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Background: Current guidelines strongly recommend the application of primary percutaneous coronary intervention (PCI) in patients with acute myocardial infarction; however, information on its efficacy in super-old patients aged >90 years is inadequate. We compared the efficacy of primary PCI and its clinical outcomes in super-old patients with those of old patients in a super-aging society., Methods: Shimane Acute Coronary Syndrome (ACS) Registry was a multicenter retrospective cohort study. Consecutive patients with ACS who visited all PCI centers in Shimane Prefecture between January and December 2020 were enrolled. Patients were classified into four age categories: non-old (<65 years), pre-old (65-<75 years), old (75-<90 years), and super-old (≥90 years). Primary endpoints were major adverse cardiovascular events (MACE), including all-cause death, recurrent ACS, any stroke, and hospitalization for worsening heart failure., Results: In total, 454 patients were enrolled: 99 non-old, 124 pre-old, 181 old, and 50 super-old. The application rate of primary PCI decreased with increased age, with 89 % in old age and 78 % in super-old age (p = 0.042). In-hospital mortality rate was significantly higher in super-old age than in old age (22 % vs. 8 %, p = 0.010), particularly in shock cases (67 % vs. 31 %, p = 0.040); no difference was observed between the two groups in non-shock cases (8 % vs. 4 %, p = 0.259) or in cases that received primary PCI (10 % vs. 6 %, p = 0.232). Landmark analysis revealed that MACE after 30th day did not differ between super-old and old age groups., Conclusions: In the advanced aging society of Shimane Prefecture, more than half of patients with ACS were aged ≥75 years, with super-old patients aged ≥90 years accounting for 11 % of all patients. In-hospital mortality rate among super-old age patients was lower among those who underwent primary PCI. The prognosis for super-old age patients who were discharged alive was similar to that of old age patients., Competing Interests: Declaration of competing interest The authors declare that there is no conflict of interest., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Although computed tomography-derived fractional flow reserve (FFR CT ) has been reimbursed in a few countries, its impacts on daily practice of coronary artery diseases are not fully elucidated. We evaluated the clinical impacts of FFR CT under the real Japanese insurance reimbursement., Methods: In the multicenter prospective registry: DYNAMIC-FFR CT study, a total of 410 patients who underwent FFR CT analysis under reimbursement were prospectively enrolled at 6 Japanese sites from October 2019 to November 2021. Coronary CT angiography and FFR CT findings, treatment plans, and 90-day outcomes were recorded. The primary endpoint was the redirection rate from the tests that might be expected without FFR CT [invasive coronary angiography (ICA)-selected group, myocardial perfusion single photon emission CT (MPS)-selected group, optimal medical therapy (OMT)-selected group, and others-selected group] to those that were actually performed based on FFR CT ., Results: ICA could be avoided in 39.5 % in the ICA-selected group (N = 233). In particular, in 94.3 % of patients with an FFR CT value of >0.80, additional examinations, such as ICA, were avoided. In addition, in the MPS-selected group (N = 133), 92.6 % had no additional tests with FFR CT  > 0.80, while only 2 cases with FFR CT  ≤ 0.80 underwent additional MPS examination. On the contrary, 33.3 % of the OMT-selected group (N = 33) had FFR CT  ≤ 0.80. Approximately, 35 % medical cost reduction was also finally expected., Conclusion: Introduction of FFR CT could not only reduce unnecessary ICA and be a test that replaces the conventional non-invasive functional assessment modality but also result in medical cost reduction even when used under real Japanese insurance reimbursement., Competing Interests: Declaration of competing interest Dr. Fujimoto has a research agreement with HeartFlow®Japan G.K. that is related to this study. Dr. Komiyama has received lecture fee from HeartFlow®Japan G.K. Dr. Tanabe has received lecture fee from HeartFlow®Japan G.K., (Copyright © 2023. Published by Elsevier Ltd.)

Background: The impact of shorter door-to-balloon (DTB time on long-term outcomes in ST-segment elevation myocardial infarction (STEMI treated with primary percutaneous coronary intervention (PPCI has not been fully elucidated., Methods: We investigated 3283 consecutive patients with acute myocardial infarction selected from a prospective, nationwide, multicenter registry (J-MINUET database comprising 28 institutions in Japan between July 2012 and March 2014. Among the study population, we analyzed 1639 STEMI patients who had PPCI within 12 h of onset. Patients were stratified into four groups (DTB time < 45 min, 45-60 min, 61-90 min, >90 min. The primary endpoint was a composite of all-cause death, non-fatal MI, non-fatal stroke, cardiac failure, and urgent revascularization for unstable angina up to 3 years. We performed landmark analysis for incidence of the primary endpoint from 31 days to 3 years among the four groups., Results: The primary endpoint rate from 31 days to 3 years increased significantly and time-dependently with DTB time (10.2 % vs. 15.3 % vs. 16.2 % vs. 19.3 %, respectively; log-rank p = 0.0129. Higher logarithm-transformed DTB time was associated with greater risk of a primary endpoint from 31 days to 3 years, and the increased number of adverse long-term clinical outcomes persisted even after adjusting for other independent variables., Conclusion: Shorter DTB time was associated with better long-term clinical outcomes in STEMI patients treated with PPCI in contemporary clinical practice. Further efforts to shorten DTB time are recommended to improve long-term clinical outcomes in STEMI patients., Trial Registration: UMIN Unique trial Number: UMIN000010037., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests. Yukio Ozaki has received several research grants from Bayer Yakuhin, Ltd., Research Institute for Production Development, Daiichi-Sankyo Co., Ltd., and Dainippon Sumitomo Co., Ltd. Kazuo Kimura has received honoraria from AstraZeneca, Toa Eiyo Ltd., MSD K.K., Bayer Yakuhin, Ltd., and Daiichi-Sankyo Co., Ltd., and has received several research grants from MSD K.K., Daiichi-Sankyo Co., Ltd., Ono Pharmaceutical Co., Pfizer Japan Inc., Bayer Yakuhin