Atrial electrical remodeling and function after transcatheter aortic valve replacement in patients with aortic stenosis.

To examine reverse atrial electrical remodeling in patients with aortic stenosis (AS) after trans-catheter aortic valve replacement (TAVR). In 65 consecutive patients with severe AS (83 ± 4 years, 47 (72.3%) females), we analyzed ECG records for the P wave duration (PWD) in lead II and P-terminal force (PTFV1) in V1, and measured cardiac dimensions and function by echocardiography (ECHO) following TAVR. Biomarkers were measured to assess myocardial injury by TAVR. TAVR was successfully performed without major complications: the aortic valve area increased from 0.62 ± 0.14 cm2 to 1.52 ± 0.24cm2, and the trans-aortic pressure gradient decreased from 58.4 ± 15.9 mmHg to 15.0 ± 19.6 mmHg. PWD and PTFV increased immediately after TAVR and returned to the pre-TAVR levels on the next day. Then, the PWD declined toward 6 months after TAVR non-significantly in all patients, but significantly in 25 patients with baseline PWD ≥ 130 ms (P = 0.039). PTFV1 showed no long-term change. Improvement was observed in the ejection fraction, all thickness of the left ventricle and in the left atrial dimensions on ECHO. After recovery from transient aggravation by TAVR procedure, PWD reversed slowly, and the change was significant in those with baseline PWD ≥ 130 ms while change in PTFV1 was not significant at 6 months of follow-up. ECHO showed a reversal of remodeling in the left ventricle and in the left atrial dimension after TAVR.

Clinical impact of ECG changes on oversensing of subcutaneous implantable cardioverter-defibrillators.

BACKGROUND: Inappropriate shocks delivered by subcutaneous implantable cardioverter-defibrillators (S-ICDs) are most frequently caused by cardiac oversensing. However, the predictors for oversensing of S-ICD remain unclear. OBJECTIVE: We aimed to investigate the predictors for oversensing of S-ICD, especially clinical impact of an electrocardiographic (ECG) change. METHODS: We retrospectively enrolled 99 consecutive patients who underwent S-ICD implantation between 2013 and 2021. Oversensing events were defined as inappropriate charge of the capacitors induced by cardiac or noncardiac signals other than tachycardia. RESULTS: During a median follow-up period of 34 months (interquartile range 20-50 months), 11 of 99 patients (11%) experienced 34 oversensing events and 4 patients (4%) received inappropriate shocks during their events. Six patients exhibited ECG changes (bundle branch block, 3; ventricular pacing, 1; inverted T wave, 1; poor R-wave progression, 1) during the follow-up period. Oversensing events were observed in 4 of 6 patients with ECG change (67%), and 3 patients underwent S-ICD removal because of inevitable shock. Contrastingly, of the remaining patients without ECG change, all 7 patients who experienced oversensing events could continue using S-ICD with the reprogramming sensing vector and/or restriction of excessive exercise. Logistic regression analysis showed that lower voltage of Sokolow-Lyon ECG (V1S + V5R) was the predictor of oversensing in patients without ECG change. When the cutoff value was 2.1 mV, the sensitivity, specificity, positive predictive value, and negative predictive value were 85.7%, 62.7%, 15.7%, and 98.1%, respectively. CONCLUSION: Unavoidable oversensing resulting in S-ICD removal is caused by ECG change. Oversensing in patients without ECG change can be managed.

Incidence and Implications of J waves Observed During Coronary Angiography.

J waves may be observed during coronary angiography (CAG), but they have not been fully studied. We investigated the characteristics of J waves in 100 consecutive patients during CAG. The patients and their family members had no history of cardiac arrest. Approximately 60% of patients had ischemic heart disease, previous myocardial infarction, or angina pectoris, but at the time of this study, the right coronary artery was shown to be normal or patent after stenting. Electrocardiogram was serially recorded to monitor J waves and alteration of the QRS complex during CAG. In 12 patients (12%), J waves (0.249 ± 0.074 mV) newly appeared during right CAG, and in another 13 patients (13%), preexisting J waves increased from 0.155 ± 0.060 mV to 0.233 ± 0.133 mV during CAG. Left CAG induced no J waves or augmentation of J waves. Distinct alterations were observed in the QRS complex during CAG of both coronary arteries. Mechanistically, myocardial ischemia induced by contrast medium was considered to result in a local conduction delay, and when it occurred in the inferior wall, the site of the late activation of the ventricle, the conduction delay was manifested as J waves. In conclusion, J waves were confirmed to emerge or increase during angiography of the right but not the left coronary artery. Myocardial ischemia induced by contrast medium caused a local conduction delay that was manifested as J waves in the inferior wall, the site of the late activation of the ventricle.

