Impact of continuous deterioration of kidney function 6 to 8 months after percutaneous coronary intervention for acute coronary syndrome.

Preprocedural chronic kidney disease and contrast-induced acute kidney injury are predictors of in-hospital death and long-term mortality. However, neither the time course of kidney function after percutaneous coronary intervention (PCI) nor the relation between the time course of kidney function and prognosis has been adequately studied. We studied 531 patients who underwent PCI for acute coronary syndrome. The continuous deterioration of kidney function (CDKF) was defined as a >25% increase in serum creatinine level or serum creatinine >0.5 mg/dl above baseline at 6 to 8 months after PCI. CDKF was observed in 87 patients (16.4%). Independent risk factors for CDKF were contrast-induced acute kidney injury, preprocedural hemoglobin level, and proteinuria. Patients with CDKF exhibited significant higher 5-year mortality rate than patients without CDKF (25% vs 9.4%, log-rank p = 0.0006). Independent risk factors for 5-year mortality were age >75 year, anemia, New York Heart Association class III or IV, low ejection fraction, and CDKF. CDKF is associated with an increased risk of all-cause mortality of 5 years in patients with acute coronary syndrome undergoing PCI.

Dramatic response to low-dose rivaroxaban in an Asian patient with deep vein thrombosis and pulmonary embolism.

We report a case of deep venous thrombosis and pulmonary embolism treated with rivaroxaban due to warfarin allergy. The patient responded well to a low dose of 15 mg/day. There has been a report about treating patients with atrial fibrillation using a low dose of rivaroxaban in Japan, but no previous reports about deep vein thrombosis/pulmonary embolism. This case suggests that rivaroxaban could be an alternative to warfarin for the treatment of deep vein thrombosis and pulmonary embolism in Japanese patients with warfarin allergy. .

Contents of second peak in the circadian variation of acute myocardial infarction in the Japanese population.

BACKGROUND: Circadian variation has been accepted as a factor in acute myocardial infarction (AMI). An increased incidence of cardiac events in the morning has been reported for a long time. Recent reports have indicated that the onset of AMI shows two peaks, which occur in the morning and evening. It has also been demonstrated that circadian pattern of AMI may vary with sex and age. METHODS AND RESULTS: We investigated 522 consecutive patients who underwent primary percutaneous coronary intervention (PCI) for ST segment elevation myocardial infarction (STEMI) between 2000 and 2010. The patients were classified into 3 age groups: younger (≤59 years old), intermediate (60-79 years old), and older (≥80 years old). Clinical data were investigated, including the age and sex, angiographic characteristics, and time of onset of STEMI. There were two peaks in the onset of STEMI throughout the day, which were at 7:00-10:00 and 19:00-21:00 h, among all patients (male and female). Stratified analysis showed that older females formed the main part of the second peak. CONCLUSIONS: There were two peaks in the onset of STEMI in a Japanese population in Tokyo. The second peak was significantly dominated by the older female group. Age and gender influenced the second peak in the circadian variation of AMI in a Japanese population in Tokyo.

Absence of circadian variation of acute coronary syndrome onset in chronic kidney disease patients.

BACKGROUND: Several studies have reported on the circadian variation in acute coronary syndrome (ACS) onset. The influence of morning blood pressure surge, platelet aggregation and sympathetic activity is believed to cause this circadian variation. At the same time, a high frequency of ACS and sympathetic nerve hyperactivity has been reported in chronic kidney disease (CKD). Therefore, we investigated the relationship between CKD and the circadian variation in ACS. METHODS: This study included 460 consecutive patients undergoing primary percutaneous coronary intervention for ACS between 2003 and 2009. Patients undergoing hemodialysis were excluded. The subjects were divided into two groups according to the value of estimated glomerular filtration rate (eGFR): CKD group [eGFR ≤ 60 ml/min/1.73 m2 by Modification of Diet in Renal Disease (MDRD) equation] and No CKD group (eGFR > 60 ml/min/1.73 m2 by MDRD equation). Clinical and angiographic characteristics, as well as the time distribution of ACS, were compared between the two groups. RESULTS: There were no significant differences in clinical and angiographic characteristics between the two groups. A significant increase in morning coronary events was observed in the No CKD group. This increase was absent in the CKD group. CONCLUSIONS: The existence of CKD affected the circadian variation associated with the more frequent ACS onset observed in the No CKD group patients. Probably, these data may suggest the cause of frequent cardiovascular events in CKD patients.

Combined endovascular and open surgical approach for the management of subclavian artery occlusion due to thoracic outlet syndrome.

A 32-year-old male with arterial thoracic outlet syndrome (TOS) underwent endovascular treatment for the chronic total occlusive lesion from the subclavian to the brachial artery after resection of the first rib and cervical rib. A combined endovascular and surgical treatment represents an attractive alternative to the traditional surgical approach for the treatment of complicated arterial TOS.

Higher body mass index at the time of acute myocardial infarction is associated with a favorable long-term prognosis (8-year follow-up).

