Features and Outcomes of Patients with Calcified Nodules at Culprit Lesions of Acute Coronary Syndrome: An Optical Coherence Tomography Study.

OBJECTIVES: We sought to clarify clinical features and outcomes related to calcified nodules (CN) compared with plaque rupture (PR) and plaque erosion (PE) detected by optical coherence tomography (OCT) at the culprit lesions in patients with acute coronary syndrome (ACS). METHODS: Based on OCT findings for culprit lesion plaque morphologies, ACS patients with analyzable OCT images (n = 362) were classified as CN, PR, PE, and other. RESULTS: The prevalence of CN, PR, and PE was 6% (n = 21), 45% (n = 163), and 41% (n = 149), respectively. Patients with CN were older (median 71 vs. 65 years, p = 0.03) and more diabetic (71 vs. 35%, p = 0.002) than those without CN. In OCT findings, the distal reference lumen cross-sectional area (median 4.2 vs. 5.2 mm2, p = 0.048) and the postintervention minimum lumen cross-sectional area (median 4.5 vs. 5.3 mm2, p = 0.04) were smaller in lesions with CN than in those without. Kaplan-Meier estimate survival curves showed that the 500-day survival without target lesion revascularization (TLR) was lower (p = 0.011) for patients with CN (72.9%) than for those with PR (89.3%) or PE (94.8%). CONCLUSIONS: ACS patients with CN at the culprit lesion had more TLR compared to those with PR or PE.

Impact of Accumulated Serum Uric Acid on Coronary Culprit Lesion Morphology Determined by Optical Coherence Tomography and Cardiac Outcomes in Patients with Acute Coronary Syndrome.

OBJECTIVES: We aimed to examine the relations of very high levels of serum uric acid (sUA) with features of culprit lesion plaque morphology determined by optical coherence tomography (OCT) and adverse clinical outcomes in patients with acute coronary syndrome (ACS). METHODS: We retrospectively compared ACS patients according to sUA levels of > 8.0 mg/dL (n = 169), 7.1-8.0 mg/dL (n = 163), 6.1-7.0 mg/dL (n = 259), and ≤6.0 mg/dL (n = 717). Angiography and OCT findings were analyzed in patients with preintervention OCT and the 4 sUA groups (> 8.0 mg/dL, n = 61; 7.1-8.0 mg/dL, n = 72; 6.1-7.0 mg/dL, n = 131; and ≤6.0 mg/dL, n = 348) were compared. RESULTS: Cardiogenic shock was more prevalent in ACS patients with sUA > 8.0 mg/dL (22% vs. 19% vs. 10% vs. 6%, p < 0.001). Plaque rupture was observed more prevalently by OCT in patients with sUA > 8.0 mg/dL (67% vs. 47% vs. 56% vs. 45%, p = 0.027). At the 2-year follow-up, Kaplan-Meier estimates showed higher cardiac mortality in patients with sUA > 8.0 mg/dL (25% vs. 12% vs. 5% vs. 5%, p < 0.001). After adjusting for traditional cardiovascular risk factors and creatinine levels, patients with sUA > 8.0 mg/dL showed a 4.5-fold increased risk in 2-year cardiac death by multivariate Cox proportional hazard analysis (hazard ratio 4.54, 95% confidence interval 2.98-6.91; p < 0.001). CONCLUSIONS: Very high sUA levels like > 8.0 mg/dL are the primary predictor of 2-year cardiac mortality and could partly be caused by adverse effects of accumulated sUA on plaque morphology in patients with ACS.

Association between the body mass index and the clinical findings in patients with acute heart failure: evaluation of the obesity paradox in patients with severely decompensated acute heart failure.

