Cardiac Structure and Cardiorespiratory Fitness in Young Male Japanese Rugby Athletes.

Limited data are available on athlete's heart for rugby athletes. This study aimed to investigate cardiac structure and its relationship with cardiorespiratory fitness in young Japanese rugby athletes. A prospective cross-sectional study using echocardiography and cardiopulmonary exercise testing (CPET) was conducted on 114 male collegiate rugby players. There was a higher prevalence of increased left ventricular (LV), atrial, and aortic dimensions in the young athletes than that in previously published reports, whereas the wall thickness was within the normal range. Anthropometry and CPET analyses indicated that the forwards and backs presented muscular and endurance phenotypes, respectively. Indexed LV and aortic dimensions were significantly larger in the backs than in the forwards, and the dimensions significantly correlated with oxygen uptake measured by CPET. On the four-tiered classification for LV hypertrophy, abnormal LV geometry was found in 16% of the athletes. Notably, the resting systolic blood pressure was significantly higher in athletes with concentric abnormal geometry than in the other geometry groups, regardless of their field positions. Japanese young athletes may exhibit unique phenotypes of cardiac remodeling in association with their fitness characteristics. The four-tiered LV geometry classification potentially offers information regarding the subclinical cardiovascular risks of young athletes.

Subacute Stent Thrombosis After Primary Percutaneous Coronary Intervention in a Middle-Aged Anabolic Steroid-Abusing Bodybuilder.

A 54-year-old male bodybuilder who was abusing anabolic steroids developed an acute ST-segment elevation myocardial infarction after strenuous strength training. Despite optimal use of dual antiplatelet therapy, on day 4 after primary coronary stenting, the patient suffered another acute coronary event due to subacute thrombosis, potentially pre-disposed by anabolic steroid use. (Level of Difficulty: Intermediate.).

Impact of Exercise-Based Cardiac Rehabilitation on the Mid-Term Outcomes of Patients After Acute Myocardial Infarction Treated With Current Acute-Phase Management and Optimal Medical Therapy.

BACKGROUND: Early reported beneficial effects of cardiac rehabilitation (CR) have recently been disputed. The present study aimed to investigate the clinical impact of CR on the mid-term outcomes of patients following ST-segment elevation myocardial infarction (STEMI) treated with currently available management. METHODS: This study reviewed 145 consecutive patients who underwent primary coronary intervention and were discharged without any disability after STEMI during 2013-2015. RESULTS: Among the patients, 66 (45.5%) completed an outpatient CR program (CR group) and 79 were their non-CR counterparts or patients who dropped out of the program (N-D group). There were no between-group differences in patient demographics and clinical profiles, including door-to-balloon times and prescriptions. A total of 27 patients developed major adverse cardiac and cerebrovascular events (MACCE) during follow-up. The MACCE-free survival rates were 88% and 76% in the CR and N-D groups, respectively (log-rank, p=0.04). Cox proportional analysis demonstrated that inclusion in the N-D group was a significant predictor of MACCEs (HR, 2.36; 95% CI, 1.07-5.74; p=0.03). In the CR group, peak oxygen consumption and ventilatory efficiency determined by cardiopulmonary exercise testing significantly improved after the program (p<0.01). CONCLUSIONS: The impact of CR on the mid-term prognosis of patients with STEMI, even in the current myocardial infarction management era, was beneficial.

Potential Association of Circulating MicroRNA-181c and MicroRNA-484 Levels with Cardiorespiratory Fitness after Myocardial Infarction: A Pilot Study.

