Diagnostic accuracy and clinical usefulness of erythrocyte creatine content to predict the improvement of anaemia in patients receiving maintenance haemodialysis.

BACKGROUND: The improvement of anaemia over time by erythropoiesis stimulating agent (ESA) is associated with better survival in haemodialysis patients. We previously reported that erythrocyte creatine content, a marker of erythropoietic capacity, was a reliable marker to estimate the effectiveness of ESA. The aim of this study was to examine the accuracy and clinical usefulness of erythrocyte creatine content to predict the improvement of anaemia in haemodialysis patients. METHODS: ESA dose was fixed 3 months prior to the enrollment and was maintained throughout the study period. Erythrocyte creatine content and haematologic indices were measured at baseline in 92 patients receiving maintenance haemodialysis. Haemoglobin was also measured 3 months after. Improvement of anaemia was defined as ≥ 0.8 g/dL change in haemoglobin from baseline to 3 months. RESULTS: Erythrocyte creatine content was significantly higher in 32 patients with improvement of anaemia compared to 60 patients with no improvement of anaemia (2.47 ± 0.74 vs. 1.57 ± 0.49 µmol/gHb, P = 0.0001). When 9 variables (erythrocyte creatine content, ESA dose, reticulocyte, haptoglobin, haemoglobin at baseline, serum calcium, intact parathyroid hormone, transferrin saturation and serum ferritin) were used in the multivariate logistic regression analysis, erythrocyte creatine emerged as the most important variable associated with the improvement of anaemia (P = 0.0001). The optimal cut-off point of erythrocyte creatine content to detect the improvement of anaemia was 1.78 µmol/gHb (Area under the curve: 0.86). Sensitivity and specificity of erythrocyte creatine content to detect the improvement of anaemia were 90.6% and 83.3%. CONCLUSION: Erythrocyte creatine content is a reliable marker to predict the improvement of anaemia 3 months ahead in patients receiving maintenance haemodialysis.

Evaluation of recombinant human erythropoietin responsiveness by measuring erythrocyte creatine content in haemodialysis patients.

BACKGROUND: One of the main causes of anaemia in patients with end-stage renal disease is relative deficiency in erythropoietin production. Eythropoiesis stimulating agent (ESA), a potent haematopoietic growth factor, is used to treat anaemia in haemodialysis patients. The effect of ESA is usually assessed by haematological indices such as red blood cell count, haemoglobin concentration and haematocrit, but erythrocyte indices do not provide information of the rapid change in erythropoietic activity. As erythrocyte creatine directly assess erythropoiesis, the aim of this study was to evaluate the effect of ESA in haemodialysis patients by measuring the erythrocyte creatine content. METHODS: ESA dose was fixed 3 months prior to the enrollment and was maintained throughout the entire study period. Erythrocyte creatine was measured with haematologic indices in 83 haemodialysis patients. Haemoglobin was also measured 3 months after. RESULTS: ESA dose (152.4 ± 62.9 vs. 82.2 ± 45.5 units/kg/week, P = 0.0001) and erythrocyte creatine (2.07 ± 0.73 vs. 1.60 ± 0.41 µmol/gHb, p = 0.0003) were significantly higher in 27 patients with haemoglobin <10 g/dL compared to 56 patients with haemoglobin ≥10 g/dL. There was a fair correlation between ESA dose and the concentration of creatine in the erythrocytes (r = 0.55, P < 0.0001). Increase in haemoglobin (>0.1 g/dL) was observed in 37 patients, whereas haemoglobin did not increase in 46 patients. Erythrocyte creatine levels were significantly higher in those patients with an increase in haemoglobin compared to those without (2.04 ± 0.64 vs. 1.52 ± 0.39 µmol/gHb, p < 0.0001). When 8 variables (ESA dose, erythropoietin resistance index, C-reactive protein, intact parathyroid hormone, iron supplementation, presence of anaemia, erythrocyte creatine and reticulocyte) were used in the multivariate logistic analysis, erythrocyte creatine levels emerged as the most important variable associated with increase in haemoglobin (Chi-square = 6.19, P = 0.01). CONCLUSION: Erythrocyte creatine, a useful marker of erythropoietic capacity, is a reliable marker to estimate ameliorative effectiveness of ESA in haemodialysis patients.

