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The clinical expert consensus statement on takotsubo syndrome (TTS) part II focuses on the diagnostic workup, outcome, and management. The recommendations are based on interpretation of the limited clinical trial data currently available and experience of international TTS experts. It summarizes the diagnostic approach, which may facilitate correct and timely diagnosis. Furthermore, the document covers areas where controversies still exist in risk stratification and management of TTS. Based on available data the document provides recommendations on optimal care of such patients for practising physicians. ispartof: EUROPEAN HEART JOURNAL vol:39 issue:22 pages:2047-2062 ispartof: location:England status: published

Diabetes mellitus (DM) is a major risk factor for the development of coronary artery disease (CAD) ([1][1]) and coronary microvascular dysfunction is a key feature of diabetic heart disease ([2][2]). An assessment of the microvascular function is important for patients with DM because diffuse

BACKGROUND Few studies have compared the platelet reactivity of prasugrel and clopidogrel in the acute phase of ST-segment elevation myocardial infarction (STEMI).Methods and Results:Primary percutaneous coronary intervention (PCI) was performed in 78 patients with STEMI within 12 h of onset. Patients were randomly assigned to receive a Japanese standard loading dose of prasugrel 20 mg or clopidogrel 300 mg. Platelet reactivity was serially assessed using the VerifyNow-P2Y12 assay, the results of which were expressed as P2Y12-reaction-units (PRU). PRU values were significantly lower in the prasugrel group (n=38) than in the clopidogrel group (n=40) at 3 h, 24 h, and 14 days after loading (191±101 vs. 271±50, 147±80 vs. 261±57, and 171±67 vs. 221±70, respectively, P

BACKGROUND There is no information on differences in the effects of moderate- and low-intensity statins on coronary plaque in patients with acute coronary syndrome (ACS). The aim of this study was to compare the effects of 4 different statins in patients with ACS, using intravascular ultrasound (IVUS). METHODS AND RESULTS A total of 118 patients with ACS who underwent IVUS before percutaneous coronary intervention and who were found to have mild to moderate non-culprit coronary plaques were randomly assigned to receive either 20 mg/day atorvastatin or 4 mg/day pitavastatin (moderate-intensity statin therapy), or 10 mg/day pravastatin or 30 mg/day fluvastatin (low-intensity statin therapy). IVUS at baseline and at end of 10-month treatment was available in 102 patients. Mean percentage change in plaque volume (PV) was -11.1±12.8%, -8.1±16.9%, 0.4±16.0%, and 3.1±20.0% in the atorvastatin, pitavastatin, pravastatin, and fluvastatin groups, respectively (P=0.007, ANOVA). Moderate-intensity statin therapy induced regression of PV, whereas low-intensity statin therapy produced insignificant progression (-9.6% vs. 1.8%, P

Aims Non-invasive positive pressure ventilation rapidly improves the symptoms of acute heart failure (AHF). A portion of patients, however, are forced to be intubated even though intubation is associated with serious complications, and hypercapnia is often observed in AHF requiring intubation. The purpose of this study is to examine the clinical profile and management of hypercapnia in AHF patients. Methods and results We examined the arterial blood gas analysis in 193 consecutive AHF patients (73 ± 12 years, 61% men) at admission. Many patients (n = 129, 66.8%) had already been treated with oxygen by the ambulance staff. Hypercapnia (PaCO2 at admission >45 mmHg) and hypocapnia (PaCO2

BACKGROUND Impaired glucose metabolism plays an important role in patients with acute myocardial infarction, but the clinical significance of glycemic variability (GV) early after the onset of ST-segment elevation myocardial infarction (STEMI) remains to be fully elucidated. METHODS AND RESULTS We prospectively investigated the clinical impact of GV, as determined by a continuous glucose monitoring system (CGMS), on left ventricular remodeling (LVR) assessed by cardiac magnetic resonance imaging (CMR) in 69 patients (63±13 years, 59 men) with a first reperfused STEMI within 12 h of onset. All patients were equipped with a CGMS when in a stable phase after admission and underwent repeat CMR at baseline and 7 months follow-up. Patients were divided into 2 groups according to the mean amplitude of glycemic excursions (MAGE). Patients in the upper tertile of MAGE were categorized as group High (H) and the other two-thirds as group Low (L). LVR was defined as an absolute increase in left ventricular end-diastolic volume index of ≥20%. LVR more frequently occurred in group H than in group L (56% vs. 11%, P

