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Kazuhiro Shimizu,1 Tomoyuki Yamamoto,2,3 Mao Takahashi,1 Shuji Sato,1 Hirofumi Noike,1 Kohji Shirai2 1Department of Internal Medicine, 2Department of Vascular Function, Toho University Sakura Medical Center, Chiba, 3Biological Information Analysis Section, Fukuda Denshi Co., Ltd, Tokyo, Japan Purpose: The purpose of this study was to clarify the difference between effects of nitroglycerin (NTG) on the functional stiffness in patients with and without coronary artery disease (CAD) using a newly developed stiffness index, cardio-ankle vascular index (CAVI).Subjects and methods: The two subject groups in this study were normal controls (n=31) and CAD patients (n=25). The normal controls had no medical history and were not on regular medications. On the other hand, the CAD patients had received various treatments like antihypertensive drugs, hypoglycemic agents, and statins. This study was conducted in CAD patients under medications. After a single sublingual administration of NTG 0.3 mg, CAVI, blood pressure (BP), and heart rate (HR) were measured every 5 minutes for 20 minutes. Comparisons of each parameter before and after taking NTG were evaluated for statistical significance using analysis of variance and post hoc tests. Tukey–Kramer test was used for post hoc comparisons.Results: In the normal controls, CAVI significantly decreased from baseline after 5, 10, and 15 minutes (from 6.5±0.9 to 5.2±0.9, 5.5±0.9, and 5.7±0.9, respectively). Systolic BP and HR were not significantly changed. Diastolic BP significantly decreased from baseline after 5 and 10 minutes (from 72±8 to 64±9 and 63±9 mmHg, respectively). On the other hand, CAVI, HR, and diastolic BP were not changed significantly in CAD patients. Systolic BP was significantly decreased from baseline after 5, 10, and 15 minutes (from 147±16 to 131±14, 129±12, and 129±13 mmHg, respectively). In the comparison of the two groups, ΔCAVI was not significantly different between the normal controls and CAD patients (–1.4±0.7 vs –1.4±0.9, –1.1±0.7 vs –1.4±1.0, –0.8±0.7 vs –1.2±1.0, and –0.5±0.7 vs –1.1±1.0 at 5, 10, 15, and 20 minutes, respectively). ΔHR was not significantly different between the two groups. ΔSystolic BP in the CAD patients was significantly higher than in the normal controls at 5, 10, 15, and 20 minutes (normal controls vs CAD; –3±7 vs –10±11, –3±5 vs –10±11, –3±6 vs –13±10, and –1±6 vs –11±10 mmHg, respectively). ΔDiastolic BP in the normal controls was significantly higher than in the CAD patients at 5 and 10 minutes (normal controls vs CAD; –8±6 vs –4±4 and –9±4 vs –6±5 mmHg, respectively). Conclusion: After NTG administration, the stiffness of the arteries from the origin of the aorta to the ankle as measured by CAVI decreased in both the normal controls and CAD patients, indicating that the response of arterial smooth muscle cells to nitric oxide is preserved even in CAD patients under medication. Keywords: arterial stiffness, cardio-ankle vascular index, nitroglycerin, nitric oxide, stiffness parameter

The cardio-ankle vascular index (CAVI) has been proposed as a new noninvasive marker of arterial stiffness independent of blood pressure. Arterial stiffness is closely related to afterload, and elevated afterload aggravates heart failure. We hypothesized that CAVI is a potential marker of afterload in patients with heart failure. Thirty patients who were admitted because of acute heart failure were identified retrospectively from a review of clinical records. Plasma brain natriuretic peptide (BNP) levels, CAVI, cardiothoracic ratio (CTR), and echocardiographic parameters obtained during acute and chronic phases of heart failure were analyzed. Left ventricular ejection fraction (LVEF) increased significantly and CTR, BNP and CAVI decreased significantly after treatment of heart failure. A significant negative correlation was observed between the change in CAVI and change in LVEF in all subjects (r = -0.3272, P < 0.05). To examine the relationship between CAVI and LVEF, we divided the patients into two subgroups (∆CAVI < -0.5; CAVI decrease group, ∆CAVI ≥ -0.5; CAVI non-decrease group). CAVI was significantly improved after heart failure treatment only in the CAVI decrease group. LVEF decreased significantly in both groups, but the P value was smaller in the CAVI decrease group than in the CAVI non-decrease group. The change in LVEF correlated significantly with the change in CAVI in the CAVI decrease group (r = -0.4201, P < 0.05), whereas no significant correlation was found in the CAVI non-decrease group. CAVI correlates inversely with LVEF after heart failure treatment. Our results suggest that CAVI might partially reflect the afterload in patients with heart failure.