Prevention of contrast-induced nephropathy by chronic pravastatin treatment in patients with cardiovascular disease and renal insufficiency.

BACKGROUND: Contrast-induced nephropathy (CIN) is known to increase morbidity and mortality of cardiovascular disease. Recent studies have shown statins prevented CIN after contrast media exposure, but optimal statin type and dosage are still unknown. PURPOSE: The aims of the present study were to evaluate whether chronic pravastatin treatment before scheduled coronary angiography or percutaneous coronary intervention could reduce the incidence of CIN and to elucidate the factors related to CIN in patients with renal insufficiency. METHODS: We studied 431 consecutive patients with renal insufficiency. One hundred ninety-four patients were receiving pravastatin treatment as standard chronic treatment of hypercholesterolemia. Serum creatinine levels were measured at baseline (pre-procedure) and within 48 h after contrast media exposure (peak post-procedure). CIN was defined as an increase in the serum creatinine values of > or = 25% or > or = 0.5 mg/dl after contrast media exposure. Logistic regression analysis was performed to evaluate the important factors related to CIN using four variables: age, pravastatin, pre-procedure serum creatinine, and contrast volume. RESULTS: CIN was observed in 36 patients (8.4%). Patients without pravastatin (p<0.01), high level pre-procedure serum creatinine (p<0.01), and high contrast volume (p=0.034) had a significantly higher incidence of CIN. Logistic regression analysis revealed that pravastatin treatment (chi(2)=6.549, p=0.011, odds ratio=0.34), pre-procedure serum creatinine (chi(2)=6.294, p=0.009, odds ratio=2.78), and contrast volume (chi(2)=4.484, p=0.034, odds ratio=1.01) were independently related to the decreased risk of CIN. CONCLUSIONS: Chronic pravastatin treatment before contrast media exposure was important for preventing CIN in patients with renal insufficiency. Also, reducing the dose of contrast media was important for preventing CIN in patients with high-baseline serum creatinine levels.

Combined analysis of multislice computed tomography coronary angiography and stress-rest myocardial perfusion imaging in detecting patients with significant proximal coronary artery stenosis.

OBJECTIVE: Multislice computed tomography (MSCT) coronary angiography (CAG) is limited in detecting significant coronary artery stenosis because of its low specificity and positive predictive value. Stress-rest myocardial perfusion imaging (MPI) can detect myocardial ischemia. The aim of this study was to evaluate the diagnostic accuracy of detecting patients with proximal coronary artery disease for coronary intervention by combined analysis of MSCT-CAG and MPI. METHODS: MSCT-CAG, MPI, and CAG were performed in 125 patients with chest pain suggestive of coronary artery disease. A significant proximal coronary artery stenosis was defined as > or = 75% stenosis by MSCT and CAG. Myocardial ischemia was defined as reversible defect by MPI. Patients were defined as having coronary artery disease with a significant coronary stenosis by CAG. RESULTS: Seventy-four patients had a significant proximal coronary artery stenosis by MSCT. Of the 74 patients with a coronary artery stenosis by MSCT, 50 (67.6%) patients had a significant proximal coronary artery stenosis by CAG. In contrast, 50 (98.0%) of 51 patients without coronary artery stenosis by MSCT did not have coronary artery disease. In detecting patients with proximal coronary artery disease, combined analysis of MSCT and MPI showed a considerable improvement in specificity (94.6 vs. 67.6%, P = 0.0001) and positive predictive value (92.3 vs. 67.6%, P = 0.01) without significant changes in sensitivity (94.1 vs. 98.0%) and negative predictive value (95.9 vs. 98.0%) compared with MSCT alone. CONCLUSION: Combined analysis of MSCT-CAG and MPI can accurately detect patients with proximal coronary artery disease.