Obesity is known to be associated with the development of heart failure (HF). However, the relationship between the body mass index (BMI) and acute HF (AHF) remains to be elucidated. Eight hundred and eight AHF patients were enrolled in this study. The patients were assigned to four groups according to their BMI values: severely thin (n = 11, BMI <16), normal/underweight (n = 579, 16 ≤ BMI <25), overweight (n = 178, 25 ≤ BMI <30) and obese (n = 40, BMI ≥30). The patients in the severely thin group were more likely to be female, have systolic blood pressure (SBP) <100 mmHg and have valvular disease than normal/underweight patients. The patients in the overweight group were significantly younger than those in the normal/underweight, and those in the overweight group were more likely to have SBP ≥140 mmHg and hypertensive heart disease and less likely to have valvular disease than the patients in the normal/underweight group. The prognosis, including all-cause death, was significantly poorer among patients who were severely thin than those who were normal/underweight, overweight and significantly better among those who were overweight than those who were normal/underweight, severely thin and obese patients. A multivariate Cox regression model identified that severely thin [HR: 3.372, 95% confidence interval (CI) 1.362-8.351] and overweight (HR: 0.615, 95% CI 0.391-0.966) were independent predictors of 910-day mortality as the reference of normal/underweight. Overweight patients tended to have SBP ≥140 mmHg and be relatively young, while severely thin patients tended to have SBP <100 mmHg and be female. These factors were associated with a better prognosis of overweight patients and adverse outcomes in severely thin patients. These factors may contribute to the "obesity paradox" in severely decompensated AHF patients.

Matrix Metalloproteinase-9 as a Marker for Plaque Rupture and a Predictor of Adverse Clinical Outcome in Patients with Acute Coronary Syndrome: An Optical Coherence Tomography Study.

OBJECTIVES: The present study sought to clarify the relationship between matrix metalloproteinase-9 (MMP-9) levels and plaque morphology demonstrated by optical coherence tomography (OCT), and to examine their prognostic impacts in patients with acute coronary syndrome (ACS). METHODS: MMP-9 levels were measured for patients with ACS (n = 249). Among 249 patients, 120 with evaluable OCT images were categorized into patients with ruptured plaques (n = 65) and those with nonruptured plaques (n = 55) on the basis of culprit lesion plaque morphology demonstrated by OCT. RESULTS: MMP-9 levels on admission were significantly higher in the rupture group than in the nonrupture group (p = 0.029). Although creatine kinase-MB (CK-MB) on admission was comparable between the groups, peak CK-MB was higher in the rupture group than in the nonrupture group (p < 0.001). By receiver operating characteristic curve analysis, the optimal cut-off value of MMP-9 to detect ruptured plaques was 65.5 ng/ml (p = 0.029). There was a nonstatistically significant trend toward increased cardiac death at 2 years (5.9 vs. 1.0%, p = 0.059) in patients with high MMP-9 (≥65.5 ng/ml) compared to those with low MMP-9 (<65.5 ng/ml). CONCLUSIONS: MMP-9 can differentiate ACS with ruptured plaques from nonruptured plaques, and MMP-9 may be a valuable predictor of long-term cardiac mortality in patients with ACS reflecting plaque rupture.

The serum heart-type fatty acid-binding protein (HFABP) levels can be used to detect the presence of acute kidney injury on admission in patients admitted to the non-surgical intensive care unit.

BACKGROUND: No cardiac biomarkers for detecting acute kidney injury (AKI) on admission in non-surgical intensive care patients have been reported. The aim of the present study is to elucidate the role of cardiac biomarkers for quickly identifying the presence of AKI on admission. METHODS: Data for 1183 patients who underwent the measurement of cardiac biomarkers, including the serum heart-type fatty acid-binding protein (s-HFABP) level, in the emergency department were screened, and 494 non-surgical intensive care patients were enrolled in this study. Based on the RIFLE classification, which was the ratio of the serum creatinine value recorded on admission to the baseline creatinine value, the patients were assigned to a no-AKI (n = 349) or AKI (Class R [n = 83], Class I [n = 36] and Class F [n = 26]) group on admission. We evaluated the diagnostic value of the s-H-FABP level for detecting AKI and Class I/F. The mid-term prognosis, as all-cause death within 180 days, was also evaluated. RESULTS: The s-H-FABP levels were significantly higher in the Class F (79.2 [29.9 to 200.3] ng/mL) than in the Class I (41.5 [16.7 to 71.6] ng/mL), the Class R (21.1 [10.2 to 47.9] ng/mL), and no-AKI patients (8.8 [5.4 to 17.7] ng/mL). The most predictive values for detecting AKI were Q2 (odds ratio [OR]: 3.743; 95 % confidence interval [CI]: 1.693-8.274), Q3 (OR: 9.427; 95 % CI: 4.124-21.548), and Q4 (OR: 28.000; 95 % CI: 11.245-69.720), while those for Class I/F were Q3 (OR: 5.155; 95 % CI: 1.030-25.790) and Q4 (OR: 22.978; 95 % CI: 4.814-109.668). The s-HFABP level demonstrating an optimal balance between sensitivity and specificity (70.3 and 72.8 %, respectively; area under the curve: 0.774; 95 % CI: 0.728-0.819) was 15.7 ng/mL for AKI and 20.7 ng/mL for Class I/F (71.0 and 83.1 %, respectively; area under the curve: 0.818; 95 % CI: 0.763-0.873). The prognosis was significantly poorer in the high serum HFABP with AKI group than in the other groups. CONCLUSIONS: The s-H-FABP level is an effective biomarker for detecting AKI in non-surgical intensive care patients.

