Efficacy of Add-on Therapy with Carvedilol and the Direct Renin Inhibitor Aliskiren for Improving Cardiac Sympathetic Nerve Activity, Cardiac Function, Symptoms, Exercise Capacity and Brain Natriuretic Peptide in Patients with Dilated Cardiomyopathy.

Purpose/Method: Aliskiren is a direct renin inhibitor that has been reported to be effective for CHF, but the usefulness of combined therapy with carvedilol and aliskiren has not been reported. Forty-four patients with dilated cardiomyopathy (DCM) were randomized into a group receiving add-on therapy with carvedilol plus aliskiren and another group receiving carvedilol alone for 6 months. Nuclear imagings with 123I-Metaiodobenzylguanidine (MIBG) and 99mTc-Sestamibi were performed. Exercise capacity using a specific activity scale (SAS) and the New York Heart Association (NYHA) class were evaluated. Cardiac sympathetic nerve activity was evaluated by 123I-MIBG imaging, with the delayed heart-to-mediastinum activity ratio (H/M), delayed total defect score (TDS), and washout rate (WR). Results: Combined add-on therapy with carvedilol and aliskiren improved several parameters much more than carvedilol alone (p<0.05) with respect to TDS, ejection fraction (EF), NYHA, SAS on 6 months and the changes in TDS, EF, end-diastolic volume and brain natriuretic peptide (BNP). Conclusion: Add-on therapy with carvedilol and aliskiren is more effective than carvedilol alone for improving cardiac sympathetic nerve activity, cardiac function, symptoms, exercise capacity, and brain natriuretic peptide in patients with DCM.

Adaptive servo-ventilation therapy improves cardiac sympathetic nerve activity, cardiac function, exercise capacity, and symptom in patients with chronic heart failure and Cheyne-Stokes respiration.

PURPOSE: Adaptive servo-ventilation (ASV) therapy has been reported to be effective for improving central sleep apnea (CSA) and chronic heart failure (CHF). The purpose of this study was to clarify whether ASV is effective for CSA, cardiac sympathetic nerve activity (CSNA), cardiac symptoms/function, and exercise capacity in CHF patients with CSA and Cheyne-Stokes respiration (CSR-CSA). METHODS: In this study, 31 CHF patients with CSR-CSA and a left ventricular ejection fraction (LVEF) ≤ 40% were randomized into an ASV group and a conservative therapy (non-ASV) group for 6 month. Nuclear imagings with 123I-Metaiodobenzylguanidine (MIBG) and 99mTc-Sestamibi were performed. Exercise capacity using a specific activity scale (SAS) and the New York Heart Association (NYHA) class were evaluated. CSNA was evaluated by 123I-MIBG imaging, with the delayed heart/mediastinum activity ratio (H/M), delayed total defect score (TDS), and washout rate (WR). RESULTS: The ASV group had significantly better (P < .05) results than the non-ASV group with respect to the changes of AHI (-20.8 ± 14.6 vs -0.5 ± 8.1), TDS (-7.9 ± 4.3 vs 1.4 ± 6.0), and H/M(0.16 ± 0.16 vs -0.04 ± 0.10) on 123I-MIBG imaging, as well as the changes of LVEF (5.3 ± 3.9% vs 0.7 ± 32.6%), SAS (1.6 ± 1.4 vs 0.3 ± 0.7), and NYHA class (2.2 ± 0.4 vs 2.7 ± 0.5) after 6-month therapy. CONCLUSIONS: Performing ASV for 6 months achieved improvement of CSR-CSA, CSNA, cardiac symptoms/function, and exercise capacity in CHF patients with CSR-CSA.

Diastolic Stunning as a Marker of Severe Coronary Artery Stenosis: Analysis by Speckle Tracking Radial Strain in the Resting Echocardiogram.