AIM Diabetes is accompanied by abdominal obesity, which produces various metabolic abnormalities. While metabolic factors have been considered to promote the development of coronary atherosclerosis in the early-stage of diabetes, it remains unknown whether the presence of obesity in early-stage diabetics affects the natural history of coronary atherosclerosis. We herein investigated the characteristics of the disease substrate in obese early-stage diabetics. METHODS The DIANA (DIAbetes and diffuse coronary NArrowing) study was a serial evaluation of angiographic disease progression in early-stage diabetics with coronary artery disease. A total of 252 study subjects were stratified into non-obese (n=168) and obese groups (n=84). Obesity in Japanese subjects was defined as a body mass index ≥25 kg/m(2) according to the statement about Japanese obesity from the Japan Society for the Study of Obesity. Coronary atherosclerotic changes were evaluated by a quantitative computed analysis. The total lesion length (TLL=total length of all atherosclerotic lesions) was compared between the groups. RESULTS The obese patients were younger (p=0.0002) and had higher levels of fasting (p=0.002) and postprandial insulin (p=0.01), and higher triglyceride levels (p=0.02). On serial angiographic evaluations, obese patients had greater disease progression, reflected by a larger percent change in the TLL (24.7±13.7 vs. 7.4±10.0%, p=0.04). However, the improvement of abnormal glucose tolerance was associated with a slowing of disease progression in both non-obese (-0.9±10.7 vs. ＋15.0±11.2%, p=0.04) and obese (＋4.2±22.8 vs. ＋55.5±26.5%, p=0.005) patients. CONCLUSIONS Obese patients with early-stage diabetes exhibit profound disease progression. Glycemic control attenuated the progression of their coronary atherosclerosis. Our findings indicate progressive but modifiable disease in obese early-stage diabetics under optimal glycemic management.

BACKGROUND Although rapid progression (RP) of coronary artery disease (CAD) has been shown to be a powerful predictor of cardiovascular events, predictors of RP are not fully understood in patients with acute coronary syndrome (ACS). METHODS AND RESULTS We prospectively investigated the clinical impact of glycemic variability (GV), as determined on continuous glucose monitoring system (CGMS), on RP of non-culprit lesions in 88 patients with ACS. RP was defined as ≥10% diameter reduction in a pre-existing stenosis ≥50%; ≥30% diameter reduction in a stenosis

The differential diagnosis between precapillary and postcapillary pulmonary hypertension (PH) is important for deciding on the appropriate therapeutic strategy. The aim of this study was to assess whether the atrial volume ratio can differentiate precapillary and post-capillary PH.Seventy-seven patients with PH who underwent transthoracic echocardiography (TTE) and right heart catheterization were retrospectively studied. Pulmonary hypertension was defined as a mean pulmonary arterial pressure of 25 mm Hg or higher by right heart catheterization. Patients with a pulmonary capillary wedge pressure higher than 15 mm Hg were classified as having postcapillary PH, and patients with a pulmonary capillary wedge pressure of 15 mm Hg or lower were classified as having precapillary PH. The atrial volume ratio derived from TTE was defined as right atrial volume divided by left atrial volume.Forty-four (57%) of 77 patients had precapillary PH by the right heart catheterization classification. The atrial volume ratio was significantly higher in precapillary PH than in postcapillary PH (1.03 ± 0.69 versus 0.50 ± 0.19; P .001). The area under the receiver operating characteristic curve of the atrial volume ratio for detecting postcapillary PH was 0.84 (95% confidence interval: 0.75-0.93). Adding the atrial volume ratio to the left ventricular ejection fraction yielded a high area under the curve of 0.90 (95% confidence interval, 0.83-0.96) for distinguishing precapillary and postcapillary PH.The atrial volume ratio assessed by TTE might be useful for differential diagnosis between precapillary and postcapillary PH.

Background The biphasic inflammation after ST ‐segment elevation myocardial infarction ( STEMI ) plays an important role in myocardial healing and progression of systemic atherosclerosis. The purpose of this study is to investigate the impact of fever during the first and second phases of post‐ STEMI inflammation on long‐term cardiac outcomes. Methods and Results A total of 550 patients with STEMI were enrolled in this study. Axillary body temperature ( BT ) was measured and maximum BT s were determined for the first (within 3 days: max‐ BT 1–3d ) and second (from 4 to 10 days after admission: max‐ BT 4–10d ) phases, respectively. Patients were followed for cardiac events (cardiovascular death, acute coronary syndrome, and rehospitalization for heart failure) for a median 5.3 years. During the follow‐up period, 80 patients experienced cardiac events. A high max‐ BT 4–10d was strongly associated with long‐term cardiac events (hazard ratio, 95% CI ) for a 1°C increase in the max‐ BT 4–10d : 2.834 (2.017–3.828), P BT 1–3d was not associated with cardiac events (1.136 [0.731–1.742], P =0.57). Even after adjustment for coronary risk factors, estimated glomerular filtration rate, infarct size, pericardial effusion, and medications on discharge, fever during the second phase (max‐ BT 4–10d ≥37.1°C) was significantly associated with future cardiac events (hazard ratio [95% CI ] 2.900 [1.710–5.143], P Conclusions Fever during the second phase but not the first phase of post‐ STEMI inflammation was a strong associated factor with worse long‐term cardiac outcomes in patients after STEMI , suggesting the need to consider the optimal timing for anti‐inflammatory strategies after STEMI .

