Landmark Analysis Exploring the Optimal Period for Intensive Monitoring After Return to Work for Employees With Sickness Absence Due to Common Mental Disorders.

OBJECTIVE: This study aimed to clarify when and how long intensive monitoring should be performed after return to work (RTW) of employees experiencing common mental disorders using landmark analysis. METHODS: We conducted a retrospective survey of workers who experienced sickness absences (SAs) during 36 months after RTW. Sustainability rates of attendance among the following groups were compared before and after the landmark (18 months): one SA episode (Group 1), two SA episodes (Group 2), and three or more SA episodes (Group 3). RESULTS: Before the landmark, sustainability in Group 1 was higher than in the other groups, with no significant differences among groups after the landmark. Sustainability rate of attendance tended to be lower before than after the landmark in each group. CONCLUSIONS: Intensive monitoring is suggested in the first 18 months after RTW.

Number of Previous Absences Is a Predictor of Sustained Attendance After Return-to-Work in Workers With Absence due to Common Mental Disorders: A Cohort 3-Year Study.

OBJECTIVE: This study evaluated the relationship of the number of previous episodes due to common mental disorders (CMDs) with long-term outcomes and sustainability of attendance after return-to-work (RTW). METHODS: Participants were assigned to the following three groups: workers having one (Group 1), two (Group 2), and three or more (Group 3) previous episodes. Outcomes were a recurrent absence and the sustainability rate of attendance after RTW. RESULTS: The sustainability rate in Group 1 was significantly higher than that in Group 3 throughout the observation period. The sustainability rates for Group 2 were significantly higher than for Group 3 at 30 and 36 months. CONCLUSIONS: The number of previous episodes was shown to affect sustainability of attendance after RTW due to CMDs, indicating that repeated previous absences are a significant prognostic factor.

Neointimal regression-induced incomplete coverage of a bare-metal stent in the left main trunk: serial angiographic and angioscopic evidence obtained by 5-year follow-up.

Very late stent thrombosis (VLST), a rare complication of stenting, has been reported to develop more frequently at later than 1 year after the deployment of the drug-eluting stent (DES) compared with the bare-metal stent (BMS). However, the causes for the difference in the incidence remain unknown. Serial angioscopy on 1,591 and 1,952 days after BMS deployment in a Japanese male patient with acute myocardial infarction revealed incomplete neointimal coverage (INC) without the development of cardiovascular event. Therefore, the potential development of VLST remains undeniable in BMS-deployed patients who had INC.

Elevation of plasma brain natriuretic peptide is a hallmark of diastolic heart failure independent of ventricular hypertrophy.

OBJECTIVES: We tested a hypothesis that elevation of the plasma level of brain natriuretic peptide (BNP) is one of the characteristics of patients with diastolic heart failure (DHF) independent of left ventricular (LV) hypertrophy. BACKGROUND: The clinical characteristics of DHF are not well acknowledged, although DHF has become a great social burden. Such a lack of clinical information leads to inaccuracy in the diagnosis of DHF. We have demonstrated enhancement of ventricular production of BNP with progression of maladaptive ventricular hypertrophy, but not with development of compensatory hypertrophy in an animal DHF model. METHODS: Of 372 patients who presented to the emergency department because of acute pulmonary congestion without acute coronary syndrome between January 1996 and May 2002, those with an ejection fraction > or =45% upon admission, who were stably controlled at least for a year in our outpatient clinics, comprised the DHF group (n = 19). A control group consisted of 22 hypertensive patients with a LV mass index greater than or equal to its minimum value of the DHF group and an ejection fraction > or =45%, in whom cardiac symptoms had not occurred. RESULTS: Despite a similar distribution of LV mass index, the BNP level was higher in the DHF group than in the control group (149 +/- 38 vs. 31 +/- 5 pg/ml, p < 0.01). There was no difference in LV cavity size or parameters derived from pulsed Doppler transmitral flow velocity curves. CONCLUSIONS: An elevation of BNP may be a hallmark of patients with or at risk of DHF among subjects with preserved systolic function independent of LV hypertrophy.

Effect of successful late reperfusion by primary coronary angioplasty on mechanical complications of acute myocardial infarction.