BACKGROUND: Two-dimensional speckle tracking (2DST) stress echocardiography detects postischemic myocardial diastolic stunning. However, the use of 2DST at rest for detecting diastolic stunning in ischemia is unclear. RESULTS: Thirty-nine patients (age = 65 ± 12 years; male/female = 34/5) with effort angina pectoris that was confirmed by stress myocardial perfusion scintigraphy were enrolled. Ischemic area (I) was determined in the middle LV short axial view using stress myocardial scintigraphy. The area opposite to it was defined as nonischemic area (non-I). Midventricular parasternal short-axis (SAX) radial strains were estimated using 2DST at rest on the following day. LV diastolic function was evaluated using diastolic index (DI, changes in the regional LV radial strain during diastole) and radial strain rate (SR) during early diastolic period. These parameters were compared between I and non-I before and 1 month after percutaneous coronary intervention (PCI) in the I of 3 coronary vessels. For the I, the DI was lower (38 ± 27 vs. 55 ± 27; P = 0.003) and SR was higher (-1.6 ± 0.6 vs. -1.9 ± 0.8; P = 0.007) than in non-I before PCI. One month after PCI, the DI and SR recovered to 53 ± 27 (P = 0.008) and -2.1 ± 0.8 (P = 0.006), respectively. Furthermore, the DI of the LAD and LCX significantly improved (P = 0.0004 and 0.002, respectively); the RCA area showed tendency to improve (P = 0.092), and the SR also improved (P < 0.05) in all areas after PCI. CONCLUSION: Diastolic stunning in ischemic areas can be detected using 2DST at rest and recover 1 month after PCI.

Effect of physical training on ventilatory patterns during exercise in patients with heart disease.

BACKGROUND: Exercise training is known to improve the shortness of breath experienced by patients with heart disease when the ventilatory pattern becomes abnormal during exercise. However, the precise relationship between breathing patterns and the effect of exercise training has not been elucidated to date. We evaluated the relationship between the effect of exercise training on exercise tolerance and the amelioration of the ventilatory response during exercise in such patients. METHODS AND RESULTS: Patients with heart disease (n=170) underwent cardiopulmonary exercise testing twice (pre- and postexercise training for 3-6 months). They were divided into the exercise training group (Group E, n=123) and control group (Group C, n=47). Regression line relating tidal volume to respiratory rate (TV-RR slope) during a ramp protocol below the inflection point was regarded as an indicator of rapid ventilation. Tidal volume after the inflection point was regarded as an indicator of shallow ventilation (TV at plateau). The TV-RR slope and TV at plateau improved after exercise training from 94.8±45.9 to 129.9±69.5 (p<0.001) and from 1473.6±321.9mL to 1673.2±355.1mL (p<0.001), respectively, in Group E. In contrast, no improvement was evident in Group C. In total, %anaerobic threshold (%AT) [AT improving ratio=(post-AT-pre-AT)/pre-AT×100] was positively correlated with both %TV-RR slope [TV-RR slope improving ratio=(post-TV-RR slope-pre-TV-RR slope)/pre-TV-RR slope×100] (r=0.60) and %TV at plateau [TV at plateau improving ratio=(post-TV at plateau-pre-TV at plateau)/pre-TV at plateau×100] (r=0.51). CONCLUSION: Exercise training improved the rapidness and depth of breathing during exercise. Therefore, improvement of abnormal ventilatory patterns is correlated with exercise tolerance.

Coronary artery calcification as a new predictor of non-target lesion revascularization during the chronic phase after successful percutaneous coronary intervention.

