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Yasushi Kono,1 Shota Fukuda,1 Kenei Shimada,2 Koki Nakanishi,2 Kenichiro Otsuka,2 Tomoichiro Kubo,1 Satoshi Jissho,1 Haruyuki Taguchi,1 Junichi Yoshikawa,3 Minoru Yoshiyama21Department of Medicine, Osaka Ekisaikai Hospital, Nishi-ku, Osaka, Japan; 2Department of Internal Medicine and Cardiology, Osaka City University School of Medicine, Abeno-ku, Osaka, Japan; 3Nishinomiya Watanabe Cardiovascular Center, Nishinomiya, JapanBackground: It has been reported that pitavastatin improves endothelial function faster than other statins. Recently introduced reactive hyperemia peripheral arterial tonometry (RH-PAT) provides objective and quantitative assessment of peripheral microvascular function.Purpose: This study aimed to investigate whether peripheral microvascular function improved 2 hours after pitavastatin in subjects with coronary artery disease (CAD) using RH-PAT, and the results were compared with those of rosuvastatin.Methods: This study included 94 subjects with CAD, assigned to a group given 2 mg of pitavastatin (n = 36), a group given 2.5 mg of rosuvastatin (n = 38), and a control group (n = 20). RH-PAT examinations were performed before and 2 hours after statin administration.Results: The RH-PAT index increased 2 hours after pitavastatin administration from 1.82 ± 0.45 to 2.16 ± 0.62 (P = 0.02), whereas there were no differences in the RH-PAT index in the rosuvastatin group (1.79 ± 0.71 to 1.91 ± 0.53, P = 0.09) and the control group (1.68 ± 0.36 to 1.84 ± 0.58, P = 0.4). No significant changes were observed at 2 hours in serum cholesterol levels in each group.Conclusion: The present study demonstrated that peripheral microvascular function improved 2 hours after a single clinical dose of pitavastatin, but not after rosuvastatin.Keywords: coronary artery disease, statin, microvascular function

Background— Although left ventricular diastolic function has been shown to deteriorate with advancing age, its gender-specific change is unknown. The aim of this study was to investigate age- and gender-specific changes in tissue Doppler–derived left ventricular diastolic index, E′. Methods and Results— A total of 1333 healthy individual without known heart disease or hypertension (mean age, 55 years; range, 10 to 89) were enrolled and studied. Peak early mitral annular velocity (E′) and peak late mitral annular velocity (A′) were recorded and measured. As an index of the left ventricular relaxation, E′ was used. As an index of the left ventricular filling pressure, E/E′ was calculated. Although systolic indices poorly correlated with age, diastolic indices correlated well with age. Among those aged 30 to 39 and 40 to 49 years, E′ was significantly lower in males than in females. In subjects aged 50 to 59 and 60 to 69 years, E′ was similar in both genders. Among those aged 70 to 79 and 80 to 89 years, E′ was significantly lower in females than in males. Predictors of the lowest quartile of E′ among subjects aged >50 years were age ( P 2 =66.11; odds ratio, 1.08; 95% CI, 1.058 to 1.097) and female gender ( P =0.002; χ 2 =9.23; odds ratio, 1.68; 95% CI, 1.202 to 2.343). Conclusion— Age-related changes in diastolic indices were gender specific. In the elderly population, diastolic function deteriorated more significantly in the female gender than in the male gender. These results may explain the relatively higher incidence in elderly females among patients with diastolic heart failure and higher cardiovascular mortality in the female gender.