Masayo Suzuki,1 Mao Takahashi,1 Takuo Iizuka,1 Hitoshi Terada,2 Hirohumi Noike,1 Kohji Shirai3 1Cardiovascular Center, Internal Medicine, 2Department of Radiology, 3Department of Vascular Function, Sakura Hospital, Medical Center, Toho University, Sakura City, Chiba Prefecture, Japan Background: Familial hypercholesterolemia (FH) is associated with premature coronary arterial disease. We aimed to determine the incidence of coronary artery stenosis (CAS) in asymptomatic FH patients using coronary computed tomography angiography (CCTA). To investigate the association between CAS and atherosclerosis of carotid arteries, we performed ultrasonography to measure the mean intima-media thickness (IMT), maximum IMT, and plaque score. We also aimed to examine the significance of the cardio-ankle vascular index (CAVI) and its association with the incidence of CAS in asymptomatic FH patients. Patients and methods: We enrolled consecutively, 31 FH patients without symptoms of coronary artery disease. Based on the CCTA findings, we divided the patients into two groups, those with and without CAS, and compared various parameters and risk factors of the two groups. Results: Of 31 FH patients, seven patients (22.6%) had CAS. The proportion of male patients and mean low-density lipoprotein-cholesterol level were higher in patients with CAS than in those without CAS (P22.6% of the asymptomatic FH patients. Patients with CAS tended to have enhanced levels of carotid plaque markers, but no increase was noted in CAVI. FH patients should be continuously monitored using CCTA and ultrasonography. Keywords: CAVI, coronary artery stenosis, heterozygous familial hypercholesterolemia, CCTA, ultrasound evaluation of the carotid artery

Background Waon therapy improves heart failure (HF) symptoms, but further evidence in patients with advanced HF remains uncertain. Methods and results In 19 institutes, we prospectively enrolled hospitalized patients with advanced HF, who had plasma levels of B-type natriuretic peptide (BNP) >500 pg/ml on admission and BNP >300 pg/ml regardless of more than 1 week of medical therapy. Enrolled patients were randomized into Waon therapy or control groups. Waon therapy was performed once daily for 10 days with a far infrared-ray dry sauna maintained at 60℃ for 15 min, followed by bed rest for 30 min covered with a blanket. The primary endpoint was the ratio of BNP before and after treatment. In total, 76 Waon therapy and 73 control patients (mean age 66 years, men 61%, mean plasma BNP 777 pg/ml) were studied. The groups differed only in body mass index and the frequency of diabetes. The plasma BNP, NYHA classification, 6-min walk distance (6MWD), and cardiothoracic ratio significantly improved only in the Waon therapy group. Improvements in NYHA classification, 6MWD, and cardiothoracic ratio were significant in the Waon therapy group, although the change in plasma BNP did not reach statistical significance. No serious adverse events were observed in either group. Conclusions Waon therapy, a holistic soothing warmth therapy, showed clinical advantages in safety and efficacy among patients with advanced HF.

AIM To investigate the effect of smoking and smoking cessation on cardio-ankle vascular index (CAVI). METHODS The subjects were 82 smokers (77 men, 64+/-10 years) and 20 non-smokers (18 men, 61+/-7 years). CAVI was measured every 3 months and CAVI severity was classified into 3 levels. Decreased, unchanged, and increased CAVI severity levels were coded as "improvement," "no change," and "exacerbation," respectively. Smoking status was coded as "success" for complete abstinence, "partial success" for a reduced number of cigarettes, and "failure" for an unchanging number of cigarettes. RESULTS Compared with non-smokers, smokers showed a higher CAVI (p

Myocardial tissue fluid flow (MTFF) directly represents the oxygen supply to the cardiomyocytes. Therefore, imaging of MTFF is carried out by fluorescence cardioscopy (FC).Sixty-six patients with coronary artery disease underwent FC using fluorescein as an indicator of MTFF because this dye exhibits fluorescence in tissue fluid but not in the blood. Three mL of 10% fluorescein was injected intravenously and fluorescence images of the left ventricular endocardial surface were obtained by FC at 30 seconds and 1, 3 and 6 minutes later to evaluate the MTFF.The CF images were classified as follows: diffuse with high intensity indicating normal MTFF; diffuse but with low intensity indicating decreased MTFF, no fluorescence indicating absent MTFF, and patchy fluorescence indicating patchy preservation of MTFF. MTFF was normal in all 18 patients with chest pain syndrome, patchy fluorescence was decreased or absent in 16 of 20 patients with angina and/or old myocardial infarction due to organic coronary artery disease, and was patchy in 21 of 28 patients with vasospastic angina. Ten of these 20 patients underwent coronary stenting with successful angiographic results in all. However, MTFF disturbance frequently remained.FC is clinically feasible for evaluation of MTFF disturbance, for evaluation of even emergency coronary interventions, and for guidance of transendocardial angiogenic and myogenic therapies in patients with coronary artery disease.