Factors associated with myocardial salvage immediately after emergent percutaneous coronary intervention in patients with ST-elevation acute myocardial infarction.

OBJECTIVE: The amount of myocardial salvage after percutaneous coronary intervention (PCI) is reported to be a major determinant of functional recovery in patients with ST-elevation acute myocardial infarction (MI). However, factors related to the amount of myocardial salvage remain unknown. The goal of this study was to investigate the factors related to the amount of myocardial salvage after emergent PCI in patients with ST-elevation acute MI by incorporating pre- and post-treatment indices and adjunctive treatments. METHODS: Technetium-99m myocardial imaging was performed before, immediately after, and one month after emergent PCI in 161 patients with ST-elevation acute MI, and the defect score was serially evaluated. A good myocardial salvage was defined as >/=4 change (before minus immediately after PCI) of the defect score. RESULTS: Good myocardial salvage was observed in 89 patients. Based on nine clinical variables, logistic regression analysis was performed to determine the important variables related to myocardial salvage. Multivariate analysis revealed that earlier time from onset to PCI (chi (2) = 6.55, P = 0.01, odds ratio = 2.78), larger defect score before PCI (chi (2) = 7.29, P = 0.01, odds ratio = 1.13) and administration of nicorandil before PCI (chi (2) = 9.88, P = 0.008, odds ratio = 4.42) were independently associated with good myocardial salvage. Thrombolysis In Myocardial Infarction (TIMI) flow grade <2 before PCI (chi (2) = 4.91, P = 0.03, odds ratio = 0.36) and TIMI flow grade

Preservation of myocardial viability within the risk area by intravenous nicorandil before primary coronary intervention in patients with acute myocardial infarction.

OBJECTIVE: To investigate the cardioprotective effect of intravenous nicorandil before primary percutaneous coronary intervention (PCI) on preservation of myocardial viability, we studied 199 consecutive patients with acute myocardial infarction. METHODS: Nicorandil was given intravenously on admission (before primary PCI). Echocardiography and technetium-99m tetrofosmin perfusion imaging were performed before and 1 month after primary PCI. Echocardiographic asynergic score before primary PCI was used to define the size of risk area, whereas the sum of scintigraphic defect grade before primary PCI was used to estimate myocardial viability within the area at risk. The change (before primary PCI and 1 month after primary PCI) in asynergic score and scintigraphic salvage index were calculated. RESULTS: Patients were divided into nicorandil (n=101) and control (n=98) groups. Although asynergic score before primary PCI was not different between the two groups (nicorandil=3.5+/-2.1 and control=3.9+/-1.5), myocardial viability was preserved in nicorandil group (defect score=11.0+/-4.0) than that in control group (defect score=14.0+/-4.7, P<0.0001). Multivariate analysis revealed that the presence of antegrade flow (P=0.015) and nicorandil (P<0.0001) were independently associated with preserved myocardial viability before primary PCI. Moreover, the greater reduction in asynergic score (66+/-41 vs. 49+/-23%, P=0.0006) and larger salvage index (65+/-25 vs. 53+/-26%, P=0.0015) were observed in nicorandil group compared with the control group. CONCLUSION: Intravenous administration of nicorandil before primary PCI preserved myocardial viability within the risk area, which leads to greater myocardial salvage and better functional recovery after primary PCI.

Non-invasive detection of ischemic left ventricular dysfunction using rest gated SPECT: expectation of simultaneous evaluation of both myocardial perfusion and wall motion abnormality.

OBJECTIVE: Although the accurate detection of ischemic etiology is important in the management of patients with severe left ventricular (LV) dysfunction, it is difficult to determine using a non-invasive strategy. The present study investigates whether perfusion and regional functional abnormalities identified by quantitative electrocardiographic gated single-photon emission computed tomography (QGS) at rest can detect ischemic LV dysfunction in patients with severe LV dysfunction. METHODS: Rest QGS with (99m)Tc-tetrofosmin was performed on 54 consecutive patients with LV ejection fraction of

The effect of verapamil on the restoration of myocardial perfusion and functional recovery in patients with angiographic no-reflow after primary percutaneous coronary intervention.

