Artificial intelligence-based detection of atrial fibrillation from chest radiographs.

OBJECTIVE: The purpose of this study was to develop an artificial intelligence (AI)-based model to detect features of atrial fibrillation (AF) on chest radiographs. METHODS: This retrospective study included consecutively collected chest radiographs of patients who had echocardiography at our institution from July 2016 to May 2019. Eligible radiographs had been acquired within 30 days of the echocardiography. These radiographs were labeled as AF-positive or AF-negative based on the associated electronic medical records; then, each patient was randomly divided into training, validation, and test datasets in an 8:1:1 ratio. A deep learning-based model to classify radiographs as with or without AF was trained on the training dataset, tuned with the validation dataset, and evaluated with the test dataset. RESULTS: The training dataset included 11,105 images (5637 patients; 3145 male, mean age ± standard deviation, 68 ± 14 years), the validation dataset included 1388 images (704 patients, 397 male, 67 ± 14 years), and the test dataset included 1375 images (706 patients, 395 male, 68 ± 15 years). Applying the model to the validation and test datasets gave a respective area under the curve of 0.81 (95% confidence interval, 0.78-0.85) and 0.80 (0.76-0.84), sensitivity of 0.76 (0.70-0.81) and 0.70 (0.64-0.76), specificity of 0.75 (0.72-0.77) and 0.74 (0.72-0.77), and accuracy of 0.75 (0.72-0.77) and 0.74 (0.71-0.76). CONCLUSION: Our AI can identify AF on chest radiographs, which provides a new way for radiologists to infer AF. KEY POINTS: • A deep learning-based model was trained to detect atrial fibrillation in chest radiographs, showing that there are indicators of atrial fibrillation visible even on static images. • The validation and test datasets each gave a solid performance with area under the curve, sensitivity, and specificity of 0.81, 0.76, and 0.75, respectively, for the validation dataset, and 0.80, 0.70, and 0.74, respectively, for the test dataset. • The saliency maps highlighted anatomical areas consistent with those reported for atrial fibrillation on chest radiographs, such as the atria.

Angioscopic Ulcerated Plaques in the Femoropopliteal Artery Associated with Impaired Infrapopliteal Runoff.

PURPOSE: To determine the correlation between upstream atherosclerosis in the femoropopliteal arteries, assessed using angioscopy, and impaired infrapopliteal runoff. MATERIALS AND METHODS: Thirty-one patients with peripheral arterial disease who underwent endovascular therapy and angioscopy were prospectively included. Yellow plaque color scores were semiquantitatively determined as 0, 1, 2, or 3. Irregular plaques with rough surfaces, similar to gastric ulcers, were defined as ulcerated plaques (UPs). Angioscopic data were correlated with angiographic runoff scores (ARS). RESULTS: UPs were detected in 74.2% of enrolled diseased legs using angioscopy. Mural thrombi were more commonly observed in the femoropopliteal artery in patients with UPs than in those without UPs (91.3% vs 37.5%, respectively; P = .006) and were frequently found on the UPs (21/23 patients with UPs). Univariate and multivariate linear regression analyses revealed that the presence of UPs was positively and independently associated with a poor ARS and that oral anticoagulant use was independently associated with a preferable ARS (standardized ß = 0.462, P = .004 and standardized ß = -0.411, P = .009, respectively, in the multivariate analysis). CONCLUSIONS: UPs, associated with mural thrombi and diagnosed by angioscopic examination, were demonstrated to be one of the factors associated with poor infrapopliteal runoff.

Association between debulking area of rotational atherectomy and platform revolution speed-Frequency domain optical coherence tomography analysis.