In the drug-eluting stent era, the outcome of patients undergoing percutaneous coronary intervention (PCI) has remarkably improved. Nevertheless, non-target lesion revascularization (non-TLR) is often performed even after successful PCI and optimized medical therapy. This study aimed to determine the predictor of non-TLR. In all, 125 consecutive patients with stable angina pectoris underwent intravascular ultrasound (IVUS)-guided PCI and were followed up for 3.3 ± 0.5 years. We performed oral glucose-tolerance tests in patients with no history of known diabetes mellitus (DM) to investigate glucose tolerance. To evaluate the severity of coronary artery calcification (CAC), we calculated CAC score by multiplying the arc (degree) with the length (mm) of the superficial calcium deposit detected by IVUS. Fourteen patients underwent non-TLR (non-TLR group); the remaining 111 did not (reference group). Glycosylated hemoglobin (HbA1c; %) and prevalence of known DM were similar in both groups, but the non-TLR group had higher fasting blood glucose (103 ± 16 vs. 94 ± 11 mg/dl, p = 0.04) and blood glucose (196 ± 60 vs. 149 ± 48 µU/ml, p = 0.01) and insulin at 2 h (184 ± 241 vs. 67 ± 49 µU/ml, p < 0.01) than did the reference group. CAC score was significantly higher in the non-TLR group (788 ± 585 vs. 403 ± 466, p = 0.01). Multiple logistic analysis indicated that CAC score is an independent predictor of non-TLR (p = 0.008). Non-TLR-free rate was significantly higher for patients with CAC score ≥400 than for those with CAC score <400 (p = 0.01). Non-TLR is associated with abnormal glucose tolerance and CAC score; CAC score is an independent predictor of non-TLR. Secondary prevention is especially important in patients with high CAC scores.

Combination of ¹²³I-metaiodobenzylguanidine scintigraphy and flow-mediated dilation for the detection of patients with coronary spastic angina.

BACKGROUND: This study evaluated the usefulness of cardiac sympathetic nerve activity, estimated by (123)I-MIBG scintigraphy, and endothelial function, estimated by flow-mediated dilation (FMD), in the detection of coronary spastic angina (CSA). METHODS AND RESULTS: We compared 78 consecutive patients suspected of CSA with ten age-matched controls. On the basis of a spasm provocation test with acetylcholine, 53 patients were diagnosed as CSA and 25 patients were considered to have chest-pain syndrome (CPS). The total defect score (TDS) by delayed (123)I-MIBG scintigraphy was significantly higher in both patient groups than in controls (P < 0.05), and was significantly higher in CSA than in CPS patients (P = 0.02). The heart/mediastinum activity (H/M) ratio by delayed (123)I-MIBG scintigraphy and FMD were significantly lower in both patient groups than in controls (P < 0.05), and were lower in CSA than in CPS patients (P = 0.04). In receiver-operating curve analysis, the areas under the curve for TDS, H/M, and FMD were 0.78, 0.72, and 0.70, respectively. The combination of delayed (123)I-MIBG scintigraphy and FMD showed a higher diagnostic value than either method alone. CONCLUSIONS: (123)I-MIBG scintigraphy and FMD can distinguish CSA patients among patients complaining of chest pain at rest, with good sensitivity and specificity.

Relation between connective tissue growth factor and cardiac sympathetic nerve activity in heart failure in DCM patients.

Cardiac fibrosis is an important process of myocardial remodeling. Connective tissue growth factor (CTGF) is a cytokine that plays a key role in the occurrence of progressive fibrosis and excessive scarring. CTGF levels are increased in the failing heart. In addition, sympathetic nerve activity is enhanced in the failing heart, and exacerbates heart failure. To clarify the relation between cardiac sympathetic nerve activity and CTGF, we studied 35 (M/F = 28/7 patients) aged 57 ± 15 years with dilated cardiomyopathy (DCM). Cardiac sympathetic nerve activity was estimated from the total defect score (TDS) and from the H/M ratio and washout rate (WR) on I-123-MIBG imaging. Cardiac symptoms (NYHA class), exercise capacity (specific activity scale: SAS), brain natriuretic peptide (BNP), hemodynamics, and CTGF were assessed. There was a significant correlation between the CTGF and WR on I-123-MIBG (r = 0.45, P = 0.008). Also, a higher plasma CTGF level was associated with a lower SAS score (r = 0.51, P = 0.002), but not the TDS, H/M ratio, or BNP concentration. Moreover, a higher NYHA class and pulmonary artery wedge pressure were associated with a higher plasma CTGF level. The plasma CTGF level can be strongly related with cardiac sympathetic nerve activity in heart failure in DCM patients.

Olmesartan improves coronary flow reserve of hypertensive patients using coronary magnetic resonance imaging compared with amlodipine.