Type A acute aortic dissection (AAD) is a serious cardiovascular emergency requiring urgent surgery. Timely accurate diagnosis is essential, but often challenging, because of the wide spectrum of clinical presentations. In patients with type A AAD, chest pain is the most common symptom; furthermore, ischemic ST-T changes such as ST-segment elevation or depression or negative T waves are frequently observed on presentation ECG. These clinical presentations of type A AAD are difficult to differentiate from those of acute coronary syndrome (ACS), which could lead to delayed diagnosis and treatment of type A AAD or misdiagnosis of ACS followed by inappropriate treatment. Of note, ischemic ST-T changes have been shown to be associated with poor outcomes in patients with type A AAD. Because ECG is simple, inexpensive, noninvasive, readily available, and rapidly interpretable at the time of presentation, risk stratification based on ECG findings is considered very useful clinically. ECG findings of type A AAD thus have clinically important diagnostic, therapeutic, and prognostic implications; however, the relationships among these factors remain poorly understood. We review the prevalence of ECG abnormalities, clinical features associated with such changes, and the prognostic importance in patients with type A AAD.

BACKGROUND Acute kidney injury (AKI) is associated with poor outcome after acute myocardial infarction (AMI), but whether hemodynamic status at presentation influences this prognostic significance is unknown.Methods and Results:A total of 2,798 AMI patients admitted within 48 h after symptom onset and who underwent urgent coronary angiography were enrolled in the present study. AKI was defined as an increase in serum creatinine ≥0.3 mg/dL or ≥50% within 48 h during hospitalization. Patients were classified into 3 groups according to Killip class on admission: Killip 1, n=2,164; Killip 2-3, n=366; and Killip 4, n=268. AKI occurred more frequently with increasing Killip class (Killip 1, 2-3, and 4: 6.3%, 15.3%, and 31.3%, respectively; P

Takotsubo cardiomyopathy (TC) is a recently recognized novel cardiac syndrome characterized by transient left ventricular dysfunction without obstructive coronary disease, electrocardiographic (ECG) changes (ST-segment elevation and/or negative T wave) or elevated cardiac enzymes. Because the clinical features and ECG findings of TC mimic those of anterior acute myocardial infarction (AMI) with occlusion of the left anterior descending coronary artery, differential diagnosis has an important role in selecting the most appropriate treatment strategy. Especially in the acute phase, differential diagnosis is essential for deciding whether reperfusion therapy is required. Although it has been suggested that ECG does not allow reliable differentiation between TC and anterior AMI, several ECG criteria distinguishing TC from anterior AMI have been proposed. In this review, we discuss ECG findings of TC, especially in the acute phase, compare them with those of anterior AMI, and identify ECG features that may facilitate early recognition of this disease.

intravascular ultrasound (IVUS)-derived fractional flow reserve (FFR) is a novel technique to estimate functional severity of coronary stenosis using a fluid dynamics algorithm. The pressure loss (ΔP) across a stenosis can be calculated by the following simplified equation: ΔP = FV + SV2, where

Several studies have demonstrated that multivessel disease is an independent predictor of coronary plaque progression and recurrent acute coronary events [(1)][1]. Angiographic-based SYNTAX (Synergy Between PCI With TAXUS and Cardiac Surgery) score (SS) has consistently been shown to be an

Aim In the DIANA(DIAbetes and diffuse coronary NArrowing) study, which evaluated the impact of glucose-lowering therapy in early-stage diabetics with coronary artery disease(CAD), optimal glycemic control resulted in reduced disease progression on angiography. However, despite having a favorable glycemic status, some patients continued to exhibit disease progression. Factors associated with disease progression despite optimal glucose control remain to be elucidated. We sought to investigate clinical characteristics associated with substantial atheroma progression in early-stage diabetic patients with CAD who achieve favorable glycemic control. Methods The DIANA study is a prospective randomized trial comparing the effects of lifestyle intervention and treatment with voglibose or nateglinide on disease progression on angiography in 302 CAD patients with impaired glucose tolerance/newly diagnosed diabetes. Of these patients, 137 CAD subjects who achieved optimal glycemic control were stratified according to the presence of disease progression on angiography: progressors(n=64) and non-progressors(n=73). Serial coronary angiography studies and quantitative coronary angiography analyses were conducted to evaluate disease progression. A multivariate analysis was performed to elucidate factors associated with disease progression. Results Despite the achievement of optimal glycemic control, atheroma progression was observed in 46% of the study subjects. The progressors exhibited lower decreases in systolic blood pressure(SBP: p=0.007) and reduced baseline total lesion lengths(TLL: p=0.01). The multivariate analysis demonstrated that a greater increase in SBP(p=0.006), treatment without statins(p=0.03) and the baseline TLL(p=0.007) were independently associated with disease progression. Conclusions Residual risk factors contribute to the progression of coronary atherosclerosis in early-stage diabetics who exhibit improvements in their glycemic status. The present findings underscore the need to intensively modify multiple risk factors during the early diabetic phase in order to prevent atheroma progression.