OBJECTIVES: In this study, we sought to investigate the association between revolution speed of rotational atherectomy (RA) and debulking area assessed by frequency domain-optical coherence tomography (FD-OCT). BACKGROUND: The number of patients with severe calcified coronary artery disease requiring treatment with calcium ablation, such as RA, is increasing. However, there is little evidence available regarding the association between debulking area and revolution speed during RA. METHODS: We retrospectively investigated 30 consecutive severely calcified coronary lesions in 29 patients who underwent RA under FD-OCT guidance. The association between preset revolution speed of RA and burr size-corrected debulking area of the calcified lesion was evaluated using a multivariable regression model with nonlinear restricted-cubic-spline, which can help assess nonlinear associations between variables. RESULTS: The median age of study participants was 73 years (quartile 65-78); 82.8% were male. The median burr size was 1.5 mm (1.5-1.75); median total duration of ablation was 120 s (100-180). FD-OCT revealed that the post-procedural minimum lumen area increased significantly from 1.64 mm2 (1.40-2.09) to 2.45 mm2 (2.11-2.98) (p < .001). In addition, the burr size-corrected debulking area increased significantly as the preset revolution speed decreased (p = .018), especially when the revolution speed was less than 150,000 rpm. This result implies that additional lumen gain will be obtained by decreasing rpm when the burr speed is set at <150,000 rpm. CONCLUSIONS: FD-OCT demonstrated that RA with lower revolution speed, below 150,000 rpm, has the potential to achieve greater calcium debulking effect in patients with severe calcified coronary lesions.

Soluble urokinase-type plasminogen activator receptor represents exercise tolerance and predicts adverse cardiac events in patients with heart failure.

Soluble urokinase-type plasminogen activator receptor (suPAR) is a membrane-binding protein that is released into the blood stream by immune activation. Recent reports suggest that circulating suPAR levels are associated with adverse cardiovascular outcomes. Exercise tolerance is an independent predictor of prognosis in patients with heart failure (HF); however, the relationship between serum suPAR level and exercise tolerance is unclear. We prospectively enrolled 94 patients who were hospitalized for worsening of HF. All patients underwent a symptom-limited cardiopulmonary exercise test to evaluate exercise tolerance. The median value of serum suPAR was 4848 pg/ml. During follow up, 44 patients (47%) were admitted for all-cause mortality and re-hospitalization for HF. Median serum suPAR was significantly higher in the patients with cardiac events than in the patients with non-event group. Patients were divided into two groups according to circulating suPAR levels. Kaplan-Meier analysis demonstrated that adverse cardiac events were significantly higher in the high suPAR group (log-rank p = 0.023). Multivariate analysis revealed that suPAR was independently correlated with the parameters of exercise tolerance such as anaerobic threshold (p = 0.007) and peak oxygen uptake (p = 0.005). suPAR levels predicted adverse cardiac events and independently correlated with the parameters of exercise tolerance. suPAR could be a useful surrogate biomarker of exercise tolerance in patients with HF.

The effects of tolvaptan dose on cardiac mortality in patients with acute decompensated heart failure after hospital discharge.

Tolvaptan (TLV) is a newly developed oral vasopressin-2 receptor antagonist that is mostly used for patients with acute decompensated heart failure (ADHF) refractory to conventional diuretic therapy. The aim of this study was to investigate the effects of outpatient TLV dose on cardiac mortality in patients discharged after hospitalization for ADHF. One hundred and five patients with ADHF who had been treated with TLV for the first time during hospitalization were retrospectively divided into three groups based on outpatient TLV use and dose. The non-TLV group comprised patients who were not treated with TLV after discharge (n = 36). Patients who continued TLV after discharge were further classified into two groups: low-dose (LD)-TLV (3.75 mg/day, n = 27) and high-dose (HD)-TLV (7.5 or 15 mg/day, n = 42). The primary endpoint was cardiac mortality. Secondary endpoint included the composite of all-cause mortality or re-hospitalization due to worsening of ADHF. There were no significant differences in demographic variables other than body mass index (p = 0.0026), echocardiographic data, laboratory data other than serum chloride before TLV administration (p = 0.041), serum sodium (p = 0.040) and potassium (p = 0.027) at discharge, and concomitant medications among the three groups. The Kaplan-Meier curve showed that the survival rate was lower in HD-TLV than in non-TLV, whereas LD-TLV showed the highest survival rate among the three groups (p = 0.0001). Multivariable Cox regression analysis of the clinical characteristics used for predicting cardiac mortality revealed that LD-TLV (hazard ratio [HR] 0.16, 95% confidence interval [CI] 0.01-0.93, p = 0.040) and HD-TLV (HR 2.43, 95% CI 1.06-6.26, p = 0.035) were significant predictors after adjustment for predictive covariates. In conclusion, the judgement of the continuation of LD-TLV according to patient hemodynamics and severity of congestion may not cause worsened prognosis.