Preventable effects of bare-metal stent on restenosis after everolimus-eluting stent deployment.

This case report describes a patient who underwent implantation of a bare-metal stent (BMS) for the treatment of everolimus-eluting stent (EES) restenosis caused by chronic stent recoil, and the BMS successfully escaped from duplicate restenosis and target lesion revascularization (TLR).

Serum heart-type fatty acid-binding protein level can be used to detect acute kidney injury on admission and predict an adverse outcome in patients with acute heart failure.

BACKGROUND: Different mechanisms of acute kidney injury (AKI) may exist for acute heart failure (AHF) patients compared with other patients. METHODS AND RESULTS: We analyzed data from 282 patients with AHF. The biomarkers were measured within 30 min of admission. Patients were assigned to a no-AKI (n=213) or AKI group (Class R (n=49), Class I (n=15) or Class F (n=5)) using the RIFLE classifications on admission. We evaluated the relationships between the biomarkers and AKI, in-hospital mortality, all-cause death and HF events (HF re-admission, all-cause death) within 90 days. The serum heart-type fatty acid-binding protein (s-HFABP) levels were significantly higher in the AKI than in the no-AKI group, and the predictive biomarker for AKI was s-HFABP (odds ratio: 6.709; 95% confidence interval: 3.362-13.391). s-HFABP demonstrated an optimal balance between sensitivity and specificity (71.0%, 79.3%; area under the receiver-operating characteristic curve [AUC]=0.790) at 22.8 ng/ml for AKI, at 22.8 ng/ml for Class I/F (90.0%, 71.4%; AUC=0.836) and at 21.0 ng/ml for in-hospital mortality (74.3%, 70.0%; AUC=0.726). The Kaplan-Meier survival curves showed a significantly poorer prognosis in the high s-HFABP group (≥22.9 ng/ml) than in other groups. CONCLUSIONS: The s-HFABP level can indicate AKI on admission, and a high s-HFABP level is associated with a poorer prognosis for AHF patients.

Seasonal variation in patients with acute heart failure: prognostic impact of admission in the summer.

There have been few reports discussing the clinical significance of the season of admission of acute heart failure (AHF) patients. The data of 661 patients with AHF admitted to the intensive care unit were analyzed. Patients were assigned to a summer admission (Group-S, n = 113, between July and September), a winter admission (Group-W, n = 214, between December and February), or to the other seasons admission group (Group-O, n = 334). We evaluated the relationships between the seasonal variations and the clinical profiles, and the long-term prognosis. There were significantly more patients with cardiomyopathy and New York Heart Association class 4, and the serum levels of total bilirubin were significantly higher in Group-S (85.8, 24.8 %, and 0.60 [0.50-0.90]) than in Group-W (75.2, 15.4 %, and 0.60 [0.40-0.78]). The left ventricular ejection fraction on admission was significantly reduced and intravenous administration of dobutamine was used more frequently in Group-S (30.0 [25.0-46.0], 31.9 %) than in Group-W (34.4 [25.2-48.0], 20.6 %) and Group-O (35.0 [25.0-46.0], 19.8 %). The multivariate Cox regression model found that summer admission was independently associated with cardiovascular death (HR: 1.58, 95 % CI 1.01-2.48; p = 0.044) and heart failure (HF) events (HR: 1.55, 95 % CI 1.05-2.28; p = 0.028). The Kaplan-Meier curves showed that the cardiovascular death rate was significantly higher in Group-S than in Group-W and Group-O, and the HF events were significantly higher in Group-S than in Group-O. The summer admission AHF patients included sicker patients, and the prognosis in these patients was worse than in the patients admitted at other times.

