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Statins were reported to have a potential effect of primary prevention of venous thromboembolism (VTE), although that of secondary prevention remains uncertain. To investigate the association between statins use and recurrent VTE in the current era. The COMMAND VTE Registry-2 is a multicenter registry enrolling 5,197 consecutive VTE patients among 31 centers in Japan between January 2015 and August 2020. We divided the entire cohort into 2 groups according to statins use at the time of discharge; the statins (N = 865) and no statins groups (N = 4332). The statins group was older (72.9 vs. 66.7 years, P < 0.001), and less often had active cancer (22.0% vs. 30.4%, P < 0.001). The cumulative incidence of discontinuation of anticoagulation was significantly lower in the statins group (60.3% vs. 52.6%, Log-rank P < 0.001). The cumulative 5-year incidence of recurrent VTE was significantly lower in the statins group (6.8% vs. 10.1%, Log-rank P = 0.01). Even after adjusting for the confounders, the lower risk of the statins group relative to the no statins group remained significant for recurrent VTE (HR 0.65, 95% CI 0.45–0.91, P = 0.01). The cumulative 5-year incidence of major bleeding was significantly lower in the statins group (12.2% vs. 14.1%, Log-rank P = 0.04), although, after adjusting for the confounders, the risk of the statins group relative to the no statins group turned to be insignificant (HR 0.77, 95% CI 0.59–1.00, P = 0.054). In this large real-world VTE registry, statins use was significantly associated with a lower risk for the recurrent VTE in the current era. [ABSTRACT FROM AUTHOR]

Background Excessive liquorice ingestion sometimes causes pseudoaldosteronism. The association between liquorice-induced pseudoaldosteronism and acute heart failure has not been well described. Case summary An 89-year-old woman was referred to the hospital due to muscle weakness with rhabdomyolysis and severe hypokalaemia. The electrocardiogram in the emergency department revealed pulseless ventricular tachycardia, thus, emergent defibrillation was delivered. Laboratory findings revealed severe hypokalaemia with metabolic alkalosis. Plasma renin activity and serum aldosterone were highly suppressed. Her medications included herbal medicines containing a great amount of liquorice. The patient was diagnosed with pseudoaldosteronism caused by liquorice over-ingestion. She developed acute pulmonary oedema with unexpected left ventricular (LV) dysfunction after the peak out of creatine kinase. She was managed with acute heart failure therapy, as well as optimal medical therapy. She accidentally developed an acute embolic stroke but fully recovered due to emergent thrombolytic therapy. Cardiac magnetic resonance imaging revealed banding late gadolinium enhancement in the basal-mid segments, which was inconsistent with takotsubo cardiomyopathy. As time passed, LV function unexpectedly improved, and congestive heart failure was completely compensated. Discussion Liquorice contains glycyrrhetinic acid that inhibits 11βHSD2. This invites the over-activation of mineralocorticoid receptors by cortisol in the kidneys and eventually causes hypokalaemia and hypertension. Acute heart failure caused by excessive liquorice ingestion is scarcely described. The triggering factors for LV dysfunction and acute congestive heart failure remain unclear. Rhabdomyolysis could affect massive catecholamine release and cause LV dysfunction. [ABSTRACT FROM AUTHOR]