経胸壁ドプラ心エコー法による冠動脈の描出が可能となり，冠血流速波形の解析から冠循環の評価が行われるようになってきた．冠動脈遠位部は検出率が高く，その血流評価に対する多数の報告がなされているのに対して，冠動脈近位部を評価した報告は少ない．今回我々は，経胸壁ドプラ心エコー法により，冠動脈近位部狭窄の診断が可能であった不安定狭心症の2症例を経験したので報告する．症例1：79歳，男性．胸痛を主訴に入院．発作時の心電図では II ，III，aVF，V3‐6のST低下を認めた．経胸壁心エコー検査では，左室壁運動が心尖部で若干低下していたが左室駆出率は正常であった．大動脈弁レベルの短軸像で冠動脈近位部を直接描出したところ，左前下行枝近位部に加速血流を認め拡張期最高血流速度は104cm/秒と高速であった．冠動脈造影の結果，分節6に99%狭窄を認め，経胸壁心エコー検査で認められた狭窄部と一致していた．狭窄部にステントを留置し良好な拡張に成功した．術後の経胸壁心エコー検査では，冠動脈内の加速血流は消失し拡張期最高血流速度は40cm/秒と正常化した．症例2：59歳，男性．胸痛を主訴に入院．発作時の心電図で II ，III，aVFの陰性T波を認めた．経胸壁心エコー検査では，左室壁運動異常は認めなかった．大動脈弁レベルの短軸像で冠動脈近位部を直接描出したところ，右冠動脈近位部に加速血流を認め拡張期最高血流速度は108cm/秒と高速血流であった．冠動脈造影の結果，分節1に99%狭窄を認め，経胸壁心エコー検査で認められた狭窄部と一致していた．狭窄部にステントを留置し良好な拡張に成功した．術後の経胸壁心エコー検査では，冠動脈内の加速血流は消失し拡張期最高血流速度は26cm/秒と正常化した．非ST上昇型の不安定狭心症において，経胸壁ドプラ心エコー法により冠動脈近位部の狭窄病変を直接描出することが可能であった．本法は，冠動脈近位部狭窄の有無を心臓カテーテル検査前に予測する上で有用な検査法と考えられた．

大動脈四尖弁は大動脈二尖弁と同様に大動脈弁機能不全の原因疾患となる先天性弁膜症である. 発生頻度は大動脈二尖弁より少なく稀な疾患である. 今回, 超音波検査により術前に大動脈弁四尖弁と診断し得た2症例を経験したので報告する. 症例1 : 63歳, 男性, ペースメーカー植込み術を受けている. 労作時呼吸困難を自覚するようになり入院した. 心エコー検査の結果, 重度の大動脈弁逆流を認め, 左冠尖と無冠尖の間に副尖を有する大動脈四尖弁であった. 手術で四尖が確認され大動脈弁置換術 (SJM 23 mm) を施行した. 組織像では軽度の線維増生と粘液変性が認められた. 症例2 : 58歳, 女性, 高血圧と気管支喘息のため近医で加療を受けていた. 労作時呼吸困難を自覚するようになり入院した. 心エコー検査の結果, 重度の大動脈弁逆流と大動脈弁狭窄の所見を認めたが, 大動脈弁形態は不明であった. 経食道心エコー検査を施行し, 左冠尖と右冠尖の間に副尖を有する大動脈四尖弁と判明した. 手術で四尖が確認され大動脈弁置換術 (SJM 17 mm) を施行した. 組織像では高度の線維増生と石灰化が認められた. 心エコー検査で大動脈弁膜症の原因を検索する際には大動脈四尖弁の可能性も考慮に入れ慎重に観察する必要がある.

Tangier disease, characterized by low or absent high-density lipoprotein (HDL), is a rare hereditary lipid storage disorder associated with frequent, but not obligatory, severe premature atherosclerosis due to disturbed reverse cholesterol transport from tissues. The reasons for the heterogeneity in atherogenicity in certain dyslipidemias have not been fully elucidated. Here, using high-performance liquid chromatography with a gel filtration column (HPLC-GFC), we have studied the lipoprotein profile of a 17-year old male patient with Tangier disease who to date has not developed manifest coronary atherosclerosis. The patient was shown to be homozygous for a novel mutation (Leu1097Pro) in the central cytoplasmic region of ATP-binding cassette transporter A1 (ABCA1). Serum total and HDL-cholesterol levels were 59mg/dl and 2mg/dl, respectively. Lipoprotein electrophoretic analyses on agarose and polyacrylamide gels showed the presence of massively abnormal lipoproteins. Further analysis by HPLC-GFC identified significant amounts of lipoproteins in low-density lipoprotein (LDL) subfractions. The lipoprotein particles found in the peak subfraction were smaller than normal LDL, were rich in triglycerides, but poor in cholesterol and phospholipids. These findings in an adolescent Tangier patient suggest that patients in whom these triglyceride-rich, cholesterol- and phospholipid-poor LDL-type particles accumulate over time, would experience an increased propensity for developing atherosclerosis.

To evaluate the stabilizing effects of an antilipemic agent, bezafibrate, on coronary plaques, we carried out a prospective angioscopic and angiographic open trial. From April 1997 to December 1998, 24 patients underwent coronary angioscopy of plaques in non-targeted vessels during coronary interventions and then again 6 months later. The patients were divided into control (10 patients, 14 plaques) and bezafibrate (14 patients, 21 plaques) groups. Oral administration of bezafibrate (400 mg/day) was started immediately after the intervention and was continued for 6 months. The vulnerability score was determined based on the angioscopic characteristics of plaques and compared before and 6 months later. Six months later, the vulnerability score was reduced (from 1.6 to 0.8; P

A sensitive immunoassay system using a specific monoclonal antibody against lipoprotein lipase (LPL) recently demonstrated the presence of an LPL mass in preheparin serum. We reported that a preheparin serum LPL mass (pre-LPL mass) reflected the level of functioning LPL activity in the whole body and could be deeply involved in the progression of coronary atherosclerosis of stable organic angina pectoris. We examined the relation between the pre-LPL mass and acute myocardial infarction (AMI). We studied 44 males with AMI (AMI group) and 16 males with a normal coronary artery (NCA group), and measured the pre-LPL mass by enzyme-linked immunosorbent assay. Coronary risk factors including the pre-LPL mass were compared between the two groups and multiple regression analysis was performed for AMI. There were no significant differences in the lipid data, but the pre-LPL mass level was significantly low in the AMI group (52 +/- 16 vs 41 +/- 14 ng/ml, p = 0.01), and a low pre-LPL mass concentration was observed in the small sized LDL group and/or the Midband positive group. Multiple regression analysis revealed that a low pre-LPL mass and hypertriglyceridemia were independent risk factors for AMI (t value = 2.1, 2.4). The result indicates that a low pre-LPL mass may be an important risk factor for AMI and stable organic angina pectoris.

