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Background: Fulminant myocarditis presentation (FMP) is a rare and severe presentation of myocarditis. The natural history of FMP and its clinical features associated with poor outcomes are incompletely understood because there is a lack of generalizable evidence. Methods: This multicenter retrospective cohort study included patients hospitalized with histologically proven myocarditis who underwent catecholamine or mechanical support from 235 cardiovascular training hospitals across Japan between April 2012 and March 2017. Clinical features and the prognostic predictors of death or heart transplantation within 90 days on the basis of clinical and pathologic findings were determined using the Kaplan-Meier method, log-rank test, and Cox regression analysis. Results: This study included 344 patients with histologically proven FMP (median age, 54 years; 40% female). The median follow-up was 600 days (interquartile range, 36 to 1599 days) and the cumulative risk of death or heart transplantation at 90 days was 29% (n=98). Results from multivariable Cox regression analysis showed that older age, nonsinus rhythm, low left ventricular wall motion ( Conclusions: The results from analyses of data from this multicenter registry demonstrated that patients with FMP are at a higher risk of death or heart transplantation in real-world settings. These observations inform which clinical and pathologic findings may be useful for prognostication in FMP. Registration: URL: https://www.umin.ac.jp/ctr ; Unique identifier: UMIN000039763.

Although high thromboembolic risk was assumed in elderly patients with heart failure (HF) and atrial fibrillation (AF), inadequate control of prothrombin time/international normalized ratio was often observed in patients using vitamin K antagonists (VKAs). We hypothesized that patients treated with direct oral anticoagulants (DOAC) would have a better outcome than those treated with VKAs. The aim of this study was to compare the efficacies of DOACs and VKAs in elderly patients with HF and AF. We retrospectively analyzed data from a multicenter, prospective observational cohort study. A total of 1036 patients who were hospitalized for acute decompensated HF were enrolled. We assessed 329 patients aged > 65 years who had non-valvular AF and divided them into 2 groups according to the anticoagulant therapy they received. A subgroup analysis was performed using renal dysfunction based on estimated glomerular filtration rate (eGFR; mL/min/1.73 m2). The primary outcome was all-cause mortality, and the secondary outcomes were non-cardiovascular death or stroke. The median follow-up period was 730 days (range 334–1194 days). The primary outcome was observed in 84 patients; non-cardiovascular death, in 25 patients; and stroke, in 14 patients. The Kaplan–Meier analysis revealed that all-cause mortality was significantly lower in the DOAC group than in the VKA group (log-rank p = 0.033), whereas the incidence rates of non-cardiovascular death (log-rank p = 0.171) and stroke (log-rank p = 0.703) were not significantly different in the crude population. DOAC therapy was not associated with lower mortality in the crude population (log-rank p = 0.146) and in the eGFR ≥ 45 mL/min/1.73 m2 subgroup (log-rank p = 0.580). However, DOAC therapy was independently associated with lower mortality after adjustments for age, diabetes mellitus, and albumin level (hazard ratio, 0.55; 95% confidence interval, 0.30–0.99; p = 0.045) in the eGFR 2 subgroup. Compared with VKA therapy, DOAC therapy was associated with lower risk of all-cause mortality in the elderly HF patients with AF and renal dysfunction.

The Glasgow Prognostic Score (GPS) has been established as a useful resource to evaluate inflammation and malnutrition and predict prognosis in several cancers. However, its prognostic significance in patients with heart failure (HF) is not well established. To investigate the association between the GPS and mortality in patients with HF, we assessed 870 patients who were 20 years old and more and had been admitted for acute decompensated HF. The GPS ranged from 0 to 2 points as previously reported. Over the 18-month follow-up (follow-up rate, 83.9%), 143 patients died. Increasing GPS was associated with higher HF severity assessed by New York Heart Association functional class and B-type natriuretic peptide (BNP) levels. Kaplan–Meier analysis showed significant associations for mortality and increased GPS. In multivariate analysis, compared to the GPS 0 group, the GPS 2 group was associated with high mortality (hazard ratio 2.92, 95% confidence interval 1.77–4.81, p