It has been suggested that early treatment decreases, but late treatment increases, the risk of mechanical complications for a thrombolytic strategy. However, few studies have evaluated whether late reperfusion (LR) by primary coronary angioplasty decreases the risk of mechanical complications. A total of 2,209 patients with acute myocardial infarction treated with primary coronary angioplasty within 24 hours after the onset of symptoms were divided into 3 groups: early reperfusion (ER; < or =12 hours, n = 1,647), LR (>12 hours, n = 219), and failed reperfusion (FR; n = 343). We evaluated the incidence, risk ratio, and predictors of mechanical complications. The overall incidence of mechanical complications was 2.0%. The incidence of mechanical complications was highest in the FR group (ER 1.4%, LR 1.8%, FR 5.0%; p <0.01). After adjusting for clinical variables, the risk ratio for mechanical complications increased in the FR group compared with the LR group (risk ratio 7.34, 95% confidence interval [CI] 1.02 to 52.80; p = 0.04). Predictors of an increased risk of mechanical complications by multivariate analysis were age > or =70 years (odds ratio [OR] 3.68, 95% CI 1.56 to 8.64; p <0.01), Killip class > or =II (OR 3.73, 95% CI 1.53 to 9.12; p <0.01), absence of collateral vessels (OR 4.09, 95% CI 1.17 to 14.26; p = 0.03), and FR (OR 2.68, 95% CI 1.09 to 6.61; p = 0.03). In conclusion, successful LR by primary coronary angioplasty is associated with the reduced risk of mechanical complications in patients with acute myocardial infarction.

Repetitive angioscopic observations of a sirolimus-eluting stent deployed in a patient with silent chronic thrombotic occlusion.

In the era of the drug-eluting stent, very late stent thrombosis has been the most serious issue in the field of interventional cardiology. A sirolimus-eluting stent (SES) was implanted in an in-stent restenotic lesion in the left circumflex artery of a 69-year-old man. Repetitive coronary angiography and angioscopy revealed that stent struts were covered with yellow neointima at 2 years after the SES deployment. At 4 years after the deployment, coronary angiography revealed the total occlusion of the SES. Angioscopy showed massive mural thrombi and yellow atherosclerotic plaques. Dual anti-platelet therapy (DAPT), ticlopidine and aspirin, had been continued since the SES deployment. Interventional cardiologists should heed the risk of silent chronic thrombotic occlusion even if struts of SES are fully covered with neointima under continued DAPT.

Admission with metabolic disorder is a useful predictor of the 1-year prognosis for patients with unstable angina, but not for patients with acute myocardial infarction: east-Osaka acute coronary syndrome registry.

BACKGROUND: For patients with acute myocardial infarction (AMI), several studies have examined the relationship between the metabolic syndrome and prognostic outcome. However, few studies have revealed an association between the metabolic syndrome and clinical outcomes in patients with unstable angina (UA). This study compared the differences in the usefulness of recognizing metabolic disorders for the prediction of a 1-year prognosis in patients with UA and AMI. METHODS: The study cohort consisted of 1173 patients with a mean age of 67 years. The focus was on general prognostic factors and five metabolic disorders (body mass index; hypertension; blood glucose/diabetes mellitus; and, serum concentrations of triglycerides and high-density lipoprotein cholesterol) at the time of admission. RESULTS: According to multivariate logistic regression analysis, metabolic scores on admission positively related to 1-year mortality or major adverse cardiovascular events (MACE) for patients with UA, but not for those with AMI, with an increase in either all-causes mortality or MACE being associated with the degree of metabolic dysfunction. No other general prognostic factors were related to either 1-year mortality or MACE in patients with UA. By contrast, general prognostic factors such as age and the Killip classification had a positive effect on 1-year mortality or on MACE for the patients with AMI. CONCLUSION: Accumulation of the effects of each metabolic disorder may affect mortality and MACE for patients with UA.

Echocardiographic progression of a subepicardial aneurysm after inferior myocardial infarction.

A 62-year-old man presented to hospital with chest oppression. Coronary angiography revealed total occlusion of the right coronary artery and inferior myocardial infarction was diagnosed. He was treated by percutaneous coronary intervention with stenting for myocardial infarction. After four months, echocardiography revealed a huge aneurysm protruding below the inferior surface of the left ventricle. It was considered to be a pseudoaneurysm from the echocardiographic findings. The patient had no symptoms and he refused surgery, so progression of the aneurysm was monitored carefully. At seven months after revascularization, the aneurysm showed a marked increase in size, with a maximal diameter of 48 mm and orifice diameter of 22 mm. Accordingly, the patient agreed to undergo surgical excision. The aneurysm was resected and the defect was closed with a pericardial patch. Pathological examination revealed all of the myocardial elements in the aneurysm wall and thrombus in its lumen. In conclusion, this was a rare case of ventricular subepicardial aneurysm.