OBJECTIVES: Hypertension impairs coronary endothelial cell function, coronary microvascular function and the coronary flow (CF) reserve (CFR). Angiotensin II receptor blockers (ARBs) have been reported to possibly improve coronary endothelial function and coronary microvascular function. The purpose of this study was to determine whether treatment with the ARB olmesartan was more effective for improving CFR than the calcium channel blocker amlodipine. METHODS: Twenty patients with untreated essential hypertension (M/F = 13/7, aged 55.6 ± 11.6 years) were randomly assigned to treatment with either olmesartan (n = 10) or amlodipine (n = 10) for 6 months. CF was measured in the proximal left anterior descending artery by magnetic resonance imaging before and during intravenous infusion of adenosine. CFR was calculated as the ratio of the hyperemic to baseline diastolic peak flow before and after 6 months of treatment. RESULTS: The extent of systolic blood pressure reduction was similar in both groups (-40.0 ± 19.1 vs. -48.8 ± 14.7 mm Hg, p = 0.26). The olmesartan group showed significant improvement of CFR (from 1.9 ± 1.0 to 3.1 ± 1.1, p = 0.005), but this did not occur in the amlodipine group. CONCLUSION: Olmesartan, but not amlodipine, improves CFR in hypertensive patients.

Low-dose and long-term G-CSF treatment can improve severe myocardial ischemia in patients with severe coronary artery disease.

BACKGROUND: It has been reported that granulocyte colony-stimulating factor (G-CSF) can promote angiogenesis by mobilizing bone marrow stem cells to blood vessels. The purpose of this study is to clarify whether low-dose and long-term G-CSF treatment can improve severe myocardial ischemia. METHODS: We studied 40 patients (M/F = 29/11, age = 68 ± 9 years) who had severe coronary artery disease (7 with and 5 without old myocardial infarction; 3VD/2VD/1VD = 17/17/6) and severe myocardial ischemia with no indication for revascularization. G-CSF (1.5 µg/kg) was injected for 14 consecutive days. All patients were evaluated using stress myocardial scintigraphy, the Canadian Cardiovascular Society (CCVS) score, and cardiopulmonary exercise testing before and after 3 months of treatment. On 17 SPECT segments, the total defect score (TDS) and delta TDS (TDS (stress) minus TDS (resting)) were evaluated to assess the severity of myocardial ischemia. RESULTS: The changes in stress TDS, delta TDS, and regional wall motion score were significantly greater in the G-CSF group than the control group (P < .0001). The CCVS score improved significantly from baseline to the 3-month follow-up assessment in the G-CSF group (P < .0001). The increase of peak VO2 was significantly larger in the G-CSF group than the control group (P = .015). CONCLUSION: Low-dose and long-term G-CSF treatment can improve severe ischemia in patients with severe coronary artery disease.

Safety and efficacy of sirolimus-eluting stent implantation in patients with acute coronary syndrome in the real world.

The use of drug-eluting stents in patients with acute coronary syndrome (ACS), particularly those with acute myocardial infarction (AMI), is controversial owing to concerns about late adverse events. We evaluated the long-term safety of sirolimus-eluting stent implantation in patients with ACS. Of 10,778 patients treated exclusively with a sirolimus-eluting stent in the j-Cypher registry, the 3-year outcomes of 2,308 patients with ACS (953 patients with AMI) were compared to those of 8,470 patients without ACS. Compared to patients without ACS, the patients with ACS had a significantly greater adjusted risk of death or myocardial infarction (hazard ratio [HR] 1.24, 95% confidence interval [CI] 1.12 to 1.37, p <0.0001) and definite or probable stent thrombosis (HR 1.43, 95% CI 1.11 to 1.82, p = 0.006) within the first year after sirolimus-eluting stent implantation. However, after 1 year, patients with ACS no longer had a greater risk of death or myocardial infarction (HR 1.01, 95% CI 0.90 to 1.13, p = 0.87) and stent thrombosis (HR 1.32, 95% CI 0.92 to 1.86, p = 0.13). Of the patients with ACS, those with AMI had a greater risk of death or myocardial infarction (HR 1.33, 95% CI 1.12 to 1.6, p = 0.001) and stent thrombosis (HR 1.57, 95% CI 1.05 to 2.39, p = 0.03) than those with unstable angina pectoris within the first year. However, they had a similar risk of death or myocardial infarction (HR 1.00, 95% CI 0.78 to 1.22, p = 0.83) and stent thrombosis (HR 0.83, 95% CI 0.38 to 1.6, p = 0.59) after 1 year. The risk of late adverse events >1 year after sirolimus-eluting stent implantation was similar between those with and without ACS and between those with AMI and those with unstable angina pectoris.