An inverse correlation between body mass index and mortality in patients with peripheral artery disease (PAD) has been reported. However, little information is available regarding the impact of body composition on the clinical outcomes in patients with PAD. This study evaluated the relationships between the lean body mass index (LBMI), body fat % (BF%), and mortality and major amputation rate in patients with PAD. We evaluated 320 patients with PAD after endovascular treatment (EVT) enrolled from August 2015 to July 2016 and divided them into low and high LBMI and BF% groups based on their median values (17.47 kg/m2and 22.07%, respectively). We assessed 3-year mortality and major amputation for the following patient groups: Low LBMI/Low BF%, Low LBMI/High BF%, High LBMI/Low BF%, and High LBMI/High BF%. During the median 3.1-year follow-up period, 70 (21.9%) patients died and 9 (2.9%) patients experienced major amputation. The survival rate was lower in the Low LBMI than in the High LBMI group, and was not significantly different between the Low and High BF% groups. Survival rates were lowest in the Low LBMI/Low BF% group (57.5%) and highest in the High LBMI/High BF% group (94.4%). There were no significant differences in major amputation rate between the Low LBMI and High LBMI groups, and between the Low BF% and High BF% groups. The Low LBMI and Low BF% groups were associated with an increased risk of mortality after adjustment for age, sex, frailty and conventional risk factors [hazard ratio (HR): 4.02; 95% confidence interval (CI) 2.10–7.70;p p = 0.005, respectively], for age, sex, hemodialysis, and prior cerebral cardiovascular disease (HR: 3.63; 95% CI 1.93–6.82;p p = 0.009, respectively) and for age, sex, and laboratory date (HR: 3.97; 95% CI 1.88–8.37;p p = 0.026, respectively). In conclusion, Low LBMI and Low BF% were associated with poor prognosis in patients undergoing EVT for PAD, and mortality was the lowest in the High LBMI/High BF% group compared with other body composition groups.

An 86-year-old woman had a pacemaker implanted into a subfascial pocket. After four months, the generator became exposed, and the pacemaker was removed. She exhibited a lack of prepectoral tissue. We therefore performed reimplantation in collaboration with plastic surgeons. We placed the leads via the extrathoracic subclavian venous approach, and plastic surgeons created a subpectoral pocket from the low lateral side of the pectoralis major muscle. General cardiologists rarely create subpectoral pockets and they are unable to implant leadless pacemakers at their hospital due to lack of sufficient skill. Our case showed that creating a subpectoral pocket in collaboration with plastic surgeons is quick and safe.

Heart failure with preserved ejection fraction (HFpEF) has currently become a major concern in the aging society owing to its substantial and growing prevalence. Recent investigations regarding sacubitril/valsartan have suggested that there is a gender difference in the efficacy of the medication in HFpEF cohort. However, information of gender difference in clinical profiles, examination, and prognosis have not been well investigated. The present study aimed to evaluate the differences in baseline characteristics and outcomes between women and men in a Japanese HFpEF cohort. We analyzed the data from our prospective, observational, and multicenter cohort study. Overall, 1036 consecutive patients hospitalized for acute decompensated heart failure were enrolled. We defined patients with an ejection fraction (EF) of ≥ 50% as HFpEF. Patients with severe valvular disease were excluded; the remaining 379 patients (women: n = 201, men: n = 178) were assessed. Women were older than men [median: 85 (79–89) years vs. 83 (75–87) years, p = 0.013]. Diabetes mellitus, hyperuricemia, and coronary artery disease were more prevalent in men than in women (34.8% vs. 23.9%, p = 0.019, 23.6% vs. 11.4%, p = 0.002, and 23.0% vs. 11.9%, p = 0.005, respectively). EF was not significantly different between women and men. The cumulative incidence of cardiovascular death or hospitalization for congestive heart failure (CHF) was significantly lower in women than in men (log-rank p = 0.040). Women with HFpEF were older and less often exhibited an ischemic etiology; further, they were associated with a lower risk for cardiovascular death or hospitalization for CHF compared with men in the Japanese population.

This study aimed to evaluate the association between abdominal fat distribution (AFD) and coronary artery disease (CAD) complexities using the computed tomography (CT)-derived SYNTAX score (CT-SXscore). Coronary computed tomographic angiography (CCTA) was performed in patients with suspected CAD. Plain abdominal CT was performed to measure visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) areas. To assess AFD, VAT/SAT (V/S) ratios were calculated. The CT-SXscore was calculated in patients with significant stenoses assessed by CCTA. Of 942 enrolled patients, 310 (32.9%) had 1 or more significant stenoses. The CT-SXscore showed a positive correlation with the V/S ratio (r = 0.33, p < 0.001). In the multivariate regression analysis, the V/S ratio was the only independent predictor for CAD severity based on the CT-SXscore (β = 0.25; t = 4.14; p < 0.001), even though the absolute SAT and VAT areas showed no relationship to the CT-SXscore. Regarding the 4 CAD-patient groups divided according to their median VAT and SAT areas, the CT-SXscore was significantly higher for the high VAT/low SAT group than for any other group (19.6 ± 11.5 vs 13.3 ± 9.6 in the low VAT/low SAT, 10.1 ± 8.5 in the low VAT/high SAT, and 12.2 ± 8.7 in the high VAT/high SAT groups; p < 0.001 for all). In conclusion, it was found that the V/S ratio is a useful index for predicting CAD severity and that AFD may be a more important risk factor for CAD than the absolute amount of each abdominal fat.