Immediate administration of tolvaptan prevents the exacerbation of acute kidney injury and improves the mid-term prognosis of patients with severely decompensated acute heart failure.

BACKGROUND: Tolvaptan, an oral selective vasopressin 2 receptor antagonist that acts on the distal nephrons to cause a loss of electrolyte-free water, is rarely used during the acute phase of acute heart failure (AHF). METHODS AND RESULTS: We investigated 183 AHF patients admitted to the intensive care unit and administered tolvaptan (7.5mg) with continuous intravenous furosemide, and then additionally at 12-h intervals until HF was compensated. When intravenous furosemide was changed to peroral use, the administration of tolvaptan was stopped. The patients were assigned to tolvaptan (n=52) or conventional treatment (n=131) groups. The amount of intravenous furosemide was significantly lower (35.4 [16.3-56.0] mg vs. 80.0 [30.4-220.0] mg), the urine volume was significantly higher on days 1 and 2 (3,691 [3,109-4,198] ml and 2,953 [2,128-3,592] ml vs. 2,270 [1,535-3,258] ml and 2,129 [1,407-2,906] ml) and the numbers of patients with worsening-AKI (step-up RIFLE Class to I or F) and Class F were significantly fewer (5.8% and 1.9% vs. 19.1% and 16.0%) in the tolvaptan group than in the conventional group, respectively. One of the specific medications indicated worsening-AKI and in-hospital mortality was tolvaptan (odds ratio [OR] 0.155, 95% confidence interval [CI] 0.037-0.657 and OR 0.191, 95% CI 0.037-0.985). The Kaplan-Meier curves showed that the death rate within 6 months was significantly lower in the tolvaptan group. The same result was found after propensity matching of the data. CONCLUSIONS: Early administration of tolvaptan could prevent exacerbation of AKI and improve the prognosis for AHF patients.

Prognostic impact of acute kidney injury in patients with acute decompensated heart failure.

BACKGROUND: The relationship between acute kidney injury (AKI) in the acute phase of acute decompensated heart failure (ADHF) and patient outcome has not yet been reported. METHODS AND RESULTS: Data for 625 patients with ADHF admitted to the intensive care unit were analyzed. No AKI occurred in 281 patients (no AKI) during the first 5 days. The AKI patients were assigned to 3 groups based on the timing: AKI present on admission and stable risk, injury, failure, loss, and endstage (RIFLE) class (stable early AKI; n=125), stepped-up RIFLE class (worsening early AKI; n=49), or AKI that occurred after admission (late AKI; n=170). The AKI patients were grouped into another 3 groups based on severity: class R (risk; n=214), class I (injury; n=73), or class F (failure; n=57). A multivariate logistic regression model found class I, class F, late AKI and worsening early AKI to be independently associated with in-hospital mortality. Kaplan-Meier survival curves showed that the survival rate in any-cause death during 2 years was significantly lower in class I, class F and the worsening early-AKI group, and there were significantly more HF events in class F and the worsening early-AKI group. There were significantly more class I and class F patients in the worsening early-AKI group. CONCLUSIONS: The presence of AKI on admission, worsening of AKI, and severe AKI (class I or class F) are associated with a poorer prognosis for ADHF patients.

Predictive score for survival after percutaneous cardiopulmonary support in cardiovascular disease patients- evaluation of pre-procedural information.