Ltd., Takeda Pharmaceutical Co., Ltd., Boehringer Ingelheim Japan, Tanabe Mitsubishi, and Astellas Pharma Inc. Wataru Shimizu has received honoraria from Daiichi-Sankyo Co., Ltd., Boehringer Ingelheim Japan, Bayer Yakuhin Ltd., Bristol, and Ono Pharmaceutical Co., and has received several research grants from Daiichi-Sankyo Co., Ltd., Boehringer Ingelheim Japan, Ono Pharmaceutical Co., Otsuka Pharmaceutical Co., Eisai Co., Mitsubishi Tanabe Pharma Co., Asterllas Pharma Inc., and St Jude Medical. Yoshihiko Saito has received honoraria from Otsuka Pharmaceutical Co., Ltd., Kowa Pharmaceutical Co., Ltd., Daiichi Sankyo Co., Ltd., Mitsubishi Tanabe Pharma Co., Pfizer Japan Inc., and Novartis Pharma K.K., and has received several research grants from Takeda Pharmaceutical Co., Ltd., Teijin Pharma Ltd., Ono Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Co., Eisai Co., Ltd., ZERIA Pharmaceutical Co., Ltd., Shionogi & Co., Ltd., Otsuka Pharmaceutical Co., Ltd., Dainippon Sumitomo Pharma Co., Ltd., Kyowa Hakko Kirin Co., Ltd., Astellas Pharma Inc., Daiichi Sankyo Co., Ltd., and Boston Scientific Japan K.K. Toshiaki Mano has received a research grant from Abbot Vascular Japan. Kengo Tanabe has received honoraria from Abbot Vascular Japan, Mitsubishi Tanabe Pharma Co., and Daiichi Sankyo Co., Ltd. and has received several research grants from Kaneka and Terumo. Kenichi Tsujita has received honoraria from Amgen Astellas Bio Pharma K.K., Bayer Yakuhin, Ltd., Daiichi Sankyo Co., Ltd., MSD K.K., and Sanofi K.K., and has received several research grants from AstraZeneca K.K., Astellas Pharma Inc., Bayer Yakuhin, Ltd., Boehringer Ingelheim Japan, Boston Scientific Japan K.K., Chugai Pharmaceutical Co., Ltd., Daiichi Sankyo Co., Ltd., Eisai Co., Ltd., Kowa Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Co., MSD K.K., Pfizer Japan Inc., Sanofi K.K., Shionogi & Co., Ltd., and Takeda Pharmaceutical Co., Ltd. Masaharu Ishihara has received honoraria from Bayer Yakuhin Ltd., MSD K.K., Astra Zeneca, and Astellas Pharma Inc. and has received several research grants from Abbott Vascular Japan, Boston Scientific Japan K.K., Sanofi K.K., MSD K.K., Astellas Pharma Inc., Bayer Yakuhin Ltd., Pfizer, Daiichi Sankyo Co., Ltd., MID, and Goodman. No funders played any role in this study., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Beta-blockers are associated with several clinical benefits in patients with reduced left ventricular ejection fraction (REF) after acute myocardial infarction (AMI), such as lower rates of mortality, recurrence of myocardial infarction, and heart failure. However, the long-term prognosis of beta-blockers has rarely been investigated in patients with non-REF after AMI. This study aimed to investigate the clinical benefits of beta-blockers in these patients., Methods: A total of 3281 consecutive patients who were hospitalized within 48 h after AMI were registered in the J-MINUET study. Patients who underwent primary percutaneous coronary intervention (PCI) and had a left ventricular ejection fraction ≥40 % were enrolled, and patients who died during admission were excluded. Included patients were divided into two groups according to the prescription of beta-blockers at discharge. Their characteristics and clinical outcomes were compared., Results: The number of AMI patients treated with beta-blockers was 1353 (70.4 %). Patients who received beta-blockers were younger and had a higher incidence of hypertension, dyslipidemia, and ST-segment elevation myocardial infarction than those who did not receive beta-blockers. The peak creatine kinase level after primary PCI was significantly higher in patients who received beta-blockers. These patients also had a lower incidence of a composite of all-cause death, myocardial infarction, and stroke compared to those that did not receive beta-blockers (7.3 % vs. 11.9 %, p = 0.001). Multivariate analysis showed that beta-blocker use was an independent factor for better clinical outcomes., Conclusions: The J-MINUET study revealed the clinical benefit of beta-blockers in AMI patients with non-REF after primary PCI., Competing Interests: Declaration of competing interest Yoshihiko Saito: grants from MEXT KAKENHI Grant Number JP19155855, grants from Health Labour Sciences Research Grant Number 19189094, grants from Health Labour Sciences Research Grant Number 17933459, grants from AMED under Grant Number JP19ek0210080, grants from AMED under Grant Number JP19ek0210118, grants from AMED under Grant Number JP19ek0210121, grants from AMED under Grant Number JP19ek0210115, grants from AMED under Grant Number JP19ek0109367, grants from AMED under Grant Number JP19ek0109406, grants from AMED under Grant Number JP19km0405009, during the conduct of the study; grants and personal fees from Otsuka Pharmaceutical Co., Ltd., grants and personal fees from Ono Pharmaceutical Co., Ltd., grants from Takeda Pharmaceutical Co., Ltd., grants and personal fees from Daiichi Sankyo Co., Ltd., grants and personal fees from Mitsubishi Tanabe Pharma Corporation, grants and personal fees from Bristol-Myers Squibb Company, grants from Actelion Pharmaceuticals Japan Ltd., grants from Kyowa Kirin Co., Ltd., grants and personal fees from Kowa Pharmaceutical Co., Ltd., grants from Shionogi & Co., Ltd., grants from Dainippon Sumitomo Pharma Co., Ltd., grants and personal fees from Teijin Pharma Ltd., grants from Chugai Pharmaceutical Co., Ltd., grants from Eli Lilly Japan K.K., grants from Nihon Medi-Physics Co., Ltd., grants, personal fees and other from Novartis Pharma K.K., grants and personal fees from Pfizer Japan Inc., grants from Fuji Yakuhin Co., Ltd., grants, personal fees and other from Bayer Yakuhin, Ltd., other from Amgen Astellas BioPharma K.K., other from Actelion Pharmaceuticals Japan Ltd., other from Roche Diagnostics K.K., personal fees from Alnylam Japan K.K., personal fees from AstraZeneca K.K., personal fees from Tsumura & Co., personal fees from Toa Eiyo Ltd., personal fees from Nippon Shinyaku Co., Ltd., personal fees from Nippon Boehringer Ingelheim Co., Ltd., personal fees from Mochida Pharmaceutical Co., Ltd. Kengo Tanabe: personal fees from Abbott Vascular, personal fees from Boston Scientific, personal fees from Medtronic, personal fees from Terumo, personal fees from Kaneka, from Japan Lifeline. Hisao Ogawa: personal fees from Towa Pharmaceutical Co., Ltd., personal fees from Bristol-Meyers Squibb Co., Ltd., personal fees from Pfizer Co., Ltd., personal fees from Toa Eiyo