Detecting intimal hyperplasia of subclavian artery stent by multislice computed tomography.

A 62-year-old man was performed stent implantation for right subclavian artery stenosis two years ago. For the evaluation of stent patency, multislice computed tomography (MSCT) was performed. Volume rendering image demonstrated that the stent was patent, but curved multiplanar reformation revealed a relatively low- density area inside the stent, suggesting intimal hyperplasia. Cross-sectional images were converted into Plaque Map display, which color-codes CT densities. Plaque was eccentrically distributed from ten o'clock to four o'clock. The attenuation of the plaque was 250--350 HU, which was less than the attenuation of contrast media (350--500 HU). Invasive aortography demonstrated the stent to be mildly stenosed in the corresponding position. Gray-scale and VH (virtual histology)-intravascular ultrasound demonstrated that eccentric intimal thickening consisted with predominant fibrous plaque. MSCT combined with Plaque Map effectively detected intimal thickening of subclavian artery stent.

Intracoronary nicorandil relieves multiple coronary vasospasm with hemodynamic collapse.

A 49-year-old woman was referred to hospital because of chest discomfort. Coronary angiography revealed subtotal occlusion of the left coronary artery and the right coronary artery, but subsequent hemodynamic collapse occurred. Based on the results of intravascular ultrasound the occlusion was suspected to be caused by coronary vasospasm, which was not relieved by intracoronary injection of isosorbide dinitrate (1 mg), but was alleviated by nicorandil (2 mg), a potassium-channel opener. After discharge from hospital, the patient stopped taking her medication and returned complaining of chest discomfort again. Intravenous verapamil (5 mg) did not improve it, but direct intracoronary administration of nicorandil (2 mg) did bring relief. This case suggests that nicorandil is effective for coronary vasospasm.

Angioscopic findings of delayed healing at sites of sirolimus-eluting stent overlap after 21-month implantation.

Treatment of de novo coronary stenosis with sirolimus-eluting stents is associated with very low rates of target lesion revascularization and other major adverse cardiac events in the short-term after implantation, but a definite frequency of late-stent thrombosis (LST) over a long-term follow-up has become evident. One of the predictors of LST is stent overlap. We reported the angioscopic findings of very delayed healing at sites of sirolimus-eluting stent overlap 21 months post-implantation.

Fourteen month follow-up angioscopic findings of a sirolimus-eluting stent implanted in a 15-year-old saphenous vein graft.

Saphenous vein grafts (SVGs) are common, as is their degeneration and early failure after coronary artery bypass graft surgery (CABG). Percutaneous SVG intervention with drug-eluting stents (DES) was associated with superior short-term clinical outcomes. However, SVG intervention compared with coronary intervention often results in distal embolisation and periprocedural myocardial infarction. In this case, we discuss 9 and 14 month follow-up neointimal coverage of a DES implanted in a 15 year-old SVG and other morphological changes using angioscopy.

Elevation of the ratio of transmitral E velocity to early diastolic mitral annular velocity continues even after recovery from acute stage in patients with diastolic heart failure.

BACKGROUND: Clinical features of diastolic heart failure (DHF) have not been well characterized, leading to an inaccuracy in the diagnosis of DHF. Recently, the ratio of transmitral E velocity to early diastolic mitral annular velocity (E/E') has been shown to be useful to assess LV filling pressure. PURPOSE: We tested the hypothesis that persistent elevation of E/E' ratio is one of the characteristics of patients with DHF. METHODS: Candidates of this study were 89 patients who presented to the emergency department because of acute pulmonary congestion. Those with an ejection fraction of >45% on admission comprised the DHF group (n=18). A control group consisted of consecutive 30 hypertensive patients with an ejection fraction of >45%. Doppler echocardiographic data were obtained with plasma BNP measure in the chronic stage >6 months after the emergent admission. RESULTS: The E/E' ratio was higher in the DHF group than in the control group (16.7±2.8 vs. 9.4±3.3, p<0.01). BNP level was also elevated in the DHF group. CONCLUSION: A persistent elevation of E/E' ratio may be an indicator of patients with or at risk of DHF among subjects with preserved systolic function independent of LV hypertrophy.

Anomalous coronary arteries in adults detected by multislice computed tomography: presentation of cases from multicenter registry and review of the literature.

