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SummaryA 69-year-old woman underwent percutaneous coronary intervention for a severe stenotic lesion in the bifurcation of the mid-left anterior descending artery and first diagonal branch. A single stent was implanted into the left anterior descending artery. After the stent strut was dilated by balloon inflation in the diagonal branch, dissection occurred at the ostium of the diagonal branch and resulted in side branch occlusion due to hematoma. Bailout stenting was performed in the diagonal branch, but thrombus projection occurred in the left anterior descending artery. Aspiration, balloon inflation and thrombolytic therapy were performed, but distal embolism developed. This case illustrates that thrombus projection caused by stenting in a side branch may occur as a rare complication in percutaneous coronary intervention.

Determining the type of cardiac dysfunction is important for implementing therapeutic strategies and for prognostic insights. We characterized systolic dysfunction (SD) and isolated diastolic dysfunction (IDD) in adults referred for echocardiographic evaluation, and compared their clinical and other characteristics. In the present work, we studied 218 patients (137 males) with cardiac dysfunction (mean age, 66.3 +/- 8.3 years). SD was defined as a left ventricular ejection fraction (LVEF) of or= 45% in addition to the standard Doppler-echocardiography diagnostic criteria for IDD. Approximately 68% of subjects had SD (70% males). The proportions of hypertension, diabetes, and dyslipidemia were 44%, 26%, and 22%, respectively, without significant association with the type of dysfunction. Myocardial infarction (MI) was found in 31% of patients, and was significantly (P < 0.001) more prevalent among SD compared with IDD cases. Cerebral stroke (18%) and malignancy (16%) were significantly associated with IDD (29% versus 13% for SD in the case of stroke, and 26% versus 11% for SD in the case of malignancy; P = 0.008 for each). In multivariately-adjusted logistic regression analysis, the following variables were found to be significantly (P < 0.05) and independently associated with IDD: female gender (odds ratio [OR] = 2.207 [95% CI = 1.302-4.608]), stroke (OR = 2.009 [1.119-3.980]), and malignancy (OR = 2.016 [1.230-4.010]). On the other hand, previous MI (OR = 2.075 [1.769-4.808]) was independently associated with SD. In conclusion, some factors/comorbidities were more likely to associate with IDD (female gender, stroke, and malignancy) or SD (previous MI) when IDD and SD were compared with each other.

Background The impact of isolated diastolic dysfunction (IDD) and systolic dysfunction (SD) on health-related quality of life (HRQOL) is unknown. Methods and Results To evaluate HRQOL in patients with IDD and SD under treatment, information on outpatients aged 60‐84 years was extracted from the records of 4,500 consecutive individuals who underwent echocardiographic examination at Sado General Hospital. The medical records of these patients were reviewed and a questionnaire, including the Medical Outcome Study Short Form 36, was mailed to 71 IDD and 99 SD patients; answers were obtained from 66 and 91 patients, respectively. The HRQOL of patients with cardiac dysfunction was impaired even when echocardiographic parameters improved with treatment. Patients with IDD showed an impairment of HRQOL similar to those with SD. Compared with males, female patients had a larger and more significant reduction in the physical and mental components of the HRQOL score. These scores correlated positively with exercise capacity in patients with IDD or SD. Conclusions Impaired HRQOL, in both its mental and physical components, is a serious problem for IDD and SD patients under treatment. Because exercise intolerance may underlie the reduced HRQOL, improving exercise capacity could be an important target for managing outpatients with heart failure. (Circ J 2008; 72: 1436 ‐ 1442)

Background Heart failure (HF), which can be caused by left ventricular systolic dysfunction (LVSD), is a growing problem in developed countries with a large aging population. The aim of the present study was to characterize outpatients with LVSD in the adult population (45-84 years) in an urban Japanese community (Niigata City), and delineate their characteristics in comparison with those in a rural one (Sado). Methods and Results Over a 5-year period, 1,297 patients (67% males) with LVSD (defined as ejection fraction ≤50%) were extracted from 87,953 echocardiography records available in 15 hospitals in Niigata City. The proportion of LVSD increased progressively with age (p-for-trend