Co., Ltd., personal fees from Bayer Yakuhin Co., Ltd., personal fees from Novartis Pharma Co., Ltd. Masaharu Ishihara: grants from Abbott Vascular Japan Co., Ltd., grants and personal fees from Amgen Astellas Bio Pharma K.K., grants from Astellas Pharma Inc., grants and personal fees from Bayer Yakuhin, Ltd., grants from Boston Scientific Japan K.K., grants and personal fees from Daiichi Sankyo Company, Limited, grants from Fukuda Denshi Co., Ltd., grants from Goodman Co., LTD., grants from Japan Lifeline Co., Ltd., grants from Kowa Pharmaceutical Co., Ltd., grants from MID, Inc., grants from Mitsubishi Tanabe Pharma Corporation, grants and personal fees from MSD K.K., grants from Nippon Shinyaku Co., Ltd., grants from Nipro Corporation, grants from Otsuka Pharmaceutical Co., Ltd., grants from Ono Pharmaceutical Co., Ltd., grants from Pfizer Japan Inc., grants and personal fees from Sanofi K.K., grants from Shionogi & Co., Ltd., grants from Sumitomo Dainippon Pharma Co., Ltd., grants from Takeda pharmaceutical Co. Ltd., grants from Teijin Pharma Ltd., grants from Terumo Corporation, grants from Abbott Medical Japan Co., Ltd., grants from Medtronic Japan Co., Ltd., grants from Nippon Boehringer Ingelheim Co., Ltd., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: Renal impairment is a common phenomenon that portends a poor prognosis of heart failure (HF). The renal arterial resistance index (RRI) can be useful for defining renal function and predicting outcomes in patients with HF. This study aimed to investigate the determining factors of the RRI in HF patients with preserved ejection fraction (HFpEF) and with reduced EF (HFrEF)., Methods: This retrospective study included 330 patients with HF. We investigated the determining factors for the RRI and the association between the RRI and 1-year composite outcome, comprising all-cause mortality and re-hospitalization for HF., Results: The independent predictors of the RRI were tricuspid regurgitation peak gradient and estimated glomerular filtration rate in HFpEF, and pulse pressure and blood urea nitrogen in HFrEF. During the follow-up, 30 (9.1%) patients presented the composite outcome. Cox proportional hazard analysis revealed the association of the RRI with the composite outcome in both HFrEF (HR 1.08; 95% CI 1.03-1.14) and HFpEF (HR 1.07; 95% CI 1.03-1.12) without an interaction (p for interaction = 0.770)., Conclusions: The RRI was a consistent prognosticator in patients with HFpEF and those with HFrEF, while factors defining RRI were different between these groups., (Copyright © 2021. Published by Elsevier Ltd.)

Background: This analysis aimed to evaluate the clinical impact of high bleeding risk (HBR) on adverse events after percutaneous coronary intervention (PCI)., Methods: We retrospectively analyzed 1695 patients in the MODEL U-SES study, which was a multicenter, open-label, prospective observational study evaluating safety of 3-month dual antiplatelet therapy (DAPT) after Ultimaster stent (Terumo Corporation, Tokyo, Japan) implantation at 65 sites in Japan. Patients were divided into 2 groups (HBR/Non-HBR) according to modified Academic Research Consortium-HBR criteria. Ischemic/thrombotic event (cardiovascular death, myocardial infarction, ischemic stroke, and stent thrombosis) and bleeding event (Bleeding Academic Research Consortium 3 or 5) at 1 year were evaluated., Results: Of 1695 patients, 840 patients were categorized as HBR and 855 patients were Non-HBR. One-year follow-up was completed in 95.3%. During 1-year follow-up, ischemic/thrombotic events were observed in 31 cases (1.8%) and bleeding events occurred in 21 cases (1.2%). Presence of HBR was significantly associated with higher incidence of ischemic/thrombotic events as compared to Non-HBR (adjusted hazard ratio, 0.16; 95% confidence interval, 0.05 to 0.50), whereas the incidence of bleeding events did not reach statistical significance between HBR and Non-HBR. In comparison of monotherapy after DAPT, P2Y 12 inhibitor monotherapy after DAPT had comparable ischemic/thrombotic and bleeding events with aspirin monotherapy after DAPT in both HBR and Non-HBR., Conclusion: In contemporary PCI practice, nearly half of patients had HBR and presence of HBR significantly increased risk of ischemic/thrombotic events. Both aspirin and P2Y 12 inhibitor monotherapy following short DAPT had low and comparable ischemic/bleeding events., (Copyright © 2021. Published by Elsevier Ltd.)

Background: Increased left ventricular (LV) afterload in patients with aortic stenosis consists of valvular and vascular loads; however, the effects of vascular load induced by arterial stiffness on clinical outcomes after transcatheter aortic valve replacement (TAVR) remain unclear. This study evaluated the prognostic value of brachial-ankle pulse wave velocity (baPWV) after TAVR., Methods: A retrospective study including 161 consecutive patients who underwent TAVR with a pre-procedural baPWV assessment was conducted. We investigated the association between baPWV and the 1-year composite outcome comprising all-cause death and rehospitalization related to heart failure. Echocardiographic measurements including the LV mass index (LVMi) and LV diastolic function at 1, 6, and 12 months after TAVR were assessed., Results: Of the 161 patients, 31 patients experienced composite outcome within 1 year after TAVR. The receiver operating characteristic curve analysis revealed that the discriminating baPWV level to discern 1-year composite outcome was 1,639 cm/s, and all subjects were allocated to two groups based on the result. Baseline characteristics were comparable between the high baPWV (n = 72) and low baPWV groups (n = 89). The Kaplan-Meier curve revealed a significantly higher cumulative 1-year composite outcome in the high baPWV group than in the low baPWV group (31% vs. 10%; log-rank test, p<0.001). High baPWV was an independent predictor of the 1-year composite outcome (adjusted hazard ratio, 3.42; 95% confidence interval, 1.62-7.85; p = 0.002). Furthermore, post-procedural echocardiography revealed that the high baPWV group had less LVMi regression and higher E/e' after TAVR compared to the low baPWV group. The delayed reversal in LVMi and diastolic function attributable to arterial stiffness might be linked to impaired clinical outcomes after TAVR., Conclusions: Higher baPWV could be associated with adverse clinical outcomes and delayed reverse LV remodeling after TAVR., (Copyright © 2021. Published by Elsevier Ltd.)