Clinical significance of discrepant mid-wall late gadolinium enhancement in patients with nonischemic dilated cardiomyopathy.

A drawback of visual assessment for late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) is the subjectivity and reproducibility of the results. The aim of this study was to investigate the relationship between left ventricular (LV) reverse remodeling in response to optimal pharmacotherapies and the definite or discrepant mid-wall LGE with visual assessment in patients with dilated cardiomyopathy (DCM). A total of 65 patients who had been hospitalized with newly diagnosed DCM and had undergone CMR, were enrolled. When the visual assessment of the presence or absence of mid-wall LGE was confirmed by the two observers, patients were classified into either the positive- (n = 20) or negative-LGE (n = 29) groups. If there was discordance between the diagnoses of the two observers, patients were classified into the discrepant-LGE (n = 16) group. LV reverse remodeling was defined as an increase in LV ejection fraction by at least 10% concomitant with a decrease in the LV end-diastolic dimension by at least 10%. Among the three groups, the frequency of early LV reverse remodeling within a 1-year follow-up was significantly different (p = 0.0068). The frequency of LV reverse remodeling within a 1-year follow-up was 59, 31, and 15%, and over 2 years was 83, 62, and 40%, in patients with negative-, discrepant-LGE, and positive-LGE, respectively. The survival rate for composite end-points of cardiovascular mortality, sustained ventricular tachycardia, appropriate cardioverter-defibrillator discharge, or rehospitalization for decompensated heart failure was lower in positive-LGEs than in negative-LGEs (p =0.0011), whereas, there were no significant differences between both negative- and discrepant-LGEs, and discrepant- and positive-LGEs. This study showed that the discordance for LGE visual assessment occupied an intermediate position between positive and negative for LGE in LV reverse remodeling in patients with DCM.

Association between duration of coronary occlusion and high-intensity signal on T1-weighted magnetic resonance imaging among patients with angiographic total occlusion.

OBJECTIVES: To evaluate the association between duration of the coronary occlusion and high-intensity signal (HIS) on noncontrast T1-weighted imaging using a 1.5-T magnetic resonance imager among patients with angiographic coronary total occlusion. METHODS: The signal intensity of the coronary target area divided by the signal intensity of the left ventricular muscle near the target area at each site (TMR) was measured. Areas with a TMR >1.0 were defined as HIS. Thirty five lesions from 33 patients were divided into the following three groups: subacute occlusion (up to 3 months; n = 7), short-duration chronic total occlusion (SD-CTO: 3-6 months; n = 9) and long-duration CTO (LD-CTO: ≥6 months; n = 19). RESULTS: All subacute occlusion lesions showed a HIS within the occlusion site. Among patients with CTO, the frequency of a HIS within the occlusion site was significantly higher in SD-CTO than in LD-CTO lesions (p = 0.013). In multivariate analyses, only an occlusion duration of less than 6 months was an independent factor associated with the presence of HIS (odds ratio 7.6, 95% CI 1.1-54.5; p = 0.044). CONCLUSIONS: The presence of a HIS in the occlusion site was associated more with SD-CTO than with LD-CTO among patients with CTO. KEY POINTS: • All subacute occlusion lesions show a high-intensity signal on T1-weighted imaging. • HIS within occlusion sites is associated with subacute or short-duration total occlusion. • T1-weighted imaging for coronary total occlusion may be useful for intervention strategy.