BACKGROUND: The predictive factors for survival after percutaneous cardiopulmonary support (PCPS) are unknown. METHODS AND RESULTS: Data for 105 patients with cardiovascular disease requiring PCPS were analyzed. The patients were divided into a survivor (n=21) or a non-survivor group (n=84). The age was significantly lower, and there were more patients with fulminant myocarditis and PCPS attempted before cardiac arrest (CA) in the survivor group. Additionally, there were fewer cases of out-of-hospital CA, and the mean time from CA to PCPS was shorter in the survivor group. On multivariate logistic regression it was found that the age and the time from CA to PCPS were independently associated with survival. A predictive scoring system was constructed that included the following: (1) age <50 years; (2) diagnosis of fulminant myocarditis; (3) no out-of-hospital CA; (4) PCPS attempted before CA; and (5) time from CA to PCPS <45 min. The predictive score was significantly higher in the survivor than in the non-survivor group (2.33 ± 1.32 vs. 1.06 ± 1.02). The sensitivity and specificity for survival were 85.7% and 66.7% when the score was ≥ 2. Kaplan-Meier survival analysis showed that any-cause death was significantly higher in patients with PCPS survival score ≤ 1 than in those with a score ≥ 2. CONCLUSIONS: PCPS survival score is suitable for clinically predicting survival in patients with cardiovascular disease undergoing PCPS.

Long-term prognostic impact after acute kidney injury in patients with acute heart failure.

The relationship between the short-term prognosis of acute heart failure (AHF) and acute kidney injury (AKI) using the risk, injury, failure, and end stage (RIFLE) criteria has already been reported, however, the relationship between the long-term prognosis and AKI has not. We investigated the relationship between the long-term prognosis after discharge and AKI using the RIFLE criteria. Five hundred patients with AHF admitted to our intensive care unit were analyzed. Patients were assigned to a no AKI (n = 156), Class R (risk; n = 201), Class I (injury; n = 73), or Class F (failure; n = 70) using the most severe RIFLE classifications during hospitalization. We evaluated the relationships between the RIFLE classifications and any-cause death, and HF events including death and readmission for HF within 1 year. A multivariate logistic regression model found that Class I (P = 0.013, OR: 2.768; 95% CI: 1.236-6.199) and Class F (P < 0.001, OR: 7.920; 95% CI: 3.497-17.938) were independently associated with any-cause death, and Class F was associated with HF events (P = 0.001, OR: 3.486; 95% CI: 1.669-7.281). The Kaplan-Meier survival curves showed the prognosis, including death, to be significantly poorer in Class I than in no AKI and Class R, to be significantly poorer in Class F than in no AKI, Class R, and Class I, and the prognosis including HF events to be significantly poorer in Class F than in no AKI, Class R, and Class I. The presence of severe AKI (Class I and F) was independently associated with long-term mortality for AHF.

Comparison of Coronary Culprit Lesion Morphology Determined by Optical Coherence Tomography and Relation to Outcomes in Patients Diagnosed with Acute Coronary Syndrome During Winter -vs- Other Seasons.

Patients diagnosed with acute coronary syndrome (ACS) during winter have worse outcomes; however, mechanisms driving this trend are unclear. We examined coronary culprit lesion morphologies using optical coherence tomography (OCT). Features and outcomes were retrospectively compared between patients admitted with ACS in winter (W-ACS; n = 390) and in other seasons (O-ACS; n = 1,027). Angiography and OCT results were analyzed in patients who underwent OCT examination (173 patients in W-ACS and 450 in O-ACS). On initial angiography, minimum lumen diameter was smaller (median; 0.12 mm vs 0.25 mm, p = 0.021) and Thrombolysis in myocardial infarction flow grade was worse (Thrombolysis in myocardial infarction 0/1; 57% vs 44%, p = 0.005) in W-ACS. OCT performed before coronary interventions or just after intracoronary thrombectomy showed that plaque rupture (56% vs 46%) and calcified nodules (8% vs 5%) were more prevalent, and plaque erosion (37% vs 49%) was less prevalent in W-ACS (p = 0.039 for all 3 variables). At 2-year follow-up for all admitted ACS patients, Kaplan-Meier estimates showed higher cardiac mortality in W-ACS (11.8% vs 8.3%, p = 0.043). Multivariate Cox proportional hazard analysis showed that patients in W-ACS group had a 1.5-fold increased risk of cardiac death within 2 years after adjusting for traditional cardiovascular risk factors (hazard ratio, 1.54 [95% confidence interval, 1.06 to 2.23]; p = 0.024). In conclusion, patients diagnosed with ACS during winter had worse angiographic results and OCT revealed less plaque erosion (more plaque rupture or calcified nodules) at the culprit lesions, which may be partly associated with worse cardiac mortality within 2 years.