Background: Left ventricular hypertrophy (LVH) develops with both structural and electrical remodeling in response to elevated afterload due to aortic stenosis (AS). This study evaluated the prognostic value of electrocardiographic LVH (ECG LVH) after transcatheter aortic valve replacement (TAVR)., Methods: A retrospective study including 157 consecutive patients who underwent TAVR was conducted. ECG LVH was defined as Sokolow-Lyon voltage (S in V 1  + R in V 5/6 ) before TAVR was ≥3.5mV. We investigated the association between ECG LVH and the 1-year composite outcome comprising all-cause death and rehospitalization related to heart failure. ECG and echocardiographic measurements at 1, 6, and 12 months after TAVR were assessed., Results: The baseline characteristics were comparable between the ECG LVH (n = 74) and non-ECG LVH groups (n = 83). The ECG LVH was associated with a significantly greater reduction of Sokolow-Lyon voltage and LV mass index than the non-ECG LVH after TAVR. The absence of ECG LVH was an independent predictor of the 1-year composite outcome [adjusted hazard ratio (HR), 2.27; 95% confidence interval (CI), 1.01 - 5.60; p = 0.04]. Furthermore, a reduction of Sokolow-Lyon voltage from baseline to 1-month follow-up, but not a reduction of LV mass index, was associated with a lower cumulative composite outcome from 1 month to 1 year (adjusted HR, 0.36; 95% CI, 0.15 - 0.86; p = 0.02)., Conclusions: ECG LVH was associated with a low incidence of adverse clinical outcomes and greater reverse LV remodeling after TAVR. Preprocedural and serial LVH assessment by ECG might be useful in AS patients undergoing TAVR., (Copyright © 2021. Published by Elsevier Ltd.)

Background: The prevalence of acute myocardial infarction (AMI) in elderly people is increasing worldwide. However, their characteristics and prognosis have been rarely investigated. This study aimed to investigate the characteristics and prognosis in elderly patients with cardiac troponin-positive AMI., Methods: Consecutive patients with AMI from the J-MINUET study were divided into the following 3 groups: patients aged less than 65 years, those aged between 65 and 79 years, and those aged 80 years or over. Their characteristics and in-hospital outcomes were compared., Results: Patients with AMI aged 80 years or over had the highest incidence of female gender, and the highest incidence of hypertension, chronic kidney disease, and cardiovascular disease, such as peripheral artery disease, atrial fibrillation, and stroke, whereas they had the lowest body mass index, and the lowest incidence of current smoker, diabetes mellitus, and dyslipidemia. Patients with AMI aged 80 years or over had significantly longer onset to door time and longer door to device time, and lower peak creatine kinase (CK). The incidence of ST-segment elevation myocardial infarction (STEMI) was the lowest in the AMI patients aged 80 years or over, but the patients had a higher incidence of in-hospital death and cardiac failure than the other two groups. In addition, the presentation with STEMI and non-ST-segment elevation myocardial infarction with CK elevation among patients aged 80 years or over showed the highest incidence of in-hospital death and cardiac failure., Conclusions: J-MINUET showed different clinical characteristics between the aged and younger populations. The incidence of in-hospital death and cardiac failure in patients aged 80 years or over with AMI was poorer than their younger counterparts., (Copyright © 2020. Published by Elsevier Ltd.)

Background: Natural history of coronary plaque progression (PP) in patients with diabetes mellitus (DM) remains unclear. This study aimed to investigate the clinical predictors of coronary PP in patients with DM., Methods: In this prospective observational study, we analyzed 70 asymptomatic patients (age, 64.4 years; male, 67%) with type 2 DM without prior history of coronary artery disease who underwent serial 320-row computed tomography coronary angiography with an interscan interval of more than 24 months (median 37.7 months). Study endpoint was PP, which was defined if coronary plaque volumes (PVs) at follow-up minus PVs at baseline was >0. We evaluated plaque composition using the Hounsfield Unit thresholds and insulin resistance estimated by the homeostasis model assessment of insulin resistance (HOMA-IR)., Results: Thirty-nine patients who showed PP had a higher increase in hemoglobin A1c (⊿HbA1c) from baseline to follow-up than those without PP (0.3% ± 0.8% vs -0.4% ± 1.1%; p = 0.01), although there was no statistical difference in HbA1c at baseline (7.1 ± 0.5% vs. 7.3 ± 1.4%; p = 0.24). In multivariable analysis, ⊿HbA1c [odds ratio (OR): 3.05; 95% confidence interval (CI): 1.39-6.67; p = 0.001] was an independent predictor for PP. Increase in low-density lipoprotein cholesterol (⊿LDL-C), not ⊿HbA1c, was significantly correlated to percent change in necrotic core (NC) volume (β-coefficients: 0.04; 95% CI: 0.004 - 0.08; p = 0.03). Among 48 patients without insulin therapy, patients with PP (n = 28) had a higher increase in HOMA-IR than those without PP (n = 20) (0.95 ± 2.00 vs. -0.63 ± 1.31; p = 0.003)., Conclusions: Increase in HbA1c and HOMA-IR was associated with PP in asymptomatic patients with type 2 DM, whereas increase in LDL-C was correlated to increase in NC., (Copyright © 2020 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Background: Patients with peripheral artery disease (PAD) are at high risk of cardiovascular events, including myocardial infarction (MI), stroke, and cardiovascular death. However, the impact of PAD on prognosis in Japanese patients with acute MI remains unclear., Methods: The Japanese registry of acute Myocardial INfarction diagnosed by Universal dEfiniTion (J-MINUET) is a prospective multicenter registry that registered 3283 patients with acute MI. Among them, 2970 patients with available data of PAD were divided into the following 4 groups: 2513 patients without prior MI or PAD (None group), 320 patients with only prior MI (Prior MI group), 100 patients with only PAD (PAD group), and 37 patients with both previous MI and PAD (Both group). The primary endpoint was a composite of all-cause death, non-fatal MI, non-fatal stroke, cardiac failure, and urgent revascularization for unstable angina., Results: The 3-year cumulative incidence of the primary endpoint was 26.9% in None group, 41.4% in Prior MI group, 48.0% in PAD group, and 60.3% in Both group (p < 0.001). In multivariate analysis, hazard ratio using None group as reference was 1.55 (95% confidence intervals 1.25-1.91; p < 0.001) for MI group, 2.26 (1.61-3.07; p < 0.001) for PAD group, and 2.52 (1.52-3.90; p < 0.001) for Both group., Conclusions: Concomitant PAD was associated with poor prognosis in Japanese patients with acute MI., (Copyright © 2020 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Background: Objective nutritional indexes have been shown to predict prognoses in some clinical settings. We aimed to investigate the prognostic values of these indexes in patients undergoing transcatheter aortic valve implantation (TAVI)., Methods: We retrospectively analyzed 95 consecutive patients who underwent TAVI at our institution from December 2013 to February 2017. As objective nutritional indexes, a controlling nutritional status (CONUT) score, prognostic nutritional index (PNI), and geriatric nutritional risk index (GNRI) were calculated at baseline. The optimal cut-off values were determined using receiver operating characteristic curve analysis. According to the cut-off values, we investigated the association of these indexes with 1-year clinical outcomes including all-cause mortality and re-hospitalization due to heart failure., Results: In the Kaplan-Meier analysis, patients with a higher CONUT score and lower PNI had significantly higher incidence rates of 1-year mortality (26.9% vs. 2.9%; p<0.001, 17.4% vs. 2.0%; p=0.011, respectively) and composite outcome of mortality and re-hospitalization due to heart failure (38.5% vs. 13.0%; p=0.006, 39.3% vs. 11.9%; p=0.002, respectively). On Cox hazard analysis, CONUT score and PNI were significantly associated with 1-year mortality [hazard ratio (HR): 1.91; 95% confidence interval (CI): 1.27-2.88; p=0.002, HR: 0.86; 95% CI: 0.75-0.99; p=0.031, respectively] and the composite outcome (HR: 1.49; 95% CI: 1.11-2.00; p=0.007, HR: 0.88; 95% CI: 0.80-0.97; p=0.011, respectively)., Conclusions: The CONUT score and PNI are associated with 1-year clinical outcomes especially with 1-year all-cause mortality in patients undergoing TAVI. Moreover, the CONUT score and PNI might have better predictive values than GNRI., (Copyright © 2019. Published by Elsevier Ltd.)