Accentuation of J waves by intracoronary administration of multiple agents in a patient with vasospastic angina: Implications for pathogenesis.

A 64-year-old man was resuscitated from out-of-hospital VF, and coronary spasm was provoked by ergonovine at catheterization. An ECG was analyzed before and after each intracoronary injection of drugs or contrast medium. The baseline ECG showed nondiagnostic J waves in leads II, III, and aVF, but administration of acetylcholine, contrast medium and nitroglycerin into the right coronary artery induced a distinct augmentation of J-wave amplitudes with changes in the QRS morphology. Transient ischemia induced by the intracoronary administration of these agents seemed to be the mechanism underlying the increase in J-wave amplitudes.

Dynamicity of hypothermia-induced J waves and the mechanism involved.

BACKGROUND: J waves develop during hypothermia, but the dynamicity of hypothermia-induced J waves is poorly understood. OBJECTIVE: The purpose of this study was to investigate the mechanism of the rate-dependent change in the amplitude of hypothermia-induced J waves. METHODS: Nineteen patients with severe hypothermia were included (mean age 70 ± 12 years; 16 men [84.2%]). The rectal temperature at the time of admission was 27.8° ± 2.5°C. In addition to prolonged PR, QRS complex, and corrected QT intervals, the distribution of prominent J waves was widespread in all 19 patients. RESULTS: Nine patients showed changes in RR intervals. When the RR interval shortened from 1353 ± 472 to 740 ± 391 ms (P = .0002), the J-wave amplitude increased from 0.50 ± 0.29 to 0.61 ±0.27 mV (P = .0075). The J-wave amplitude increased in 7 patients (77.8%) and decreased in 2 patients (22.2%) after short RR intervals. The augmentation of J waves at short RR intervals was associated with a significant prolongation of ventricular activation time (35 ± 5 ms vs 46 ± 5 ms; P = .0020), suggesting accentuated conduction delay. Increased conduction delay at short RR intervals was suggested to accentuate the phase 1 notch of the action potential and J waves in hypothermia. None developed ventricular fibrillation, and in 2 of 9 patients with atrial fibrillation, atrial fibrillation persisted after rewarming to normothermia. CONCLUSION: J waves in severe hypothermia were augmented after short RR intervals in 7 patients as expected for depolarization abnormality, whereas 2 patients showed a bradycardia-dependent augmentation as expected for transient outward current-mediated J waves. Increased conduction delay at short RR intervals can be responsible for the accentuation of the transient outward current and J waves during severe hypothermia.

Clinical Predictors of Recurrent Ventricular Arrhythmias in Secondary Prevention Implantable Cardioverter Defibrillator Recipients With Coronary Artery Disease　- Lower Left Ventricular Ejection Fraction and Incomplete Revascularization.

BACKGROUND: The implantable cardioverter defibrillator (ICD) is a standard prevention therapy for patients at high risk for sudden cardiac death (SCD) due to life-threatening ventricular arrhythmia (VA), that is, ventricular fibrillation and ventricular tachycardia. However, clinical predictors of recurrent VA in secondary prevention ICD recipients with coronary artery disease (CAD) remain unknown. Methods and Results: We followed up 96 consecutive patients with CAD undergoing ICD implantation for secondary prevention of SCD. Long-term rates and clinical predictors of appropriate ICD therapy (ICD-Tx) for VA were analyzed. Appropriate ICD-Tx occurred in 41 (42.7%) patients during a median follow-up of 2.4 years (interquartile range, 0.9-6.1). These patients had significantly greater left ventricular end-diastolic diameter (62.3±1.3 vs. 54.6±1.1 mm, P<0.001), lower left ventricular ejection fraction (LVEF; 36.3±2.0% vs. 45.7±1.8%, P<0.001), and more incomplete revascularization (ICR; 70.7% vs. 45.5%, P=0.014) than those without appropriate ICD-Tx. Multivariable analysis showed that LVEF (hazards ratio [HR], 0.950; 95% CI: 0.925-0.975; P<0.001) and ICR (HR, 2.293; 95% CI: 1.133-4.637; P=0.021) were significant predictors of appropriate ICD-Tx for VA. CONCLUSIONS: Lower LVEF and ICR were independent predictors of recurrent VA in secondary prevention ICD recipients with CAD.