Sirolimus-eluting stent versus balloon angioplasty for sirolimus-eluting stent restenosis: Insights from the j-Cypher Registry.

BACKGROUND: Optimal treatment strategies for restenosis of sirolimus-eluting stents (SES) have not been adequately addressed yet. METHODS AND RESULTS: During the 3-year follow-up of 12 824 patients enrolled in the j-Cypher registry, 1456 lesions in 1298 patients underwent target-lesion revascularization (TLR). Excluding 362 lesions undergoing TLR for stent thrombosis or TLR using treatment modalities other than SES or balloon angioplasty (BA), 1094 lesions with SES-associated restenosis in 990 patients treated with either SES (537 lesions) or BA (557 lesions) constituted the study population for the analysis of recurrent TLR and stent thrombosis after the first TLR. Excluding 24 patients with both SES- and BA-treated lesions, 966 patients constituted the analysis set for the mortality outcome. Cumulative incidence of recurrent TLR in the SES-treated restenosis lesions was significantly lower than that in the BA-treated restenosis lesions (23.8% versus 37.7% at 2 years after the first TLR; P<0.0001). Among 33 baseline variables evaluated, only hemodialysis was identified to be the independent risk factor for recurrent TLR by a multivariable logistic regression analysis. After adjusting for confounders, repeated SES implantation was associated with a strong treatment effect in preventing recurrent TLR over BA (odds ratio, 0.44; 95% confidence interval, 0.32 to 0.61; P<0.0001). The 2-year mortality and stent thrombosis rates between the SES- and the BA-treated groups were 10.4% versus 10.8% (P=0.4) and 0.6% versus 0.6%, respectively. CONCLUSIONS: Repeated implantation of SES for SES-associated restenosis is more effective in preventing recurrent TLR than treatment with BA, without evidence of safety concerns.

Transesophageal echocardiography for thrombus screening prior to left atrial catheter ablation.

BACKGROUND: Transesophageal echocardiography (TEE) is useful for detecting left atrial (LA) thrombus prior to percutaneous LA catheter ablation in patients with atrial fibrillation (AF). This study was designed to evaluate clinical predictors of LA thrombus and determine indications for TEE screening prior to LA ablation. METHODS AND RESULTS: The study consisted of 446 patients with drug-resistant AF who were scheduled to undergo initial LA ablation (age 59+/-11 years, 312 males, 136 persistent AF). TEE was performed in all cases within 24 h before ablation. We assessed clinical parameters including CHADS(2) score and echocardiographic parameters. LA thrombus was detected in 13 cases (2.9%) prior to LA ablation (67+/-8 years, 10 males, 12 persistent AF). In multiple logistic regression analysis, advanced age (odds ratio (OR) 1.1, 95% confidence interval (CI) 1.0-1.2; P<0.05), persistent AF (OR 38.1, 95%CI 1.4-988; P<0.05) and structural heart diseases (OR 29.8, 95%CI 2.8-383; P<0.01) were independent positive predictors of LA thrombus prior to ablation, while CHADS(2) score and LA volume were not significant predictors. None of the 136 patients with paroxysmal lone AF whose age was below 60 years had LA thrombus prior to ablation. CONCLUSIONS: It might be reasonable to omit TEE as a screening examination for LA thrombus prior to LA ablation in younger paroxysmal lone AF patients.

Hybrid therapy of radiofrequency catheter ablation and percutaneous transvenous mitral commissurotomy in patients with atrial fibrillation and mitral stenosis.