Prolonged anticoagulation therapy is recommended for patients with intermediate-risk for recurrence of venous thromboembolism (VTE). The current study aimed to identify risk factors of VTE recurrence and major bleeding in intermediate-risk patients. The COMMAND VTE Registry is a multicenter registry enrolled consecutive 3027 patients with acute symptomatic VTE among 29 centers in Japan. The current study population consisted of 1703 patients with intermediate-risk for recurrence. The primary outcome measure was recurrent VTE during the entire follow-up period, and the secondary outcome measures were recurrent VTE and major bleeding during anticoagulation therapy. In the multivariable Cox regression model for recurrent VTE incorporating the status of anticoagulation therapy as a time-updated covariate, off-anticoagulation therapy was strongly associated with an increased risk for recurrent VTE (HR 9.42, 95% CI 5.97–14.86). During anticoagulation therapy, the independent risk factor for recurrent VTE was thrombophilia (HR 3.58, 95% CI 1.56–7.50), while the independent risk factors for major bleeding were age ≥ 75 years (HR 2.04, 95% CI 1.36–3.07), men (HR 1.52, 95% CI 1.02–2.27), history of major bleeding (HR 3.48, 95% CI 1.82–6.14) and thrombocytopenia (HR 3.73, 95% CI 2.04–6.37). Among VTE patients with intermediate-risk for recurrence, discontinuation of anticoagulation therapy was a very strong independent risk factor of recurrence during the entire follow-up period. The independent risk factors of recurrent VTE and those of major bleeding during anticoagulation therapy were different: thrombophilia for recurrent VTE, and advanced age, men, history of major bleeding, and thrombocytopenia for major bleeding. Clinical Trial Registration: Unique identifier: UMIN000021132. COMMAND VTE Registry: http://www.umin.ac.jp/ctr/index.htm. [ABSTRACT FROM AUTHOR]

Objective: We recently developed the self-management system using the HF points and instructions to visit hospitals or clinics when the points exceed the pre-specified levels. We found that the self-management system decreased the hospitalization for HF with an increase in unplanned visits and early intervention in the outpatient department. However, it is unclear whether we managed severe HF outpatients who should have been hospitalized. In this study, we aimed to compare HF severity in rehospitalized patients with regard to self-management system use. Results: We retrospectively enrolled 306 patients (153 patients each in the system user and non-user groups) using propensity scores (PS). We compared HF severity and length of readmission in rehospitalized patients in both groups. During the 1-year follow-up period, 24 system users and 43 non-system users in the PS-matched cohort were hospitalized. There were no significant differences between the groups in terms of brain natriuretic peptide levels at readmission, maximum daily intravenous furosemide dose, percentage of patients requiring intravenous inotropes, duration of hospital stay and in-hospital mortality. These results suggest that the HF severity in rehospitalized patients was not different between the two groups. [ABSTRACT FROM AUTHOR]

Background: The detailed causes of death in non–ST-segment–elevation myocardial infarction (NSTEMI) have not been adequately evaluated compared to those in ST-segment elevation myocardial infarction (STEMI). Methods: The study population was 6,228 AMI patients who underwent percutaneous coronary intervention (STEMI: 4,625 patients and NSTEMI: 1,603 patients). The primary outcome was all-cause death. Results: Within 6 months after AMI, the adjusted mortality risk was not significantly different between NSTEMI patients and STEMI patients (HR: 0.83, 95%CI: 0.67–1.03, P = 0.09). Regarding the causes of death within 6 months after AMI, mechanical complications more frequently occurred in STEMI patients than in NSTEMI patients, while proportions of post resuscitation status on arrival and heart failure were higher in in NSTEMI patients than in STEMI patients. Beyond 6 months after AMI, the adjusted mortality risk of NSTEMI relative to STEMI was not significantly different. (HR: 1.04, 95%CI: 0.90–1.20, P = 0.59). Regarding causes of death beyond 6 months after AMI, almost half of deaths were cardiovascular causes in both groups, and breakdown of causes of death was similar between NSTEMI and STEMI. Conclusion: The mortality risk within and beyond 6 months after AMI were not significantly different between STEMI patients and NSTEMI patients after adjusting confounders. Deaths due to post resuscitation status and heart failure were more frequent in NSTEMI within 6 months after AMI. [ABSTRACT FROM AUTHOR]