Several studies have shown higher early mortality for ST-segment elevation acute coronary syndrome (STEACS), but late mortality remains consistently higher for non-ST-segment elevation acute coronary syndrome (NSTEACS). We hypothesized that ST-segment category at acute presentation is associated with the time course of coronary artery disease progression (CP) of nonculprit lesions in patients with acute coronary syndrome (ACS). A total of 226 patients (182 men, age 65 ± 10 years) with STEACS (n = 95) or NSTEACS (n = 131) who underwent percutaneous coronary intervention (PCI) during initial hospitalization were studied. All patients underwent serial coronary angiograms (CAGs) performed immediately before PCI and at 7 ± 3 months and 60 ± 10 months after presentation. CP was defined as an increase in stenosis severity >15% of a nonculprit lesion between 2 serial CAGs. The rate of CP between the first and second CAGs did not differ by ST-segment category at acute presentation. Compared to STEACS, NSTEACS had a higher rate of CP between the second and final CAGs (27.4 vs. 42.7%, P = 0.018). Multivariate analysis showed that the independent predictors of CP between the second and final CAGs were NSTEACS (odds ratio 2.709, P = 0.003), estimated glomerular filtration rate

BACKGROUND Target lesion calcification is known to influence percutaneous coronary intervention. We evaluated the effects of rotational atherectomy (RA) and subsequent balloon angioplasty on calcified coronary lesions using optical coherence tomography (OCT). METHODS AND RESULTS Thirty-seven calcified lesions in 36 patients were treated with RA followed by balloon angioplasty and stent implantation. In all patients, serial OCT images obtained after RA, after balloon angioplasty, and after stent implantation were analyzed at 1-mm intervals. The arc and thickness of the calcium component were measured after RA. The formation of calcium cracks was assessed after balloon angioplasty. A total of 625 segments were analyzed. The formation of calcium crack after balloon angioplasty was associated with greater stent cross-sectional area (7.38±1.92 vs. 7.13±1.68 mm(2), P=0.035) as well as greater lumen gain (3.89±1.53 vs. 3.40±1.46 mm(2), P

The 12-lead electrocardiogram (ECG) is the important, initial examination for diagnosing acute coronary syndrome (ACS). In the traditional 12-lead ECG display, the precordial leads are displayed in their anatomically contiguous order, which makes it easy to understand the positional relationships between the precordial leads and the heart, but the limb leads are not. The "Cabrera sequence" displays the limb leads in an anatomically contiguous manner, which facilitates understanding of the positional relations between the limb leads and the heart, resulting in more rapid, easy, and accurate ECG interpretation than the traditional limb leads display. This review explores the clinical advantages of the Cabrera sequence as compared with the traditional limb leads display for the diagnosis of ACS. (Circ J 2016; 80: 1087-1096).

Contrast-induced nephropathy (CIN) and chronic kidney disease (CKD) are associated with poor outcomes after primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI); however, its combined prognostic significance remains unclear. We enrolled 577 patients with AMI undergoing primary PCI within 12 h after symptom onset and measured serum creatinine on admission and the next 3 days. CKD was defined as admission estimated glomerular filtration rate

Negative T waves in precordial leads often occur in patients with acute coronary syndrome (ACS), but are also found in acute pulmonary embolism (APE) and Takotsubo cardiomyopathy (TC). Because the clinical features of these two diseases mimic those of ACS, differential diagnosis is essential to select an appropriate treatment strategy improve outcomes. This study aimed to clarify the differences in negative T waves among ACS, APE and TC.We studied admission ECGs in 300 patients (198 patients with ACS caused by the left anterior descending coronary artery disease, 81 with APE and 21 with TC). All patients were admitted within 48 h from symptom onset and had negative T waves ≥1.0 mm without ST-segment elevation in leads V1 to V4. The number and maximal amplitude of negative T waves were greatest in patients with TC, followed by in those with ACS, and were lowest in patients with APE (p0.001, respectively). The prevalence of negative T waves significantly differed in all 12 leads among the three groups (p0.01, respectively). Negative T waves in both leads III and V1 identified APE with 90% sensitivity and 97% specificity. Negative T waves in lead -aVR (i.e., positive T waves in lead aVR) and no negative T waves in lead V1 identified TC with 95% sensitivity and 97% specificity. These values represented the highest diagnostic accuracies.The distributions of negative T waves differed among ACS, APE and TC, and these differences were useful for differentiating among these three diseases.