Coronary plaque rupture with subsequent thrombosis typifies the culprit lesion of non-ST-segment-elevation myocardial infarction, not unstable angina: non-ST-segment-elevation acute coronary syndrome study.

Recently, unstable angina pectoris (UAP) and non-ST-segment-elevation myocardial infarction (NSTEMI) have been considered together because they exhibit indistinguishable clinical and electrocardiogram features, and constitute non-ST-segment-elevation acute coronary syndrome (NSTE-ACS). However, no optical coherence tomography (OCT) studies have reported the association between vulnerable plaque morphology and clinical characteristics in NSTE-ACS patients based on assessment of clinical symptoms and myocardial necrosis. The aim of this study was to investigate the differences in clinical characteristics and plaque morphology assessed by OCT between patients with UAP and NSTEMI. Preinterventional OCT images of 84 NSTE-ACS patients were studied, 19 with NSTEMI and 65 with UAP, according to levels of high-sensitivity troponin T. The frequency of plaque rupture and thrombus in patients with NSTEMI was higher than in UAP patients with either class I or II + III (rupture: NSTEMI, 68 %; UAP classes II + III, 30 %; UAP class I, 19 %, thrombus: NSTEMI, 73 %; UAP classes II + III, 22 %; UAP class I, 14 %). In NSTEMI patients, the frequency of occurrence of both thrombus and rupture was the highest. Conversely, patients with UAP class I or those with UAP classes II + III most frequently had no thrombus and rupture, and the frequencies of the presence of thrombus were only 14 and 22 %, respectively. Multivariate analysis revealed that thrombus and plaque rupture were independently associated with NSTEMI. This study demonstrates that the morphological features of culprit lesions could be related to clinical severity in NSTE-ACS patients.

Characteristic patterns of the longitudinal and circumferential distribution of calcium deposits by parent coronary arteries observed from computed tomography angiography.

Many investigators have reported that the total amount of coronary calcium correlates with the overall magnitude of atherosclerotic plaque burden in the entire coronary tree and is a powerful predictor of future cardiovascular events. However, the development and spatial distribution of coronary calcifications remain unclear. We investigated the spatial distribution of calcifications throughout the coronary tree during coronary artery evaluation using coronary computed tomography angiography (CTA). A further aim was to assess the progression of existing calcifications and the development of new deposits in a follow-up study. The study population consisted of 287 patients for the cross-sectional study using CTA to evaluate the spatial distribution of calcifications by parent coronary arteries. Next, we analyzed a CTA dataset of 57 patients who had undergone two CTA examinations. In this group, the two CTA images were used for assessing the progression of existing calcifications and the development of new deposits. The coronary calcifications tended to be clustered within the proximal and middle portions. Moreover, in the proximal left anterior descending coronary artery (LAD), small calcifications were located more toward the inner pericardial side. Finally, new calcium deposits developed within the proximal and middle portions of the LAD and left circumflex coronary artery, but those in the right coronary artery were likely to appear evenly from the proximal to the distal portion. This study shows the characteristic patterns of the longitudinal and circumferential distribution of calcifications by parent coronary arteries.

New insights into spotty calcification and plaque rupture in acute coronary syndrome: an optical coherence tomography study.

Although recent optical coherence tomography (OCT) studies have focused on spotty calcification, whether there were any characteristics in the concomitant existence of calcification and plaque rupture remains unknown. The aim of the present study was to investigate the characteristics of spotty calcification in acute coronary syndrome (ACS) patients with or without plaque rupture, using OCT. This study enrolled 98 consecutive patients with ACS. OCT image acquisitions were performed in the culprit lesions, and patients were divided into the plaque rupture group (n = 38) and the non-rupture group (n = 60). The frequency of spotty calcification (p = 0.006), thin-capped fibroatheroma (p = 0.012), macrophage infiltration (p = 0.022), and the number of spotty calcification per patient (p < 0.001) were significantly higher and the largest arc and the minimum depth of spotty calcification from the luminal surface were significantly smaller in the rupture group. Moreover, in the rupture group, most of the spotty calcifications in the site nearest to the minimum lumen area were observed in the proximal portion of that site, and tended to be located near the plaque rupture. Multivariate analysis revealed that the presence of spotty calcification (OR 3.19, 95 % CI 1.12-9.76, p = 0.030) and age (OR 1.08, 95 % CI 1.02-1.14, p = 0.008) were independent predictive factors for plaque rupture. This study demonstrates the characteristics of spotty calcification in ACS patients with plaque rupture and the positional relationship between spotty calcification and plaque rupture. These detailed observations could impact on treatment strategies for the prevention of ACS.