While the prognostic impact of QRS axis deviation has been assessed, it has never been investigated in patients without conduction block. Thus, we evaluated the prognostic impact of QRS-axis deviation in patients without conduction block. We retrospectively analyzed 3353 patients who had undergone both scheduled transthoracic echocardiography and electrocardiography in 2013 in a hospital-based population, after excluding patients with a QRS duration of ≥ 110 ms, pacemaker placement, and an QRS-axis − 90° to − 180° (northwest axis). The study population was categorized into three groups depending on the mean frontal plane QRS axis as follows: patients with left axis deviation (N = 171), those with right axis deviation (N = 94), and those with normal axis (N = 3088). The primary outcome was a composite of all-cause death and major adverse cardiovascular events. The cumulative 3-year incidence of the primary outcome measure was significantly higher in the left axis deviation group (26.4% in the left axis deviation, 22.7% in the right axis deviation, and 18.4% in the normal axis groups, log-rank P = 0.004). After adjusting for confounders, the excess risk of primary outcome measure remained significant in the left axis deviation group (hazard ratio [HR] 1.44; 95% confidence interval [CI] 1.07–1.95; P = 0.02), while the excess risk of primary outcome measure was not significant in the right axis deviation group (HR 1.22; 95% CI 0.76–1.96; P = 0.41). Left axis deviation was associated with a higher risk of a composite of all-cause death and major adverse cardiovascular events in hospital-based patients without conduction block in Japan. [ABSTRACT FROM AUTHOR]

A 74‐year‐old woman, with a history of aortic valve replacement and open mitral commissurotomy due to rheumatic aortic and mitral stenosis, presented with dyspnea. She developed severe tricuspid regurgitation (TR), requiring tricuspid valve replacement (TVR). Despite an uneventful postoperative course, she was readmitted for dyspnea 2 months later. Trans‐thoracic echocardiogram revealed severe mitral regurgitation (MR), despite mild MR at the time of TVR, which has not been previously reported. The main MR mechanism was increased left ventricular preload due to improved TR. Increased diuresis has controlled her congestive heart failure, but her MR remained moderate. [ABSTRACT FROM AUTHOR]

The prognostic impact of left atrial size in patients without systolic dysfunction nor atrial fibrillation (AF) has not been fully elucidated in Japan. We retrospectively analyzed data obtained from 4444 consecutive patients who had undergone both scheduled transthoracic echocardiography and electrocardiography in 2013 in our hospital. Those who presented with a history of myocardial infarctions, severe and moderate valvular diseases, low ejection fraction (< 50%), and documented AF, and without data on LA volume index (LAVI) or tissue Doppler early diastolic mitral annular velocity were excluded. We defined high LAVI as a value > 34 ml/m2. The primary outcome measure was a composite of all-cause death and major adverse cardiac events. A total of 2792 patients were categorized into two groups: 2627 with normal LAVI (94.1%), 165 with high LAVI (5.9%). The median age of patients in the normal and high LAVI groups were 67, and 77 years, respectively (p < 0.001). Prevalence of diabetes mellitus, hypertension, and chronic kidney disease, and left ventricular mass index was higher in the high-LAVI group than normal-LAVI group. After adjusting for confounders, the excess 3-year risk of primary outcome of high-LAVI related to normal-LAVI was significant (hazard ratio 1.44; 95% confidence interval 1.03–1.97, p = 0.032). High-LAVI should be considered a marker of a worse long-term follow-up in patients without systolic dysfunction nor AF. [ABSTRACT FROM AUTHOR]

Background: Normal findings of cardiac scintigraphy predict good outcomes. However, a paucity of the data exists for elderly patients 85 years or older. In the present study, we aimed to demonstrate the association between the abnormal findings of cardiac scintigraphy and the risk of all cause death in patients 85 years or older.Methods: We enrolled 143 consecutive patients 85 years or older with known or suspected coronary artery disease who underwent stress scintigraphy under adenosine or an exercise test and a 99mTechnetium (Tc)-labeled tracer or thallium 201 (201Tl), dual tracer rest scintigraphy using 201Tl and 123I-β-methyl iodophenyl pentadecanoic acid (123I-BMIPP), or 123I-BMIPP single tracer scintigraphy. Ischemia was defined by an induced perfusion abnormality according to a provocation test with recovery at rest or decreased uptake of 123I-BMIPP despite normal perfusion at rest. Infarction was defined by perfusion abnormalities assessed by images at rest on 201Tl or 99mTc-labeled tracer. We defined these findings as abnormal when at least one of these aforementioned characteristics was observed.Results: Patients in the abnormal findings group (N = 62) were more likely to have undergone prior coronary angiography and to have decreased ejection fraction than those in the normal findings group (N = 81). The median follow-up duration was 797 days (interquartile range, 635-1045 days), with follow-up rates of 90% at 1 year and 73% at 2 years. The 2-year mortality rate were significantly higher in the abnormal findings group than in the normal findings group (26.8% vs. 10.9%; p = 0.01). The risk of abnormal findings relative to normal findings remained significant for the mortality (adjusted hazard ratio, 5.99; 95% CI, 1.37-42.8; P = 0.015).Conclusion: Abnormal myocardial scintigraphy findings were associated with the increased risk for mortality, even for patients 85 years or older. [ABSTRACT FROM AUTHOR]