During inferior acute myocardial infarction, ST-segment elevation (ST↑) often occurs in leads V(5) to V(6), but its clinical implications remain unclear. We examined the admission electrocardiograms from 357 patients with a first inferior acute myocardial infarction who had Thrombolysis In Myocardial Infarction 3 flow of the right coronary artery or left circumflex artery within 6 hours after symptom onset. The patients were divided according to the presence (n = 76) or absence (n = 281) of ST↑2 mm in leads V(5) and V(6). Patients with ST↑ in leads V(5) and V(6) were subdivided into 2 groups according to the degree of ST↑ in leads III and V(6): ST↑ in lead III greater than in V(6) (n = 53) and ST↑ in lead III equal to or less than in V(6) (n = 23). The perfusion territory of the culprit artery was assessed using the angiographic distribution score, and a mega-artery was defined as a score of ≥0.7. ST↑ in leads V(5) and V(6) with ST↑ in lead III greater than in V(6) and ST↑ in leads V(5) and V(6) with ST↑ in lead III equal to or less than in V(6) were associated with mega-artery occlusion and impaired myocardial reperfusion, as defined by myocardial blush grade 0 to 1. Right coronary artery occlusion was most common (96%) in the former, and left circumflex artery occlusion was most common (96%) in the latter, especially proximal left circumflex occlusion (74%). Multivariate analysis showed that ST↑ in leads V(5) and V(6) with ST↑ in lead III greater than that in V(6) (odds ratio 4.81, p0.001) and ST↑ in leads V(5) and V(6) with ST↑ in lead III equal or less than that in V(6) (odds ratio 5.96, p0.001) were independent predictors of impaired myocardial reperfusion. In conclusion, ST↑ in leads V(5) and V(6) suggests a greater risk area and impaired myocardial reperfusion in patients with inferior acute myocardial infarction. Furthermore, comparing the degree of ST↑ in lead V(6) with that in lead III is useful for predicting the culprit artery.

To assess the role of percutaneous cardiopulmonary support (PCPS) for the resuscitation of patients with massive pulmonary embolism (PE) with circulatory collapse. We also compared outcomes for PCPS between patients with massive PE with circulatory collapse and patients with AMI with cardiogenic shock.The effectiveness of PCPS for acute myocardial infarction (AMI) complicated with cardiogenic shock has been reported, but there are few reports on the use of PCPS for massive PE with circulatory collapse.We studied 12 consecutive patients with massive PE and 16 patients with AMI, who required PCPS for resuscitation either during cardiopulmonary resuscitation (CPR) or after successful CPR.Twelve patients with PE and 16 patients with AMI were identified. There were no differences in age, the Acute Physiology, Age and Chronic Health Evaluation II (APACHE II) score at admission, rate of cardiac arrest on arrival, and time from first circulatory collapse to PCPS between the two groups. However, the proportion of men with PE (33%) was smaller than those with AMI (87%, p0.05). The duration of PCPS was shorter in PE (38 h) compared with AMI (83 h, p=0.051) patients. The proportion of patients successfully weaned from PCPS (100% vs. 37.5%, p0.01), survival rate at discharge (83.3% vs. 12.5%, p0.001) and good neurological outcome (58.3% vs. 6.3%, p=0.004) was significantly higher for PE compared to AMI patients.In our small case series, percutaneous cardiopulmonary support (PCPS) had a life saving role in patients with massive PE and cardiac arrest. PCPS was also more effective in patients with massive PE with cardiac arrest than in patients with AMI and cardiac arrest.

Background: In both takotsubo cardiomyopathy (TC) and reperfused anterior acute myocardial infarction (AMI), negative T waves commonly appear on the ECG in the subacute phase. This study aimed to clarify the ECG differences between these diseases. Methods and Results: We compared the ECGs with the greatest amplitude of negative T wave from 34 patients with TC and 237 patients with a first reperfused anterior AMI who were admitted within 6h of symptom onset and who had no abnormal Q-waves on discharge ECG. Time from symptom onset to recording the ECG did not differ between TC and anterior AMI (2.4±1.5 vs. 2.1±2.0 days, P=0.48). TC was associated with a greater maximal amplitude of negative T wave (1.00±0.44 vs. 0.79±0.46mV, P=0.044), and a greater number of leads with negative T waves (9.5±1.0 vs. 6.0±2.1, P

We thank Dr. Lichtenberg for his interest and insightful comments regarding our study of the prognostic value of coronary flow reserve (CFR) evaluated by phase-contrast cine cardiac magnetic resonance imaging (MRI) of the coronary sinus to patients with known or suspected coronary artery disease (

SummaryBackgroundAlthough there has been an intense debate whether concomitant use of proton-pump inhibitors (PPIs) attenuates the antiplatelet effects of thienopyridine derivatives, the drug–drug interaction remains unclear in Japanese patients with coronary artery disease.Methods and resultsPlatelet function test was performed in 461 patients who were scheduled for or had undergone stent implantation, treated with 100mg/day of aspirin and a thienopyridine (200mg/day of ticlopidine or 75mg/day of clopidogrel) for at least 14 days. Adenosine diphosphate-induced platelet aggregation was evaluated with screen filtration pressure method, and the upper quartile of high platelet reactivity was defined as high on-treatment platelet reactivity (HPR). PPI use was at physician's discretion. Patients taking a thienopyridine plus a PPI (n=166) were older and had a higher incidence of acute coronary syndromes on admission compared with patients taking a thienopyridine without a PPI (n=295). The rate of HPR was higher in patients taking a thienopyridine plus a PPI than in patients taking a thienopyridine without a PPI (31% vs 21%, p=0.01). On multivariate logistic regression analysis, independent predictors of HPR were concomitant PPI use [odds ratio (OR): 1.66, 95% confidence interval (CI): 1.03–2.68], diabetes mellitus (OR: 1.76, CI: 1.11–2.81), and calcium channel blockers use (OR: 1.93, CI: 1.18–3.18). However, there was no significant difference in the rate of extremely high platelet reactivity [58 patients (12.5%) with PATI