Relation of Coronary Culprit Lesion Morphology Determined by Optical Coherence Tomography and Cardiac Outcomes to Serum Uric Acid Levels in Patients With Acute Coronary Syndrome.

The aims of the present study were to elucidate features of culprit lesion plaque morphology using optical coherence tomography (OCT) in relation to elevated serum uric acid (sUA) levels and to clarify the impact of sUA levels on adverse clinical outcomes in patients with acute coronary syndrome (ACS). Clinical data and outcomes were compared between ACS patients with sUA ≥6 mg/dl (high-sUA; n = 506) and sUA <6.0 mg/dl (low-sUA; n = 608). Angiography and OCT findings were analyzed in patients with preintervention OCT and compared between groups of high-sUA (n = 206) and low-sUA (n = 273). Patients with high-sUA were more frequently male (88% vs 74%, p <0.001), younger (median 65 years vs 67 years, p = 0.017), more obese (median body mass index; 24.3 kg/m2 vs 23.2 kg/m2, p <0.001), and had a more frequent history of hypertension (72% vs 62%, p <0.001). ACS with lung congestion or cardiogenic shock was more prevalent in patients with high-sUA (30% vs 13%, p <0.001). Plaque rupture (54% vs 42%, p = 0.021) and red thrombi (55% vs 41%, p = 0.010) were more prevalently observed by OCT in patients with high-sUA. Kaplan-Meier estimate survival curves showed that the 2-year cardiac mortality was higher in patients with high-sUA (12.1% vs 4.2%, p <0.001). The multivariate Cox proportional hazard analysis showed that sUA values independently and significantly predicted cardiac death within 2 years (hazard ratio 1.41 [95% confidence interval 1.26 to 1.57], p <0.001). In conclusion, sUA levels are associated with culprit lesion coronary plaque morphology and raised sUA levels affect cardiovascular mortality after adjusting for several cardiovascular risk factors.

Relation of coronary culprit lesion morphology determined by optical coherence tomography and cardiac outcomes to preinfarction angina in patients with acute myocardial infarction.

BACKGROUND: While preinfarction angina pectoris (pre-IA) is recognized as favorable effects on acute myocardial infarction (AMI), the detail has not been fully investigated. The aims of the current study were to clarify patient characteristics, lesion morphologies determined by optical coherence tomography (OCT), and cardiac outcomes related to pre-IA in patients with AMI. METHODS: Clinical data and outcomes were compared between AMI patients with pre-IA (pre-IA group, n = 507) and without pre-IA (non-pre-IA group, n = 653). Angiography and OCT findings were analyzed in patients with pre-intervention OCT and compared between groups of pre-IA (n = 219) and non-pre-IA (n = 269). RESULTS: ST-segment elevation myocardial infarction (61% vs. 75%, p < 0.001) and cardiogenic shock (8% vs. 14%, p = 0.001) were less prevalent in pre-IA group. Peak creatine kinase-MB levels were lower in pre-IA group (median 83 IU/mL vs. 126 IU/mL, p < 0.001). In pre-intervention coronary angiography findings, initial TIMI flow grade 0/1 (43% vs. 56%, p = 0.019) and Rentrop collateral circulation 0/1 (69% vs. 79%, p = 0.018) were less frequently observed in pre-IA than in non-pre-IA patients. In post-thrombectomy OCT images, plaque rupture (39% vs. 56%, p = 0.003) and red thrombi (42% vs. 54%, p = 0.027) were also less frequently observed in pre-IA group. Kaplan-Meier estimate survival curves showed that cardiac death at 12-months was lower in pre-IA group than in non-pre-IA group (6.9% vs. 10.1%, p = 0.036). CONCLUSIONS: Patients with pre-IA had less severe AMI on admission, smaller infarction size, and more favorable long-term survival, which may be caused by difference of lesion morphology between patients with and without pre-IA.

