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Asymptomatic paroxysmal atrial fibrillation (AF) is often found in patients implanted with cardiac implantable electronic devices (CIEDs). Second-generation atrial antitachycardia pacing (A-ATP) is effective in managing AF in patients implanted with CIEDs. The purpose of this study was to evaluate the efficacy and safety of A-ATP in patients implanted with CIEDs. This was a single-center retrospective study involving 91 patients (male 46 patients, mean age 74 ± 9 years) implanted with Reactive A-ATP equipped devices (84 patients with pacemakers, 6 with ICDs, and 1 with a CRT-D). The AF burden, rate of AF termination, and details of the activation of the A-ATP were analyzed in each patient. During a mean follow-up period of 21 ± 13 months, A-ATP was activated in 45 of 91 patients (49.5%). No patients had adverse events. Although the efficacy of the A-ATP varied among the patients, the median rate of AF termination was 44%. In comparison to the A-ATP start time, "0 min" had a higher AF termination rate by the A-ATP (39.4% vs. 24.4%, P = 0.011). The rate of termination by the A-ATP was high for AF with a long cycle length and a relatively regular rhythm. A-ATP successfully terminated AF episodes in some patients implanted with CIEDs. The optimal settings of the A-ATP will be determined in future studies. [ABSTRACT FROM AUTHOR]

Limited data exists on ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) managed by a well-organized cardiac care network in a metropolitan area. We analyzed the Tokyo CCU network database in 2009-2010. Of 4329 acute myocardial infarction (AMI) patients including STEMI ( n = 3202) and NSTEMI ( n = 1127), percutaneous coronary intervention (PCI) was performed in 88.8 % of STEMI and 70.4 % of NSTEMI patients. Mean onset-to-door and door-to-balloon times in STEMI patients were shorter than those in NSTEMI patients (167 vs 233 and 60 vs 145 min, respectively, p < 0.001). Coronary artery bypass graft surgery was performed in 4.2 % of STEMI and 11.4 % of NSTEMI patients. In-hospital mortality was significantly higher in STEMI patients than NSTEMI patients (7.7 vs 5.1 %, p < 0.007). Independent correlates of in-hospital mortality were advanced age, low blood pressure, and high Killip classification, statin-treated dyslipidemia and PCI within 24 h were favorable predictors for STEMI. High Killip classification, high heart rate, and hemodialysis were significant predictors of in-hospital mortality, whereas statin-treated dyslipidemia was the only favorable predictor for NSTEMI. In conclusion, patients with MI received PCI frequently (83.5 %) and promptly (door-to-balloon time; 66 min), and had favorable in-hospital prognosis (in-hospital mortality; 7.0 %). In addition to traditional predictors of in-hospital death, statin-treated dyslipidemia was a favorable predictor of in-hospital mortality for STEMI and NSTEMI patients, whereas hemodialysis was the strongest predictor for NSTEMI patients. [ABSTRACT FROM AUTHOR]

Regional myocardial ischemia is thought to be characterized by diastolic dysfunction. We aimed to clarify whether temporal analysis of strain rate (SR) index derived from two-dimensional speckle-tracking echocardiography (2DTE) can assess the regional myocardial ischemia or not. Forty-two patients with significant coronary stenoses were referred for percutaneous coronary intervention (PCI). 2DTE was performed before and a day after PCI. Time from aortic valve closure to peak early diastolic longitudinal SR ∆(TAVC- E) was measured both at baseline and during adenosine triphosphate (ATP) infusion. TAVC- E was calculated as TAVC- E during ATP infusion subtracted by TAVC- E at baseline. In forty-five target ischemic regions, TAVC- E at baseline was significantly longer than that of control regions (166 ± 28 vs. 136 ± 32 ms, P < 0.0001). TAVC- E in target ischemic regions significantly prolonged during ATP stress to 221 ± 37 ms ( P < 0.0001), while it did not change in control regions. Immediately after PCI, TAVC- E in target regions significantly decreased to 135 ± 27 ms, P < 0.0001 without prolongation during ATP stress. Receiver operating characteristic curves demonstrated that ∆TAVC- E could assess regional myocardial ischemia by a cutoff criterion of 14 ms with sensitivity of 93 % and specificity of 95 %. 2DTE-derived TAVC- E significantly increased during ATP stress only in ischemic myocardium. This phenomenon disappeared immediately after PCI. Temporal analysis of TAVC- E appeared to be useful to assess the regional myocardial ischemia. [ABSTRACT FROM AUTHOR]