Obesity is an important public health problem, especially among patients with cardiovascular disease. However, little is known about the impact of obesity on the long-term prognoses of patients with acute myocardial infarction (AMI). Major adverse cardiac and cerebrovascular events (MACCE) consist of all causes of death, stroke, target lesion revascularization, target vessel revascularization, non-fatal myocardial infarction, and hospitalization. From January 2001 to March 2005, we analyzed 121 patients who survived >30 days after suffering their first AMI of the left anterior descending artery for MACCE. The mean follow-up period for this study was 59 ± 26 months. Seventy-five patients presented with normal weight (BMI <25 kg/m(2)) and 46 were obese (BMI >25 kg/m(2)). During the follow-up period, 56 patients presented MACCE, including 18 deaths, 11 strokes, and seven non-fatal myocardial infarctions. Normal weight was significantly associated with the occurrence of MACCE (p = 0.012). Grouping of the patients by BMI and homeostasis model assessment ratio (HOMA-R) indicated that the combination of a higher BMI (>25) and lower insulin resistance (HOMA-R < 2.0) provided the best prognosis (p = 0.0006). Kaplan-Meier curves stratified to the four groups, sorted by diabetes mellitus and BMI at admission, showed that the normal weight patients with diabetes mellitus presented the highest risk of MACCE (p < 0.0001). Patients with higher BMI and no insulin resistance or diabetes mellitus present better long-term outcomes following anterior AMI.

A slightly elevated level of N-terminal pro-brain natriuretic peptide can predict coronary artery disease in a population with normal left ventricular function.

The prognostic and diagnostic values of N-terminal pro-brain natriuretic peptide (NT-pro-BNP) in ischemic heart disease have already been investigated in many previous studies. Although NT-pro-BNP is affected by many factors, these previous studies did not strictly exclude them. This study included 110 patients who received coronary arteriography between November 2007 and September 2009. Excluded from the study were those patients who had clinical symptoms of heart failure, asynergy by echocardiography or left ventriculography (LVG), atrial fibrillation, prior myocardial infarction, valvular disease, lung disease, anemia or renal dysfunction. We compared the laboratory data, LVG and early transmitral-to-early diastolic annular velocity ratio (E/E (a)) in echocardiography between the group with coronary stenosis and the group without it. NT-pro-BNP and the low-density lipoprotein/high-density lipoprotein ratio (LDL/HDL) independently associated with the presence of coronary artery stenosis (odds ratio of NT-pro-BNP, each 50 pg/ml 2.367, 95% confidence interval 1.302-4.303, p = 0.005). The area under the curve of the receiver-operating characteristic (ROC) curve of NT-pro-BNP, used to predict coronary artery stenosis, was 0.801 (0.719-0.883, p < 0.001). According to the ROC curve, the optimal cut-off level for predicting coronary stenosis was 64.3 pg/ml (sensitivity 82.5%, false-positive 34%). NT-pro-BNP is an attractive supplemental marker to predict the presence of coronary artery stenosis in a population that strictly excluded any affecting factors. In the population without factors affecting NT-pro-BNP, a slight increase suggests the presence of ischemic heart disease. The normal criteria for NT-pro-BNP in the patients undergoing coronary angiography may be much lower than the one currently used.

Bilateral spontaneous renal artery dissection.

Spontaneous renal artery dissection is a rare condition that precedes renal infarction. We describe a 48-year-old, normotensive healthy woman presenting with left flank pain of sudden onset. Enhanced abdominal computed tomography demonstrated a dissecting intimal flap of the left renal artery complicating renal infarction. Doppler ultrasonography, selective angiography, and intravascular ultrasound revealed a dissecting intimal flap, with a large false lumen and narrow true lumen, of the renal artery bilaterally. Conservative management was undertaken with anticoagulant and analgesic therapy, and the patient was discharged after an uneventful clinical course.

Endovascular treatment of innominate artery stenosis via the bilateral brachial approach.

Endovascular treatment (stenting) has evolved as an effective and safe treatment modality for symptomatic subclavian and innominate artery disease. Most of these patients have comorbid conditions associated with atherosclerotic vascular disease, which is responsible for the access site and increased difficulty of procedure. We report a case of symptomatic innominate artery stenosis with concomitant atherosclerotic disease of the abdominal aorta successfully treated with using coronary devices and the pull-through technique via the bilateral brachial approach.

Aggressive statin therapy in multicenter and effectiveness for the reduction of intra-myocardial damage caused by non-ST elevation acute coronary syndrome: AMERICA study.

BACKGROUND: While preprocedural statin treatment for acute coronary syndrome (ACS) is widely regarded as beneficial, there has been no prospective randomized multicenter trial of patients with non-ST elevation ACS in the Japanese population to examine the efficacy of preprocedural aggressive statin use. The aim of this study was to confirm this effect by prospective randomized multicenter design. METHODS: Fifty patients who presented with non-ST elevation ACS were enrolled, and randomly assigned to aggressive statin administration before percutaneous coronary intervention (PCI). Troponin-T (TnT), creatine phosphokinase (CK), CK-myocardial band (CK-MB), high-sense C-reactive protein (hs-CRP), and brain natriuretic peptide (BNP) were measured at baseline and/ or after procedure. RESULTS: Three days after PCI, the statin group had significantly less CK elevation compared with the nonstatin group (84+/-17 IU/l versus 180+/-68 IU/l, respectively, p = 0.02). CK-MB elevation also tended to be lower in the statin group than in the nonstatin group (3.2+/-1.9 versus. 7.0+/-3.0, respectively, p = 0.07), as was BNP level (3.2+/-1.9 versus 7.0+/-3.0 pg/ml, respectively, p = 0.07). The change of serum LDL cholesterol was significantly correlated with CK (p = 0.01) and TnT (p = 0.02) at 1 day after PCI. CONCLUSIONS: Aggressive statin usage before PCI to Japanese patients with non-ST elevation ACS appears to reduce myocardial damage after procedure. The degree of serum lipid level reduction may reflect the vulnerability of atheromatous plaques that could cause cardiac damage after PCI.