OBJECTIVES: In the field of exercise physiology, there has been great interest in exploring circulating microRNAs (miRs) as potential biomarkers. However, it remains to be determined whether circulating miRs reflect cardiorespiratory fitness. The aim of this study was to investigate the association between circulating levels of specific miRs and cardiorespiratory fitness evaluated by cardiopulmonary exercise testing (CPET) after acute myocardial infarction (MI). METHODS: Twenty patients who had had an acute MI were included. All patients underwent CPET in the convalescent phase. Quantitative real-time polymerase chain reaction analyses for miR-181 members (a/b/c) and miR-484 were performed to determine the expression levels in the peripheral blood of the included patients and healthy control subjects (n=5). RESULTS: Post-MI patients showed impaired exercise tolerance and ventilatory efficiency in CPET analysis. Compared with controls, circulating levels of miR-181a and 181c were gradually and significantly elevated through the 1st to 7th days after acute MI, whereas miR-181b and miR-484 were not. Circulating miR levels did not correlate with clinical or echocardiographic parameters. However, circulating levels of miR-181c and miR-484 on the 7th day showed significant positive correlations with the anaerobic threshold and peak oxygen consumption from CPET analysis. Moreover, miR-181c levels were inversely associated with the ventilatory inefficiency index. Patients with high exercise capacity after MI showed significantly higher expressions of circulating miR-181c and miR-484 than those with low exercise capacity. CONCLUSIONS: The results of this pilot study suggest that circulating levels of miR-181c and miR-484 after acute MI may be predictive biomarkers of post-MI cardiorespiratory fitness.

The Prognostic Value of Left Atrial Reservoir Functional Indices Measured by Three-Dimensional Speckle-Tracking Echocardiography for Major Cardiovascular Events.

BACKGROUND: Left atrial (LA) volume and left ventricular longitudinal strain (LVLS) have significant prognostic values for major cardiovascular events (MACEs). Prognostic values of LA reservoir functional indices measured by 3-dimensional (3D) speckle-tracking echocardiography (STE) were evaluated.Methods and Results:A total of 264 patients, who underwent 2-dimensional (2D) echocardiography and 3DSTE for various underlying heart diseases, were followed up to record MACE. After a mean follow up of 547±435 days, 30 patients developed MACE: 7 cardiac deaths, 6 strokes, 1 non-fatal myocardial infarction, and 22 admissions for heart failure (5 of these had cardiac death after discharge, whereas 1 sustained stroke after discharge). Receiver operating characteristic curve analysis was performed to determine the optimal cut-off levels of 4 LA functional indices: LA emptying fraction (LAEmpF), LA longitudinal strain (LALS), LA circumferential strain (LACS), and LA area change ratio (LAAC), using 3DSTE. Among these factors, 2DLVLS, 3DLAEmpF, and 3DLALS demonstrated a higher hazard ratio (>5.0) than other variables. The 3DLAEmpF and 3DLALS had a higher average treatment effect (ATE) and ATE on the treated (ATT), respectively, than the other indices after propensity score matching. Addition of 3DLAEmpF to the base model using clinical variables and LV ejection fraction or 2DLVLS demonstrated higher prognostic power. CONCLUSIONS: LAEmpF calculated using 3DSTE possessed additive prognostic values for the prediction of MACE.

Optimal timing of echocardiography for heart failure inpatients in Japanese institutions: OPTIMAL Study.

AIMS: Guidelines for the diagnosis and treatment of acute and chronic heart failure (HF) provided by the European Society of Cardiology state that echocardiography is recommended for the assessment of the myocardial structure and function of subjects with suspected HF including HF with reduced (HFrEF), mid-range (HFmrEF), and preserved ejection fraction (HFpEF) as class I of recommendation and level C of evidence. However, the impact of timing of echocardiography on survival for hospitalized HF patients or the prevalence of echocardiography during their stay has not yet been fully investigated. Therefore, we designed and conducted a prospective multicentre study, Optimal Timing of Echocardiography for Heart Failure Inpatients in Japanese Institutions (OPTIMAL) study, to investigate and evaluate the prevalence of echocardiography during the in-hospital stay of HF patients, and the impact of timing of echocardiography on their survival. METHODS AND RESULTS: OPTIMAL was based on a nationwide, prospective, multicentre registry at 10 institutions in Japan endorsed by the Japanese Society of Echocardiography. A total of 601 patients hospitalized with HF were enrolled between August 2016 and July 2018 at the participating centres. Their mean age was 73.9 ± 13.0 years, left ventricular ejection fraction was 37.0% (26.0-50.0), and 256 patients (42.6%) were female. Admission echocardiography (admission echo) was categorized as either standard or point-of-care echocardiography performed within 3 days of admission, as was pre-discharge echocardiography (pre-discharge echo) within 3 days of discharge. The primary endpoint was defined as cardiovascular death over a median follow-up period of 18.9 months (9.3-26.5 months). Admission echo was performed for 476 patients (79.2%) and pre-discharge echo for 216 patients (35.9%). The primary endpoint of cardiovascular death occurred in 65 patients (10.8%). Kaplan-Meier curve findings indicated that survival of patients with pre-discharge echo was significantly better than that of patients without it (log-rank P < 0.001), and the same findings were obtained for patients with HFrEF, HFmrEF, and HFpEF. However, survival of patients with and without admission echo was similar (log-rank P = 0.33). CONCLUSIONS: This OPTIMAL study prospectively showed the importance of pre-discharge echo for hospitalized HF patients. Careful attention is needed regarding the haemodynamic status of HF patients by administering pre-discharge echo to avoid HF re-hospitalization after discharge, and pre-discharge echo may provide additional information for deciding the appropriate discharge time. Our findings may thus offer a new insight into the management of hospitalized HF patients.