Background No reflow following percutaneous coronary intervention (PCI) is a major concern in patients with acute coronary syndrome (ACS) and it may be influenced by the preexisting plaque type. Methods and Results To evaluate the impact of plaque characteristics on coronary reflow following PCI in patients with ACS, a total of 110 patients (89 acute myocardial infarction, 21 unstable angina) were assessed by intravascular ultrasound. Plaque type was categorized as either atherosclerotic plaque without ultrasonic attenuation (group 1) or atherosclerotic plaque with attenuation (group 2). External elastic membrane, plaque plus media, and lumen area were measured. Coronary flow was assessed by Thrombolysis in Myocardial Infarction (TIMI) grade and TIMI frame count. Although the final TIMI frame count was similar between the 2 groups, TIMI frame count immediately after the first balloon inflation was significantly higher in group 2 (p=0.03). Despite the similar final TIMI grade and TIMI frame count, peak creatine kinase level was significantly higher (3,035±2,553 vs 1,950±1,958 IU/L, p=0.04) and fatal arrhythmia more frequently observed (16.4% vs 2.7%, p=0.04) in group 2 than in group 1. Conclusions Atherosclerotic plaque with ultrasonic attenuation may be related to a transient deterioration in coronary flow and as a result larger infarct size and higher incidence of fatal arrhythmia following PCI in patients with ACS. These results may help in selecting lesions suitable for distal protection devices. (Circ J 2007; 71: 648 - 653)

To investigate whether the ratio of early transmitral flow velocity (E) to early diastolic mitral annular velocity (E') predict prognosis in patients with non-valvular atrial fibrillation.230 patients with non-valvular atrial fibrillation were enrolled and studied. According to E/E' value, patients were divided into groups with lower (group A with E/E'or= 15) and higher (group B with E/E'15) E/E'.During follow up (average 245 days), 21 (9.1%) deaths were documented. All cause death (15/90 (16.7%) v 6/140 (4.3%)), cardiac death (10 (11.1%) v 2 (1.4%)) and congestive heart failure (16 (17.8%) v 8 (5.7%)) were more common in group B than in group A (all p0.01). A Kaplan-Meier survival curve showed that the cumulative survival rate was significantly lower in group B than in group A (log rank p = 0.0013). By multivariate logistic regression analysis, E/E' (chi(2) = 4.47, odds ratio (OR) 1.05, 95% confidence interval (CI) 1.01 to 1.11, p = 0.03) and age (chi(2) = 6.45, OR 1.06, 95% CI 1.01 to 1.11, p = 0.02) were independent predictors of mortality.The Doppler-derived index of left ventricular filling pressure, E/E', is a powerful predictor of the clinical outcome of patients with non-valvular atrial fibrillation.

Nightshift work, which is known to cause mental stress and disrupt normal biological diurnal rhythms, leads to endothelial dysfunction resulting in increased risk for cardiovascular disease. This study aimed to investigate the acute effect of night-shift work on coronary microcirculation through assessment of coronary flow reserve (CFR) by transthoracic Doppler echocardiography. This study consisted of 36 women nurses who underwent transthoracic Doppler echocardiographic examinations after working a nightshift and on a regular day without previous nightshift work. Flow velocity in the distal portion of the left anterior descending coronary artery was measured at baseline and during adenosine infusion. CFR was calculated as the ratio of hyperemic to basal mean diastolic flow velocity. CFR after night work was lower than that on a regular workday (3.8 ± 0.6 vs 4.1 ± 0.6, p