Early Effects of Oral Pulmonary Vasodilators in an Elderly Patient with Critical Thromboembolic Pulmonary Hypertension: A Case Report.

A 70-year-old woman who had been treated for bipolar disorder and dementia was admitted to the intensive care unit of a university hospital with severe dyspnea; pulmonary arterial hypertension was diagnosed after cardiac catheterization was performed. Computed tomography pulmonary angiography showed typical signs of chronic thrombosis in the proximal pulmonary artery without an adequate amount of fresh thrombi, which appeared to be the cause of the elevation in pulmonary artery pressure, and resulted in severe hypoxemia. Therefore, the pulmonary arterial hypertension was classified as belonging to the chronic thromboembolic pulmonary hypertension subgroup. Although the patient's respiratory condition was classified as World Health Organization class IV, she was treated with the combination of oral ambrisentan and tadalafil, rather than intravenous epoprostenol, which she was unable to tolerate. Consequently, both her symptom and hemodynamic status showed rapid improvement with only oral pulmonary vasodilators. This case demonstrates the efficacy of oral treatment alone in elderly patients with severe chronic thromboembolic pulmonary hypertension.

Usefulness of a surface cooling device (Arctic Sun®) for therapeutic hypothermia following cardiac arrest.

AIMS: Cardio-pulmonary resuscitation and therapeutic hypothermia (TH) have improved the neurological outcomes of patients who have suffered sudden cardiac arrest; however, the benefits of and differences between cooling devices remain unclear. The aim of this study was to clarify the significance of the Arctic Sun(®) for surface cooling in patients treated with TH. METHODS: Fifty-one patients (60.2±14.2 years, 42 males and 9 females) who experienced cardiogenic cardiac arrest, including both shockable and non-shockable cardiac arrest, were enrolled in this study. Forty patients were treated with TH using the Arctic Sun 2000(®) for surface cooling, while the other 11 patients were treated with TH using conventional standard cooling blankets. The patients' clinical courses during TH and the neurological outcomes were compared between the two groups. RESULTS: The body temperature before TH was not significantly different between the two groups; however, the minimal body temperature during TH was significantly lower in the patients cooled with conventional standard blankets than in those cooled using the Arctic Sun 2000(®). The rates of catecholamine administration, left ventricular ejection fraction, and mechanical support were not significantly different between the two groups; however, the maximum infusion dose of dobutamine was significantly lower in the patients with the Arctic Sun 2000(®) than in those treated with standard cooling blankets. CONCLUSIONS: The use of TH with the Arctic Sun 2000(®) following cardiac arrest is safe and effective in precisely maintaining the target body temperature, and can be used to reduce the infusion dose of dobutamine to treat heart failure during TH.

Prognostic impact of the serum heart-type fatty acid-binding protein (H-FABP) levels in patients admitted to the non-surgical intensive care unit.

BACKGROUND: Biomarkers predicting adverse outcomes in non-surgical intensive care patients have not been reported. METHODS AND RESULTS: Data for 1,006 emergency department patients were prospectively analyzed. The serum heart-type fatty acid-binding protein (s-H-FABP) level was measured within 10 min of admission. The patients were assigned to intensive care (n = 835) or other departments (n = 171). The intensive care patients were divided into survivors (n = 745) and non-survivors (n = 90) according to the in-hospital mortality and assigned to four groups according to the quartiles of s-H-FABP (Q1, Q2, Q3 and Q4). The s-H-FABP levels were significantly higher in the intensive care patients (12.7 [6.1-38.8] ng/ml versus 5.3 [3.1-9.4] ng/ml) and in the non-survivors (44.9 [23.2-87.6] ng/ml versus 11.5 [5.6-32.6] ng/ml). A Kaplan-Meier curve showed a significantly higher survival rate in Q3 than in Q1 and Q2 and in Q4 than in the other groups. The multivariate Cox regression model identified Q3 (HR 4.646, 95 % CI 1.526-14.146) and Q4 (HR 9.483, 95 % CI 3.152-28.525) as independent predictors of 90-day mortality. The sensitivity and specificity of H-FABP for in-hospital mortality were 81.1 and 66.0 % (AUC 0.775) at 20.95 ng/ml. The in-hospitality rate was significantly higher in the high s-H-FABP patients than in the low s-H-FABP patients in each etiology group. CONCLUSIONS: The s-H-FABP level is an effective biomarker for risk stratification in non-surgical intensive care patients.