The comparison of early healing 1-month after PCI among CoCr-everolimus-eluting stent (EES), biodegradable polymer (BP)-EES and BP-sirolimus-eluting stent: Insights from OFDI and coronary angioscopy.

BACKGROUND: Third-generation stents with abluminal biodegradable polymer (BP) might facilitate early healing. Therefore, we compared early healing between second-generation and third-generation stents using coronary angioscopy (CAS) and optical frequency domain imaging [OFDI]. METHODS: We prospectively enrolled 30 consecutive patients with stent implantation for acute coronary syndrome (cobalt­chromium [CoCr] everolimus-eluting stent [EES] [n = 10], BP-EES [n = 10], and BP-sirolimus eluting stent [SES] [n = 10]). All patients underwent CAS and OFDI 1 month after initial percutaneous coronary intervention. On OFDI, the stent coverage (SC), thrombus, and peri-strut low intensity area (PLIA) were assessed. CAS findings were recorded for the grade of SC, grade of yellow color (YC), and grade of the thrombus (TG). RESULTS: On OFDI, the incidences of any thrombus at the 1-month follow-up were 70%, 80%, and 80% in the CoCr-EES, BP-EES, and BP-SES groups, respectively. The percentage of coverage was comparable among the groups (CoCr-EES 79.8 vs. BP-EES 79.9 vs. BP-SES 80.1%, P = 0.96). However, the number of struts with PLIA was numerically higher in the BP-SES group than in the CoCr-EES and BP-EES groups (46.4 ±â€¯25.1 vs. 21.6 ±â€¯13.2 vs. 22.0 ±â€¯7.2%, P = 0.08). In the CoCr-EES, BP-EES, and BP-SES groups, mean grades of SC were 1.25 ±â€¯0.5, 1.25 ±â€¯0.5, and 0.85 ±â€¯0.70 (P = 0.60); mean grades of YC were 0.75 ±â€¯0.5, 0.80 ±â€¯0.45, and 0.88 ±â€¯0.37 (P = 0.65), and mean grades of TG were 1.00 ±â€¯1.00, 1.20 ±â€¯0.83, and 0.88 ±â€¯0.64 (P = 0.75), respectively. CONCLUSION: Third-generation stents are not inferior to second-generation stents regarding stent coverage. However, PLIA on OFDI was often observed with BP-SESs, indicating involvement of the fibrin component.

The Comparison of Inappropriate-Low-Doses Use among 4 Direct Oral Anticoagulants in Patients with Atrial Fibrillation: From the Database of a Single-Center Registry.

BACKGROUND: Inappropriate doses of direct oral anticoagulants (DOACs) are often prescribed. This study evaluated the prevalence, outcomes, and predictors of the prescription of inappropriately low doses of 4 types of DOACs in patients with atrial fibrillation (AF). METHODS: We retrospectively analyzed prospectively collected data from a single-center registry with 2272 patients prescribed DOACs for AF (apixaban: 1014; edoxaban: 267; rivaroxaban: 498; dabigatran: 493). Patients were monitored for 2years and classified into appropriate-dose (n = 1,753; including appropriate low doses), inappropriate-low-dose (n = 490) and inappropriate-high-dose groups (n = 29). Major bleeding (MB) and thromboembolic events (TEEs) were evaluated. RESULTS: The mean age was 72 ± 10years. The CHADS2 and HAS-BLED scores were 1.95 ± 1.32 and 1.89 ± .96, respectively. Overall, the incidences of MB and TEE were 2.3 and 2.1 per 100-patinet year, respectively. The inappropriate-low-dose group had younger age, heavier body weight, and higher creatinine clearance value than the appropriate-dose group. Multiple logistic regression analyses demonstrated the following independent determinants of the prescription of an inappropriately low dose: apixaban: HAS-BLED score; edoxaban: age; rivaroxaban: age, creatinine clearance value, HAS-BLED score, CHADS2 score, and antiplatelet therapy; dabigatran: age. There were not significant differences in the incidence of major bleeding and stroke/systemic emboli among the inappropriate-low-dose group of 4 DOACs compared with the appropriate-dose group of 4 DOACs. CONCLUSIONS: In a single-center registry, 23% of patients with AF treated with a DOAC received an inappropriate dose. Several clinical factors, such as age and the creatinine clearance value, can identify patients at risk of under-treatment with DOACs.