Aims Tricuspid regurgitation (TR) has been reported to be associated with worse survival in various heart diseases, but there are few data in aortic stenosis (AS). Methods and results In the Contemporary Outcomes after Surgery and Medical Treatment in Patients with Severe Aortic Stenosis (CURRENT AS) Registry enrolling 3815 consecutive patients with severe AS, there were 628 patients with moderate or severe TR (TR group) and 3187 patients with no or mild TR (no TR group). The study patients were subdivided into the initial aortic valve replacement (AVR) stratum (n  = 1197) and the conservative stratum (n  = 2618) according to treatment strategy. The primary outcome measure was a composite of aortic valve-related death or hospitalization due to heart failure. The 5-year freedom rate from the primary outcome measure was significantly lower in the TR group than in the no TR group (49.1% vs. 67.3%, P  < 0.001). Even after adjusting for confounders, the excess risk of TR relative to no TR for the primary outcome measure remained significant [hazard ratio (HR): 1.25, 95% confidence interval (CI): 1.06–1.48; P  = 0.008]. The trend for the excess adjusted risk in the TR group was consistent in the initial AVR and the conservative strata (HR 1.55, 95% CI: 0.97–2.48; P  = 0.07; HR 1.22, 95% CI: 1.02–1.46; P  = 0.03, respectively). In the initial AVR stratum, the 5-year freedom rate from the primary outcome measure was not different between the two groups with (n  = 56) or without (n  = 91) concomitant tricuspid annuloplasty (61.5% vs. 72.1%, P  = 0.48). Conclusion The presence of clinically significant TR concomitant with severe AS is associated with a poor long-term outcome, regardless of the initial treatment strategy. [ABSTRACT FROM AUTHOR]

Background: We aimed to investigate the values and the changes of brain natriuretic peptide (BNP) and cardiac troponin in pregnant women. Methods and results: We prospectively collected the data of 405 pregnant women who were treated at Japanese general hospital between 2012 and 2013. We analyzed their laboratory data and echocardiographic findings during the third trimester (28–30 weeks’ gestation) and within 4 days of delivery. In addition, we evaluated the factors associated with elevation of BNP and cardiac troponin I (cTnI) levels. The pregnant women were 33.8 ± 5.0 years old and the prevalence of pregnancy induced hypertension (PIH) and placental abnormality was 4.2% and 2.5%, respectively. BNP levels increased after delivery (13.2 pg/mL vs. 23.5 pg/mL; P <0.001), correlated with increased left ventricular diastolic dimension (P = 0.035), left atrial dimension (P <0.001), and decreased hemoglobin (P <0.001). Moreover, cTnI levels increased to over 0.015 ng/mL after delivery in 4.0% of pregnant women. In multivariate analysis, PIH (OR: 18.71, P = 0.003), placental abnormality (OR: 26.78, P = 0.007), and decreased hemoglobin after delivery (OR: 2.59, P <0.001) were the factors associated with elevated cTnI. Conclusions: BNP levels increased in association with cardiac chamber enlargement and decreased hemoglobin after delivery. Additionally, the factors affecting elevated cTnI levels were related to labor and delivery. [ABSTRACT FROM AUTHOR]

