Low Consultation Rate of General Population with Atrial Fibrillation.

In order to prevent ischemic stroke, it is important to identify and treat patients with atrial fibrillation (AF) who do not consult a doctor in a medical institution. The aim of this study was to determine the consultation rate at medical institutions for patients with AF in group medical examinations conducted in a city in western Japan. Of 6101 examinees of group medical examinations (40 years of age or older) conducted in Ibara City, Okayama Prefecture, Japan, from 2012 to 2014, 4338 participants (71.1%) who were evaluated by electrocardiogram (ECG) gave written informed consent and responded to surveys in the form of questionnaires through a personal interview conducted by nurses were included in the Ibara-AF study. A cumulative total of 82 subjects were diagnosed as having AF by ECG (prevalence of AF = 1.89%), and 51 individuals had AF during the three-year period.15 (29.4%) of the 51 patients with AF did not regularly visit medical institutions. Among them, 46.7% (n = 7) and 53.3% (n = 8) of the patients were symptomatic and asymptomatic, respectively, and 73.3% of the patients had a CHADS2 score of more than one point. There were no significant differences in patients' characteristics between regular and non-regular visit groups. In conclusion, about one-third of the patients with AF did not regularly see a doctor in a medical institution and most of them had a CHADS2 score of more than one point in a Japanese rural area. Educating the public about the risks of AF is required.

Clinical features of acute myocardial infarction in elderly patients.

The aim of this study was to clarify the prevalence of coronary risk factors in order to characterize the prognostic factors in elderly patients and to also identify any factors beneficial for the prevention of further cardiac events and death. We studied 888 patients with ST-elevation acute myocardial infarction who were admitted within 48 h of symptom onset. The patients were divided into 3 groups according to age for comparison of variables:a younger group (n＝99) aged ≤ 50, a middle-aged group (n＝435) ≥ 51 years but＜70 years and an elderly group (n＝354) aged ≥ 71 years. The elderly group had higher rates of female gender, pulmonary congestion, in-hospital mortality, and atrial fibrillation and a higher plasma concentration of high-sensitivity CRP (hs-CRP) (p＜0.05). Hypertension, diabetes mellitus, and dyslipidemia were more common in the middle-aged group (p＜0.05). The prevalence of smokers and the plasma level of total cholesterol, LDL-cholesterol and triglycerides were lower in the elderly group (p＜0.05). The grade of collateral circulation was highest in the elderly group, but the success rate of reperfusion therapy was lowest. Multiple regression analysis showed that age, pulmonary congestion, CKD and hs-CRP were predictors of in-hospital mortality. This investigation indicated that elderly patients with acute myocardial infarction have different clinical characteristics than younger patients. A specific algorithm might be needed in elderly patients, and could use hs-CRP, eGFR and atrial fibrillation as factors.

Sex difference of in-hospital mortality in patients with acute myocardial infarction.

Factors contributing to the sex difference of in-hospital mortality after acute myocardial infarction (MI) are still unknown. We compared the clinical characteristics on admission and in-hospital outcome of consecutive 1,354 patients with acute MI between the 2 sexes. Age on admission was about 7 years older in women than in men. In-hospital death was significantly more frequent in women. Pulmonary congestion and hypertension were more likely in women with higher serum levels of total cholesterol and LDL cholesterol. A higher prevalence of current smoking and inferior wall involvement and lower serum HDL cholesterol level were observed in man. After adjusting for age, adverse in-hospital mortality for women was observed in both younger and older patients. Multivariate logistic regression analysis demonstrated that age, location of infarction, recanalization and serum C-reactive protein (CRP) concentration were independent predictors for in-hospital mortality for overall patients, while age and recanalization were independent predictors for male gender, and pulmonary congestion and serum CRP concentration were independent predictors for female gender. In-hospital outcome after acute MI was worse in women. A multivariate logistic regression model revealed that the sexually different factors affected in-hospital mortality in females.