Introduction: Although abdominal fat distribution given by the ratio of visceral adipose tissue (VAT) to subcutaneous adipose tissue (SAT) area (V/S ratio) is possibly associated with an increased risk of cardiovascular disease (CVD), few studies have examined the effect of the V/S ratio and physique stratified by body mass index (BMI) on long-term clinical outcomes. Methods: We assessed 945 consecutive patients (mean age, 69 years; 42.5% females) with suspected coronary artery disease who underwent computed tomography (CT) angiography. The patients also underwent plain abdominal CT to measure VAT and SAT areas. The V/S ratio was calculated to assess abdominal fat distribution. The patients were classified into four groups based on the median V/S ratio and median BMI (0.627 and 23.61 kg/m 2 , respectively). We examined the association between the V/S ratio and long-term outcomes in each BMI group. The primary outcome was major adverse cardiac events (MACEs, including all-cause death, acute coronary syndrome, emergent hospitalization due to CVD, and any coronary revascularization). Results: Over a median follow-up of 792 days, although the incidence of any cardiovascular event was not associated with the V/S ratio among patients with high BMI, a higher incidence of MACE, all-cause death, and any coronary revascularization was noted among patients with low BMI in the high V/S ratio group than in the low V/S ratio group. In the Kaplan-Meier analysis, a statistically significantly lower MACE-free survival rate was noted among patients with low BMI in the high V/S ratio group than in the low V/S ratio group, despite no differences among high BMI patients in both the V/S ratio groups (Figure). Conclusion: Only in patients with low BMI, a high V/S ratio was associated with increased risks of MACE. A high V/S ratio may be an important risk factor for CVD, especially in patients with low BMI. In contrast, abdominal fat distribution did not affect CVD prognosis in patients with high BMI.

Introduction: Although visceral fat accumulation is an important risk factor for coronary artery diseases (CAD), the relationship between visceral fat accumulation and its long-term outcomes has not been extensively investigated. Hypothesis: In patients with suspected CAD, the distribution of subcutaneous fat and visceral fat is associated with cardiovascular events. Methods: Computed tomography (CT) angiographies (CTA) were performed on 945 consecutive patients with suspected CAD. Plain abdominal CT scanning was performed to measure the patients’ visceral fat area (VFA) and subcutaneous fat area (SFA). The VFA/SFA (V/S) ratios were calculated to assess the visceral fat accumulation. Based on the results of the CTA, the prevalence of CAD was assessed. The patients were classified into low ( Results: The average follow-up period was 845.3 days. The baseline characteristics for patients in the high V/S ratio group were worse than those for patients in the low high V/S ratio group. As compared to the low V/S ratio group, a higher incidence of MACE and ACS, and a higher tendency of mortality was observed in the high V/S ratio group. After adjusting for traditional coronary risk factors, the V/S ratio was independently associated with incidence of MACE, ACS, and increase of mortality (table). Conclusions: The present study suggests that the V/S ratio is an independent predictor of long-term outcomes in patients with suspected CAD. The visceral fat accumulation indicated by high V/S ratio signifies a potential risk and may contribute to the future cardiovascular events in patients with suspected CAD.

Although visceral fat accumulation (VFA) has been identified as a potential risk factor for arteriosclerosis progression, only a few studies have reported the association between them. The cardio-ankle vascular index (CAVI) has been proposed as a feasible method to assess arterial stiffness from the

Although visceral fat accumulation is an important risk factor for coronary artery diseases (CAD), the relationship between visceral fat accumulation and its long-term outcomes have been rarely studied. We performed computed tomography (CT) angiographies (CTA) in 612 consecutive patients with

A 24 year-old woman had a congenital solitary kidney with renovascular hypertension due to fibromuscular dysplasia. She had been treated as having essential hypertension until she developed preeclampsia and HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome at 28 weeks of gestation. Plasma renin activity and captopril test results did not indicate any abnormalities. However, renography revealed captopril-induced deterioration. Magnetic resonance angiography was also useful to detect renal artery stenosis. These findings were confirmed by renal angiography. After successful percutaneous transluminal renal angioplasty, her blood pressure and the pattern of captopril renography normalized.