Background: Large V waves in the pulmonary capillary wedge pressure (PCWP) waveform traditionally indicate severe mitral regurgitation (MR). However, our understanding of MR etiology and hemodynamics has changed in recent decades. Objectives: We aimed to reevaluate the association between large V waves and current MR to determine whether traditional large V wave criteria remain optimal. Method: We reviewed 1,964 right heart catheterizations (RHCs) performed at our institution from 2010 to 2017, and retrospectively selected 126 patients with sinus rhythm who underwent echocardiography within 2 days (0.3 ± 0.5 days) of the RHC. The diagnostic accuracy of 3 traditional criteria for large V waves was assessed, and the optimal cut-off points were determined as those with the maximal Youden indices. Results: Severe MR was observed on echocardiography in 26 (21%) patients, including 15 (58%) with Carpentier classification type II MR and 11 (42%) with type IIIB MR. Large V waves, defined as a difference between the peak V wave and mean PCWP ≥10 mm Hg, had a high specificity of 94% (95% confidence interval: 87–98%), but a low sensitivity of 27% (12–48%) for diagnosing severe MR. The optimal cut-off point for the V wave was 3 mm Hg above the mean PCWP, with a sensitivity of 73% (52–88%) and a specificity of 64% (54–73%). Conclusions: For diagnosing current MR, the cut-off point for a large V wave should be reduced from that previously employed for rheumatic valvular heart disease. This information may be useful in guiding contemporary transcatheter therapies for MR under RHC monitoring. [ABSTRACT FROM AUTHOR]

Background: The prognostic impact of relative wall thickness (RWT), ventricular concentricity, is controversial. Methods: We retrospectively analyzed data obtained from 4444 consecutive patients who had undergone both transthoracic echocardiography and electrocardiography at our hospital in 2013. Those who presented with a history of previous episodes of myocardial infarctions and severe or moderate valvular disease were excluded from the analysis. We calculated RWT as follows: (2 x diastolic posterior wall thickness) / (the diastolic LV dimension). We defined high RWT as a ratio > 0.42. A total of 3654 patients were categorized into two groups: 492 with high RWT, and 3162 with normal RWT. Results: The mean ages of those in the normal and high RWT groups were 64.6 (±standard deviation 16.3) and 71.6 (± 12.7) years, respectively (p<0.001). Prevalence of male sex, history of diabetes, hypertension, and chronic kidney disease, and the left atrium volume index was higher for the high RWT group than for the normal RWT group. The median follow-up period was 1274 days (interquartile range, 410–1470). The Kaplan-Meier curves showed a constant increase in all-cause death, with cumulative 3-year incidences of 18.3% and 10.8% for the high RWT and normal RWT groups, respectively (log-rank p<0.001). After adjusting for confounders, the increased mortality risk for those with high RWT relative to normal RWT was significant (hazard ratio, 1.64; 95% confidence interval, 1.27–2.10). This trend was consistent for the composite of deaths and major adverse cardiac events. Conclusion: High RWT has a deleterious impact on long-term mortality. [ABSTRACT FROM AUTHOR]

One-month duration of dual antiplatelet therapy (DAPT) has widely been adopted after bare-metal stent (BMS) implantation in the real clinical practice. However, it has not been adequately addressed yet whether DAPT for only 1-month could provide sufficient protection from ischemic events beyond 1-month after BMS implantation. We assessed the effects of short DAPT relative to prolonged DAPT on clinical outcomes with the landmark analysis at 2 month after BMS implantation. Among 13,058 consecutive patients enrolled in the CREDO-Kyoto registry cohort-2, this study population consisted of 4905 patients treated with BMS only in whom the information on the status of antiplatelet therapy was available at 2 month after stent implantation [single-antiplatelet therapy (SAPT) group: N = 2575 (acute myocardial infarction (AMI): N = 1257, and non-AMI: N = 1318), and DAPT group: N = 2330 (AMI: N = 1304, and non-AMI: N = 1026)]. Cumulative 3-year incidence of the primary outcome measure (a composite of cardiovascular death, myocardial infarction, stroke, definite stent thrombosis, and GUSTO moderate/severe bleeding) was not significantly different between the SAPT and DAPT groups (9.8 versus 10.6 %, P = 0.34). After adjusting confounders, the risk of SAPT relative to DAPT for the primary outcome measure remained insignificant in the entire cohort (HR 0.97, 95 % CI 0.79-1.19, P = 0.77), and in both AMI and non-AMI strata without any significant interaction between clinical presentation (AMI versus non-AMI) and the effect of SAPT relative to DAPT (P interaction = 0.56). In conclusion, short DAPT <2 month after BMS implantation was as safe as prolonged DAPT ≥2-month in both AMI and non-AMI patients. [ABSTRACT FROM AUTHOR]