Background Since long-term administrations of anti-hyperlipidemic agents result in reduction in % stenosis or increase in minimum lumen diameter (MLD) of stenotic coronary segments, it is generally believed that anti-hyperlipidemic agents stabilize vulnerable coronary plaques. However, recent pathologic and angioscopic studies revealed that vulnerability of coronary plaques is not related to severity of stenosis and the rims rather than top of the plaques disrupt, and therefore, angiography is not adequate for evaluation of vulnerability.Angioscopy enables macroscopic pathological evaluation of the coronary plaques. Therefore, we carried out a prospective angioscopic open trial for evaluation of the stabilizing effects of bezafibrate on coronary plaques.Methods From April, 1997 to December, 1998, 24 patients underwent coronary angioscopy of the plaques in the non-targeted vessels during coronary interventions and 6 months later. The patients were divided into control (10 patients, 14 plaques) and bezafibrat (14 patients, 21 plaques) groups. Oral administration of bezafibrate (Bezatol SR, 400mg/day) was started immediately after the interventions and was continued for 6 months. The vulnerability score was determined based on angioscopic characteristics of plaques and it was compared before and 6 months later.Results Six months later, vulnerability score was reduced (from 1.6 to 0.8;p < 0.05) in bezafibrate group and unchanged (from 1.4 to 1.3; NS) in control group. In bezafibrate group, the changes in vulnerability score was not correlated with those in % stenosis or MLD. Conclusion The results indicate that bezafibrate can stabilize coronary plaques.

We report a case of dilated cardiomyopathy with hyperthyroidism. A 28-year-old man was admitted because of congestive heart failure and atrial fibrillation, and was newly diagnosed as having hyperthyroidism. Despite administration of antithyroid medication, he developed recurrent congestive heart failure. An echocardiogram revealed a moderately dilated left ventricle with diffuse hypokinesis. Though his thyroid function normalized, the patient's cardiac dysfunction did not improve. Beta-blocker therapy was begun with subsequent improvement in clinical symptoms. This suggests that beta-blocker treatment may be effective in patients with atrial fibrillation associated with cardiomyopathy and hyperthyroidism.

Emergency coronary angiography of a 53-year-old man with acute coronary syndrome revealed stenosis in right coronary artery. During angioplasty, the ECG change showed three kind of ST deviation, namely inferior ST elevation with precordial ST depression, inferior ST elevation with precordial ST elevation, and inferior ST depression with precordial ST elevation. The present case shows that the ST deviation of the inferior ischemia with right ventricular ischemia takes various patterns. This phenomenon is decided by degree of right main coronary and right side branch blood flow.

Aim: The aim of this study was to clarify the relationship between CAVI and serum cystatin C levels to understand the role of arterial stiffness in the presence of renal insufficiency.Methods: We enrolled 206 consecutive patients with cardiovascular risk factors and/or coronary artery disease (CAD) in the study. Serum cystatin C, estimated glomerular filtration rate (eGFR), and plasma levels of von Willebrand factor (vWF) and plasminogen activator inhibitor (PAI-1) were measured. CAVI was determined as an index of arterial stiffness.Results: For all patients, the mean serum cystatin C level was 0.81±0.21 mg/L and mean eGFR was 65.8±15.5 mL/min per 1.73 m2. In univariate analysis, CAVI levels significantly correlated with cystatin C levels (r=0.414, p

LR11, an LDL receptor family member, is expressed in intimal smooth muscle cells. It was found that the soluble form of LR11 (sLR11) is detected in serum, and the circulating sLR11 levels are positively correlated with intima-media thickness of carotid arteries in dyslipidemic subjects. To clarify the significance of serum sLR11, the circulating sLR11 levels in patients with organic coronary stenosis and the contributing risk factors for them were studied. The subjects, 150 patients with symptoms of coronary artery disease, underwent coronary angiographic examination, and were divided into sex- and age-matched two groups; one is organic coronary stenosis group (OCS) and the other is normal coronary group (NC). Serum sLR11 levels were significantly higher in OCS than in NC (4.9+/-2.7 U vs 3.6+/-1.8 U, p0.05). Multivariate regression analysis showed that circulating sLR11 is independent contributing factor for the OCS, as well as diabetes mellitus and dyslipidemia. Among various coronary risk factors for sLR11 level, HbA1c showed the highest correlation coefficient (p0.01). These results suggest that the circulating sLR11 might reflect coronary organic stenosis, and that hyperglycemic condition might be promoting factor for expression of LR11 in intimal smooth muscle cells.