Advances in electronic miniaturization and digital techniqueshave resulted in the advent of portable transthoracic echocar-diography (pTTE) imaging devices in the area of echocardiog-raphy. A pocket-sized pTTE imaging device that has colorDoppler imaging capability has been recently introduced intoclinical practice. This study aimed to examine the feasibilityand accuracy of the pocket-sized pTTE in the assessment ofthe severity of mitral regurgitation (MR) and tricuspid regur-gitation (TR).One hundred and eighty-six consecutive patients (ages 66 19 years; 107 male) underwent standard transthoracic echo-cardiography (sTTE) and pTTE. Initially, pTTE was per-formed by a well-trained sonographer for 121 patients. For thelater 65 patients, pTTE was examined by a less experiencedsonographer who had 6 months of experience in echocardiog-raphy, with the number of TTE examinations compatible withAmerican Society of Echocardiography training level 1 (1).These sonographers were blinded to sTTE results and allclinical information.This study was approved by the ethics committees of OsakaEkisaikai Hospital and Okayama University. Pocket-sized pTTEwas performed using the Vscan (GE Medical Systems, Milwau-kee,Wisconsin).Theapical4-chamberviewbythecolorDopplerimages was obtained with sTTE and pTTE, respectively. Theratio of regurgitant jet area to atrial area was then calculated forMR (%MR) and TR (%TR). The severity of regurgitation wasgraded as mild if it occupied 20%, moderate if between 20%and 34%, and severe if 34% in TTE examination.Linear regression analysis was used for the correlation ofvariables of interest. Differences were considered significant atp 0.05.DifferencesbetweensTTEandpTTEresultswerealsocompared with the mean value obtained by sTTE and pTTEusing the Bland-Altman method, with the limits of agreementdefined as 2 SD of the difference between the 2 methods.Echocardiographic measurements were completed for sTTEand pTTE in all patients (feasibility 100%). In the examinationby the well-trained sonographer, there were excellent correlationsin MR jet area, left atrial area, %MR, TR jet area, right atrialarea, and %TR between sTTE and pTTE (r 0.89 to 0.96, p 0.001). Also, there were small systematic differences with closelimits of agreement between sTTE and pTTE measurements,respectively: 20.2 cm

Background— Plaque rupture may be present in the peripheral arteries of the patients at high risk for cardiovascular events and is possibly associated with vascular vulnerability. Methods and Results— One hundred one iliofemoral arteries from 101 patients undergoing angioplasty were studied. Intravascular ultrasound imaging was performed before intervention. Plaque rupture was defined as presence of a cavity that communicated with the lumen with an overlying residual fibrous cap fragment. Incidence, numbers, and location of the plaque rupture were investigated. Plaque rupture was found in 42 of 101 arteries (42%). Patients with plaque rupture had significantly higher prevalence of acute coronary syndrome than did patients without plaque rupture (42% vs 16%, P =0.01). By multivariable logistic regression analysis, acute coronary syndrome ( P =0.004) and male sex ( P =0.01) were independent clinical correlates of plaque rupture. During follow-up (median, 14.7 months), the incidence of major adverse cardiac or cerebrovascular events (death, myocardial infarction, and ischemic stroke) was similar between the 2 groups. The incidence of major adverse cardiac or cerebrovascular events plus peripheral vascular events (unplanned vascular intervention and amputation) was significantly higher in patients with plaque rupture than in patients without plaque rupture (46% vs 21%, P =0.008). By multivariable Cox regression analysis, plaque rupture (hazard ratio=2.80, 95% CI: 1.23 to 6.37, P =0.01) and Fontaine stage IV (hazard ratio=3.50, 95% CI: 1.58 to 7.71, P =0.002) were independent predictors of major adverse cardiac or cerebrovascular events plus peripheral vascular events. Conclusions— Ruptured plaque of the iliofemoral arteries is a common finding. Patients with plaque rupture had a higher prevalence of history of acute coronary syndrome and lower major adverse cardiac or cerebrovascular events plus peripheral vascular event-free survival.