Introduction. The aim of this study was to examine the incidence and risk factors of catheterization-related CI in the contemporary era, using diffusion-weighted magnetic resonance imaging. Methods. We retrospectively analyzed consecutive 84 patients who underwent MRI (magnetic resonance imaging) after 2.81±2.4 days (mean±SD) of catheterization via aortic arch. We categorized the patients by the presence or absence of acute CI determined by diffusion-weighted MRI and analyzed the incidence and predictors. Results. Of 84 patients that underwent MRI after catheterization, acute CI was determined in 27 (32.1%) patients. In univariate analysis, dyslipidemia, age, coronary artery disease, antiplatelet agents, number of catheters used, urgent settings, and interventional procedures were significantly different. Multivariate analysis revealed dyslipidemia (odds ratio [OR], 4.46; 95% confidence interval [CI], 1.41–16.03; p=0.01), higher age (OR, 1.09; 95% CI, 1.007–1.19; p=0.03), and the number of catheters used (OR, 2.21; 95% CI, 1.21–4.36; p=0.01) as independent predictors of the incidence of catheterization-related acute CI. Conclusions. Dyslipidemia, higher age, and number of catheters used were independent predictors for acute CI after catheterization. These findings imply that managing dyslipidemia and comprehensive planning to minimize the numbers of catheters are important. [ABSTRACT FROM AUTHOR]

Background: Psoriasis vulgaris is a chronic inflammatory skin disease with an immune-genetic background. It has been reported as an independent risk factor for coronary heart disease (CHD) in the United States and Europe. The purpose of this study was to investigate the association between psoriasis and CHD in a hospital-based population in Japan. Methods: For 113,065 in-hospital and clinic patients at our institution between January 1, 2011 and January 1, 2013, the diagnostic International Classification of Diseases (ICD)-10 codes for CHD, hypertension, dyslipidemia, diabetes, and psoriasis vulgaris were extracted using the medical accounting system and electronic medical record, and were analyzed. Results: The prevalence of CHD (n = 5,167, 4.5%), hypertension (n = 16,476, 14.5%), dyslipidemia (n = 9,236, 8.1%), diabetes mellitus (n = 11,555, 10.2%), and psoriasis vulgaris (n = 1,197, 1.1%) were identified. The prevalence of CHD in patients with hypertension, dyslipidemia, diabetes, and psoriasis vulgaris were 21.3%, 22.2%, 21.1%, and 9.0%, respectively. In 1,197 psoriasis patients, those with CHD were older, more likely to be male, and had more number of the diseases surveyed by ICD-10 codes. Multivariate analysis showed that psoriasis vulgaris was an independent associated factor for CHD (adjusted odds ratio [OR]: 1.27; 95% confidence interval [CI]: 1.01–1.58; p = 0.0404) along with hypertension (adjusted OR: 7.78; 95% CI: 7.25–8.36; p < 0.0001), dyslipidemia (adjusted OR: 2.35; 95% CI: 2.19–2.52; p < 0.0001), and diabetes (adjusted OR: 2.86; 95% CI: 2.67–3.06; p < 0.0001). Conclusion: Psoriasis vulgaris was independently associated with CHD in a hospital-based population in Japan. [ABSTRACT FROM AUTHOR]

Introduction. Cardiac involvement of myasthenia gravis (MG) accompanies a poor prognosis. In the present study, we aimed to investigate the relationship between ECG abnormality and cardiac involvement. Methods. Of 178 patients diagnosed with MG between 2001 and 2013 at our hospital, we retrospectively analyzed consecutive 58 patients who underwent both ECG and echocardiography and without underlying cardiovascular disease. ECG abnormalities were defined by computer-assigned Minnesota-codes. Cardiac damage was defined as either (1) ejection fraction (EF) <55% on echocardiography or (2) elevated E/e′, the ratio of mitral velocity to early diastolic velocity of the mitral annulus >8 on echocardiography. Results. Thirty-three patients (56.8%) had ECG abnormality. An elevated E/e′ was observed in patients with ECG abnormality compared to those without ECG abnormality (11.2±3.2, 8.7±2.2, resp., p=0.03). Among patients with ECG abnormality, 14 of 15 patients showed cardiac damage. Among patients without ECG abnormality, 6 of 33 patients showed cardiac damage (p=0.003). Reduced EF was observed in five patients (8.6%) with ECG abnormality and none in patients without ECG abnormality. Conclusions. ECG may aid as the first step for the further examination of cardiac damage in patients with MG. [ABSTRACT FROM AUTHOR]