For percutaneous transluminal coronary angioplasty (PTCA) of oversized arteries, often-times a satisfactory dilatation cannot be achieved with conventional balloon systems due to the unavailability of adequately sized balloons. This fact has contributed to a higher restenosis rate for this group of patients. We were able to obtain a satisfactory dilatation result in an oversized right coronary artery with a shepherd's crook configuration and eccentric anatomy at the origin using two balloon-on-a-wire systems and an Amplatz type guiding catheter. Although such favorable dilatation of an oversized artery using this "hugging balloon technique" can be expected, issues do exist such as difficult maneuverability and estimation of the balloon size obtained through simultaneous dual balloon inflation wherein size does not simply equal the sum of the two balloon catheters. It is hoped that there will be further improvements of the technique and development of new systems. At this time, however, it is felt that this is the most effective and reasonable strategy to achieve a high chance of success in oversized vessel lesions.

急性前壁梗塞発症6時間以内にECG記録し得た85例を増高T波(type A, n=12), ST上昇(type B, n=21)およびドーム型,平坦型ST上昇(type C, n=52)の3 typeに分類し比較検討した。(1)3ヵ月以上前より狭心症の既往を有する割合はtype Aでは25%を占め,type B (33%)およびC (50%)に比し少ない傾向を示した。(2)type Aは梗塞発症より1.6時間とtype B (2.4時間)およびtype C (2.6時間)に比し早期ECGに認められ,それぞれの時間におけるCPK値は112IU/l, 347IU/lおよび522IU/lとtype Aはtype Bおよびtype Cに比し低値を示した。また最大CPK値はそれぞれ2,729IU/l, 1,986IU/lおよび2,152IU/lと有意差はなかった。梗塞発症より最大CPKを示すまでの時間は,type Aは12.6時間とtype B (17.6時間)およびC (18.0時間)に比しより短いことが示された。(3)type Aの死亡率は41.7%とtype B (19.0%)およびC (30.8%)に比し高率を占めた。一方,生存例のCCU滞在日数は,type Aは3.8日でtype B (5.1日)およびtype C (7.2日)に比し短いことからその早期予後は良好と解された。(4)慢性期冠動脈造影所見上,type Aは梗塞責任冠動脈の完全閉塞を認めず,type Bでは55%, type Cでは全例に完全閉塞を認めた。以上の結果より増高T波は,急性心筋梗塞発症早期心電図に認められ,狭心症の既往なく突発する傾向を示した。また最大CPKまでの時間は短く,生存例は良好な経過をとり,その冠動脈造影上,全例完全閉塞がないことより内科的初期治療による梗塞責任冠動脈の早期再疎通の結果と思われた。さらに狭心症の既往歴が少ないこと,梗塞発症時の症状が強いこと,および慢性期の冠動脈造影上側副血行路が不良であることから推測すると,増高T波を示す一要因として梗塞発症前の虚血程度が軽微である可能性が示唆された。

Background Recently, arterial stiffness parameter called cardio-ankle vascular index (CAVI) has been developed. In the current study, using coronary angiographic (CAG) findings, the usefulness of CAVI as a marker of the severity of coronary atherosclerosis was compared with that of carotid atherosclerosis parameters obtained from high-resolution B-mode ultrasonography. Method and Result A total of 109 participants who underwent CAG were enrolled in the current study. They were divided into 4 groups according to the number of stenotic vessels on CAG; no lesion (0VD), 1-vessel (1VD), 2-vessel (2VD) and 3-vessel (3VD) groups. CAVI was significantly higher in 1VD group compared with the 0VD group (p

急性心筋梗塞に対する急性期治療の進歩は目覚ましいものがある。しかし,急性期心室性不整脈の発生頻度はいまだ高率で,とくにsecondary VTなどのポンプ失調に伴う不整脈の予後は不良とされている。今回われわれは急性心筋梗塞130例のうち,発症24時間以内にLown分類2以下の心室性不整脈を呈した88例をA群,Lown分類3以上の心室性不整脈を呈した42例をB群とし,その臨床像,予後につき比較検討した。平均年齢はA群64.3歳,B群66.7歳,性別はA群男性69例,女性19例,B群男性26例,女性16例であった。CCU入室中の完全房室ブロック合併はA群9%, B群26.2%,ショック合併はA群10.2%, B群64.3%,入院時Forrester 3以上のポンプ失調合併はA群4.5%, B群19.1%とそれぞれB群はA群に比し有意に高率を示した。入院中のcardiac eventの発生頻度は心不全がA群6.8%, B群30.9%,重度不整脈がA群19.3%, B群52.4%,死亡がA群5.7%, B群57.1%とそれぞれB群はA群に比し有意に高率を示した。入院中死亡のA群5例,B群24例の死因についてはA群で心不全・心破裂が80%を占めるのに比し,B群ではVT・Vfが21%を占めた。また,入院中死亡29例中,入院時Killip 4以上のポンプ失調合併は75.9%と高率であった。一方,A群71例,B群15例の最長3年での長期予後では,cardiac event (AMI, UAP, heart failure, death)の発生頻度に両群間に差異はなかった。Kaplan-Meier法を用いた生存曲線では,退院直前の生存率はA群94.3%, B群42.8%とB群はA群に比し有意に低率であった。しかし,退院後では両群間に差異はなかった。以上より,急性期重度不整脈は急性期死亡と関連があり,そのほとんどはポンプ失調に伴うもので急性期重度不整脈とポンプ失調は相互に悪影響し,予後不良の要因と思われた。