A 28-year-old man without coronary risk factors was admitted to the hospital with acute coronary syndromes (ACS). The angiogram and intravascular ultrasound revealed myocardial bridge (MB) in the mid-left anterior descending artery and flow-limiting plaque located 15.4 mm proximal to MB. The culprit lesion was treated only with drug-coated balloon, considering the patient's extremely young age. This case suggests that an accelerated formation of plaque caused by MB appeared to contribute to the development of ACS; thus, MB should be considered as an important cause of ACS in young patients with low cardiovascular risk.

Reperfusion therapy has dramatically reduced mortality from ST-segment elevation myocardial infarction (STEMI) during the past 30 years. Such therapy is thought to act primarily by promoting recanalization of the occluded coronary artery and reperfusion of the coronary microcirculation, thereby salvaging ischemic myocardium, reducing infarct size, and improving left ventricular function. Even when the ischemic myocardium has already become necrotic and myocardial salvage is not feasible, restoration of coronary blood flow can inhibit left ventricular remodeling, prevent fatal arrhythmias, and provide collateral circulation to other occluded vessels, thereby improving outcomes. To ensure maximal effectiveness, reperfusion therapy should be administered within 2–3 h after symptom onset at the latest; this applies to primary percutaneous coronary intervention (PCI) as well as fibrinolytic therapy [1] (Fig. 1). In this paper, we outline the current status of reperfusion therapy in Japan, focusing on catheter-based interventions in patients with STEMI. Reperfusion therapies for STEMI include fibrinolysis, primary PCI, and a combination of both treatments. Fibrinolysis is a simple procedure, but has a low rate of recanalization and high rates of recurrent ischemia including reinfarction and hemorrhagic complications. Many randomized clinical trials and meta-analyses have shown that primary PCI carefully performed without delay by skillful, experienced operators in well-equipped hospitals generally produces better outcomes than either fibrinolysis alone or a combination of fibrinolysis and primary PCI. In principle, primary PCI is indicated for all patients with STEMI who present within 12 h after the onset of symptoms [2, 3].

Acute kidney injury (AKI) is associated with poor outcomes after acute myocardial infarction (AMI); however, its prognostic impacts of AKI on short- and long-term mortality in ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) patients is

Extracellular volume (ECV) derived cardiac magnetic resonance (CMR) T1-mapping has emerged as a non-invasive method to quantify extracellular matrix of human heart. The aim of this study was to assess the impact of ECV assessed by CMR T1 mapping on systolic and diastolic function of the heart

Background: Ruptured plaque and culprit lesions associated with anterior acute myocardial infarction cluster mainly in the proximal segment of the left anterior descending coronary artery (LAD). This study investigated whether the tissue characteristics of plaque in the proximal LAD differs from that of plaque in the distal LAD as assessed by integrated backscatter (IB)-intravascular ultrasound (IVUS). Methods and Results: IVUS interrogation was used to study 107 non-culprit intermediate plaques in 68 patients with angina pectoris who underwent percutaneous coronary interventions. Proximal and distal segments were defined as

Background: Few studies have examined whether high-responsiveness to antiplatelet therapy is associated with an increased risk of bleeding in patients receiving dual antiplatelet therapy. MethodsandResults: Elective drug-eluting stent implantation was performed in 184 patients treated with aspirin and a thienopyridine (200 mg/day of ticlopidine or 75 mg/day of clopidogrel). The subjects were divided into 3 groups according to post-treatment platelet reactivity before stenting as measured by the response to adenosine diphosphate: the 1st quartile group was defined as high-responders, the 4th as low-responders, and the other 2 quartiles as middle-responders. Major bleeding occurred more frequently in high-responders than in middle- or low-responders during an average of 16 months' follow-up (15 vs 4, 2%, P=0.02). High-responsiveness was the independent predictor of major bleeding (odds ratio 4.26, P=0.03). Adverse cardiac events were less frequent in high- and middle-responders than in low-responders (24, 16 vs 37%, P=0.02). Middle-responders had better net clinical outcomes, defined as the sum of major bleeding and adverse cardiac events, than did high- or low-responders (21 vs 39, 39%, P=0.02). Conclusions: In the present study high-responsiveness to antiplatelet therapy was associated with an increased risk of bleeding with no reduction in adverse cardiac events. Measuring platelet reactivity may be useful for risk stratification according to bleeding complications, as well as adverse cardiac events, in patients treated with drug-eluting stents. (Circ J 2010; 74: 679-685)

