Relation of estimated glomerular filtration rate to the presence of coronary plaque and obstructive coronary artery disease in a zero or low coronary artery calcium score.

OBJECTIVES: Although renal dysfunction is associated with the presence of atherosclerosis, little is known about the relationship between reduced estimated glomerular filtration rate (eGFR) and the presence of atherosclerosis detected by coronary computed tomographic angiography (CCTA). This study evaluated the relation of eGFR to the presence of coronary plaque and obstructive coronary artery disease (CAD) in patients with a zero or low coronary artery calcium score (CACS). METHODS: Coronary artery calcium scoring and CCTA were performed with CT scanners. Serum creatinine was measured before CCTA, and GFR was estimated. A total of 720 patients with a CACS ≤ 10 were enrolled. RESULTS: Coronary plaque was detected in 118 patients. Of the 118 patients, 36 had a diagnosis of obstructive CAD. The multiple-adjusted odds ratios of presenting with coronary plaque and obstructive CAD were 1.82 (95% CI 1.06-3.12, p = 0.030) and 1.79 (95% CI 0.71-4.49, p = 0.217) for the lowest tertile of eGFR compared with the highest tertile, respectively. CONCLUSIONS: Lower eGFR levels were associated with the presence of coronary plaque in patients with a zero or low CACS. However, the association between eGFR and the presence of obstructive CAD was not statistically significant.

Novel combined GPIHBP1 mutations in a patient with hypertriglyceridemia associated with CAD.

AIM: Lipoprotein lipase (LPL) deficiency is a rare autosomal recessive disorder characterized by severe hypertriglyceridemia. Similar clinical phenotypes have been reported with respect to defects in several LPL-associated proteins. However, it remains controversial whether severe hypertriglyceridemia itself is atherogenic. We herein present a case of LPL deficiency due to novel combined mutations of glycosylphosphatidylinositol (GPI)-anchored high-density lipoprotein (HDL)-binding protein 1 (GPIHBP1) in a patient with coronary artery disease (CAD). PATIENT: We evaluated a 54-year-old woman with severe hypertriglyceridemia and double vessel CAD. Although the LPL mass and activity in the postheparin plasma were extremely low, no mutations were detected in the LPL gene itself. RESULTS: Genetic analyses revealed that the patient had double homozygous mutations at 41 bp (c.41 G > T) and 202 bp (c.202 T > C) in the GPIHBP1 gene, resulting in C14F and C68R, respectively. Although the C14F/C68R GPIHBP1 exhibited a normal LPL-binding activity, the levels of mutant proteins were extremely reduced compared to those of the wild-type proteins in vitro. CONCLUSION: We found novel combined mutations of GPIHBP1 in a patient with hypertriglyceridemia and severe CAD. The present case provides important insight into the pathogenesis of severe hypertriglyceridemia associated with atherosclerosis.

Takotsubo Cardiomyopathy in Two Patients without Any Cardiac Symptom on Maintenance Hemodialysis.

Takotsubo cardiomyopathy is a disorder characterized by left ventricular apical ballooning and electrocardiographic changes in the absence of coronary artery disease. While reversible in many cases, the mechanism of this disorder remains unclear. The most frequent clinical symptoms of takotsubo cardiomyopathy on admission are chest pain and dyspnea, resembling acute myocardial infarction. Here, we describe two cases of takotsubo cardiomyopathy without chest pain or dyspnea in patients on maintenance hemodialysis. The asymptomatic nature of these two cases may be due to the patients being on hemodialysis. Periodic electrocardiograms (ECG) may be helpful in screening this population for asymptomatic takotsubo cardiomyopathy and in evaluating its incidence.

Relation of cardiovascular risk factors and angina status to obstructive coronary artery disease according to categorical coronary artery calcium score.