A 46-year-old male with asthma bronchiale and eosinophilia was admitted to our hospital because of continuous severe chest pain. Electrocardiography showed ST segment elevation in leads II, III and aVF during chest pain. Emergency coronary angiography showed a series of coronary arterial narrowings in segments 1 and 2. After injection of nitroglycerin 0.1 mg and nicorandil 2 mg into the right coronary artery, the coronary arterial narrowing was gradually relieved. The artery became completely normal after 10 min. Left coronary arterial angiography showed no abnormalities. The diagnosis was spontaneous coronary arterial spasm based on the coronary angiographic findings. The spasm occurred as multiple short narrow arterial segments. Normalization of the coronary artery took a long time. In a case like this, thrombus is easily formed that may cause acute myocardial infarction and unnecessary coronary angioplasty may be performed.

To identify the relationship of risk factors for atherosclerosis with venous thromboembolism (VTE) and the utility of transthoracic echocardiography in acute pulmonary thromboembolism (APTE).In 75 patients with VTE (VTE group), 101 patients with suspected VTE (N group), and 50 control subjects (control group), the frequency of atherosclerosis risk factors such as hyperlipidemia, obesity, hypertension, smoking, and diabetes mellitus and the number of risk factors were evaluated. Transthoracic echocardiographic findings such as tricuspid regurgitation, right ventricular dilation, pulmonary hypertension, and right ventricular dysfunction were evaluated in 15 patients with APTE (APTE group) and 38 patients in the N group (NC group).The incidence of hyperlipidemia in the VTE group was statistically higher than that in the control group (odds ratio 2.16, 95% confidence interval 1.43-3.08). Additionally, the incidence of obesity was higher in the VTE and N groups than in the control group (odds ratio was 2.76, 95% confidence interval 1.67-4.37). Risk factors other than obesity and hyperlipidemia and the number of risk factors were not significant. The incidence of tricuspid regurgitation, right ventricular dilation, and pulmonary hypertension in APTE was statistically greater than that in NC group. Right ventricular dilation and right ventricular dilation + tricuspid regurgitation are reliable findings in echocardiography. However, even combining with tricuspid regurgitation, right ventricular dilation is insufficient to identify or screen patients with APTE.Hyperlipidemia and obesity may be risk factors for VTE. However, obese patients can manifest similar findings to VTE. Although transthoracic echocardiograpghy is not recommended as a diagnostic or screening test in APTE, it should be used as an ancillary test.

The cause of exercise-induced ST depression was studied by assessing left ventricular end-diastolic pressure (LVEDP).This study included 28 patients with normal coronary artery, 24 patients with vasospastic angina pectoris and 28 patients with fixed organic lesion who underwent both treadmill exercise testing and selective coronary arteriography. Exercise-induced ST deviation was considered as maximal ST deviation during the exercise test and maximum LVEDP was considered as the pressure measured 1 min after left ventriculography.The degree of exercise-induced ST depression in aVF showed no significant differences between the three groups. Exercise-induced ST elevation occurred in the intracardiac leads and exercise-induced ST depression occurred in the epicardial leads. These electrocardiographic changes were not contradictory to subendocardial ischemia. In addition, there was a good correlation (r = - 0.465, p0.01) between exercise-induced ST depression and maximum LVEDP elevation.Exercise-induced ST depression was caused by subendocardial ischemia due to increased LVEDP.

Indicators of ischemic heart disease were studied for the practice of preventive medicine.Intravascular ultrasonography was performed in 97 patients with no abnormalities by left anterior descending artery angiography. Coronary risk factors were evaluated based on the relationship between plaque formation and lipoprotein levels.Plaque was observed in 81% of patients. The relationship between mean plaque area(%) and the low-density lipoprotein/high-density lipoprotein(LDL/HDL)ratio was examined. Mean plaque area(%) was significantly higher at LDL/HDLor = 2.5 than at LDL/HDL2.5. The border of significant change level of mean plaque area(%)was LDL/HDL = 2.5. There was a good correlation between mean plaque area (%) and LDL/HDL (r = 0.65, p0.01). Mean plaque area (%) at LDL/HDL 2.5 was calculated at 15%. Patients with coronary risk factors had LDL/HDL lower than 2.5 at mean plaque area of 15%.Maintaining LDL/HDL at 2.5 is very important for preventive medicine. However, LDL/HDL should be managed at under 2.5 in patients with coronary risk factors.

