW adiponectin levels were measured using the enzyme-linked immunosorbent assay system based on a monoclonal antibody to humans. There were negative correlations between the plasma total and HMW adiponectin levels and visceral and subcutaneous adipose tissue areas using simple correlation analysis. Multiple linear regression analysis clearly indicated that the subcutaneous adipose tissue area was independently correlated with the HMW adiponectin levels in men and closely related in women. Many studies reported that only the visceral adipose tissue area showed a significant correlation with metabolic syndrome. However, these results clearly indicate that it is also important to consider the subcutaneous adipose tissue area in metabolic syndrome.

Role of osteoprotegerin in arterial calcification: development of new animal model.

OBJECTIVES: Enhanced osteoclastogenesis, increased bone resorption, and osteoporosis have been reported in osteoprotegerin-deficient (OPG (-/-)) mice. OPG (-/-) mice available in Japan usually do not show vascular calcification. We have found that arterial calcification can be quickly induced by a simple procedure in OPG (-/-) mice. METHODS AND RESULTS: Male OPG (-/-), OPG (+/-), and OPG (+/+) mice were fed a high phosphate diet from 6 to 10 weeks after birth, and then 1alpha,25-dihydroxyvitamin D3 (calcitriol) was injected for 3 days. We found that severe calcification developed in the media of the aorta in OPG (-/-) mice. Under electron microscopy, calcium deposits were observed in the cytoplasm and extracellular matrix of vascular smooth muscle cells (VSMCs). Neither apoptosis of VSMCs nor infiltration of macrophages was observed. Alkaline phosphatase (ALP) activity of aortic tissue correlated with the calcified lesion area. Mouse aorta and bone extracts revealed an identical pattern by ALP electrophoresis. CONCLUSIONS: Our results demonstrated that OPG had anticalcification activity in the aorta, probably through the downregulation of ALP activity. Because the time course of arterial calcification after the injection of calcitriol is accurate and reproducible, this mouse model will be useful for further investigation of vascular calcification.