OBJECTIVE: Angiographic thrombolysis in myocardial infarction (TIMI) flow grade < or = 2 after primary percutaneous coronary intervention (PCI), defined as angiographic no-reflow, predicts poor functional recovery in patients with acute myocardial infarction. We investigated the effect of verapamil on the restoration of myocardial perfusion and functional recovery in patients with angiographic no-reflow after PCI. METHODS: 99mTc tetrofosmin single photon emission computed tomographic (SPECT) imaging was performed (before, immediately after and 1 month after PCI) in 101 consecutive patients with acute myocardial infarction. The defect score was calculated as the sum of perfusion defect in a 13-segment model (scores of 3, complete defect to 0, normal perfusion). The asynergic score, defined as the number of asynergic segments, was assessed by echocardiography before and 1 month later. Multiple logistic regression analysis was performed to elucidate the effect of verapamil administration. RESULTS: Of 101 patients, 32 (31%) had angiographic no-reflow and were divided into two groups: 18 patients with verapamil (group 1) and 14 patients without verapamil (group 2). Sixty-nine patients had TIMI grade 3 reflow after PCI (group 3). The change in the defect score 1 month after PCI in group 1 was significantly larger than that in group 2 (P = 0.003). The asynergic score improved more at 1 month in group 1 compared to that in group 2 (P = 0.007). Moreover, logistic regression analysis revealed that TIMI grade reflow < or = 2 after PCI (P = 0.04, OR = 5.51), the defect score before PCI (P = 0.03, OR = 1.15), the asynergic score before PCI (P = 0.01, OR = 0.64) and the administration of verapamil (P = 0.002, OR = 22.4) were independently associated with successful myocardial reperfusion immediately after PCI. CONCLUSIONS: Intracoronary verapamil restored myocardial perfusion in patients with angiographic no-reflow after PCI and lead to better functional recovery after acute myocardial infarction.

Assessment of coronary artery disease in hemodialysis patients with delayed systolic blood pressure response after exercise testing.

BACKGROUND: We evaluated usefulness of the postexercise systolic blood pressure (SBP) response for detecting coronary artery disease (CAD) in hemodialysis patients. METHODS: A treadmill exercise testing was done, and the SBP response was measured in 44 hemodialysis patients (30 men, 14 women; age 41 to 81 years). The postexercise SBP response was defined as the ratio of SBP after 3 minutes of recovery to SBP at peak exercise. RESULTS: The SBP ratio of the 25 subjects with coronary artery stenosis (1.01+/- 0.13) was significantly greater (p<0.01) than 19 subjects without coronary artery stenosis (0.83+/- 0.10). An SBP ratio greater than 0.92 identified CAD with higher sensitivity, specificity, and accuracy than did the conventional ST-segment depression criterion (76 vs. 56%, 90 vs. 53%, and 82 vs. 55%, respectively). CONCLUSION: Determination of the SBP ratio is a clinically useful, noninvasive method for accurately detecting CAD in hemodialysis patients.

Clinical factors associated with persistent pericardial effusion after successful primary coronary angioplasty.