To examine the relationship between insulin resistance (IR) and the reduction of oxidative stress in vivo by the statin atorvastatin.This study included 40 patients with hypercholesterolemia without a history of diabetes mellitus (21 males, 19 females, mean age 62 +/- 11 years). Homeostasis assessment insulin resistance (HOMA-IR) was used as a marker for insulin resistance. The patients were divided into two groups [IR group (n = 24) and non-IR group (n = 16), using the cut off level of 1.73]. Urinary 8-iso-prostaglandin F2alpha (U-8-iso) excretion was used as an oxidative stress marker. The subjects were treated with atorvastatin (10 mg/day) for 12 weeks.The IR group had significantly higher U-8-iso levels than the non-IR group before atorvastatin administration (211 +/- 112 vs 137 +/- 33 pg/mg Cr, p = 0.01). Low-density lipoprotein cholesterol, triglyceride, and 8-iso levels were significantly reduced in both groups after 12 weeks, U-8-iso levels were significantly higher in the IR group than the non-IR group (178 +/- 61 vs 110 +/- 38 pg/mg Cr, p = 0.003), and HOMA-IR showed no significant change. Multiple regression analysis after 12 weeks showed that HOMA-IR and triglyceride levels were independent variables for U-8-iso levels (standard regression coefficient = 0.60, 0.59, p0.0001, p = 0.0002).Insulin resistance is important in the occurrence of oxidative stress in patients with hypercholesterolemia. Since atorvastatin does not reduce insulin resistance, further therapy to reduce insulin resistance is necessary for early prevention of cardiovascular events during atorvastatin treatment.

The preventive effect of pemirolast against restenosis after coronary stent placement was evaluated.Eighty-four patients with 89 de novo lesions who underwent successful coronary stenting were assigned to the pemirolast group(40 patients, 45 lesions) and the control group(44 patients, 44 lesions). Administration of pemirolast(20 mg/day) was initiated from the next morning after stenting and continued for 6 months of follow-up. Quantitative coronary angiography was performed immediately after stenting and at follow-up. Angiographic restenosis was defined as diameter stenosisor = 50% at follow-up. Intravascular ultrasound study conducted at follow-up angiography was used to measure vessel cross-sectional area(CSA), stent CSA, lumen CSA, neointima CSA(stent CSA--lumen CSA), and percentage neointima CSA(neointima CSA/stent CSA x 100%) at the minimal lumen site.There were no significant differences in baseline characteristics between the two groups. Restenosis rate was significantly lower in the pemirolast group than in the control group(15.0% vs 34.1% of patients, 13.3% vs 34.1% of lesions, p0.05, respectively). The intravascular ultrasound study at follow-up(36 lesions in the pemirolast group, 33 in the control group) found no significant differences in vessel CSA and stent CSA between the two groups(17.3 +/- 2.2 vs 16.8 +/- 2.4 mm2, 8.6 +/- 1.9 vs 8.4 +/- 1.7 mm2, respectively). However, lumen CSA was significantly larger in the pemirolast group than in the control group(5.5 +/- 1.3 vs 4.4 +/- 1.1 mm2, p0.05). Moreover, neointima CSA and percentage neointima CSA were significantly smaller in the pemirolast group(3.1 +/- 1.1 vs 4.0 +/- 1.2 mm2, p0.05 and 36.2 +/- 15.9% vs 47.4 +/- 15.6%, p0.01).Pemirolast has a preventive effect against restenosis after stent placement, possibly by inhibiting neointimal hyperplasia.

This study assessed the side effects of nitroglycerin administration and their clinical significance.Adverse reactions associated with sublingual nitroglycerin administration were investigated in 103 patients, 71 men and 32 women (mean age 56 +/- 11 years), 32 patients with coronary artery stenosis and 71 without coronary artery stenosis.Fifty-one percent of patients experienced headache and 30% experienced other adverse reactions, whereas 19% experienced no adverse reactions. The relationship was investigated between headache, the most common adverse reaction, and the following eight clinical background factors: coronary angiographic findings, sex, age, hyperlipidemia, hypertension, diabetes mellitus, smoking and drinking. Multiple regression analysis was conducted by treating sublingual nitroglycerin-induced headache as an object variable and the clinical background factors as explanatory variables. Statistically, the onset of headache correlated most closely to coronary angiographic findings, followed by smoking, hypertension, diabetes mellitus and drinking. The first four factors suppressed the onset of headache, whereas drinking facilitated the onset of headache.There is a close relationship between the onset of headache following sublingual nitroglycerin administration and coronary angiographic findings. Sublingual nitroglycerin-induced headache as a predictor of coronary angiographic findings has a sensitivity and specificity of 81% and 66%, respectively, for patients without coronary artery stenosis based on the absence of headache.

Some normocholesterolemic patients have coronary artery disease (CAD) in Japan. This study evaluated the clinical significance of preheparin lipoprotein lipase mass as a risk factor for normocholesterolemic patients with CAD.This study included 89 normocholesterolemic male patients with CAD (CAD group, 40 with stable organic angina pectoris, 19 with vasospastic angina pectoris, and 30 with acute myocardial infarction), and 13 normocholesterolemic males with normal coronary arteries (control group) with no stenotic lesion and negative reaction to intracoronary administration of acetylcholine. Preheparin lipoprotein lipase mass was measured by enzyme-linked immunosorbent assay. Coronary risk factors including preheparin lipoprotein lipase mass were compared between the two groups. Low-density lipoprotein (LDL) particle size and presence of midband were estimated by polyacrylamide gel disc electrophoresis.Mild hypertriglyceridemia and low high-density lipoprotein (HDL) cholesterolemia were observed in the CAD group, and small particle size LDL and presence of midband were also common in the CAD group. Preheparin lipoprotein lipase mass level was significantly lower in the CAD group than the control group (52 +/- 18 vs 40 +/- 13 ng/ml, p = 0.005) as well as in each type of patient in the CAD group. Multiple regression analysis showed that small particle size LDL, low preheparin lipoprotein lipase mass and smoking were independent risk factors for CAD (p0.001, p = 0.007, p = 0.037). Low preheparin lipoprotein lipase mass concentration was observed in the small particle size LDL group and/or the midband positive group.These results indicate that low preheparin lipoprotein lipase mass reflects insulin resistance and may be deeply involved in the progression of coronary arteriosclerosis.