Noninvasive detection of left main/three-vessel diseases (LM/3VD) among patients with non-ST-elevation acute coronary syndromes (NSTEACS) has been difficult using echocardiography. However, two-dimensional (2D) strain/strain-rate analysis is more sensitive in quantitatively assessing contractile abnormality. Accordingly, we aimed to clarify the usefulness of 2D strain/strain-rate analysis for risk stratification of NSTEACS. A total of 50 patients with NSTEACS underwent echocardiography and coronary angiography. We evaluated global longitudinal peak strain (global PS), peak systolic strain rate (global SSR), early diastolic global peak strain rate (global ESR), time from aortic valve closure to peak strain (TAVC-global PS), and global ESR (TAVC-global ESR) in apical four-, two-, and three-chamber views. Patients were divided into two groups according to coronary angiographic findings, the high-risk group ( n = 15) with either of left main or three-vessel disease, and the low-risk group ( n = 35). There were no significant differences in global SSR and global ESR between the two groups. The amplitude of global PS was significantly reduced in high-risk patients with LM/3VD in comparison with low-risk patients (−17.5 ± 2.4 % vs −19.8 ± 2.7 %, P = 0.007, respectively). TAVC-global PS and TAVC-global ESR were significantly prolonged in high-risk patients with LM/3VD in comparison with low-risk patients (15.3 ± 25.7 ms vs −36.8 ± 32.7 ms, P < 0.0001 and 162.8 ± 32.7 ms vs 135.7 ± 41.5 ms, P < 0.03, respectively). Receiver-operating characteristic analysis demonstrated that TAVC-global PS most strongly detected high-risk patients with sensitivity of 100 % and specificity of 74.3 % (area under the curve = 0.938, 95 % confidence interval 0.832-0.986, P = 0.0001). Temporal analysis of 2D strain appeared to be useful in detecting high-risk patients with LM/3VD among patients with NSTEACS. [ABSTRACT FROM AUTHOR]

Guidelines have not recommended routine echocardiography to predict perioperative cardiac events (PCE). We aimed to evaluate the prognostic significance of tissue Doppler echocardiography-derived E/ E′ for risk stratification before noncardiac surgery. We reviewed 445 consecutive patients with cardiovascular diseases who had undergone tissue Doppler echocardiography before noncardiac surgery. The revised cardiac risk index (RCRI) was assessed from clinical records. After excluding patients who could not have E/ E′ measurements, 200 patients were further analyzed. PCEs included death, arrhythmia, myocardial infarction, heart failure and deferred surgery. Eleven patients developed PCEs. E/ E′ was significantly higher in patients with PCE (18.4 ± 5.8 vs. 12.2 ± 4.5, p < 0.0005). Multivariate analysis showed E/ E′ (odds ratio 1.2, p < 0.007) and RCRI (OR 4.8; 95%, p < 0.006) were independent predictors of PCE. E/ E′ appeared to be useful in perioperative risk stratification among patients with cardiovascular diseases undergoing noncardiac surgery. [ABSTRACT FROM AUTHOR]

Hemodialysis patients were recognized as a high-risk group for restenosis after percutaneous coronary intervention in the era of the bare-metal stent. Recently, sirolimus-eluting stents (SES) have reduced restenosis and target lesion revascularization (TLR); however, it has been reported that their efficacy in hemodialysis patients is limited. The purpose of this study was to investigate whether paclitaxel-eluting stents (PES) improved angiographic outcomes of hemodialysis patients compared with SES. This study is a retrospective cohort study. We analyzed 54 hemodialysis patients with 87 lesions implanted with PES from February 2007 to September 2008, and 49 hemodialysis patients with 68 lesions implanted with SES from August 2004 to January 2007. Angiographic follow-up after 8-10 months was obtained for 59 lesions (67.8%) in the PES group and 43 lesions (63.2%) in the SES group. At baseline, the PES patients had more peripheral artery disease compared with the SES group (66.7 vs. 34.7%; p = 0.0012). There were no significant differences in the angiographic characteristics or procedural index. The binary restenosis rate was lower in lesions implanted with PES than in those with SES (13.6 vs. 39.5%; p = 0.034). Accordingly, the TLR rate was lower in lesions implanted with PES than with SES (9.3 vs. 26.5%; p = 0.041). Our results suggest that PES is more effective than SES in reducing restenosis and TLR in hemodialysis patients. [ABSTRACT FROM AUTHOR]

In patients with acute myocardial infarction (AMI), both myocardial blush grade (MBG) and coronary flow pattern obtained by transthoracic Doppler echocardiography (TTDE) have limitations in assessing myocardial viability. Accordingly, we assessed the usefulness of combination of MBG and TTDE in predicting myocardial damage following AMI. A total of 45 patients with anterior AMI were enrolled. Myocardial blush grade and coronary flow velocity (CFV), diastolic deceleration time (DDT), and coronary flow velocity reserve (CFVR) were measured immediately after reperfusion. The regional wall motion score index (RWMSI) was measured at 14 days after onset. The MBG was normal in 12 patients. The RWMSI was significantly better in the patients with normal than with abnormal MBG (1.65 ± 0.29 vs 2.03 ± 0.46, P < 0.05). Among the coronary flow indices, only DDT showed the significant correlation with RWMSI ( P < 0.05, r = −0.44). To predict RWMSI ≥2, sensitivity and positive predictive value (PPV) were 86.3% and 65.5% in DDT alone, 90.9% and 65.5% in MBG alone, respectively. Predictable value was enhanced by the combination with DDT and MBG, with sensitivity of 100% and PPV of 70.8% in 31 patients whose results of both corresponded. MBG in conjunction with TTDE was useful in predicting myocardial damage after anterior AMI. [ABSTRACT FROM AUTHOR]