The Clinical Value of High-Intensity Signals on the Coronary Atherosclerotic Plaques: Noncontrast T1-Weighted Magnetic Resonance Imaging.

Over the past several decades, significant progress has been made in the pathohistological assessment of vulnerable plaques and in invasive intravascular imaging techniques. However, the assessment of plaque morphology by invasive modalities is of limited value for the detection of subclinical coronary atherosclerosis and the subsequent prediction or prevention of acute cardiovascular events. Recently, magnetic resonance (MR) imaging technology has reached a sufficient level of spatial resolution, which allowed the plaque visualization of large and static arteries such as the carotids and aorta. However, coronary wall imaging by MR is still challenging due to the small size of coronary arteries, cardiac and respiratory motion, and the low contrast-to-noise ratio between the coronary artery wall and the surrounding structures. Following the introduction of carotid plaque imaging with noncontrast T1-weighted imaging (T1WI), some investigators have reported that coronary artery high-intensity signals on T1WI are associated with vulnerable plaque morphology and an increased risk of future cardiac events. Although there are several limitations and issues that need to be resolved, this novel MR technique for coronary plaque imaging could influence treatment strategies for atherothrombotic disease and may be useful for understanding the pathophysiological mechanisms of atherothrombotic plaque formation.

Cardio-ankle Vascular Index Associated with Coronary Plaque Burden not Plaque Morphology.

Background Cardio-ankle vascular index (CAVI) is a marker that reflects the overall stiffness of the aorta, femoral artery, and tibial artery. Several previous reports have shown the usefulness of CAVI for coronary artery disease (CAD) presence and severity. According to coronary angiography (CAG) and intracoronary imaging such as optical coherence tomography (OCT), coronary plaque burden and morphology as predictors of all-cause and cardiovascular mortality were previously evaluated. The aim of our study was to assess the correlation between CAVI value and Gensini's score for the coronary plaque burden as well as CAVI value and plaque morphology by using OCT. Methods A total of 548 consecutive patients who underwent CAG were enrolled in this study. CAVI value was evaluated in all patients, and OCT was performed in 89 of the 548 patients. CAVI ratio is calculated as CAVI/CAVIex (expected normal value of CAVI, which is calculated using patient age and sex). Results On multivariable analysis, sex, age, hypertension, diabetes mellitus, and CAVI were significantly correlated with logarithmized Gensini's score. CAVI values were significantly higher in the groups with CAD, which were 1 vessel disease (VD), 2VD, and 3VD, than in the OVD group (p<0.001). However, there was no statistical significance between CAVI ratio and OCT findings in terms of plaque morphology. Conclusions CAVI might be useful as a routine test for the detection of CAD and the evaluation of atherosclerotic plaque burden but not coronary plaque vulnerability.

Clinical Characteristics of Late Gadolinium Enhancement in Patients with Cardiac Sarcoidosis.