Objectives The aim of this study was to investigate impact of arterial remodeling on long-term clinical outcome following stent implantation in patients with acute coronary syndrome (ACS). Methods A total of 134 patients with ACS were enrolled. External elastic membrane cross sectional area (EEM CSA) and lumen CSA were measured. Plaque plus media (P+M) CSA was calculated as EEM minus lumen CSA. Final minimal stent area (MSA) was also measured after stenting. Positive remodeling (PR) was defined as the ratio of the EEM CSA at the target lesion to that at the proximal reference of > 1.05, and intermediate or negative remodeling (IR/NR) was defined as that of ≤ 1.05. Results Although final MSA was similar, target lesion revascularization (TLR) rates at 2 years were significantly higher in patients with PR (33.7 %) than IR/NR (13.7 %) (p=0.01). In addition, non-TLR rates was also significantly higher in patients with PR (42.2 %) than IR/NR (23.5 %) (p=0.03). Cardiac events (death, myocardial infarction, TLR and non-TLR)-free survival was significantly lower in patients with PR than IR/NR (Log-rank, p=0.001). By multivariate logistic regression analysis, PR (chi-square 6.57, OR 2.70; 95% CI, 1.27-5.78; p=0.01) and plaque rupture (chi-square 4.17, OR 2.38; 95% CI, 1.04-5.45; p=0.04) were independent predictors of cardiac events. Conclusion In patients with ACS, PR and IVUS findings that may correspond with plaque rupture predict cardiac events including both TLR and non-TLR at 2 years.

The purpose of this study was to investigate the prognostic impact of functional mitral regurgitation (FMR) and tissue Doppler-derived index of left ventricular filling pressure, E/E', on long-term clinical outcome in a broad spectrum of ischemic heart disease.FMR has been shown to predict prognosis in patients with myocardial infarction.A total of 524 patients with ischemic heart disease were enrolled. Patients were categorized according to the presence (n = 58) or absence (n = 466) of severe FMR.Patients with severe FMR were significantly older. By echocardiography, ejection fraction was significantly lower (43.0% +/- 14.6% vs. 56.4% +/- 12.8%, P.01) and E/E' was significantly higher (21.3 +/- 9.0 vs. 14.6 +/- 6.4, P.01) in patients with FMR than without FMR. Event-free (death and congestive heart failure) survival was significantly lower in patients with FMR than in those without (log-rank P.0001). By multivariate logistic regression analysis, E/E' greater than 15 (relative risk [RR] 3.49; 95% confidence interval [CI] 2.08-5.88, P.0001), ejection fraction less than 50% (RR 3.33; 95% CI 1.96-5.64, P.0001), and severe FMR (RR 2.34; 95% CI 1.22-2.48, P = .01) were independent echocardiographic predictors of cardiac events. In further analysis of 116 patients matched by a propensity score, severe FMR remained associated with reduced event-free survival (log-rank P = .004).FMR is a strong predictor of cardiac events independently of left ventricular systolic and diastolic indices in patients with ischemic heart disease.

The purpose of this study was to assess the feasibility and usefulness of coronary flow velocity measurements of the left anterior descending coronary artery (LAD) by transthoracic Doppler echocardiography (TTDE) to differentiate ischemic cardiomyopathy (ICM) from non-ICM in patients.ICM and non-ICM have similar 2-dimensional echocardiographic features, left ventricular dilatation, and diffuse wall-motion abnormalities. TTDE may be useful to differentiate ICM from non-ICM by detecting significant LAD stenosis based on LAD flow signal analysis.TTDE was performed in 52 consecutive patients with left ventricular dilatation and diffuse wall-motion abnormalities of unknown origin. Peak and averaged systolic and diastolic flow velocities of the distal LAD flow could be recorded and measured from 44 patients (85%). Peak and mean diastolic/systolic velocity ratio (DSVR) were calculated.By coronary angiogram, 13 patients were given the diagnosis of ICM and 31 of non-ICM. Left ventricular end-diastolic and end-systolic volumes and ejection fraction were similar between ICM and non-ICM. On the other hand, peak DSVR (1.47 +/- 0.38 vs 2.34 +/- 0.67, P.0001) and mean DSVR (1.40 +/- 0.42 vs 2.24 +/- 0.61, P.0001) were significantly lower in patients with ICM than non-ICM. Either peak DSVR less than 1.8 or mean DSVR less than 1.8 had a sensitivity of 77% and a specificity of 77% for detecting the presence of severe LAD stenosis and, therefore, the diagnosis of ICM.TTDE is a useful noninvasive method to differentiate ICM from non-ICM.