We present a case of syncope caused by coronary artery spasm without chest pain leading to ventricular fibrillation despite of vasodilator therapy with a calcium channel blocker (CCB). A 68-year-old man presented with two episodes of syncope without chest pain. Ergonovine provocation test induced a diffuse spasm in the right coronary artery (RCA) and subsequently, ventricular fibrillation. Under the therapy with multiple vasodilators including two CCBs, a second ergonovine provocation induced a spasm of the proximal RCA resulting in complete obstruction. Owing to drug-resistant coronary spasm complicated by ventricular fibrillation, an implantable cardioverter defibrillator (ICD) was implanted. This case report highlights the occurrence of syncope caused by coronary artery spasm without chest pain that was refractory to single CCB therapy and needed ICD implantation. Therapy with multiple vasodilators, including two or more CCBs, along with ICD implantation may be required to treat such refractory coronary artery spasms leading to lethal arrhythmia. [ABSTRACT FROM AUTHOR]

A 75-year-old male presented with palpitation on exertion. He suffered from frequent tachycardia attacks. His 12-leads electrocardiogram showed irregular cycle lengths (400–550 ms) of tachycardia with occasional 2:1 atrioventricular conduction (thus AV reentry was excluded). He had a complex anatomy of persistent left superior vena cava (PLSVC)/ enlarged coronary sinus (CS). The activation map in a 3-dimensional CARTO system (Biosense-Webster, USA) was merged with the multi-detector computed tomography image and revealed that the tachycardia spread centrifugally from the junction between the PLSVC and enlarged CS. However, delivery of radio frequency (RF) energy to the earliest atrial activation site did not affect the tachycardia. Finally, the tachycardia was diagnosed as a fast/ slow type atrioventricular nodal reentrant tachycardia (AVNRT) because the tachycardia was cured only after the anterograde/retrograde AV conduction was disturbed by the application of RF energy to the posteroseptal perimitral area, possibly due to the injury to the AV node. [Copyright &y& Elsevier]

We report 2 cases of reversible ventricular hypertrophy in patients with takotsubo cardiomyopathy (stress-induced cardiomyopathy) during recovery of cardiac function. The first case involved a 72-year-old woman who presented with cerebral infarction. On admission, an elevated troponin I and decreased apical wall motion were observed with normal myocardial perfusion imaging. The second case involved a 79-year-old woman who presented with angina, anxiety resulting from emotional stress, slightly decreased apical wall motion, and normal epicardial arteries. In both cases, apical hypertrophy of the left ventricle was observed at approximately 3 weeks after onset, when the wall motion had improved. The ventricular wall gradually became thinner over time. To our knowledge, this is the first report of reversible ventricular hypertrophy in patients with takotsubo cardiomyopathy. We hypothesize the hypertrophic signaling in the myocardium was stimulated by catecholamines, which are the suggested etiology of takotsubo cardiomyopathy, and the hypertrophied myocardium gradually returned to normal as the syndrome receded. [ABSTRACT FROM AUTHOR]

Key Clinical Message The decreased 123I- BMIPP uptake, while having normal perfusion, in the correspondent coronary artery territory is caused by a delayed metabolic recovery after the recovery of perfusion. This phenomenon termed ischemic memory can clearly differentiate vasospastic angina from other chest pain syndromes. [ABSTRACT FROM AUTHOR]

A reply to a letter to the editor in response to the article "Two Cases of Reversible Left Ventricular Hypertrophy during Recovery from Takotsubo Cardiomyopathy" published in a previous issue is presented.