STUDY OBJECTIVE: To evaluate the incidence and clinical factors related to the persistence of infarct-associated pericardial effusion (PE) after primary angioplasty. DESIGN: Consecutive case-series analysis. SETTING: Coronary care unit in a university hospital. PATIENTS: Three hundred ninety-one consecutive patients with acute myocardial infarction (AMI) who underwent successful primary percutaneous transluminal coronary angioplasty (PTCA) at hospital admission. INTERVENTIONS: Coronary angiography and primary PTCA on hospital admission and serial echocardiography. MEASUREMENTS AND RESULTS: The status of coronary flow before and after primary PTCA was evaluated by coronary angiography at hospital admission, while PE was studied by echocardiography within 24 h of admission and 1 month after the onset of AMI. PE was present in the acute phase in 76 patients (19%), and patients with PE had a significantly higher incidence of in-hospital death than those without PE (11% vs 2%, p < 0.001). Among 68 patients who had PE in the acute phase and underwent echocardiography 1 month later, PE persisted to 1 month after the onset of AMI (persistent PE) in 26 patients (38%). Patients with persistent PE had a significantly higher incidence of pericardial rub (p = 0.010), Killip class > 1 (p = 0.025), no reflow after PTCA (p = 0.026), lower incidence of collaterals (p = 0.024), and tended to have higher peak creatine kinase (CK) [p = 0.05] levels than those with transient PE. When five variables (peak CK, collaterals, no reflow, pericardial rub, and Killip class > 1) were used in the multivariate analysis, pericardial rub (p = 0.023; odds ratio [OR], 5.45), absence of collaterals (p = 0.011; OR, 0.16), and Killip class > 1 (p = 0.027; OR, 3.80) were the significant variables related to persistent PE. CONCLUSIONS: PE remains a relatively common complication of AMI even in the era of reperfusion therapy and is associated with increased mortality. Furthermore, the presence of a pericardial rub, Killip class > 1, and absence of collateral flow in the early phase of the infarct are associated with persistence of the PE to 1 month after the onset of AMI.

[Acute myocardial infarction due to late stent thrombosis seventeen months after stent implantation: a case report].

A 59-year-old man with acute myocardial infarction underwent successful stent implantation for proximal left anterior descending coronary artery occlusion. Antiplatelet therapy with 100 mg aspirin/day and 200 mg cilostazol/day was started after stenting and continued for 4 weeks. There was no cardiac event during the 1 year follow-up period. Follow-up coronary angiography at 12 months after stenting revealed no in-stent restenosis. The patient was admitted 17 months later due to sudden onset of severe chest pain. Electrocardiography revealed ST segment elevation in leads V1-V4. Emergency coronary angiography disclosed obstruction of the proximal left anterior descending coronary artery with thrombus. Intracoronary aspiration thrombectomy was successful. We describe a patient with acute myocardial infarction who had late stent thrombosis 17 months after stent implantation.

Scintigraphic prediction of left ventricular functional recovery early after primary coronary angioplasty using single-injection quantitative electrocardiographic gated SPECT.

OBJECTIVE: The clinical usefulness of characterizing reperfused myocardium by perfusion/thickening assessment using electrocardiographic gated single photon emission computed tomography (SPECT) has not been investigated. We evaluated whether single-injection gated SPECT with 99mTc tetrofosmin early after primary percutaneous coronary intervention (PCI) can predict left ventricular (LV) functional recovery. METHODS: Gated SPECT was performed 3 days after primary PCI in 45 patients with acute myocardial infarction and revascularized segments were classified into perfusion/thickening mismatched segments, matched normal and matched abnormal segments. Gated SPECT was repeated 3 months later to evaluate the changes in LV ejection fraction (deltaLVEF). RESULTS: Among 332 revascularized segments, there were 83 mismatched segments, 163 matched abnormal segments and 86 matched normal segments. In all the patients, LVEF increased significantly from 3 days to 3 months after primary PCI (52+/-13 to 57+/-14%, P<0.0001). Patients were divided into two groups according to deltaLVEF: 24 patients with LV functional recovery (deltaLVEF > or = 5%) and 21 patients without LV functional recovery. The number of mismatched segments in patients with LV functional recovery was significantly greater than that in patients without (2.7+/-1.7 vs. 0.8+/-1.4, P<0.0003) despite no differences in the number of matched abnormal and matched normal segments. There was a significant correlation between deltaLVEF and the number of mismatched segments (r=0.56, P<0.0001) and LVEF at 3 months after primary PCI was related to the number of matched abnormal segments (r=-0.78, P<0.0001). CONCLUSION: Single-injection gated SPECT early after primary PCI can predict LV functional recovery.

Left ventricular free wall rupture after reperfusion therapy for acute myocardial infarction.