BACKGROUND: The presence of cardiac involvement in sarcoidosis, a multisystem granulomatous disease of unknown etiology, is associated with very poor prognosis. Therefore, early detection of cardiac sarcoidosis (C-sar) is very important for effective treatment. Recently, the value of late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR), which allows visualization of even minute amounts of myocardial damage, has been emphasized in diagnosing C-sar. Although the presence of LGE has been added as a minor criterion for diagnosing C-sar in the most recent Japan Ministry of Health and Welfare (JMHW) guidelines, its clinical utility remains unknown. METHODS: A total of 17 patients with biopsy-proven extracardiac sarcoidosis, who underwent CMR and examinations using a sufficient number of modalities to diagnose or exclude C-sar in accordance with the JMHW diagnostic criteria, were retrospectively enrolled in this study. Among these 17 patients, 7 patients were diagnosed with C-sar and 10 with non-C-sar. We investigated the clinical performance of LGE in the detection of cardiac involvement, compared the distribution of LGE with perfusion defects of iodine-123-labeled 15-(p-iodophenyl)-3R,S-methyl pentadecanoic acid (BMIPP) or thallium-201 (201Tl) scintigraphy, and evaluated the prognostic value of LGE on CMR in identifying adverse clinical events. RESULTS: All patients diagnosed with C-sar were positive for LGE and all diagnosed with non-C-sar patients were negative. Evaluation of LGE revealed a broader range of abnormalities than the evaluation of the defects shown by either BMIPP or 201Tl scintigraphy. All adverse events occurred in the C-sar patients with LGE. CONCLUSIONS: This study showed that LGE is useful for the detection of cardiac involvement, and it might be a promising tool for determining the prognosis of patients with biopsy-proven extracardiac sarcoidosis.

The strain pattern, and not Sokolow-Lyon electrocardiographic voltage criteria, is independently associated with anatomic left ventricular hypertrophy.

Although obesity and chest-wall thickness influence the Sokolow-Lyon electrocardiographic (ECG) voltage criteria and strain pattern, these factors have not been taken into account in previous studies that evaluate the relationship between the ECG criteria and anatomic left ventricular hypertrophy (LVH). The introduction of multislice computed tomography (MSCT) has enabled assessment of not only coronary artery stenoses but also left ventricular volume and mass, left atrial volume, and chest-wall thickness. We hypothesized that evaluating the relation between the ECG voltage criteria or strain pattern and the aforementioned factors using MSCT would be highly valuable. The study population consisted of 93 patients who required MSCT angiography. The Sokolow-Lyon voltage and strain patterns were determined to detect anatomic LVH, which was defined as increased left ventricular mass. The Sokolow-Lyon voltage criteria, as an indicator of anatomic LVH, had a sensitivity of 57 %, specificity of 67 %, positive predictive value of 36 %, and negative predictive value of 82 %. By contrast, the strain pattern had a sensitivity of 65 %, specificity of 87 %, positive predictive value of 63 %, and negative predictive value of 88 %. Multivariate analysis revealed that the strain pattern was associated with the presence of anatomic LVH, whereas the Sokolow-Lyon voltage was not. This MSCT study demonstrated that even after removing the effects of various factors, the strain pattern remained associated with the presence of anatomic LVH, in contrast to the Sokolow-Lyon voltage.

Serum n-3 to n-6 polyunsaturated fatty acids ratio correlates with coronary plaque vulnerability: an optical coherence tomography study.

A low ratio of eicosapentaenoic acid to arachidonic acid (EPA/AA) has been demonstrated to be associated with a higher risk of cardiovascular events. Optical coherence tomography (OCT) is useful for the assessment of coronary plaque vulnerability. The purpose of this study was to evaluate the association between EPA/AA ratio and coronary plaque vulnerability. This study involved 58 patients with stable angina pectoris undergoing percutaneous coronary intervention. OCT image acquisition was performed before the procedure in the culprit lesions. We assessed lipid-rich plaque length and arc, fibrous cap thickness, frequency of thin-cap fibroatheroma (TCFA), thrombus, ruptured plaque, macrophage infiltration, and microvessels using OCT. Patients were divided into two groups according to the median value of serum EPA/AA ratio: a low-EPA/AA group (n = 29, EPA/AA ratio <0.36) and a high-EPA/AA group (n = 29, EPA/AA ratio ≥0.36). In qualitative analyses, TCFA (35.4 vs 6.9 %, P = 0.0095), macrophage infiltration (48.3 vs 13.8 %, P = 0.0045), and microvessels (44.8 vs 10.3 %, P = 0.0033) were more frequently observed in the low-EPA/AA group. In quantitative analyses, the low-EPA/AA group had wider maximum lipid arc (114.0 ± 94.8° vs 56.4 ± 66.0°, P = 0.0097), longer lipid length (4.8 ± 4.5 vs 1.6 ± 2.6 mm, P = 0.0037), and thinner fibrous cap (69.3 ± 28.3 vs 113.3 ± 46.6 µm, P = 0.005) compared with the high-EPA/AA group. EPA/AA ratio was positively correlated with fibrous cap thickness (r = 0.46, P = 0.007). In a multivariate model, an EPA/AA ratio <0.36 was associated with the presence of TCFA (odds ratio 6.41, 95 % confidence interval 1.11-61.91, P = 0.0371). In our detailed OCT analysis, lower EPA/AA ratio was associated with higher vulnerability of coronary plaques to rupture.