Background: Malnutrition in heart failure (HF) is related to altered intestinal function, which could be due to hemodynamic changes. We investigated the usefulness of novel nutritional indexes in relation to hemodynamic parameters., Methods: We retrospectively analyzed 139 HF patients with reduced ejection fraction who underwent right heart catheterization. We investigated correlations between right side pressures and nutritional indexes, which include controlling nutritional (CONUT) score and geriatric nutritional risk index (GNRI). Receiver operating characteristic (ROC) curves were generated to investigate the prognostic accuracy of CONUT score and GNRI for a composite of death or HF hospitalization in 12 months. Logistic regression analysis was performed to investigate whether hemodynamic correlates were associated with malnutrition, which was defined based on CONUT sore or GNRI., Results: Higher right side pressures were positively correlated with worse nutritional status according to CONUT score, but were negatively correlated with worse nutritional status according to GNRI. Area under ROC curve for the composite endpoint was 0.746 in CONUT score and 0.576 in GNRI. The composite endpoint occurred in 40% of CONUT score≥3 and in 11% of CONUT score<3 (p<0.001). These relationships were also investigated with GNRI (40% of GNRI<95 vs. 17% of GNRI≥95, p=0.002). In multivariate analysis, higher right atrial pressure was significantly associated with higher CONUT score, while no hemodynamic parameter was related to GNRI., Conclusions: CONUT score was associated with right side congestion, while no association between GNRI and right side congestion was noted. CONUT score had better predictive value than GNRI., (Copyright © 2017 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Background: The GRACE risk score was developed to predict in-hospital mortality for acute coronary syndrome (ACS) using multinational registries, but did not include Japanese data. Therefore, GRACE risk scores are not extensively used in Japan. The present study aimed to evaluate the relationship between the GRACE risk score and in-hospital mortality among Japanese patients with ACS using the Tokyo CCU (cardiovascular care unit) Network Database., Methods and Results: A total of 9460 patients with ACS hospitalized at 67 Tokyo CCUs between January 2011 and December 2013 were retrospectively reviewed and GRACE risk scores were calculated. Patients in the Tokyo CCU Network database had more severe conditions compared to those of the original GRACE study. There was a strong correlation between the GRACE risk score and in-hospital mortality for patients with ST-segment elevation myocardial infarction (STEMI) or non ST-segment elevation myocardial infarction (NSTEMI) (r=0.99, p<0.001); however, the correlation was not significant for patients with unstable angina (r=0.35, p=0.126). For STEMI+NSTEMI patients, the discrimination ability of the GRACE risk score was excellent, with a c statistic of 0.87 (95% confidence interval, 0.86-0.89)., Conclusions: The GRACE risk score is a good predictor of in-hospital mortality for Japanese patients with STEMI or NSTEMI, and can help clinicians stratify patients by risk for optimal patient triage and early treatment management., (Copyright © 2017 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Background: This study aimed to compare very late vascular response after stent implantation between everolimus-eluting stent (EES) with a thin, non-adhesive, durable, biocompatible fluorinated polymer and biolimus-eluting stent (BES) with a biodegradable polymer by optical coherence tomography (OCT)., Methods and Results: In the NOBORI-BES Versus XIENCE V/PROMUS-EES Trial (NEXT), a formal OCT substudy investigated 48 patients (27 EES-treated lesions in 23 patients and 28 BES-treated lesions in 25 patients) with 2-year (18-30 months) follow-up imaging at 18 centers. The percentage of uncovered strut by neointima was significantly lower in EES compared with BES (2.1±4.7% vs. 7.9±10.8%, p=0.013). The percentage of malapposed strut was not different between EES and BES (0.1±0.3% vs. 0.5±1.3%, p=0.138). The frequency of stent with evagination, which is identified as outward bulges in the luminal contour between struts, was significantly lower in EES compared with BES (22% vs. 86%, p<0.001). The frequency of neoatherosclerosis was not different between EES and BES (11% vs. 11%, p=1.000)., Conclusions: At 2 years after stent implantation, uncovered stent strut by neointima and evagination were less frequently observed in EES compared with BES. This OCT study suggests that the very late vascular response is different between EES and BES., (Copyright © 2017 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Background: The association between patients with acute myocardial infarction (AMI) who present during off-hours and clinical outcomes has not been fully elucidated., Methods: We investigated 3283 consecutive patients with AMI who were selected from a prospective, nationwide, multicenter registry (J-MINUET) database comprising 28 institutions in Japan between July 2012 and March 2014 to determine the current impact of off-hours presentation on in-hospital mortality among Japanese patients with AMI., Results: Among the patients, 52% presented in off-hours. Baseline characteristics were comparable, although those who presented during off-hours were younger and had a higher incidence of ST-elevation myocardial infarction and advanced Killip Class. The time from symptom onset to presentation time was shorter in off-hour patients (120min, interquartile range 60 to 256 vs. 215min, interquartile range 90 to 610, p<0.0001). In contrast, 85% of patients underwent primary percutaneous coronary intervention (PCI) and door to balloon time was comparable between the groups (74min, interquartile range 52 to 113 vs. 75min, interquartile range 52 to 126, p=0.34). The rates of in-hospital mortality were comparable (6.2% vs 6.8%, p=0.39). Multivariate logistic regression analysis revealed that off-hours presentation was not significantly associated with in-hospital mortality [odds ratio (OR) 0.94; 95% CI, 0.68-1.30, p=0.70]., Conclusion: The clinical impact of presenting during off-hours or regular hours on AMI patients in Japan is comparable in contemporary practice., Trial Registration: UMIN Unique trial Number: UMIN000010037., (Copyright © 2017 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Background: The autonomic nervous system involves the genesis of premature ventricular contractions (PVCs). Previous studies demonstrated that heart rate (HR) dependency of idiopathic PVCs has different autonomic mechanisms. Recently, the bisoprolol patch, a novel transdermal β1-blocker formulation containing bisoprolol, became clinically available. We examined the efficacy of the bisoprolol patch for treating frequent PVCs in patients without structural heart disease (SHD) regarding the HR dependency of PVCs., Methods: This prospective study included 44 consecutive patients without SHD (25 men, mean age, 63.6±12.3 years) with PVC counts≥3000 beats as measured by 24-hour Holter electrocardiograms (ECGs). PVCs were divided into positive HR-dependent PVCs (P-PVCs) and non-positive HR-dependent PVCs (NP-PVCs) based on the relationship between the hourly PVC density and hourly mean HR. A bisoprolol patch was administered once daily at a dose of 4mg. The 24-hour Holter ECGs were performed before and 1 month after the initiation of the therapy., Results: In 44 patients, there were 24 P-PVCs and 20 NP-PVCs. The bisoprolol patch reduced the PVC count significantly (from 16,563±10,056 to 7892±8817 beats/24hours, p<0.001) in the P-PVC group, while the PVC count did not