The utility of total lipid core burden index/maximal lipid core burden index ratio within the culprit plaque to predict filter-no reflow: insight from near-infrared spectroscopy with intravascular ultrasound.

Filter-no reflow (FNR) is a phenomenon wherein flow improves after the retrieve of distal protection. Near-infrared spectroscopy with intravascular ultrasound (NIRS-IVUS) enables lipid detection. We evaluated the predictors of FNR during PCI using NIRS-IVUS. Thirty-two patients who underwent PCI using the Filtrap® for acute coronary syndrome (ACS) were enrolled. The culprit plaque (CP) was observed using NIRS-IVUS. Total lipid-core burden index (T-LCBI) and maximal LCBI over any 4-mm segment (max-LCBI4mm) within CP were evaluated. T-LCBI/max-LCBI4mm ratio within CP was calculated as an index of the extent of longitudinal lipid expansion. The attenuation grade (AG) and remodeling index (RI) in CP were analyzed. AG was scored based on the extent of attenuation occupying the number of quadrants. The patients were divided into FNR group (N = 8) and no-FNR group (N = 24). AG was significantly higher in FNR group than in no-FNR group (1.6 ± 0.6 vs. 0.9 ± 0.42, p = 0.01). RI in FNR group tended to be greater than in no-FNR group. T-LCBI/max-LCBI4mm ratio within the culprit plaque was significantly higher in FNR group than in no-FNR group (0.50 ± 0.10 vs. 0.33 ± 0.13, p < 0.01). In multivariate logistic regression analysis, AG > 1.04 (odds ratio [OR] 18.4, 95% confidence interval [CI] 1.5-215.7, p = 0.02) and T-LCBI/max-LCBI4mm ratio > 0.42 (OR 14.4, 95% CI 1.2-176.8, p = 0.03) were independent predictors for the occurrence of FNR. The use of T-LCBI/max-LCBI4mm ratio within CP might be an effective marker to predict FNR during PCI in patients with ACS.

The effect of dapagliflozin treatment on epicardial adipose tissue volume.

BACKGROUND: Glycosuria produced by sodium-glucose co-transporter-2 (SGLT-2) inhibitors is associated with weight loss. SGLT-2 inhibitors reportedly might reduce the occurrence of cardiovascular events. Epicardial adipose tissue (EAT) is a pathogenic fat depot that may be associated with coronary atherosclerosis. The present study evaluated the relationship between an SGLT-2 inhibitor (dapagliflozin) and EAT volume. METHODS: In 40 diabetes mellitus patients with coronary artery disease (10 women and 30 men; mean age of all 40 patients was 67.2 ± 5.4 years), EAT volume was compared prospectively between the dapagliflozin treatment group (DG; n = 20) and conventional treatment group (CTG; n = 20) during a 6-month period. EAT was defined as any pixel that had computed tomography attenuation of - 150 to - 30 Hounsfield units within the pericardial sac. Metabolic parameters, including HbA1c, tumor necrotic factor-α (TNF-α), and plasminogen activator inhibitor-1 (PAI-1) levels, were measured at both baseline and 6-months thereafter. RESULTS: There were no significant differences at baseline of EAT volume and HbA1c, PAI-1, and TNF-α levels between the two treatment groups. After a 6-month follow-up, the change in HbA1c levels in the DG decreased significantly from 7.2 to 6.8%, while body weight decreased significantly in the DG compared with the CTG (- 2.9 ± 3.4 vs. 0.2 ± 2.4 kg, p = 0.01). At the 6-month follow-up, serum PAI-1 levels tended to decline in the DG. In addition, the change in the TNF-α level in the DG was significantly greater than that in the CTG (- 0.5 ± 0.7 vs. 0.03 ± 0.3 pg/ml, p = 0.03). Furthermore, EAT volume significantly decreased in the DG at the 6-month follow-up compared with the CTG (- 16.4 ± 8.3 vs. 4.7 ± 8.8 cm3, p = 0.01). Not only the changes in the EAT volume and body weight, but also those in the EAT volume and TNF-α level, showed significantly positive correlation. CONCLUSION: Treatment with dapagliflozin might improve systemic metabolic parameters and decrease the EAT volume in diabetes mellitus patients, possibly contributing to risk reduction in cardiovascular events.