Evaluation of a new patient safety educational programme to reduce adverse events by encouraging staff to speak up: application of the trigger tool methodology.

BACKGROUND: Poor communication contributes to adverse events (AEs). In our hospital, following an experience of a fatal incident in 2014, we developed an educational programme aimed at improving communication for better teamwork that led to a reduction in AEs. METHODS: We developed and implemented an intervention bundle comprising external investigation committee reviews, the establishment of a working group (WG), standards and emergency response guidelines, as well as educational programmes and tools. To determine the effectiveness of the educational programmes, we measured communication abilities among doctors and nurses by administering psychological scales focused on their confidence in speaking up. Furthermore, we applied the trigger tool methodology in a retrospective study to determine if our interventions had reduced AEs. RESULTS: The nurses' scores for 'perceived barriers to speaking up' and 'negative attitude toward voicing opinions in the healthcare team' decreased significantly after the training from 3.20 to 3.00 and from 2.47 to 2.29 points, respectively. The junior doctors' scores for the same items also decreased significantly after the training from 3.34 to 2.51 and from 2.42 to 2.11 points, respectively. The number of AEs was 32.1 (median) before the WG, 39.9 (median) before the general training, 22.2 (median) after the general training and 18.4 (median) after implementing the leadership educational programmes. During the intervention period the hospital's incident reports per employee kept increasing. CONCLUSION: Our new educational programmes improved junior doctors and nurses' perceptions of speaking up. We speculated that our intervention may have improved staff communication, which in turn may have led to a reduction in AEs and a sustained increase in incident reports per employee.

A case of a lesion containing an intracoronary thrombus detected as hyperintense plaque on T1-weighted cardiovascular magnetic resonance in a patient with silent myocardial ischemia.

Many investigators have speculated that hyperintense plaques (HIPs) of the carotid artery on noncontrast T1-weighted imaging (T1WI) in cardiovascular magnetic resonance indicate the presence of mural or intraplaque hemorrhage containing methemoglobin. However, coronary plaque imaging with T1WI is challenging, and the clinical significance of coronary HIPs on T1WI remains unknown. Incidentally, it is very rare to find an intracoronary thrombus at the culprit lesion site in patients in stable condition. This article reports the case of a lesion containing an intracoronary thrombus, detected as HIP on T1WI associated with the filter no-reflow phenomenon in a patient with silent myocardial ischemia.

Quantitative analysis of abdominal aortic calcification in CKD patients without dialysis therapy by use of the Agatston score.