Background:Statins reduce the incidence of cardiovascular events, but no randomized trial has investigated the best statins for secondary prevention. We compared the efficacy of hydrophilic pravastatin with that of lipophilic atorvastatin in patients with acute myocardial infarction (AMI).Methods and Results:A prospective, multicenter study enrolled 508 patients (410 men; mean age, 66.0±11.6 years) with AMI who were randomly assigned to atorvastatin (n=255) or pravastatin (n=253). The target control level of low-density lipoprotein cholesterol (LDL-C) was

Nuclear factor-κB (NFκB) plays a significant role in the coordinated transactivation of cytokine, inducible NO synthase (iNOS), and adhesion molecule genes. Although inflammation is an essential pathological feature of myocarditis, the role of NFκB in this process remains obscure. We examined the role of NFκB in the progression of rat experimental autoimmune myocarditis (EAM) and tested the hypothesis that NFκB blockade with a decoy against the cis element of NFκB can prevent the progression of EAM. Lewis rats were immunized with purified porcine cardiac myosin to establish EAM on day 0. NFκB decoy was infused into the rat coronary artery on day 0 (group NF0), 7 (group NF7), or 14 (group NF14) and harvested on day 21. Scrambled decoy was infused on day 0 (group SD0), 7 (group SD7), or 14 (group SD14) and served for control groups. The ratios of myocarditis-affected areas to the ventricular cross-sectional area of all treatment groups were significantly lower than those of the control groups (group NF0, 33±18% versus SD0, 53±14%; group NF7, 19±15% versus SD7, 50±16%; and group NF14, 34±10% versus SD14, 52±14%). Immunohistochemical and immunoblot analyses showed expression of ICAM-1, iNOS, IL-2, and TNFα in myocardium of scrambled decoy groups, and this expression was effectively suppressed by NFκB decoy treatment. Thus, we found that NFκB is a key regulator in the progression of EAM and that in vivo transfection of NFκB decoy reduces the severity of EAM.

TC-99m MAAによる肺血流シンチグラフィを応用して, 換気に伴う肺・胸郭系の動きを描画・定量する独自の方法, 肺換気運動イメージングを考案・利用し, 原発性肺癌84例における本法の臨床的意義を検討した.本法により, 肺内および肺辺縁の動きが描出され, 肺門型, 胸水型, T3+T4において, 肺の動きは担癌肺で低値, 両肺で低値の傾向を示した.局所肺における動きと肺血流分布の一致, 解離など多様な関係も示され, 胸膜病変, 横隔膜神経麻痺を含む種々の呼吸運動 (換気) の異常が描出された.本法は本症において肺の動きと肺血流を同時に把握でき, 病変の広がり・進展度および病態の評価に役立ち, 補助診断法として利用しうる方法である.

Previous studies have reported an association between abdominal obesity and coronary artery disease (CAD). The computed tomography (CT)-derived SYNTAX score (CT-SXscore) was recently proposed as a feasible method of grading CAD severity based on coronary CT angiography (CTA). We aimed to evaluate

This report describes a patient with severe pulmonary hypertension accompanied by a congenital intrahepatic portosystemic shunt. Primary pulmonary hypertension was suspected initially because none of the classic symptoms of a portosystemic shunt were present. Physicians should note that disorders of the portal system may cause pulmonary hypertension even in the absence of symptoms suggesting liver disease.

TANAKA, H., et al.: Successful Prevention of Recurrent Ventricular Fibrillation by Intravenous Isoproterenol in a Patient with Brugada Syndrome. Intravenous administration of isoproterenol restored the ST-segment configuration to nearly normal in the right precordial leads and completely prevented spontaneous VF attacks in a patient with Brugada syndrome. The formation of a Brugada-type ECG has been attributed to the transmural dispersion of repolarization of the right ventricular epicardium and related to modulation of the autonomic nervous system. Our case may provide clues to the pathophysiological mechanism of this syndrome.

FTY720 is a new immunosuppressant agent and selectively decreases the number of circulating lymphocytes. In this study, we compared the effects of FTY720 with those of tacrolimus on experimental autoimmune myocarditis (EAM) in rats. A significant decrease in circulating lymphocyte counts was noted after a single administration of FTY720 in normal rats. At day 0, 7-week-old male Lewis rats were immunized with purified porcine cardiac myosin emulsified in complete Freund's adjuvant. FTY720 or tacrolimus was administered intraperitoneally daily. The number of myocarditis-affected areas in the FTY720 treatment groups with doses of 0.1 mg/kg/ day was significantly lower than those in control groups at days 14 and 28. In addition, at day 28, the myocarditis-affected areas in the FTY720 treatment group were significantly smaller than those in the tacrolimus treatment group receiving the same dose. Effects of early administration (days 0-10) and delayed administration (days 11-20) of FTY720 also were examined. At day 28, the myocarditis-affected areas in the early therapy group were significantly lower than those in the control group. In conclusion, we demonstrated that the development of EAM could be prevented by FTY720. These data also indicated that lymphocyte-mediated immunity is critically involved in the development of EAM.

Right ventricular thrombus is a very rare manifestation of cardiovascular Behcet's disease. A 25-year-old man was admitted to hospital due to cough and fever of unknown origin. He experienced repetitive pulmonary embolism due to a right ventricular thrombus, which was surgically removed. A diagnosis of Behcet's disease was made based on his clinical course and the histological findings of the right ventricular wall and the skin lesion. He was quickly relieved of his symptoms after warfarinization and cyclosporine therapy.