The Impact of Cancer on Major Bleeding and Stroke/Systemic Emboli in Patients Using Direct Oral Anticoagulants:From the Database of a Single-Center Registry.

BACKGROUND: Few data are available on direct oral anticoagulant (DOAC) use in patients with cancer and atrial fibrillation (AF). METHODS: We retrospectively analyzed prospectively collected data from a single-center registryon 2,272 patients who tookDOACs for AF (apixaban:1,014; edoxaban:267; rivaroxaban:498; dabigatran:493). Patients were monitored for 2 years andclassified into non-cancer (n=2009) and cancer group (n=263) (cancer onset during DOAC treatment, active canceratDOAC administration, and cancer history).Major bleeding (MB) and thromboembolic events (TEEs) were evaluated. RESULTS: The mean age was 73±10 years. CHADS2 and HAS-BLED scores were 1.95±1.32 and 1.89±0.96,respectively.In the present study, the prevalence of gastrointestinal and genitourinary cancer was 61% and 8%, respectively.The MB and TEEs incidences were 2.4 and 2.2 per 100-patient years, respectively. The appropriate dosing rate, body weight, and Ccrvalue in cancer patients were significantly lower than those in non-cancer patients. Cancer patients were significantly older than non-cancer patients. In MB patients diagnosed with gastrointestinal or genitourinary cancer during follow-up, the clinically relevant bleeding such as melena or hematuria occurred.Additionally, there was a significantly higher MB incidence in cancer patients than in non-cancer patients (p<0.01). CONCLUSIONS: AF patients with cancer was associated with a higher risk of MB compared with those without cancer despite higher rate of inappropriate low dose. Bleeding such as melena and hematuria after DOAC administration might suggest that the symptoms are associated with cancer of the site.

Comparison of clinical outcomes of coronary artery stent implantation in patients with end-stage chronic kidney disease including hemodialysis for three everolimus eluting (EES) stent designs: Bioresorbable polymer-EES, platinum chromium-EES, and cobalt chrome-EES.

BACKGROUNDS: New-generation bioresorbable polymer-everolimus eluting stents (BP-EES) are available. This study aimed to compare the clinical outcomes for BP-EES compared to more established stent designs, namely the platinum chromium-EES (PtCr-EES) and cobalt chrome-EES(CoCr-EES) in patients with the end-stage chronic kidney disease (CKD) including hemodialysis (HD). METHODS: One-hundred-forty-one consecutive stents (BP-EES [n = 44], PtCr-EES [n = 45], and CoCr-EES [n = 52]) were implanted in 104 patients with CKD. All patients underwent a follow-up coronary angiography at 12 months after implantation. End-stage CKD was defined as an estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m2 , or the need for HD. The following outcome variables were compared among the three stent groups after implantation and the 12-month follow-up: target lesion revascularization (TLR), stent thrombosis (ST), and major adverse cardiac event (MACE). Minimal stent diameter (MSD) and %diameter-stenosis (%DS) were measured using quantitative coronary angiography. RESULTS: The overall rate of TLR and MACE was 14.6% and 30.8%, respectively, with no incidence of ST. Immediately after implantation, the MSD (P = 0.22) and %DS (P = 0.42) were equivalent among the three groups. However, at the 12-month follow-up, a tendency towards higher TLR was observed for the BP-EES group (22.7%) compared with the PtCr-EES (8.8%) and CoCr-EES (9.6%) groups (P = 0.07). Late loss in lumen diameter was also significantly greater for the BP-EES (0.51 ± 0.64 mm) group than either the PtCr-EES (0.20 ± 0.61 mm) and CoCr-EES (0.25 ± 0.70 mm) groups (P = 0.03). CONCLUSIONS: BP-EES might increase the risk of in-stent restenosis in patients with end-stage of CKD or the need for HD.