Previous studies have reported that acute hyperglycemia is associated with high mortality after acute myocardial infarction (AMI). However, optimal plasma glucose level may be different between diabetic and nondiabetic patients. The purpose of this study was to assess the relation between admission glucose and in-hospital mortality after AMI in patients with and without diabetes. This study consisted of 3,750 patients who were admitted to the 35 hospitals participating to the Japanese Acute Coronary Syndrome Study (JACSS) group within 48 hours after the onset of AMI. Plasma glucose was measured at the time of hospital admission. In patients without a history of diabetes, there was a linear relation between admission glucose and in-hospital mortality. Nondiabetic patients with a glucose level6 mmol/L had the lowest mortality (2.5%). As admission glucose increased by 1 mmol/L, mortality increased by 17% (13% to 21%, p0.001). In patients with a history of diabetes, however, there was a U-shape relation between glucose and mortality. Diabetic patients with glucose 9 to 10 mmol/L had the lowest mortality (1.9%); not only severe hyperglycemia (glucoseor =11 mmol/L, 9.1%, p0.001) but also euglycemia (glucose7 mmol/L, 9.4%, p = 0.009) were associated with higher mortality compared to moderate hyperglycemia (glucose 9 to 11 mmol/L, 3.2%). Diabetic patients with admission glucose 9 to 10 mmol/L had the lowest mortality, whereas lower glucose was better in nondiabetic patients. In conclusion, optimal glucose level on admission may be different between diabetic and nondiabetic patients with AMI.

Although high white blood cell (WBC) count and plasma glucose (PG) and low glomerular filtration rate (GFR) on admission have been associated with poor outcomes after acute myocardial infarction (AMI), the combined prognostic utility of these 3 variables was unclear. The association of WBC count, PG, and GFR on admission to in-hospital outcomes was examined in 2,633 patients who underwent primary stent placement for ST-segment elevation AMI within 48 hours after symptom onset. In-hospital mortality progressively increased as the number of the variables of high WBC count (or =11,120/microl; upper tertile), high PG (or =10.4 mmol/L; upper tertile), and low GFR (or =60 ml/min/1.73 m(2); lower tertile) increased. Patients with all 3 variables had a strikingly higher in-hospital mortality rate (25.9%). After adjusting for baseline characteristics, multivariate analysis showed that compared with patients who had none of these variables, odds ratios for in-hospital mortality were 1.63 (95% confidence interval [CI] 0.88 to 3.03, p = 0.12) in patients with only 1 variable, 2.33 (95% CI 1.28 to 3.96, p = 0.047) in those with 2 variables, and 6.16 (95% CI 2.98 to 12.6, p0.001) in those with all 3 variables. In conclusion, combined evaluation of WBC count, PG, and GFR on admission was a simple and useful method for the early prediction of risk of in-hospital death in patients undergoing primary stent placement for ST-segment elevation AMI.

In patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS), identification of left main and/or 3-vessel disease (LM/3VD) is crucial for deciding whether to initiate early treatment with clopidogrel, which can increase the risk of surgical bleeding.On admission, the clinical factors of 501 patients with NSTE-ACS, who underwent coronary angiography, were evaluated. ST-segment shifts and the widest QRS duration were measured on an admission 12-lead electrocardiogram. Ninety-six patients had LM/3VD. Univariate analysis indicated that many factors were related to LM/3VD. On multivariate analysis, QRS duration (odds ratio (OR) 9.04, P0.01), the degree of ST-segment elevation in lead aVR (OR 7.10, P0.01), and positive-troponin T (OR 1.52, P0.05) were independent predictors of LM/3VD. A QRS duration of90 ms and a ST-segment elevation in lead aVR ofor=0.5 mm best identified LM/3VD. A QRS duration of90 ms, a ST-segment elevation in lead aVR ofor=0.5 mm, and a positive-troponin T identified LM/3VD with sensitivities of 88%, 76%, and 54% (P0.01), and specificities of 88%, 86%, and 71% (P0.01), respectively.A prolonged QRS duration, ST-segment elevation in lead aVR, and a positive-troponin T on admission are useful predictors of LM/3VD in patients with NSTE-ACS. In particular, a maximal QRS duration of90 ms was the most sensitive predictor of LM/3VD.

In patients with non-ST-segment elevation acute coronary syndromes, early risk stratification is crucial for appropriate management of this condition and for deciding whether early invasive strategies should be adopted. The electrocardiogram (ECG) has been extensively used for risk stratification, and the presence of ST-segment depression is an especially strong predictor of poor outcomes. Furthermore, quantitative analysis of ST-segment depression, ie, the degree and extent of ST-segment depression, and the time from symptom onset to the evaluation of ECG provide important information on prognosis. ST-segment elevation in lead a V(R) in addition to ST-segment depression in other leads is a very valuable marker of left main and/or 3-vessel disease. This review explores the clinical importance of the ECG in the current interventional era.