BACKGROUND/AIM: The aim of the present study was to quantitatively examine factors associated with aortic calcification in non-dialysis CKD patients. METHODS: We quantitatively investigated aortic calcification from the renal artery to the bifurcation in 149 non-dialysis CKD patients (58±16 years; 96 males and 53 females, 48 diabetics; eGFR 40.3 ± 29.3 ml/min), and measured Agatston scores using multi-slice computed tomography. RESULT: Of 149 patients, aortic calcification was present in 117. In patients with aortic calcification, age (p<0.001), C-reactive protein (p<0.001), and intact-PTH (p < 0.001) were significantly higher, estimated glomerular filtration rate (eGFR) was significantly lower (p<0.001), and diabetes was observed more often (p<0.05). In regards to the degree of aortic calcification, the Agatston scores correlated significantly and positively with age (ρ=0.438, p<0.001) and serum phosphate (ρ=0.208, p=0.024), and correlated significantly but negatively with e-GFR (ρ=-0.353, p<0.001). In multiple regression analysis, eGFR was associated significantly and independently with the log [Agatston score] (ß=-0.346, p<0.01), after adjustment for several confounders including serum phosphate and the presence of diabetes. CONCLUSIONS: Hyperphospatemia, chronic inflammation, diabetes, and decreased GFR are associated significantly with the presence of aortic calcification in non-dialysis CKD patients. Decreased eGFR was associated significantly and independently with the quantitative degree of aortic calcification.

Typical coronary appearance of dilated cardiomyopathy versus left ventricular concentric hypertrophy: coronary volumes measured by multislice computed tomography.

Several coronary angiographic studies have reported that enlarged and tortuous epicardial coronary arteries are characteristic of patients with left ventricular concentric hypertrophy (LVCH). Recently, we showed that small volumes opacified by contrast medium can be accurately measured by 64-multislice computed tomography (MSCT) and that there is a direct relationship between the coronary artery volume and left ventricular (LV) mass. However, the relationship of coronary artery volume with LV mass in patients with dilated cardiomyopathy (DCM) is unknown. The present study was designed to investigate this issue. Thirteen patients with DCM and 18 patients with LVCH who underwent MSCT angiography were included in this analysis. The coronary arteries were segmented on a workstation, and the appropriate window settings obtained from the results of the phantom experiments were applied to the volume-rendered images to calculate the total coronary artery volume (right and left coronary arteries). The absolute coronary lengths and volumes in patients with LVCH and DCM were greater than those in controls. The coronary artery volumes adjusted for LV mass in patients with DCM were found to be smaller than those in patients with LVCH or in controls, and these values did not differ between patients with LVCH and controls (DCM 4.1 ± 0.9, LVCH 5.4 ± 1.4, controls 5.5 ± 2.3 ml/100 g of LV mass, P < 0.005; DCM vs LVCH, P < 0.01; and DCM vs control, P < 0.0005). This study showed that the increase in the coronary artery volume in patients with LVCH matched the increase in LV mass, but a decreased coronary volume with regard to LV mass was characteristic of patients with DCM.

Effects of intravenous atrial natriuretic peptide and nitroglycerin on coronary vasodilation and flow velocity determined using 3 T magnetic resonance imaging in patients with nonischemic heart failure.

Although atrial natriuretic peptide (ANP) is widely used in patients with congestive heart failure (CHF), little is known about its effect on epicardial coronary arteries. Magnetic resonance imaging (MRI) enables precise measurement of coronary vasodilation and flow velocity. In this study, we examined the changes in epicardial coronary artery size and flow velocity in response to intravenous infusion of ANP or nitroglycerin (NTG) by using 3 T MRI in patients with CHF. The study cohort contained a total of 14 subjects: 8 patients with CHF and 6 healthy volunteers as controls, randomly divided into two groups: the ANP group (0.03 µg/kg/min) and the NTG group (0.3 µg/kg/min). Cross-sectional MR angiography and phase-contrast flow velocity of the right coronary artery in the same in-plane slice were obtained at the baseline, during drug infusion, and at two subsequent time points after stopping drug infusion. A significant increase was observed in the coronary cross-sectional area at 15 min after drug infusion in both groups compared with that at baseline; however, a late peak was observed at 15 min after stopping infusion in the ANP group. No significant differences were detected in the flow velocity in both groups. Furthermore, although NTG increased the heart rate, this change was not found in the ANP group. Coronary vasodilation and flow velocity can be measured simultaneously using 3 T MRI. Using this method, we showed that the effects of ANP on the coronary artery vasodilation and flow velocity were not inferior to those of NTG, with no significant alteration in heart rate.