change significantly (from 16,409±9571 to 13,476±12,191beats/24hours, p=0.34) in the NP-PVC group. Moreover, in the P-PVC group, the patients with mean HRs ≥80 beats/minute had a significantly higher percent improvement in the PVC count than those with mean HRs <80 beats/minute (p=0.0080). The bisoprolol patch resulted in a significant reduction in the PVC count from baseline during each time period for the changes within a 24-hour period in the P-PVC group., Conclusions: The transdermal bisoprolol patch was effective for a PVC reduction in patients with P-PVCs, particularly in those with faster mean HRs. Furthermore, it demonstrated a stable PVC-reducing effect during the 24-hour period in the P-PVC group., (Copyright © 2017 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Background: Previous animal studies have shown that a potassium channel opener, nicorandil, provokes vasodilation in renal microvasculature and increases renal blood flow. We conducted a clinical study that aimed to evaluate the effect of nicorandil on renal artery blood flow in comparison with nitroglycerin by using color Doppler ultrasound., Methods: The present study enrolled 40 patients with stable coronary artery disease who had no renal arterial stenosis and renal parenchymal disease. The patients received intravenous administration of nicorandil (n=20) or nitroglycerin (n=20). Before and after the administration, renal artery blood flow velocity was measured by color-guided pulsed-wave Doppler., Results: The peak-systolic, end-diastolic, and mean renal artery blood flow velocities before the administration were not different between the nicorandil group and the nitroglycerin group. The peak-systolic (79±15cm/s to 99±21cm/s, p<0.001; and 78±19cm/s to 85±19cm/s, p=0.004), end-diastolic (22±5cm/s to 28±8cm/s, p<0.001; and 24±6cm/s to 26±6cm/s, p=0.005) and mean (41±6cm/s to 49±9cm/s, p<0.001; and 43±9cm/s to 45±9cm/s, p=0.009) renal artery flow velocities increased significantly in either group. The nominal changes in the peak-systolic (20±10cm/s vs. 7±8cm/s, p<0.001), end-diastolic (5±4cm/s vs. 2±3cm/s, p=0.001), and mean (8±5cm/s vs. 2±2cm/s, p<0.001) renal artery blood flow velocities were significantly greater in the nicorandil group compared with the nitroglycerin group., Conclusion: Intravenous nicorandil increased renal artery blood flow velocity in comparison with nitroglycerin. Nicorandil has a significant effect on renal hemodynamics., (Copyright © 2016 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Background: The outcome of percutaneous coronary intervention (PCI) has been reported to be poor in hemodialysis (HD) patients even in the drug-eluting stent era. We have reported relatively poor outcomes after sirolimus-eluting stent implantation in the OUCH study., Methods: The OUCH-TL study is a prospective, non-randomized, single-arm registry designed to assess the results of paclitaxel-eluting stent (PES) in HD patients with follow-up quantitative coronary angiography analysis. The primary endpoint was the occurrence of target-vessel failure (TVF) defined as cardiac death, myocardial infarction (MI), and target-vessel revascularization (TVR) at 12 months., Results: A total of 119 patients with 154 lesions were enrolled (one withdrawal). Mean age was 65±10 years, male gender was 79%, 89% of cases had stable coronary disease. Diabetic nephropathy was diagnosed in 61% of the patients. American College of Cardiology/American Heart Association type B2/C accounted for 96% of lesions and 22.7% of lesions were treated with Rotablator (Boston Scientific Corporation, Natick, MA, USA). Rates of TVF, death, MI, stent thrombosis and TVR at 12 months were 20.2%, 5.9%, 5.0%, 1.4%, and 12.6%, respectively. TVR was performed in 8.4% of the patients up to 12 months. Late loss in-stent was 0.48±0.61mm, and late loss in-segment was 0.37±0.61mm at 9 months. Binary restenosis in-stent was 10.3% and in-segment was 14.5%., Conclusions: Outcomes of PES implantation in hemodialysis patients appears comparable to those of non-hemodialysis patients., (Copyright © 2015 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Background: The endothelial progenitor cell (EPC) plays an important role in repairing vascular injury. Statins and angiotensin II receptor blockers increase the level of circulating EPCs. However, it is unknown whether the angiotensin II receptor blocker olmesartan synergistically acts with statins to increase the levels of circulating EPCs. Moreover, the association between the levels of circulating EPCs and endothelial dysfunction after implantation of drug-eluting stents (DESs) has not been evaluated., Methods: Nine patients with stable coronary artery disease underwent percutaneous coronary intervention (PCI) and received DES implantation. All patients received olmesartan in addition to statin therapy after PCI. The dose of olmesartan was based on the physician's discretion as per the patients' blood pressure. The levels of circulating EPCs were analyzed at baseline, post-PCI, and 1, 2, 3, and 8 months after PCI. Coronary angiography and the acetylcholine provocation test were performed on all patients at 8 months., Results: Although the angiotensin II level significantly changed, the levels of circulating EPCs did not change during 8 months of olmesartan treatment (3.1±0.6cells/ml, 2.5±0.8cells/ml, 2.0±0.6cells/ml, 2.9±0.9cells/ml, 3.0±0.4cells/ml, 3.4±0.8cells/ml, p=0.64). The patients were subsequently divided into two groups based on whether the level of circulating EPCs was less or greater than 4cells/ml at 8 months. There were no significant differences in the mean vessel diameter of each segment (proximal, proximal edge, distal edge, and distal) after the acetylcholine provocation test between the two groups., Conclusions: Low-to-moderate doses of olmesartan might not increase the level of circulating EPCs in patients receiving statin therapy. There might be no association between the levels of circulating EPCs and the degree of coronary vasospasm in the acetylcholine provocation test 8 months after DES implantation., (Copyright © 2014 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Background: Endothelial dysfunction of the coronary arteries caused by oxidative stress plays an important role in the pathogenesis of coronary vasospasm. However, it is not clear whether circulating biomarkers for oxidative stress are altered after coronary vasospasm. We investigated temporal changes in the levels of oxidative stress biomarkers after coronary vasospasm induced by intracoronary acetylcholine provocation testing, resulting in transient myocardial ischemia., Methods and Results: Thirty consecutive patients with suspected vasospastic angina pectoris (VSAP) were enrolled in the study. Patients were categorized into the VSAP-positive group (n=14) and the VSAP-negative group (n=16) on the basis of test results. Serum samples were examined for the levels of the oxidative stress markers 4-hydroxynonenal (HNE) and nitrotyrosine (NT) before, and 15min, 3h, and 12h after the provocation test. The serum HNE levels did not change in either group after the test. The serum NT levels in the VSAP-positive group significantly increased at 3h and 12h after the test (11.3±3.3μg/ml at 3h, p=0.015, and 12.1±5.7μg/ml at 12h, p=0.03), as compared with baseline (8.1±3.2μg/ml). In the VSAP-negative group, the serum NT levels significantly decreased from baseline at each of the 3 time points., Conclusions: Serum NT significantly increased after coronary vasospasm induced by acetylcholine provocation, suggesting that serum NT could be a biomarker of transient myocardial ischemia and could contribute to the development of VSAP., (Copyright © 2014. Published by Elsevier Ltd.)