Anomalous coronary arteries are a rare condition, but they may cause myocardial ischemia, heart failure, and sudden death. We evaluated the prevalence and multislice computed tomographic (MSCT) findings of anomalous coronary arteries in a large number of patients from the multicenter registry. At four institutes, 29 (0.74%) out of 3910 patients were found to have anomalous coronary arteries by MSCT. They consisted of 15 patients with anomalous origins of the right coronary artery, 1 with right-sided origin of the left circumflex artery, 1 with right-sided origin of the left main coronary artery, 2 with double right coronary arteries, 2 with the absence of the left circumflex artery, 1 with absence of the right coronary artery, 6 with coronary artery fistulas, and 1 with Bland-White-Garland syndrome. Multislice computed tomography findings were consistent with those obtained by conventional coronary angiography in all 14 patients undergoing both diagnostic procedures. Multislice computed tomography permits three-dimensional comprehension of coronary arteries, which is suitable for the diagnosis of anomalous coronary arteries.

Acute myocardial infarction caused by "malignant" anomalous right coronary artery detected by multidetector row computed tomography.

Anomalous coronary arteries are usually identified incidentally by angiography or autopsy, but some "malignant" coronary anomalies are associated with a high incidence of syncope, arrhythmia, myocardial infarction, and sudden death. So far, the pathogenesis of the coronary events in such cases has only been revealed by autopsy. In the present case report, a patient with anomalous origin of the right coronary artery from the left sinus of Valsalva developed acute myocardial infarction, and visualization of the anomaly and assessment of the culprit plaque in the artery were done by multidetector row computed tomography and intravascular ultrasound.

Identification of uncomplicated patients with acute myocardial infarction undergoing percutaneous coronary intervention: are these patients suitable for early discharge?

BACKGROUND: The hospital stay after acute myocardial infarction (AMI) is still extremely long in Japan and does not correspond with disease severity. The purpose of the present study was to identify a subgroup of AMI patients suitable for early discharge. METHODS AND RESULTS: A total of 3,739 AMI patients treated with percutaneous coronary intervention (PCI) within 24 h after onset, who enrolled Osaka Acute Coronary Insufficiency Study between April 1998 and March 2004, were studied. Patients showing no complications within the first 7 days (n=1,786) were considered to be eligible for early discharge. In these patients, multivariate logistic regression analysis selected prior myocardial infarction, left anterior descending coronary artery disease and failed PCI as independent predictors of major complications from day 8 to discharge. Patients without any predictor had significant lower rates of major complications from day 8 to 6 months after discharge than those with 1 or more predictors. Furthermore, in the present study there were no deaths in patients without any predictors. CONCLUSION: Patients who either do not have serious complications during the first 7 days or any predictor are at very low risk of major complications from day 8 to 6 months after discharge. These carefully selected patients may be suitable for early (day 8) hospital discharge after AMI.

[Effect of successful late reperfusion by primary coronary angioplasty on mechanical complications of acute myocardial infarction].

It has been suggested that early treatment decreases, but late treatment increases, the risk of mechanical complications for a thrombolytic strategy. However, few studies have evaluated whether late reperfusion by primary coronary angioplasty decreases the risk of mechanical complications. A total of 2,209 patients with acute myocardial infarction treated with primary coronary angioplasty within 24 hr after the onset of symptoms were divided into three groups: early reperfusion (ER; <- 12 hr, n = 1,647), late reperfusion (LR; > 12 hr, n = 219), and failed reperfusion (RF; n = 343). We evaluated the incidence, risk ratio, and predictors of mechanical complication. The overall incidence of mechanical complications was 2.0%. The incidence of mechanical complications was highest in the FR group (ER 1.4%, LR 1.8%, FR 5.0%, p <0.01). After adjusting for clinical variables, the risk ratio for mechanical complications increased in the FR group compared with LR group [risk ratio 7.34, 95% confidence interval (CI) 1.02 - 52.80, p = 0.04]. Predictors of an increased risk of mechanical complications by multivariate analysis were age >- 70 years (odds ratio 3.68, 95% CI 1.56-8.64, p < 0.01), Killip class >- II (odds ratio 3.73, 95% CI 1.52-9.12, p >- 0.01), absence of collateral vessels (odds ratio 4.09, 95% CI 1.17-14.26, p = 0.03), and FR (odds ratio 2.68, 95% CI 1.01-6.61, p = 0.03). In conclusion, successful late reperfusion by primary coronary angioplasty is associated with the reduced risk of mechanical complications in patients with acute myocardial infarction.