BACKGROUND: The rhythm control of atrial fibrillation (AF) associated with mitral stenosis (MS) is often difficult using antiarrhythmic drugs (AADs), even after a percutaneous transvenous mitral commissurotomy (PTMC). Few studies have examined the efficacy and safety of simultaneously performing radiofrequency catheter ablation (RFCA) and a PTMC in patients with MS and AF. METHODS: Twenty consecutive patients with drug-resistant AF and rheumatic MS underwent RFCA combined with a PTMC (n = 10; persistent AF-8, long-lasting [>1 year] persistent AF-2; RFCA group) or transthoracic direct cardioversion (DC) following a PTMC (n = 10; persistent AF-7, long-lasting persistent AF-3; DC group). In all patients, the mitral valve morphology was amenable to a PTMC, and more than 2 AADs had been ineffective in maintaining sinus rhythm (SR). In the RFCA group, a segmental pulmonary vein isolation (PVI) was performed in the initial 5 patients, and an extensive PVI was performed in the remaining 5. RESULTS: During a mean follow-up period of 4.0 +/- 2.7 years, 8 patients (80%) in the RFCA group were maintained in SR, as compared to 1 (10%) in the DC group (hazard ratio, 0.16; 95% confidence interval, 0.03 to 0.75; P = 0.008 by the log-rank test). The prevalence of the concomitant use of class I and/or class III AADs was comparable between the 2 groups (P = 0.70). No complications occurred during the procedure or follow-up period in either group. CONCLUSIONS: The hybrid therapy using RFCA and a PTMC was safe and feasible, and significantly improved the AF free survival rate compared to DC following a PTMC.

Levels of serum deoxyribonuclease I activity on admission in patients with acute myocardial infarction can be useful in predicting left ventricular enlargement due to remodeling.

OBJECTIVES: Serum deoxyribonuclease I (DNase I) activity has recently been highlighted as a potential diagnostic marker for the early detection of an acute myocardial infarction (AMI). We evaluated whether the serum DNase I activity was associated with the parameters of the left ventricular (LV) remodeling after an AMI. METHODS: We measured the serum DNase I activity in 45 patients with an AMI who were admitted to our hospital within approximately 4 h of the onset of their chest pain. We also evaluated the LV ejection fraction (LVEF), LV end-diastolic volume (LVEDV), and LV end-systolic volume (LVESV) of each patient by echocardiography at the time of admission and at 6 months after the onset of the AMI. RESULTS: The serum DNase I activity peaked at 3.5+/-2.0 h after the onset of the symptoms in the patients with an AMI, thereafter exhibiting a time-dependent decline within 12 h, and a return to the basal level within 24 h in almost all cases. Neither the LVEF, LVEDV, nor LVESV in each patient on admission exhibited a significant correlation to the peak levels of the serum DNase I activity. Although there was no correlation between the peak DNase I activity and LVEF at 6 months after the onset, a significant positive correlation of the peak DNase I activity with LVEDV and LVESV (r=0.48, p<0.001 and r=0.34, p=0.02, respectively) was found. Furthermore, the LVEDV at 6 months after the onset in the high DNase I activity group (> 17.9 U/L) were significantly higher than those in the low DNase I activity group (< or = 17.9 U/L) (118.0+/-28.2 ml vs 89.3+/-25.4 ml, p=0.026). CONCLUSIONS: The serum DNase I activity level may predict LV enlargement associated with remodeling after an AMI.

Effectiveness of nocturnal home oxygen therapy to improve exercise capacity, cardiac function and cardiac sympathetic nerve activity in patients with chronic heart failure and central sleep apnea.