Background: Recent reports revealed the presence of acquired von Willebrand syndrome type 2A in patients with aortic valve stenosis (AS). von Willebrand factor (vWF) has been shown to play a vital role in platelet adhesion. Therefore, we measured the platelet retention rates, which reflect platelet adhesion, in patients with severe AS., Methods: In addition to echocardiography, routine blood screening tests were performed and the platelet retention rates were measured using collagen-coated bead columns in 21 patients with severe AS and in 21 control subjects., Results: Patients with severe AS showed the maximum aortic valve pressure gradients of 110.9±22.7 mmHg, and effective orifice areas of 0.59±0.20 cm2. The results of routine blood tests in patients with severe AS were comparable to those of control subjects; however, the platelet retention rates in the AS patients (7.3±5.0%) were significantly lower than those in control subjects (30.5±11.8%, p<0.001). A significant negative correlation was observed between maximum aortic valve pressure gradients and platelet retention rates (r = -0.81, p<0.001). In 8 patients with severe AS, the platelet retention rates increased from 5.8±3.6% to 16.0±2.4% after aortic valve replacement (p<0.001)., Conclusion: These findings suggest that impairment of platelet retention rate is seen in almost all patients with severe AS. Clinicians should be aware of the possibilities of vWF-mediated platelet dysfunction and bleeding tendency in patients with severe AS., (Copyright © 2013 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Background: Left atrial (LA) enlargement has been documented to occur in hypertension (HT), and has been an index for evaluating the diastolic function of the left ventricle. Enlargement of the LA is one of the vital factors that induce heart failure and atrial fibrillation (AF) in patients with HT., Methods and Subjects: 130 treated hypertensive patients were enrolled. All recruits participated in an echocardiogram, electrocardiogram, a routine blood examination including brain natriuretic peptide (BNP), and physical examinations., Results: Left ventricular mass (LVM) indexed to height(2.7) had a significant positive correlation with left atrial volume index (LAVI) (p<0.0001), as well as natural logarithm BNP (p<0.001). Blood pressure levels were not associated with LAVI, neither body mass index nor age. LAVI had a positive correlation with factors involving the left ventricle volume, LVM, and right ventricle systolic pressure (RVSP) (r=0.687, p<0.0001). The parameters of LV diastolic function were positively but weakly associated with LA size. In the subgroup of LAVI, the evidence of paroxysmal atrial fibrillation (PAF): LAVI<32 ml/m(2) had no PAF, whereas the incidence of PAF was 7.5%, 11.4%, and 15.2%, respectively in the LAVI>32 ml/m(2) group. Of anti-hypertension drugs, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers had a tendency to reduce LAVI; however, there was no statistical significance within the groups., Conclusions: Left ventricular volume and mass are independent factors affecting LAVI in treated HT. The incidence of PAF is associated with LA size. In patients with treated HT, LA size may be a useful surrogate marker for monitoring the effectiveness of medical therapy and occurrence of AF., (Copyright © 2012 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Objectives: The plasma brain natriuretic peptide concentrations (brain natriuretic peptide (BNP) levels) have a prognostic value of mortality and morbidity in patients with chronic heart failure and in a community-based population. However, the prognostic value of BNP levels in outpatients of general practice is not well known. This study investigated the relations of BNP levels to cardiovascular events and death in general practice., Methods: This study covered 3123 consecutive outpatients (mean age 59.3±15.3 years; 42% men). BNP levels were measured by immunoradiometric assay (Shionogi) in an occasional sample of each person., Results: During a median follow-up of 5.5 years, 271 patients underwent a cardiovascular event (heart failure 65, coronary heart disease events 63, arrhythmia 26, stroke 96, others 21), 92 died from cardiovascular disease and 227 died from all causes. The patients were stratified into two groups based on a cut-off level of BNP (100 pg/ml). A BNP level ≥100 pg/ml was associated with a hazard ratio (95% confidence interval) of 4.6 (3.5-6.1) for cardiovascular events compared with a BNP <100 pg/ml (p<0.0001), 7.0 (4.5-10.9) for cardiovascular mortality (p<0.0001), 3.2 (2.4-4.2) for all-cause mortality (p<0.0001), 18.8 (11.3-31.1) for heart failure (p<0.0001), 2.5 (1.5-3.9) for stroke (p=0.0002), 5.0 (2.4-11.2) for atrial fibrillation (p<0.0001); however, it was 0.6 (0.2-1.7) for coronary heart disease events (p=0.337). Furthermore, the result of investigation with stratification into six groups based on BNP cut-off levels (20, 40, 100, 200, 500 pg/ml) showed that cardiovascular events, cardiovascular mortality, all-cause mortality, heart failure, stroke, and atrial fibrillation increased stepwise as BNP levels increased (p<0.0001), except for coronary heart disease events (p=0.986)., Conclusions: In general practice, BNP levels predicted the risk of cardiovascular events other than coronary heart disease events and of death.