Risk stratification among patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) has been made by clinical scoring. Recently, multiple-detector computed tomography (MDCT) appeared to provide noninvasive coronary angiography (CAG). To clarify the prognostic significance of MDCT, we aimed to evaluate the clinical utility of MDCT in the early management and in predicting the long-term prognosis of NSTE-ACS with low to intermediate risk. Among 84 consecutive patients with NSTEACS, risk stratification using a TIMI risk score was done. A total of 48 patients were categorized as low to intermediate risk. Multiple-detector CT was performed in 30 patients using 16-slice MDCT. MDCT detected coronary stenoses in 18 patients. Compared to invasive CAG, MDCT successfully depicted the coronary stenosis ( P < 0.005), with sensitivity of 100% and specificity of 86%. The incidence of in-hospital major adverse clinical events (death, subsequent myocardial infarction, revascularization) was significantly higher in patients with a positive MDCT than in those with a negative MDCT test (44% vs 0%, P < 0.005). Moreover, a Kaplan-Meier analysis showed a significant difference in the event — free survival between MDCT positive and negative groups (33% vs 100%, respectively, P < 0.0001) during the mean follow-up period of 9.9 ± 7.5 months. Sixteen-slice MDCT in conjunction with a TIMI risk score appeared to demonstrate prognostic significance in patients with NSTE-ACS. [ABSTRACT FROM AUTHOR]

Objective evaluation of the functional significance of individual stenosis in patients with multiple lesions is crucial when performing percutaneous coronary intervention (PCI). Here we propose a novel lesion-specific parameter, the epicardial resistance index (ERI), which is derived from intracoronary pressure measurements, and validate its clinical usefulness. The ERI is defined as the ratio of the resistance of an epicardial coronary stenosis to that of downstream myocardium. After obtaining intracoronary pressure data by pull-back of a 0.014″ pressure wire, the ERI was calculated as the trans-lesional pressure gradient divided by (P d–P v) at maximum hyperemia, where P d = the mean distal coronary pressure in the absence of any stenosis and P v = the central venous pressure. Using 170 measurements obtained from 75 patients, the correlation of ERI with parameters obtained from quantitative coronary angiography (QCA) and intravascular ultrasound (IVUS) was studied. ERI showed a significant correlation with the QCA-derived percent diameter stenosis ( r = 0.67, P < 0.001), and with the IVUS-derived minimum luminal area ( r = 0.68, P < 0.001). In 55 patients who underwent PCI with bare metal stents, a postprocedural target lesion ERI value greater than 0.16 strongly predicted the need for subsequent revascularization within six months (81% sensitivity and 80% specificity). The ERI is a useful pressure-derived hemodynamic parameter that correlates with anatomical parameters. In addition, the postprocedural resistance of the target lesion indicated by the ERI is a reliable predictor of the late outcome of PCI. [ABSTRACT FROM AUTHOR]

HMG-CoA reductase inhibitors (statins) have been shown to improve the endothelial function by lowering lipids. Recent studies also suggest a direct impact of statins on the vascular wall. We assessed the rapid effect of cerivastatin on the coronary flow velocity reserve (CFVR) using transthoracic Doppler echocardiography (TTDE). The coronary flow velocity from the distal left anterior descending artery was measured in 16 healthy subjects (all male, age 24–38 years) using a 5-MHz transducer, on the day before, just before, and 3 h after administering 0.3 mg of cerivastatin. Hyperemia was achieved by the intravenous administration of adenosine, and the CFVR was calculated as the radio of the mean diastolic hyperemic coronary flow velocity to the basal flow velocity. The serum lipid profile and high-sensitivity C-reactive protein (hsCRP) were measured. The CFVR following the single administration of cerivastatin increased from 2.93 ± 0.58 to 3.91 ± 0.86, P = 0.003, and was significantly higher than the CFVR measured at the same time on the previous day (3.91 ± 0.86 vs 3.37 ± 0.48, P = 0.009). Neither the serum lipid profile nor hsCRP exhibited a remarkable change after cerivastatin administration. We concluded that a single-dose administration of cerivastatin, an HMG-CoA reductase inhibitor, improves the coronary flow velocity reserve without modifying the serum lipid profile. [ABSTRACT FROM AUTHOR]

We experienced a 78-year-old man in whom transient pulmonary hypertension was documented during epileptic seizure. A Swan-Ganz catheter demonstrated that pulmonary arterial pressure rose immediately after the initiation of the seizure, which was followed by systemic hypertension. The plasma level of angiotensin II increased in pulmonary circulation during the seizures; however, catecholamines did not change from the baseline. The patient responded well to treatment with an antiepileptic drug and losartan potassium. [ABSTRACT FROM AUTHOR]