Association of Potentially Inappropriate Medications With All-Cause Mortality in the Elderly Acute Decompensated Heart Failure Patients: Importance of Nonsteroidal Anti-Inflammatory Drug Prescription.

BACKGROUND: Acute decompensated heart failure (ADHF) is the most common cause of readmissions in the hospital. ADHF patients are associated with polypharmacy. It is a common problem among elderly patients due to frequently occurring multiple morbidities and is associated with the use of potentially inappropriate medications (PIMs). The aim of this study was to examine the association between PIMs and all-cause mortality in elderly ADHF patients. METHODS: This retrospective study included ADHF patients who were admitted to the Showa University Fujigaoka Hospital between January 2015 and August 2016. We investigated the proportion of patients taking at least one PIM at admission and the characteristics of patients at admission. PIMs were defined based on the Screening Tool of Older People's potentially inappropriate Prescriptions (STOPP). Multiple Cox regression analysis was performed to examine the association between PIM use and all-cause mortality. RESULTS: A total of 193 elderly patients (median age 81 years, interquartile range (IQR) 65 - 99 years) were included in the study. All-cause death occurred in 30 patients. The median number of medications at admission was 7 (IQR 0 - 18). The number of medications (greater than or equal to six) at admission was associated with mortality. Multivariate Cox regression analysis revealed that systolic blood pressure (SBP) < 100 mm Hg at admission, chronic obstructive pulmonary disease (COPD), and use of non-steroidal anti-inflammatory drugs (NSAIDs) at admission were independent predictors for all-cause mortality. CONCLUSIONS: The medical staff should attempt to stop unnecessary medications that are prone to be inappropriate prescribing. In particular, prescription of NSAIDs should be carefully assessed and monitored.

Prognostic Value of Left Atrial Size and Functional Indices Measured by 3-Dimensional Speckle-Tracking Analysis.

BACKGROUND: The prognostic value of indices for left atrial volumes (LAV) and reservoir function measured by 3D speckle-tracking analysis (3DSTA) has not been determined. Methods and Results: LA maximal and minimal volume indices (LAVImax, LAVImin), and LA emptying fraction (LAEmpF) were measured via 2D echocardiography (2DE) and 3DSTA in 514 patients (62% male, mean age: 66±15 years) with various cardiovascular diseases. Two cutoff values using normal±2SD (cutoff criterion 1) and receiver-operating characteristic analysis (cutoff criterion 2) were evaluated. During a mean follow-up of 720±383 days, MACE (cardiac death, nonfatal myocardial infarction, stroke and admission for heart failure) occurred in 98 patients. Kaplan-Meier survival analysis showed both cutoff criteria measured by 2DE and 3DSTA had significant predictive power for MACE (P<0.001). For cutoff criterion 1, 3DSTA measurements yielded higher hazard ratios than 2DE by Cox proportional hazard model. Cutoff criterion 2 using 3DSTA had higher average treatment effect values than 2DE by matching propensity scores on the outcome. Further, a regression model that included clinical variables, left ventricular ejection fraction and cutoff criterion 2 using 3DSTA-derived LAEmpF had significantly higher prognostic power than 2DE. CONCLUSIONS: LA indices measured by 3DSTA had greater prognostic power for future MACE than 2DE. In particular, 3DSTA-derived LAEmpF has the potential to be a valuable prognostic tool in clinical settings.