BACKGROUND: Central sleep apnea, often found in patients with chronic heart failure (CHF), has a high risk of poor prognosis. METHODS AND RESULTS: This study involved 20 patients with CHF (left ventricular ejection fraction (LVEF) <45%, M/F =19/1, age 65+/-10 years) and an apnea-hypopnea index (AHI) >5 times/h who were divided into 2 groups: 10 patients treated with nocturnal home oxygen therapy (HOT) and 10 patients without HOT (non-HOT). All patients had dilated cardiomyopathy and underwent overnight polysomnography, cardiopulmonary exercise testing, and nuclear cardiac examinations to evaluate AHI, exercise capacity according to the specific activity scale and oxygen uptake at anaerobic threshold and peak exercise (peak VO(2)). Cardiac function according to (99m)Tc-MIBI QGS, and the total defect score (TDS), H/M ratio and the washout rate (WR) on (123)I-metaiodobenzylguanidine (MIBG) imaging were calculated for all patients. As compared with the non-HOT group, the HOT group demonstrated a greater reduction in AHI (26.1+/-9.1 to 5.1+/-3.4), (123)I-MIBG TDS (31+/-8 to 25+/-9), and (123)I-MIBG WR (48+/-8% to 41+/-5%) and a greater increase in the specific activity scale (4.0+/-0.9 to 5.8+/-1.2 Mets), peak VO(2) (16.0+/-3.8 to 18.3+/-4.7 ml . min(-1) . kg(-1)), and LVEF (27+/-9% to 37+/-10%). CONCLUSIONS: HOT improves exercise capacity, cardiac function, and cardiac sympathetic nerve activity in patients with CHF and central sleep apnea.

Important factors for salvaging myocardium in patients with acute myocardial infarction.

BACKGROUND: This study was designed to evaluate the factors that affect myocardial salvage after percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI). METHODS AND RESULTS: One hundred and eighty-three patients with AMI who had undergone successful PCI were recruited for this study. Patients underwent (99m)Tc-pyrophosphate single photon emission computed tomography (SPECT) on the third day and (99m)Tc-MIBI SPECT on the sixth day after admission. In the 20 SPECT segments, the summed defect score (TDS) and extent score (ES) of AMI segments were determined and the percentage of the salvaged myocardium was calculated based on the TDS and ES. We performed multivariate analysis to evaluate factors that can affect myocardial salvage. Multivariate analysis was performed among the value of myocardial salvage rate and the 15 clinical variables. Administration of nicorandil (p=0.006), prodromal angina (p<0.001), and high TIMI grade (p<0.001) had significant positive correlation to myocardial salvage rate. Use of a distal protection device had a significant negative correlation with myocardial salvage rate (p=0.006). CONCLUSIONS: The presence of high TIMI grade before PCI and prodromal angina are very important for salvaging myocardium. Furthermore, administration of nicorandil is important in salvaging myocardium in patients with AMI.

Combined therapy with carvedilol and amiodarone is more effective in improving cardiac symptoms, function, and sympathetic nerve activity in patients with dilated cardiomyopathy: comparison with carvedilol therapy alone.

BACKGROUND: Carvedilol therapy has been reported to be more effective than other beta-blockers in patients with chronic heart failure (CHF). Amiodarone is an anti-arrhythmic medicine that has also been reported to be effective in patients with CHF. But the usefulness of combined therapy with carvedilol and amiodarone has not been reported. METHODS: We compared 15 patients (M/F = 3/12, age = 57 +/- 8 y) with dilated cardiomyopathy (DCM) receiving carvedilol and amiodarone with 15 patients (M/F = 3/12, age = 61 +/- 9 y) receiving carvedilol alone. Patients were studied before and after 1 year of treatment (1Y). NYHA class and exercise capacity based on the specific-activity-scale (SAS), were assessed. Cardiac sympathetic nerve activity was estimated using total defect score (TDS), H/M ratio and washout rate (WR) of 123I-MIBG imaging. Cardiac function was evaluated using 99mTc-MIBI QGS. RESULTS: Combined therapy improved several parameters much more than carvedilol alone (p < 0.05) including delta-TDS (15.0 +/- 8.6 vs. 7.6 +/- 7.2) and delta-WR (15.9 +/- 11.0% vs. 7.3 +/- 10.0%) for 123I-MIBG imaging, delta-LVEF (26.1 +/- 11.4% vs. 15.5 +/- 13.8%), delta-end-systolic volume (100 +/- 63.8 ml vs. 58.9 +/- 47.3 ml), 1Y NYHA class (1.5 +/- 0.5 vs. 1.9 +/- 0.5), 1Y SAS (7.3 +/- 0.7 Mets vs. 6.2 +/- 1.0 Mets), and delta-SAS (3.4 +/- 0.8 Mets vs. 2.6 +/- 1.1 Mets). CONCLUSION: Combined therapy with carvedilol and amiodarone is more effective in improving cardiac symptoms, exercise capacity, cardiac function and cardiac sympathetic nerve activity in patients with DCM.