Incidence and outcomes of out-of-hospital cardiac arrest in the eastern part of Yamaguchi prefecture.

The aim of the present study was to evaluate the factors related to poor prognosis of out-of-hospital cardiac arrest patients in one local area of Japan. From May 1, 2002 to April 30, 2008, a total of 442 patients with cardiopulmonary arrest were transferred for resuscitation to the National Hospital Organization, Iwakuni Clinical Center. Of 325 patients with cardiopulmonary arrest of cardiac etiology, 126 patients were witnessed by a bystander. However, only 37 received bystander cardiopulmonary resuscitation, 13 had shockable cardiac rhythm, 3 survived 1 month, and 2 had a good neurological discharge. Multivariate analysis of overall cardiac arrest showed that 1-month survival and neurologically favorable discharge were associated with bystander cardiopulmonary resuscitation (P=0.049 and 0.013) and initial shockable cardiac rhythm (P=0.001 and 0.007). In this region, the survival rate for patients with cardiopulmonary arrest was lower than that reported in other areas, probably because fewer patients received bystander CPR or had shockable cardiac rhythm. This may result from CPR being less popularized in this region than in other areas, suggesting that raising the awareness of CPR would improve the survival rate.

Prognostic significance of right bundle branch block in patients with acute inferior myocardial infarction.

There is little information available concerning the influence of right bundle branch block (RBBB) on the prognosis of patients with inferior myocardial infarction (MI). In this study we evaluated the influence of RBBB on the short-term prognosis of patients with inferior MI. Our study subjects were 1,265 hospitalized patients with Q wave MI. Patients were divided into 4 groups based on the presence or absence of RBBB and on the location of the infarction. RBBB was classified into 4 categories according to the timing of its appearance and its duration as new permanent, transient, old and age indeterminate. In-hospital death and pulmonary congestion were observed more frequently in patients with RBBB than in those without RBBB. Moreover, in inferior MI as in anterior MI, in-hospital death and pulmonary congestion occurred more frequently in new permanent RBBB patients than in patients with other types of RBBB. Multivariate regression analysis reveals that new permanent RBBB was a strong independent predictor for an adverse short-term prognosis in patients with inferior MI, as well as in patients with anterior MI. New permanent RBBB during inferior MI is a strong independent predictor for increased in-hospital mortality, regardless of the infarction location.

Complete atrioventricular block secondary to lithium therapy.

Sinus node dysfunction has been reported most frequently among the adverse cardiovascular effects of lithium. In the present case, complete atrioventricular (AV) block with syncopal attacks developed secondary to lithium therapy, necessitating permanent pacemaker implantation. Serum lithium levels remained under or within the therapeutic range during the syncopal attacks. Lithium should be used with extreme caution, especially in patients with mild disturbance of AV conduction.

Postprandial hypotension due to a lack of sympathetic compensation in patients with diabetes mellitus.

Postprandial hypotension is an important hemodynamic abnormality in diabetes mellitus, but few reports are available on the relationship between autonomic dysfunction and postprandial hypotension. Ten diabetic patients and 10 healthy volunteers were recruited for this study. Postural blood pressure and heart rate changes were measured before lunch, and then the hemodynamic responses to a standardized meal were investigated. Holter electrocardiogram (ECG) monitoring was conducted for assessing spectral powers and time-domain parameters of RR variations. Postural changes from the supine to the upright position decreased the systolic blood pressure of the diabetics from 133(+/-)16 to 107(+/-)20 mmHg (p<0.01), but did not decrease the systolic blood pressure of the controls. The heart rate remained constant in the diabetics but was increased in the controls. Food ingestion decreased systolic blood pressure in the diabetics, with a maximum reduction of 25(+/-)5 mmHg. This decrease was not associated with any changes in the ratio of low frequency to high frequency, and yet the heart rate remained almost constant. Indexes involving parasympathetic tone were not affected. Food ingestion did not affect blood pressure in the control group. These findings suggest that lack of compensatory sympathetic activation is a factor contributing to postprandial hypotension in diabetics, and that parasympathetic drive does not make a significant contribution to this condition.