Coronary artery calcium (CAC) is associated with the presence of coronary artery disease (CAD) and cardiovascular risk factors. However, the relation between cardiovascular risk factors and CAD has not yet been fully elucidated in patients with a zero or low coronary artery calcium score (CACS). The purpose of this study was to evaluate the relation of cardiovascular risk factors and angina status to obstructive CAD according to categorical CACS. A total of 753 patients were enrolled in this study. CAC scoring and coronary computed tomographic angiography (CCTA) were performed with dual-source 64-slice CT scanners. The number of patients with a CACS ≤10 and ≤100 were 358 and 528, respectively. Patients with a higher CACS were older and more frequently male, and had a greater frequency of hypertension, diabetes, and hypercholesterolemia. The prevalence of obstructive CAD increased with the CACS. Among patients with a CACS ≤100, age, male gender, diabetes, hypercholesterolemia, and typical angina pectoris were related to obstructive CAD. The presence of hypercholesterolemia was relatively strongly associated with obstructive CAD (OR 6.67, 95% CI 2.91-15.3, p < 0.001) on multivariate analysis. Among patients with a CACS ≤10, men, hypercholesterolemia, and typical angina pectoris were significantly more frequent in patients with than in those without obstructive CAD (p < 0.01). Our data suggest that neither the absence nor low of coronary calcium burden may reliably exclude obstructive CAD in typical symptomatic male patients with hypercholesterolemia. This result may be useful to interpret the relation of CACS to obstructive CAD.

An autopsy case of left ventricular apical ballooning probably caused by pheochromocytoma with persistent ST-segment elevation.

We describe the autopsy case of an 86-year-old man who experienced left ventricular (LV) apical ballooning with pheochromocytoma. During the follow-up period, his electrocardiogram (ECG) showed persistent ST-segment elevation in leads V3 to V6, and an echocardiogram revealed persistent LV dysfunction in the apical region. He died 64 days after admission. Pathological findings suggested catecholamine-induced cardiomyopathy and pheochromocytoma. This is the report of a rare autopsy case of LV apical ballooning.

Glycosylated hemoglobin is a predictor of major adverse cardiac events after drug-eluting stent implantation in patients with diabetes mellitus.

OBJECTIVES: Diabetes mellitus is associated with the risk of restenosis and mortality after coronary stenting, but the relation between glycosylated hemoglobin (hemoglobin A1c) and prognosis has not yet been fully elucidated in patients with diabetes mellitus. The purpose of this study was to evaluate whether hemoglobin A1c is associated with a risk of major adverse cardiac events (MACE) after successful drug-eluting stent (DES) implantation in patients with diabetes mellitus. METHODS: In a retrospective study with a prospective follow-up, 206 patients with diabetes mellitus undergoing successful DES implantation were enrolled in this study. Hemoglobin A1c levels were measured within 1 month before coronary stenting. RESULTS: During a period of 4,811 person-months, we confirmed 40 cases of MACE. Higher hemoglobin A1c levels increased the incidence of MACE. Based on multivariate analysis, hemoglobin A1c was a significant predictor of MACE. The multiple-adjusted hazard ratio for a 1% increase in hemoglobin A1c levels was 1.40 (95% CI: 1.13-1.74, p = 0.002) for MACE after adjustment for age, gender, ejection fraction, chronic renal failure on hemodialysis, and statins. CONCLUSIONS: Hemoglobin A1c is associated with an increased risk of MACE after successful DES implantation in patients with diabetes mellitus.

QT dispersion and prognosis after coronary stent placement in acute myocardial infarction.