We evaluated the clinical significance of angiographic indexes and pericardial involvement in predicting increased risk of free wall rupture after reperfusion therapy and found that Thrombolysis In Myocardial Infarction (TIMI) <3 flow grade after reperfusion therapy was a significant variable related to the free wall rupture. Moreover, pericardial rub was found to be a significant variable related to TIMI <3 grade flow after reperfusion, which indicates that detection of pericardial rub is one of the clinical signs that predicts inadequate anterograde flow of the infarct-related artery after reperfusion and hence, higher risk for free wall rupture.

Quantitative estimation of myocardial salvage after primary percutaneous transluminal coronary angioplasty in patients with angiographic no reflow.

Angiographic Thrombolysis in Myocardial Infarction (TIMI) flow grade

[Infective endocarditis complicating bilateral bacterial ophthalmitis: a case report].

A 53-year-old female suddenly went blind in her left eye on 3 June, 2000. She was admitted to the Department of Ophthalmology of our hospital under the diagnosis of endophthalmitis. Her left eye was enucleated, and Streptococcus agalactiae was found in the vitreous fluid. After left ophthalmectomy, inflammation recurred after cessation of antibiotic administration. Echocardiography demonstrated a vegetation of the posterior mitral valve. The diagnosis was infective endocarditis. She was transferred to the Department of Internal Medicine. Mitral regurgitation deteriorated during the course of medical therapy, but she was discharged on 13 September, 2000 because inflammation had improved remarkably and the vegetation had disappeared after administration of penicillin G, panipenem, cefotaxime and clindamycin. We suspected that embolism of the ophthalmic artery was the cause of the sudden blindness in her left eye. Infective endocarditis with bacterial endophthalmitis is very rare in Japan.

Early prediction of regional functional recovery in reperfused myocardium using single-injection resting quantitative electrocardiographic gated SPET.

By evaluating concordant or discordant perfusion and systolic wall thickening patterns, resting quantitative electrocardiographic (ECG) gated single-photon emission tomography (SPET) can identify various myocardial pathological conditions with different functional recovery after revascularisation therapy. However, no data are available on the ability of this methodology to predict regional functional recovery after primary percutaneous transluminal coronary angioplasty (PTCA). This study evaluated whether single-injection ECG gated SPET imaging performed at rest with 99mTc-tetrofosmin early after successful PTCA can predict recovery of regional wall motion. ECG gated SPET was performed 3 days and 3 weeks after successful PTCA in 26 patients. Regional functional parameters were automatically calculated with a 20-segment model on the day 3 image, and segments with perfusion/thickening mismatch were defined as showing preserved perfusion (>55% uptake on the end-diastolic image: mean-standard deviation of the normal value) without systolic wall thickening (mean-standard deviation of the normal value). On the third day, the regional wall motion score of 37 mismatched segments (3.8+/-2.1) was significantly lower than that of 41 matched normal segments (6.0+/-2.9), but was significantly higher than that of 108 matched abnormal segments (1.4+/-1.9, both P<0.01). At 3 weeks after acute MI, the regional wall motion score of mismatched segments (6.4+/-3.9) improved to the level of matched normal segments (7.1+/-3.0) and was significantly higher than that of matched abnormal segments (2.5+/-3.0, P<0.01). Absolute change in the regional wall motion score (3 days to 3 weeks) of mismatched segments (2.6+/-3.5) was significantly greater than that in the regional wall motion score of matched normal segments and matched abnormal segments (1.1+/-1.3 and 1.2+/-2.6, respectively, both P<0.05). Twenty-seven of 37 segments (73%) with perfusion/thickening mismatch showed significant improvement in regional wall motion, whereas improvement in regional wall motion was observed in 22 of 108 segments (20%) with matched abnormal segments and 6 of 41 segments (15%) with matched normal segments. Segments with perfusion/thickening mismatch had a significantly higher incidence of regional functional improvement than did matched abnormal or matched normal segments (chi2=42.3, P<0.01). Thus, by estimating both perfusion and wall thickening, single-injection resting ECG gated SPET imaging with 99mTc-tetrofosmin early after primary PTCA can predict recovery of regional wall motion after successful reperfusion.