[Highly concentrated vascular endothelial growth factor in Crow-Fukase syndrome with high output heart failure: a case report].

Crow-Fukase syndrome is a disease of plasma cell dyscrasia. Congestive heart failure is the biggest complication affecting the prognosis. A 57-year-old male was admitted with edema and low grade fever. Globe and stocking type polyneuropathy, increased levels of adrenocorticotropic hormone and thyroid-stimulating hormone, serum M-protein component of the immunoglobulin A-lambda type, skin polypoid lesion, and organomegaly including cardiomegaly were observed. The diagnosis was Crow-Fukase syndrome based on these clinical features. High output heart failure and pulmonary hypertension were determined with a cardiac catheter. Diuretics and angiotensin converting enzyme inhibitor were effective to control his overhydration. The level of serum vascular endothelial growth factor was markedly increased and might be responsible for the manifestation of this syndrome with cardiac involvement.

Effect of short-term administration of high dose L-arginine on restenosis after percutaneous transluminal coronary angioplasty.

BACKGROUND: A single and local administration of L-arginine after balloon angioplasty enhances nitric oxide (NO) generation and inhibits lesion formation in animals. OBJECTIVES: The present study assessed the effect of increasing NO to inhibit restenosis after percutaneous transluminal coronary angioplasty (PTCA) in humans by local and systemic administration of L-arginine, a precursor of NO in humans. METHODS: L-arginine was administered to 34 consecutive patients with angina pectoris or old myocardial infarction via a cardiac catheter (500 mg/4 min) before PTCA, and via a peripheral vein (30 g/4 hr, for 5 days) after PTCA. Patients were treated between December 1998 and December 2000. Plasma concentrations of L-arginine, NO (as nitrite + nitrate) and cyclic guanosine monophosphate (cGMP) were measured before and after L-arginine administration. The control group consisted of 90 patients who underwent PTCA successfully without L-arginine administration in the period between July 1996 and November 1998. Baseline clinical and angiographic characteristics were compared between the two groups. All patients were followed by coronary angiography for 3 months after PTCA. Quantitative coronary angiography and restenosis rate were studied. RESULTS: Baseline clinical and angiographic characteristics were not different between the two study groups. Despite a significant elevation in plasma L-arginine concentration after L-arginine administration, NO and cGMP did not increase significantly. After PTCA, the difference in restenosis rates between L-arginine and control subjects (34% vs 44%) was not significantly different. CONCLUSIONS: Short-term administration of high dose L-arginine did not significantly change the restenosis rate after PTCA.

Risk factors indicating recurrent myocardial infarction after recovery from acute myocardial infarction.

Little is known of the risk factors of recurrent myocardial infarction (MI) among Japanese patients who have survived their first MI. The risk factors for the second MI were studied in 808 of 1,042 consecutive patients who recovered from an acute MI in Iwakuni National Hospital. Multivariate logistic regression analysis revealed that only 3 of 21 variables measured were closely related with the recurrence of MI during a follow-up period of 3.2 +/- 4.3 years: (1) transient atrial fibrillation (relative risk (RR) 3.16), (2) previous cerebrovascular accident (RR 3.05), and (3) dyslipidemia (RR 2.19). Of the parameters of dyslipidemia, a low ratio of high-density lipoprotein-cholesterol (HDL-C) to low-density lipoprotein-cholesterol (LDL-C) alone indicated subsequent MI. None of age, gender, location of the infarction, hypertension, diabetes mellitus, pulmonary congestion (Killip's class > or = 2), peak serum creatine kinase activity, serum total-cholesterol, HDL- and LDL-cholesterol levels, nor smoking habit on admission was a statistically significant predictor for the second MI. The result suggests that more intensive treatment is needed for patients with the 3 risk factors.