The present study investigated the clinical significance of preheparin serum lipoprotein lipase (LPL) mass in coronary vasospasm by examining its relationship with the acetylcholine-induced coronary artery response in patients without angiographically demonstrable atherosclerotic coronary artery disease (CAD). The subjects were 39 men who had suspected CAD and who underwent coronary angiography. Coronary vasospasm was defined as a marked luminal narrowing or total occlusion provoked by the intracoronary administration of acetylcholine. Preheparin LPL mass was lower (p

In preheparin serum, there exists lipoprotein lipase (LPL) mass with little activity. The clinical significance of this preheparin serum LPL mass (preheparin LPL mass) is unclear. We studied the levels of preheparin LPL mass in patients with coronary atherosclerosis, comparing the results with those in healthy men. We also evaluated the correlation between preheparin LPL mass and the severity of coronary atherosclerosis by comparing with other risk factors such as age, smoking, family history, hypertension, hyperuricemia, diabetes mellitus, total cholesterol, triglyceride, high density lipoprotein-cholesterol and body mass index. The subjects, 70 men presenting with symptoms of coronary artery disease, underwent coronary angiographic examination. Significant narrowness was defined as > or = 75%. Control group comprised 77 men who had annual health checks and showed no abnormal findings. Preheparin LPL mass in the stenosis group was lower than normal coronary group and also than the control group. Multivariate analysis showed that preheparin LPL mass had the highest t-value (-2.53) for the number of lesions among the risk factors listed above. These results suggest that low preheparin LPL mass may be deeply involved in the progression of coronary atherosclerosis.

We recently confirmed that pemirolast potassium, an antiallergic agent, markedly inhibits migration and proliferation of vascular smooth muscle cells. It has also been reported that pemirolast inhibits intimal hyperplasia in animal experiments.To elucidate the preventive effects of pemirolast on restenosis after percutaneous transluminal coronary angioplasty (PTCA), 227 patients were enrolled in this prospective, randomized trial. A total of 205 patients who were compatible with the protocol were analyzed (pemirolast group, 104 patients with 140 lesions; control group, 101 patients with 133 lesions). Patients in the pemirolast group received 20 mg/d of pemirolast from 1 week before PTCA until the time of follow-up angiography (4 months after PTCA). Angiographic restenosis was defined as diameter stenosis/=50% at follow-up. Restenosis rates were significantly lower in the pemirolast group than in the control group (24.0% vs 46.5% of patients, 18.6% vs 35.3% of lesions, P.01, respectively). During 8 months of follow-up, there were no coronary events (death, myocardial infarction, coronary artery bypass surgery, or repeated PTCA) in 81.7% of the pemirolast group and in 63.4% of the control group (P =.013).This study suggested that pemirolast would be useful in the clinical setting to prevent restenosis after PTCA.

We report a 63-year-old woman, with a partial type of common atrioventricular canal and mitral stenosis, who was hospitalized because of dyspnea on exertion. Two-dimensional echocardiogram showed an ostium primum atrial septal defect with two well-formed AV valves located at the same level. However, both anterior and posterior mitral leaflets were markedly thickened with a thickened subvalvular apparatus, and the commisures were fused. Echocardiographic measurements demonstrated a mitral valve area of 1.48 cm2 with mild mitral regurgitation. Cardiac catheterization demonstrated mild pulmonary artery hypertension with a large left to right shunt (72%) at the atrial level. The combination of the partial type of common atrioventricular canal and mitral stenosis is rare; only one similar case has been reported previously in the literature.(Internal Medicine 34: 441-145, 1995)

Background Factor Xa inhibitor is a key drug in the coagulation cascade. Parenteral anticoagulation using low molecular weight heparin or fondaparinux is the recommended form of treatment for most patients presenting with venous thrombosis. Following the acute phase, edoxaban is recommended. We present a case of extensive deep vein thrombosis treated using fondaparinux and edoxaban. Case presentation A 63-year-old man with redness, pain, and swelling of the left leg lasting for more than 1 month was referred to our hospital. Ultrasonography revealed a thrombus in the left femoral vein. Computed tomographic angiography revealed clots in the distal right pulmonary artery. Thus, the anticoagulant treatment was initiated with subcutaneous injections of fondaparinux (7.5 mg) for 5 consecutive days, followed by once daily oral administration of edoxaban (60 mg). After 3 months of treatment, a regression of thrombotic clots was shown. Three months later, the remaining clots disappeared, leaving only mural thrombi; no bleeding complications were observed during the treatment period. Conclusion The anticoagulant treatment with subcutaneous fondaparinux and subsequently with oral edoxaban was effective for treating extensive deep vein thrombosis. Electronic supplementary material The online version of this article (doi:10.1186/s12959-016-0089-x) contains supplementary material, which is available to authorized users.