A case of central diabetes insipidus associated with cardiac dysfunction.

Central diabetes insipidus (CDI) results from a deficiency of arginine vasopressin (AVP) secretion. It is treated by replacement therapy with the synthetic AVP analogue desmopressin. To prevent heart failure in patients with CDI accompanied by cardiac dysfunction, controlling sodium and water intake is essential, using the minimum effective dose of desmopressin.

Electrical alternans induced by a brief period of myocardial ischemia during percutaneous coronary intervention: The characteristic ECG morphology and relationship to mechanical alternans.

BACKGROUND: Electrical alternans (EA) has not been fully studied in the current percutaneous coronary intervention (PCI) procedure. OBJECTIVE: The purpose of this study was to evaluate visible EA and the morphology of ST segment during PCI. METHODS: The incidence of visible EA and ST-segment morphology were studied while the coronary artery was occluded for 20 seconds. When data were available, the relationship between EA and blood pressure was analyzed. The clinical and electrocardiographic data were compared with those of the age- and sex-matched controls. RESULTS: During balloon inflation, visible EA was observed in 5 of 306 patients (1.6%) in the last 2 years. EA was limited to PCI in the proximal left anterior descending artery. The ST segment elevated to 10.1 ± 3.2 mm, followed by an alternating QRS complex with a lower ST segment (5.6 ± 1.9 mm; P = .0047) with characteristic ST-segment morphology, which is known as lambda pattern. The mean age of the 5 patients was 68 ± 20 years, and 4(80%). were men. After the release of inflation, the ST-segment level returned rapidly to baseline, followed by normalization of J point. Compared with controls, the maximal elevated ST segment was significantly higher in patients with EA (5.7 ± 2.7 mm; P = .0028). The occlusion of the proximal left anterior descending artery with more severe ischemia seemed to be a prerequisite for developing EA. A higher ST segment was associated with a lower blood pressure and vice versa. CONCLUSION: A short period of ischemia during PCI may induce visible EA and alternating QRS complexes with a characteristic ST-segment morphology. A higher ST segment was associated with a lower blood pressure and vice versa.

Brugada syndrome combined with monomorphic ventricular tachycardia and atrioventricular nodal reentrant tachycardia.

A 41-year-old man developed sustained monomorphic ventricular tachycardia (VT) with a left bundle branch block and inferior axis pattern during treadmill exercise concomitantly with unmasking of the typical Brugada electrocardiography (ECG) pattern. The typical ECG phenotype was provoked by a class IC drug. VT was not inducible with programmed electrical stimulation, but premature ventricular beat and non-sustained VT with the same morphology increased in frequency with isoproterenol treatment. Additionally, atrioventricular nodal reentrant tachycardia (AVNRT) was induced by electrical stimulation and VT and AVNRT were treated by radiofrequency catheter ablation.

Cardiogenic shock induced by bisoprolol in a patient with CYP2D6 variant. A case report.

A 66-year-old man was admitted for congestive heart failure with tachycardiac atrial fibrillation (AF). Heart failure was improved by diuretics, but control of heart rate by verapamil was insufficient, and bisoprolol was prescribed. After taking 2.5 mg of bisoprolol, he developed a general malaise followed by sinus bradycardia and shock. In addition to catecholamines, the patient was treated with intra-aortic balloon pumping and a pacemaker. With intensive therapy, the general condition was improved, and acute elevation of liver enzymes after bisoprolol was normalized by the 17th hospital day. The blood sample taken 30 h after the intake of bisoprolol showed abnormally high levels. Although the patient was CYP2D6*10 heterozygote, the precise mechanism for excess accumulation of bisoprolol and refractory shock remains unknown. .

Papaverine-induced QT interval prolongation and ventricular fibrillation in a patient with a history of drug-induced QT prolongation.