BACKGROUND: QT dispersion is increased in acute myocardial infarction (AMI), but the relation of QT dispersion to prognosis has not yet been fully elucidated. HYPOTHESIS: The purpose of this study is to evaluate prospectively whether QT dispersion is associated with the risk of major adverse cardiac events (MACEs) and mortality after successful coronary stenting in AMI. METHODS: One hundred and forty-two patients with AMI and undergoing successful percutaneous coronary intervention (PCI) were enrolled in this study. Corrected QT dispersion was measured before and 24 h after PCI. RESULTS: During a period of 4477 person-months, we confirmed 21 cases of MACE. Univariate analysis indicated that corrected QT dispersion before and 24 h after PCI, age, number of Q waves, and Killip class > or = 2 were related to MACE and mortality. By multivariate analysis, corrected QT dispersion before PCI was an independent predictor of MACE and mortality, but corrected QT dispersion at 24 h after PCI was not statistically associated with MACE and mortality. Multiple-adjusted hazard ratios for a 1 standard deviation (SD) magnitude increase in corrected QT dispersion before PCI were 2.24 (95% confidence interval, 1.36-3.68, p = 0.001) for MACE and 2.71 (95% confidence interval, 1.50-4.89, >) for mortality after adjustment for age, gender, ejection fraction, and Killip class > or = 2. CONCLUSIONS: Corrected QT dispersion before PCI is associated with an increased risk of MACE and mortality after successful PCI in patients with AMI.

Inflection point of ascending aortic waveform is a predictive factor for major adverse cardiac events after successful coronary stent placement in acute myocardial infarction.

OBJECTIVE: The reflection waveform in the ascending aortic pressure has been reported to reflect systemic arterial stiffness, and increase the risk of coronary heart disease. The purpose of this study is to evaluate prospectively whether the reflection waveform in the ascending aortic pressure is associated with the risk of major adverse cardiac events (MACE) after successful coronary stenting in acute myocardial infarction (AMI). METHODS AND RESULTS: One hundred and twenty-five patients with AMI and undergoing successful coronary stenting were enrolled in this study. We measured the inflection time to determine the reflection waveform in the ascending aortic pressure at angioplasty. Inflection time was defined as the time interval from initiation of a systolic pressure waveform to the inflection point. During a period of 2945 person-months, we confirmed 42 cases of MACE. Shorter inflection time increased incident MACE. Kaplan-Meier analysis demonstrated a significantly reduced event-free rate in patients with inflection time < or = 86 ms (MACE; p < 0.01, cardiovascular death; p < 0.001 by log-rank test). The multiple-adjusted hazard ratio for a I standard deviation (SD) magnitude decrease in inflection time was 1.46 (95% confidence interval, 1.03 to 2.05) for MACE, and 5.76 (95% confidence interval, 1.78 to 18.67) for cardiovascular death. CONCLUSIONS: Shorter inflection time increased the risk of MACE after successful coronary stenting in patients with AMI.

QT dispersion and left ventricular function after stent placement in acute myocardial infarction.

BACKGROUND: QT dispersion is increased in acute myocardial infarction (AMI), but the relation of QT dispersion to left ventricular (LV) function has not yet been fully elucidated. The purpose of this study was to evaluate the relationship between QT dispersion and LV function in patients with successful coronary stenting in AMI. METHODS: Seventy five patients with AMI who underwent percutaneous transluminal coronary angioplasty (PTCA) were enrolled in this study. Corrected QT dispersion was measured before, immediately after, 24 h after, 48 h after, and 6 months after PTCA. Left ventricular ejection fraction (LVEF) was evaluated by left ventriculography at 6 months after PTCA. RESULTS: Corrected QT dispersion at 24 h after and 48 h after PTCA were significantly related to LVEF by univariate analysis (r=-0.282, p<0.05 and r=-0.326, p<0.01, respectively). In multiple regression model, corrected QT dispersion at 24 h after and 48 h after PTCA revealed significant associations with LVEF (R(2)=0.441, coefficient=-0.283, p=0.006 and R(2)=0.411, coefficient=-0.225, p=0.039, respectively), but corrected QT dispersion before, immediately after, and 6 months after PTCA were not associated with LVEF. CONCLUSIONS: Corrected QT dispersion at 24 h after and 48 h after PTCA in AMI correlate with LVEF at 6 months after PTCA.