Background The prevalence of congestive heart failure (CHF) is increasing with the aging of the community. Management of patients with systolic dysfunction (SD) is important for prevention of CHF, but there is little information regarding the burden of SD on Japanese communities. Methods and Results In order to delineate the epidemiological and clinical characteristics of SD patients, the medical records of patients from Sado Island were collected and summarized in 2003. From the 5 years prior to 2003, data for 497 patients were extracted. The mortality rate was significantly higher compared with the general population; and the total number of survivors had decreased to 410 by 2003. The proportion of SD patients in the general population increased sharply after the age of 65 years in males and 70 years in females, reaching 3.3% and 1.7% for men and women, respectively, in their 80 s. In 49% of the patients, the Charlson comorbidity index was ≥2, whereas 24% of females led a solitary life. Conclusions The total count of outpatients with SD is progressively increasing with age. These patients have multiple comorbidities, making the outcome of SD a poor one. The gender difference in disease characteristics and living conditions should be taken into consideration when establishing preventive strategies for CHF in Japanese communities. (Circ J 2007; 71: 1004 - 1012)

Background The incidence of diastolic heart failure (DHF) is increasing with the aging of the community and identifying patients with isolated diastolic dysfunction (IDD) is important for preventing DHF. However, very little information is available about such patients in the Japanese community. Methods and Results The medical information of all outpatients with moderate to severe IDD was extracted from the records of approximately 6,948 individuals who underwent echocardiographic (Echo) examinations during the past 5 years in Sado Island. Of the 284 patients extracted, 272 survived until 2003. In January 2003 the proportion of patients with moderate to severe IDD in the general population sector aged 45-84 years was 0.9% for males and 0.5% for females, and this proportion increased sharply after the age of 65 in both genders, reaching 1.6% for men in their 70 s and 0.8% for women in their 80 s. On Echo, 165 patients (61%) showed hypertrophic left ventricular geometry. The Charlson comorbidity index score was ≤1 in 63% of patients. The cumulative survival of IDD patients, irrespective of a history of congestive heart failure (HF), was significantly lower than in the general population. Conclusions Moderate to severe IDD is not uncommon in the elderly and has a poor prognosis. Characteristics of outpatients with IDD should be taken into consideration when establishing a preventive strategy for HF in the Japanese community. (Circ J 2007; 71: 1013 - 1021)

Background The future burden of heart failure in Japan was projected to 2055 in order to prospectively estimate of the number of these patients. Methods and results The statistics are based on prevalence data of left ventricular dysfunction (LVD) in Sado City using the Sado Heart Failure Study (2003) and population estimates from the Japanese National Institute of Population and Social Security Research Report (2006). The number of Japanese outpatients with LVD was 979,000 in 2005, and is predicted to increase gradually as the population ages, reaching 1.3 million by 2030. Conclusion LVD is expected to precipitate a future epidemic of heart failure in Japan.

The role of neural factors in experimental renal hypertension was studied from the points of peripheral vascular reactivity, function of baroceptors and sympathetic activity in renal hypertensive dogs and the isolated smooth muscle strips of hypertensive rats. (1) The hypotensive responses to pentobarbital was more marked and continued longer in chronic renal hypertensive dogs than the controls. (2) The pressor responses to noradrenaline was remarkably augmented in renal hypertensive dogs, while the changes in those to angiotensin and Pitressin were not so marked. (3) The threshold for adrenaline or noradrenaline of isolated smooth muscle strips of intestine, rectum and uterus of rats was lower in hypertensive rats than in the operated normotensive and control groups. But the threshold for angiotensin and acetylcholine was rather higher in the hypertensive group. (4) The sensitivity of baroceptors examined by using the isolated perfusion method was unchanged and the baroceptors were resetted to the higher blood pressure level in chronic renal hypertension. (5) The influence of sympathetic innervation on carotid sinus activity was not different between the normotensive and renal hypertensive dogs. (6) The depressor responses to the sufficient amounts of ganglioplegics were not significantly changed in hypertensive dogs compared with the normotensives. (7) After the extensive sympathectomy the direct blood pressure fall was not significantly different between the normotensive and renal hypertensive dogs and the final blood pressure level was higher in renal hypertension than the control level. (8) The urinary excretion of adrenaline and noradrenaline was not significantly changed in chronic renal hypertensive dogs except the slight increase in the stage of blood pressure rising. Thus, increased sensitivity of peripheral blood vessels to noradrenaline was demonstrated in vivo and in vitro experiments in hypertensive animals. The baroceptors were resetted to the higher blood pressure level, and their sensitivity itself remained unchanged in renal hypertension. The sympathetic overactivity was not recognized in hypertension. Therefore, only the increased sensitivity of peripheral vessels to noradrenaline contributes to a part of the pressor mechanism in renal hypertension, while the baroceptors and sympathetic activities are passively adjusted to the higher blood pressure levels in hypertension.