Long-Term Effects of Enzyme Replacement Therapy for Anderson-Fabry Disease.

Anderson-Fabry disease is a rare X-linked lysosomal storage disease caused by α-galactosidase A (α-GalA) gene variants and characterized by a large genotypic and phenotypic spectrum. Enzyme replacement therapy (ERT) using recombinant α-GalA has been approved for > 10 years as a specific therapy for the disease. However, the long-term clinical efficacy for cardiac manifestations has been equivocal because it depends on several factors such as genotype, sex, age, and disease severity at the initiation of ERT. We report the differences in the clinical effects of ERT continued for > 10 years in three patients with the same genotype. Left ventricular hypertrophy and myocardial dysfunction progressed in the heterozygote proband even under ERT, although disease progression was prevented in two sons of Case 1.

Cardiac Sarcoidosis Mimicking Septal Tumor with Intermittent Complete Atrioventricular Block.

A 52-year-old woman with intermittent complete atrioventricular (AV) block detected on exercise was admitted to the hospital. Echocardiography revealed lesions on the right ventricular side of the interventricular septum and free wall of the basal inferolateral area. Gadolinium-enhanced cardiovascular magnetic resonance (CMR) imaging revealed the mass and wall thickening at the same locations with late gadolinium enhancement (LGE). Focal uptake at the septal lesion was detected using 67Ga scintigraphy. Focal on diffuse intense uptake in the lesions was observed on Fluorine-18 fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) imaging. Whole-body CT and laboratory evaluations uncovered no signs of malignant tumors in other organs. Ophthalmologic evaluation revealed ophthalmologic sarcoidosis. Although the result of endomyocardial biopsy was negative, the presence of cardiac sarcoidosis was strongly suggested on the basis of the new Japanese guidelines published in 2017. AV conduction disturbance and tracer accumulation on 67Ga scintigraphy completely disappeared after 2 weeks of steroid therapy. The size of mass, inferolateral wall thickness in echocardiography and CMR, and standardized uptake value (SUV) of the masses on 18F-FDG PET also decreased over time.

Clinical impact of undersized- versus oversized-stenting approaches in ST-elevation myocardial infarction.

BACKGROUND: Primary percutaneous coronary intervention (PCI) is the standard treatment in patients with ST-elevation myocardial infarction (STEMI). However, some patients still develop ST re-elevation during PCI, resulting in further myocardial damage and a poor outcome. An undersized-stenting approach may prevent ST re-elevation. We aimed to determine the association between final stent area and ST re-elevation during primary PCI for STEMI. METHODS: Overall, 102 consecutive STEMI patients who underwent primary PCI under integrated backscatter intravascular ultrasound guidance were enrolled. The stent-reference (SR) ratio was defined as the stent cross-sectional area (CSA) divided by the average CSA of the 5-mm proximal and distal reference lumens. The patients were divided into two groups according to the SR ratio: undersize group (SR<1.0, n=62) and oversize group (SR≥1.0, n=40). The incidences of ST re-elevation and total ST resolution (STR) were compared. RESULTS: The oversize group showed a higher incidence of ST re-elevation (32.5 vs. 9.7%, p=0.004) and a lower total STR (22.4±62.7 vs. 43.4±38.6%, p=0.04). After adjustment, the oversized-stenting approach was independently associated with ST re-elevation [odds ratio: 3.74, 95% confidence interval (CI) 1.27-12.1, p=0.02]. The peak creatine kinase-MB level was higher in the oversize group (341±259 vs. 242±208IU/l, p=0.04). The incidences of stent thrombosis and restenosis were similar between the two groups. CONCLUSIONS: An oversized-stenting approach in patients with STEMI was associated with a higher incidence of ST re-elevation and a lower total STR, resulting in increased myocardial damage.