Correction of the maxillary occlusal plane relieves persistent headache and shoulder stiffness.

It has been known for many years that deformations of the occlusal plane of the teeth cause indefinite symptoms such as headaches or stiffness of the shoulders. However, how the occlusal plane of the teeth should be corrected remains uncertain. The purpose of this study was to examine whether a correction of the deviation of the maxillary occlusal plane (MOP) from the center of dens of axis vertebrae (DAV) improves symptoms in patients having intractable headache or shoulder-stiffness. Forty patients who complained of dental abnormalities and persistent headache or shoulder-stiffness that had not responded to conventional medical treatment and 17 healthy controls were recruited. All subjects received a lateral cephalometric x-ray examination to measure a distance from the MOP and the center of DAV. In the healthy subjects, both the upper and the lower shift of the MOP from the center of DAV were minimal (the upper shift was 1 +/- 2 [mean +/- S.D.] mm and the lower shift was 4 +/- 4 mm). By contrast, the patients had a significantly greater deviation of the MOP from the center of DAV. Dental adjustment treatment was performed in fourteen patients who had a substantial deviation of the MOP from the center of DAV. Those patients were asked about their symptoms which were scored using a point system and were compared before and after treatment. An adjustment procedure of the MOP passing through the DAV significantly relieved clinical symptoms in these patients (before 42.5 +/- 34.4 vs after 7.0 +/- 8.2, p < 0.01). Correction of the MOP passing through the near center of DAV might be effective in relieving clinical symptoms associated with dental deformities.

Inflection point of ascending aortic waveform is a predictive factor for all-cause and cardiovascular mortality in patients with chronic renal failure on hemodialysis.

BACKGROUND: The reflection waveform in the ascending aortic pressure has been reported to reflect systemic arterial stiffness, and increase risk of coronary heart disease. The purpose of this study is to evaluate prospectively whether the reflection waveform in the ascending aortic pressure is associated with the mortality in patients with chronic renal failure on hemodialysis. METHODS: Fifty two patients with chronic renal failure on hemodialysis and undergoing cardiac catheterizations were enrolled in this study. Inflection time was measured to determine the reflection waveform in the ascending aortic pressure at angiography. Inflection time was defined as the time interval from initiation of a systolic pressure waveform to the inflection point. RESULTS: The mean duration of follow-up was 55 +/- 49 months (mean +/- SD). Mean age at entry was 58.5 +/- 9.0 years. We confirmed 14 cardiovascular deaths, and 5 non-cardiovascular deaths. Shorter inflection time increased all-cause and cardiovascular mortality. Kaplan-Meier analysis demonstrated a significantly reduced survival ratio in patients with inflection time < or =87 msec (all-cause death; P < 0.01, cardiovascular death; P < 0.001 by log-rank test). Multiple-adjusted hazard ratio for 10 msec decrease in inflection time was 1.49 (95% confidence interval, 1.07 to 2.08) for all-cause mortality, and was 4.66 (95% confidence interval, 1.82 to 11.95) for cardiovascular mortality. CONCLUSION: Shorter inflection time increased all-cause and cardiovascular mortality in patients with chronic renal failure on hemodialysis.

The timing of the reflected wave in the ascending aortic pressure predicts restenosis after coronary stent placement.

It has been reported that the reflection waveform in the ascending aortic pressure is associated with systemic arterial stiffness. Stiffening of the aortic walls leads to a decrease in coronary perfusion and an increase in restenosis rate. The purpose of this study was to evaluate whether the reflection waveform in the ascending aortic pressure could be used to predict restenosis after percutaneous coronary stenting. One hundred and three patients who underwent percutaneous coronary stenting were enrolled in this study. We measured the inflection time and augmentation index (AIx) to determine the reflection waveform in the ascending aortic pressure at angioplasty. We then prospectively investigated the effect of inflection time and AIx in relation to the subsequent risk of restenosis after coronary stenting. After adjustments for age, gender, smoking habits, hypertension, type 2 diabetes, hypercholesterolemia, stent size, and heart rate, the odds ratio of restenosis in inflection time was 4.62 (95% confidence interval (CI), 1.39 to 15.4) for the lowest tertile of the inflection time level compared with the highest tertile level. As for AIx, the odds ratio of restenosis was 6.96 (95% CI, 1.93 to 25.1) for the highest tertile of the AIx level compared with the lowest tertile level. Inflection time and AIx are related to restenosis after percutaneous coronary stenting.