Impact of lesion calcification on clinical and angiographic outcome after sirolimus-eluting stent implantation in real-world patients.

BACKGROUND: Previous studies have demonstrated similar efficacy of the drug-eluting stent (DES) in patients with and without calcified lesions. However, most of the randomized trials have excluded patients with severe calcified lesions. This study aimed to examine the impact of lesion calcium on clinical and angiographic outcome after sirolimus-eluting stent (SES) implantation in real-world patients. METHODS: Consecutive 380 patients with 556 lesions treated with SES were enrolled. Lesions were divided into Calc lesions (moderate or sever calcification; 195 lesions) and non-Calc lesions (none or mild calcification; 361 lesions) according to the lesion calcium. Quantitative coronary angiography (QCA) parameters, binary restenosis rate (%restenosis), target lesion revascularization (TLR) rate, and major adverse cardiac events (MACE) during follow-up were compared between the two groups. All patients were contacted at 1, 6, and 12 months after the procedure. RESULTS: Lesion success rate was similar in the two groups. %Restenosis (9.2% vs. 3.6%; P<.05) and TLR (7.3% vs. 2.8%; P<.05) were significantly higher in Calc lesions. Stent thrombosis was observed in 0.7% of overall lesions with no difference between the two groups. The MACE rate in Calc patients (13.8%) was significantly higher than in non-Calc patients (6.1%). By multivariate analysis, hemodialysis (HD) and requirement of rotational atherectomy (RA) were predictive factors of TLR in the Calc lesions. CONCLUSIONS: Coronary lesions with calcification comprise a high-risk cohort and are associated with a higher TLR and binary restenosis rates in real-world patients treated with SES. Moreover, patients with calcified lesions and on HD are associated with higher MACE rate.

Usefulness of virtual histology intravascular ultrasound to predict distal embolization for ST-segment elevation myocardial infarction.

OBJECTIVES: We aimed to predict the high-risk plaque of distal embolization after stent deployment in patients with acute ST-segment elevation myocardial infarction (STEMI) with Virtual Histology intravascular ultrasound (VH-IVUS) (Volcano Therapeutics, Inc., Rancho Cordova, California). BACKGROUND: Distal embolization during primary percutaneous coronary intervention (PCI) carries a poor prognosis in patients with STEMI. However, it is unclear which plaque characteristics cause distal embolization after stent deployment. METHODS: A total of 71 patients with STEMI were included prospectively. All patients underwent primary PCI within 12 h of symptom onset. After crossing the lesion with a guidewire and performing thrombectomy with an aspiration catheter, VH-IVUS of the infarct-related vessel was performed. Stent deployment was then undertaken without embolic protection. ST-segment re-elevation (STR) was used to evaluate distal embolization. Correlations among plaque characteristics, morphology, and distal embolization were analyzed. RESULTS: The STR after stent deployment was observed in 11 patients (STR group, 15.5%). Necrotic core volume was significantly higher in the STR group than in the non-STR group (32.9 +/- 14.1 mm3 vs. 20.4 +/- 19.1 mm3, p < 0.05). Total plaque volume was similar in both groups. On receiver-operating characteristic analysis, necrotic core volume clearly predicted STR after stent deployment as compared with fibrous, fibro-lipid, dense calcium, and total plaque volumes. The necrotic core volume that was best predictive for STR was 33.4 mm3, with a sensitivity of 81.7% and a specificity of 63.6%. CONCLUSIONS: Virtual Histology IVUS is a useful means of predicting the risk of distal embolization after primary stent deployment in patients with STEMI.