Background Elevated C-reactive protein (CRP) levels at admission are associated with adverse outcomes in patients with non ST-segment elevation acute coronary syndromes (NSTE-ACS). Hypothesis C-reactive protein measurement not only at admission, but also after admission, may be useful for predicting adverse outcomes in NSTE-ACS. Methods We measured high-sensitivity CRP levels at admission and at 24 h in 215 patients with NSTE-ACS. An elevated CRP level at admission (admission elevation) was defined as a CRP level of ≥ 0.300 mg/dL. An increase in the CRP level after admission (increase at 24 h) was considered present when the CRP level at 24 h was higher than the level at admission. Patients were divided into 4 groups according to the presence or absence of admission elevation and increase at 24 h. Coronary angiography was performed at a mean of 3 d after admission. Results There were no significant differences among the 4 groups in age, sex, coronary risk factors, or multivessel disease. Patients with both admission elevation and increase at 24 h had higher rates of ST-segment depression and positive troponin T at admission. Multivariate analysis showed that admission elevation (odds ratio [OR] 1.50, p < 0.05) and increase at 24 h (OR 6.56, p = 0.03) were independent predictors of 30-d events (e.g., death, myocardial infarction, or refractory angina). The highest risk of 30-d events was associated with both admission elevation and increase at 24 h. Conclusions Serial CRP measurements are useful for predicting the risk of subsequent ischemic complications in patients with NSTE-ACS. Copyright © 2008 Wiley Periodicals, Inc.

Background The impact of ST-segment elevation resolution in lead aVR on outcomes in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) is unclear. Methods and Results Electrocardigrams (ECGs) were recorded on admission and 6 h later in 367 patients with NSTE-ACS. ST-segment deviation ≥0.5 mm was considered significant: 92 patients had ST-segment elevation in lead aVR on admission ECG (ST↑aVR), and 275 did not. Among patients with ST↑aVR, 50 had ST resolution, defined as a reduction >50% in the degree of ST-segment elevation in lead aVR from admission to 6 h later, and 42 did not. ST↑aVR without ST resolution was associated with older age, greater ST-segment depression in other leads on admission and 6 h later, higher rates of positive troponin T, left main and/or 3-vessel coronary disease, and adverse events such as death, (re)infarction, or urgent revascularization within 30 days after admission. Multivariate analysis showed that ST↑aVR without ST resolution was the strongest independent predictor of death or (re)infarction within 30 days after admission (hazard ratio 5.62, p=0.018). Conclusions ST↑aVR without ST resolution is a strong predictor of 30-day adverse outcomes and correlates with the extent and severity of coronary artery disease in patients with NSTE-ACS. (Circ J 2008; 72: 1047 - 1053)

Background In patients with acute myocardial infarction (AMI), the relationship of serial changes in ST-segment elevation after reperfusion to left ventricular (LV) function remains unclear. Methods and Results The study group comprised 164 patients with reperfused anterior AMI within 6 h of symptom onset. The sum of ST-segment deviation was calculated on admission (ΣST-admission), and 1 h (ΣST-1 h) and 24 h (ΣST-24 h) after reperfusion. ST resolution was defined as a reduction in ΣST-1 h of ≥50% as compared with ΣST-admission. Patients were classified into 3 groups: group A, 82 patients with ST resolution in whom ΣST-1 h ≥ ΣST-24 h; group B, 37 patients with ST resolution in whom ΣST-1 h < ΣST-24 h; group C, 45 patients without ST resolution. Peak creatine kinase were higher in groups B and C than in group A (4,578±2,176, 4,236±2,638, 2,222±1,926 mU/ml, p

ST-segment elevation (STE) in leads V1-2 is often observed in patients with severe aortic stenosis (AS), but its significance remains unknown.We retrospectively evaluated baseline ECGs and 5-year clinical outcomes in 211 consecutive patients with severe AS, defined as peak aortic jet velocity (Aortic Vmax)4.0 m/s, or mean aortic pressure gradient40 mmHg, or aortic valve area (AVA)1.0 cm(2). The primary outcome measure was a composite of death or surgical aortic valve replacement (AVR). Patients with STE in leads V1-2(≥0.15 mV) had greater Aortic Vmax and smaller AVA than patients without. With a median follow-up of 4.9 years, the cumulative 5-year incidence of death or AVR was significantly higher in patients with STE in leads V1-2 than in patients without (91.4% vs. 77.1%; P=0.003). After adjusting for confounders, STE in leads V1-2 was independently associated with higher risk for death or AVR (hazard ratio, 1.53; 95% confidence interval, 1.06-2.22; P=0.02). In 64 asymptomatic patients without any indication for AVR at initial diagnosis of severe AS, the cumulative incidence of AVR was significantly higher in patients with STE in leads V1-2 than in patients without (57.6% vs. 30.5%; P0.001).STE in leads V1-2 independently predicted poorer prognosis and more frequent need for AVR in patients with severe AS.