Intravenous nicorandil can reduce QT dispersion and prevent bradyarrhythmia during percutaneous transluminal coronary angioplasty of the right coronary artery.

BACKGROUND: Nicorandil, a potassium channel opener, is used for the treatment of angina pectoris and has a pharmacologic preconditioning effect. This study evaluated whether intravenous nicorandil reduces QT dispersion and prevents bradyarrhythmia during percutaneous transluminal coronary angioplasty (PTCA) of the right coronary artery. METHODS: A historical cohort study on the effect of nicorandil on QT dispersion and bradyarrhythmia was conducted. Fifty patients who underwent PTCA of the right coronary artery were enrolled. The patients were divided into a nicorandil (n = 25) group and control group (n = 25). Nicorandil was injected at 4 mg/h continuously 1 hour before PTCA in the nicorandil group. QT dispersion was measured at 1 hour before PTCA (baseline), immediately before PTCA, and 1 minute after the initiation of the first balloon inflation. RESULTS: QT dispersion at 1 minute after the initiation of the first balloon inflation in the control group increased significantly (QT dispersion: 37.1 +/- 17.8 msec and 21.7 +/- 12.2 msec, respectively, P < .001 vs baseline in the control group), and this was larger than at 1 minute after the initiation of the first balloon inflation in the nicorandil group (QT dispersion: 37.1 +/- 17.8 msec and 20.8 +/- 9.4 msec, respectively, P < .001). By two-way repeated measures analysis of variance, there were significant interactions between the time factor and the grouping factor in QT dispersion (P < .001). Bradyarrhythmia was observed in 6 patients in the control group, but none was observed in the nicorandil group. CONCLUSIONS: Intravenous nicorandil reduces QT dispersion and prevents bradyarrhythmia during PTCA of the right coronary artery.

Intravenous nicorandil can reduce the occurrence of ventricular fibrillation and QT dispersion in patients with successful coronary angioplasty in acute myocardial infarction.

BACKGROUND: Because nicorandil, a potassium channel opener, has a cardioprotective effect and attenuates reperfusion injury in patients with acute myocardial infarction (AMI), intravenous nicorandil should reduce arrhythmic mortality and QT dispersion in patients with AMI. OBJECTIVES: The purpose of this study was to evaluate whether intravenous nicorandil reduces the occurrence of ventricular fibrillation and QT dispersion in patients with successful coronary angioplasty in AMI. METHODS: A historical cohort study on the effect of nicorandil on ventricular fibrillation and QT dispersion was conducted. Eighty-three patients with AMI who underwent successful percutaneous transluminal coronary angioplasty (PTCA) were enrolled. The patients were divided into two groups: nicorandil (n=46) and control group (n=37). Nicorandil was injected at 4 mg/h continuously from admission to 48 h after PTCA in the nicorandil group. QT dispersion was measured before, immediately after, 24 h after and 48 h after PTCA. RESULTS: Ventricular fibrillation was observed in three patients in the control group, but none was observed in the nicorandil group. QT dispersion in the nicorandil group was shorter than that in the control group 48 h after PTCA (QT dispersion was 23.2+/-16.1 ms and 33.4+/-24.0 ms, respectively, P<0.05). There was a significant difference between the two groups in time course after the onset of AMI (P<0.05). CONCLUSIONS: Because intravenous nicorandil reduces the occurrence of ventricular fibrillation and QT dispersion in patients with successful coronary angioplasty in AMI, it would prevent the occurrence of cardiac events after successful PTCA for AMI.