New scoring system (APACHE-HF) for predicting adverse outcomes in patients with acute heart failure: evaluation of the APACHE II and Modified APACHE II scoring systems.

BACKGROUND: No scoring system for assessing acute heart failure (AHF) has been reported. METHODS AND RESULTS: Data for 824 AHF patients were analyzed. The subjects were divided into an alive (n=750) and a dead group (n=74). We constructed a predictive scoring system based on eight significant APACHE II factors in the alive group [mean arterial pressure (MAP), pulse, sodium, potassium, hematocrit, creatinine, age, and Glasgow Coma Scale (GCS); giving each one point], defined as the APACHE-HF score. The patients were assigned to five groups by the APACHE-HF score [Group 1: point 0 (n=70), Group 2: points 1 and 2 (n=343), Group 3: points 3 and 4 (n=294), Group 4: points 5 and 6 (n=106), and Group 5: points 7 and 8 (n=11)]. A higher optimal balance was observed in the APACHE-HF between sensitivity and specificity [87.8%, 63.9%; area under the curve (AUC)=0.779] at 2.5 points than in the APACHE II (47.3%, 67.3%; AUC=0.558) at 17.5 points. The multivariate Cox regression model identified belonging to Group 5 [hazard ratio (HR): 7.764, 95% confidence interval (CI) 1.586-38.009], Group 4 (HR: 6.903, 95%CI 1.940-24.568) or Group 3 (HR: 5.335, 95%CI 1.582-17.994) to be an independent predictor of 3-year mortality. The Kaplan-Meier curves revealed a poorer prognosis, including all-cause death and HF events (death, readmission-HF), in Group 5 and Group 4 than in the other groups, in Group 3 than in Group 2 or Group 1, and in Group 2 than in Group 1. CONCLUSIONS: The new scoring system including MAP, pulse, sodium, potassium, hematocrit, creatinine, age, and GCS (APACHE-HF) can be used to predict adverse outcomes of AHF.

Efficacy of therapeutic hypothermia for neurological salvage in patients with cardiogenic sudden cardiac arrest: the importance of prehospital return of spontaneous circulation.

AIM OF THE STUDY: Cardiopulmonary resuscitation and mild therapeutic hypothermia (MTH) have improved neurological outcomes after sudden cardiac arrest, but the factors affecting favorable neurological outcome remain unclear. The aim of this study was to clarify these factors in patients in cardiac arrest treated with MTH. METHODS: Forty-six consecutive patients (mean age, 59.4 ± 14.3 years; 37 men and 9 women) who had had cardiogenic cardiac arrest from January 2008 through December 2011, including cases that were and were not shockable, were enrolled in this study, and the factors affecting favorable neurological outcome were retrospectively investigated. The interval from cardiac arrest to cardiopulmonary resuscitation, the return of spontaneous circulation (ROSC), the start of MTH, and the attaining of the target temperature were retrieved from the medical records. The relationship between the neurological outcome and clinical findings, including the causes of cardiac arrest and vital signs before MTH, were also investigated. RESULTS: Blood pressure and body temperature before MTH were higher, the interval from cardiac arrest to ROSC was shorter, and MTH was started earlier in patients with favorable neurological outcomes than in those with unfavorable outcomes. A multivariate logistic regression model revealed that the presence of prehospital ROSC was predictive of a favorable neurological outcome. In addition, renal failure during MTH occurred more frequently in patients with unfavorable neurological outcomes. CONCLUSION: MTH is associated with favorable neurological outcomes after sudden cardiac arrest, including those with non-shockable rhythms, especially in patients with prehospital ROSC.