A 64-year-old woman underwent a coronary flow reserve evaluation using intracoronary-administered papaverine into the left anterior descending artery. Her baseline electrocardiogram (ECG) was normal, but toward the end of papaverine administration, the QTU intervals were excessively prolonged and torsade de pointes occurred, leading to ventricular fibrillation. Ten months previously, the patient's ECG showed mildly prolonged QTc (480 ms(1/2)), which normalized after the cessation of bepridil. This case report suggests that a history of drug-induced QT prolongation can be a risk factor for papaverine-induced fatal ventricular arrhythmia.

Long-term PT-INR levels and the clinical events in the patients with non-valvular atrial fibrillation: a special reference to low-intensity warfarin therapy.

BACKGROUND: Anticoagulation therapy is essential in atrial fibrillation (AF), and in Japan, less intense control is popular. PURPOSE: To assess the efficacy and safety with a special reference to low intensity warfarin therapy. SUBJECTS AND METHODS: In 488 out of 508 patients with non-valvular AF, prothrombin time-international normalized ratio (PT-INR) was kept at 1.6-2.59, and they were followed for 49.5 months: 2098 person-years. The mean age was 73.7±9.9 years and 62% were male. The patients were divided by age: ≥70 years and <70 years, and by the intensity of warfarin therapy: PT-INR at 1.6-1.99 and at 2.0-2.59, respectively. The clinical data and event rates, ischemic stroke and major bleeding, were compared among the subgroups. RESULTS: Heart failure, previous stroke, and higher CHADS2 score were more often reported in patients ≥70 years while males were involved more often as younger patients. A total of 166 of 339 patients ≥70 years and 69 of 149 patients <70 years belonged to the low intensity group. Ischemic stroke and major bleeding occurred in 1.47%/year and 1.27%/year, respectively but there was no difference between the two age groups and between the two intensities of warfarin therapy. Time in therapeutic range was a predictor for ischemic stroke. A fall of PT-INR to <1.6 was found in 41.9% with ischemic stroke and a rise >2.61 in 40.0% with major bleeding at the time of the events. Blunt trauma and concomitant use of antiplatelets were risks for intracranial hemorrhage in the patients ≥70 years. CONCLUSIONS: The event rates were similar between the low- (1.6-1.99) and high- (2.0-2.59) intensity warfarin therapy groups in aged patients: <70 years and ≥70 years. Time in therapeutic range and a transient fall or rise in PT-INR were risks for clinical events. Blunt head trauma and concomitant use of antiplatelets were risks for intracranial hemorrhage.

The association between obesity and acute myocardial infarction is age- and gender-dependent in a Japanese population.

Controversies concerning the association between obesity and acute myocardial infarction (AMI) are still ongoing in Japan. We investigated the association between obesity defined by body mass index of 25 kg/m(2) or higher and AMI by a case-control study using data from 1199 AMI cases and 4056 apparently healthy controls. The analysis was performed in age- and sex-matched samples of 621 case-control pairs younger than 80 years and in crude samples aged 40-79 years divided into 10-year age groups. Prevalence of obesity, diabetes, current smoking, hypertension, and hypercholesterolemia were compared between cases and controls, and a multivariable odds ratio (OR) of AMI was calculated for each risk factor in various age groups. The OR (95 % confidence interval (CI)) of AMI for obesity was 1.63 (1.23-2.17), P = 0.0008 in men younger than 80 years; 2.65 (1.41-5.00), P = 0.0025 in women younger than 80 years; 2.23 (1.46-3.41), P = 0.0002 in men aged 59 years or younger; 1.34 (0.90-2.01), P = 0.1510 in men aged 60-79 years; and 2.98 (1.56-5.71), P = 0.0010 in women aged 60-79 years using paired samples. The OR (95 % CI) of AMI for obesity was 4.92 (2.53-9.58), P < 0.0001 in men aged 40-49 years; 1.54 (1.07-2.21), P = 0.0197 in men aged 50-59 years; 1.07 (0.69-1.66), P = 0.7717 in men aged 60-69 years; 2.24 (1.20-4.20), P = 0.0118 in men aged 70-79 years; 2.48 (1.12-5.48), P = 0.0245 in women aged 60-69 years; and 3.05 (1.46-6.37), P = 0.0029 in women aged 70-79 years using crude samples. The association between obesity and AMI was age- and gender-dependent in a Japanese population.