Thrombus formation after aortic valvular replacement using Björk-Shiley valve occluding the right coronary orifice.

We describe a patient with unstable angina due to occlusion of the orifice of the right coronary artery by thrombus formation after aortic valvular replacement using a Björk-Shiley valve. After strict anticoagulant treatment, transesophageal echocardiography demonstrated disappearance of the thrombus formation around the orifice of the right coronary artery.

Fusiform coronary aneurysm in the left circumflex artery with recurrent myocardial infarction and idiopathic thrombopenia.

The authors describe the rare case of a patient with fusiform coronary aneurysm with myocardial infarction in the left circumflex artery complicated by idiopathic thrombopenia. Medical treatment with a combination of warfarin and aspirin could not prevent recurrence of angina pectoris and myocardial infarction, but surgical ligation of the proximal site of the fusiform aneurysm and coronary bypass to the distal site of the fusiform aneurysm prevented further myocardial infarction and angina pectoris.

Inflection point of ascending aortic waveform is a powerful predictor of restenosis after percutaneous transluminal coronary angioplasty.

BACKGROUND: Although it was reported that the pulsatility of ascending aortic pressure is closely related to restenosis after percutaneous transluminal coronary angioplasty (PTCA), it is not known whether the reflection period of ascending aortic pressure can predict restenosis after PTCA. The purpose of this study was to evaluate whether reflection in the arterial system can be used to predict restenosis after PTCA. METHODS: We used the inflection point as the reflection period index and measured the coronary artery diameter, aortic pressure, and inflection time before PTCA. We defined the inflection time as the time interval from the initiation of systolic pressure waveform to the inflection point. We prospectively investigated the effect of inflection time in relation to the subsequent risk of restenosis after PTCA in patients with coronary artery disease. RESULTS: Crude cumulative incidence rates of restenosis were 74.1% for the lowest, 33.3% for the middle, and 26.1% for the highest tertile of inflection point levels. After adjustments for age, gender, smoking habits, hypertension, type 2 diabetes, hypercholesterolemia, old myocardial infarction, vessel location, post-minimal lumen diameter, heart rate, and ejection fraction, the odds ratio of restenosis was 6.99 (95% confidence interval, 1.54 to 31.7) for the lowest tertile of the inflection time level compared with the highest tertile level. CONCLUSIONS: Inflection time is a powerful predictor of restenosis after PTCA.

Reflection in the arterial system and the risk of coronary heart disease.

BACKGROUND: Although it was reported that the augmentation index and inflection time are closely related to reflection in the arterial system and large artery function, it is not known whether these indices of the ascending aortic pressure waveform increase the risk of coronary heart disease (CHD). The purpose of this study was to evaluate whether the aortic reflection of the ascending aortic pressure waveform is related to an increased risk of CHD. METHODS: We enrolled 190 men and women who had chest pain, normal contractions, no local asynergy, and no history of myocardial infarction. We measured the ascending aortic pressure using a fluid-filled system. The inflection time was defined as the time interval from initiation of a systolic pressure waveform to the inflection point. We investigated the association between the inflection time and augmentation index of the ascending aorta and the risk of CHD. RESULTS: Both the inflection time and augmentation index were associated with an increased risk of CHD. The crude prevalence rates of CHD were 66.0% for the shortest quartile and 10.6% for the longest quartile of the inflection time, and 17.0% for the lowest quartile and 40.4% for the highest quartile of the augmentation index. The multiple-adjusted odds ratio of CHD was 30.8 (95% confidence interval [CI] 7.43-128.05) for the shortest quartile of the inflection time compared with the longest quartile and was 3.82 (95% CI 1.26-11.59) for the highest quartile of the augmentation index compared with the lowest quartile. CONCLUSIONS: The augmentation index and inflection time were associated with an increased risk of CHD.