Objectives: Visual assessment of the ejection fraction (EF) is often used in clinical practice, but is subjective and requires training and experience. The auto EF method has been newly developed for automated detection of the left ventricular (LV) endocardial border throughout the cardiac cycle. The clinical feasibility was assessed of the auto EF method for measuring LV volumes and EF in patients. Manually traced EF measured by the biplane modified Simpson's rule was used as the reference standard., Methods: The study population consisted of 30 consecutive patients with normal sinus rhythm. All patients underwent two-dimensional echocardiography. The auto EF method incorporated pattern and shape recognition to automatically locate the LV, track the endocardium, and calculate EF from routine digital images. LV end-diastolic and end-systolic volumes and EF measured by the auto EF method were compared those by the manually traced method. LVEF by the Auto EF method was also compared with visual EF determined by nonattending physicians., Results: Auto EF was more reproducible than visual EF by the expert reader. LVEF by the auto EF method had excellent correlation and close limits of agreement with manually traced EF compared with visual EF(4-chamber view: y = 1.10 x - 4.28, r = 0.94, bias = 1.6%, 2-chamber view: y = 0.88 x + 7.25, r = 0.90, bias = 0.4%). LV volumes by the auto EF method underestimated those by manually traced EF (end-diastolic volume by 4-chamber view: y = 0.72 x + 8.92, r = 0.93, bias = - 16.7 ml, end-systolic volume by 4-chamber view: y = 0.82 x - 0.97, r = 0.98, bias = - 8.5 ml, end-diastolic volume by 2-chamber view: y = 0.73 x + 12.4, r = 0.82, bias = - 12.3 ml, end-systolic volume by 2-chamber view: y = 0.65 x + 6.94, r = 0.90, bias = - 6.8 ml)., Conclusions: The auto EF method is a clinically useful tool for the measurement of LV volumes and EF.

A 66-year-old male was referred to our hospital because of severe pitting edema in the lower extremities in April 2003. He had undergone a partial gastrectomy for gastric cancer 17 years before and radiotherapy for oropharyngeal cancer 1 year before. He had suffered from the edema for 4 years. Loop diuretics prescribed by his family doctor were effective for relieving the edema at first, but the edema was not resolved. He was hospitalized with evidence of hypothyroidism from blood analysis. Administration of levothyroxin partially relieved the edema, but loop diuretics were continued because the edema was not completely diminished. He was admitted to our hospital again in October 2003, because of unsteady gait and worsened edema. Neurological examination revealed the stocking-and-glove pattern of sensory disturbance and distal muscle weakness in the lower extremities. Plasma vitamin B1 (thiamine)concentration was low, and the diagnosis was beriberi. After vitamin B, supplementation was initiated, the patient's edema completely disappeared in a few days, and his gait disturbance gradually subsided. Diuretics lead to increased urinary vitamin B1 excretion, so we should be watchful for thiamine deficiency in patients treated with diuretics who underwent gastrectomy and potentially have latent vitamin B1 deficiency.

The surgical treatment for ischemic mitral regurgitation remains controversal. Ring annuloplasty results in recurrent mitral regurgitation in some cases. Strut chordal cutting is a new surgical procedure in addition to ring annuloplasty for ischemic mitral regurgitation. Two patients (63-year-old woman, 53-year-old man) with severe ischemic mitral regurgitation were treated with this procedure. The patients had congestive heart failure due to mitral regurgitation, associated with inferior myocardial infarction. Regurgitant fraction of mitral regurgitation was 70% and 52% before surgery. Mitral leaflet tethering caused by apical displacement of the papillary muscle was observed. Mitral valve repair was performed by ring annuloplasty and chordal cutting. Intraoperative echocardiography showed that chordal cutting improved the configuration of the anterior leaflet, resulting in good mitral valve coaptation without regurgitation.

Objectives: Plasma brain natriuretic peptide (BNP) concentration is higher during atrial fibrillation (Af) than sinus rhythm, based on studies of electrical defibrillation treatment of patients with chronic Af. However, the change in paroxysmal atrial fibrillation (PAf) is not well known. This study investigated such changes and the relationship between BNP and Af., Methods: BNP levels were successfully measured at three time points: before Af attack, during Af attack, and after (spontaneous or pharmacological) termination of 68 consecutive Af attacks in 35 outpatients with PAf (23 men, 12 women, mean age 70.4 +/- 9.6 years). BNP was measured by immunoradiometric assay., Results: BNP (median[quartiles]) during PAf was increased by 66[25, 120] pg/ml (2.4-fold) compared to during sinus rhythm (p < 0.0001), and fell to the former level after return to sinus rhythm (before attack = 39[18, 70], during attack = 102[52, 205], after attack = 35[20, 67]). BNP increased in 55 (81%) of 68 attacks, did not change (within +/- 20 pg/ml) in 11 (16%), and decreased in 2 (3%). BNP was already elevated immediately (within 4 hr) after onset of Af, and BNP elevation (delta BNP) showed no significant relationship with the time elapsed after onset. During the Af attack, 41% of PAf patients were asymptomatic although BNP increased significantly., Conclusions: These results suggest that elevated amounts of BNP during Af are released from secretory granules in the atrium, and BNP elevation of unknown cause may be attributed to the presence of asymptomatic Af. Cardiac function evaluation using BNP during Af requires special consideration, unlike during sinus rhythm, even in patients with PAf or chronic Af, because BNP during Af is the sum of the BNP values from the ventricle (reflecting left ventricular function) and the atrium (due to Af).

Objectives: This study evaluated the accuracy of the directional color power Doppler (DCPD) and continuous wave Doppler (CWD) methods incorporated in the new hand-carried SonoSite 180PLUS ultrasound device., Methods: The hand-held ultrasound system with 2.5 MHz transducer and SONOS 5500 was used as a standard ultrasound system with a 2 to 4 MHz wideband transducer. The experimental study used a Doppler wire phantom to evaluate the influence of target wire speed and angle of transducer on DCPD imaging. The clinical study included 48 consecutive patients. DCPD assessment of valvular regurgitation measured the distances of DCPD signals of mitral, aortic and tricuspid valve regurgitation using the apical four-chamber view for comparison with standard echocardiography. CWD assessment measured the peak velocities of the aortic flow and tricuspid valve regurgitant flow for comparison with standard echocardiography., Results: In the experimental study, DCPD signals were not influenced by target wire speed changes and transducer incident angles. In the clinical study, agreements for mitral, aortic and tricuspid regurgitation between the two methods were 89.6%, 81.8% and 78.7%, respectively. The distances of DCPD valve regurgitant signals by the hand-carried ultrasound device showed good correlation (mitral regurgitation: y = 0.84x + 0.55; r = 0.93, aortic regurgitation: y = 0.95x + 0.27; r = 0.94, tricuspid regurgitation: y = 0.86x + 0.61; r = 0.90) with those by standard echocardiography. Evaluation of CWD velocity measurements showed good agreement for the lower flow velocities (< 2.0 m/sec). However, underestimation occurred for the high flow velocities (> 2.0 m/sec) compared with those by standard echocardiography (aortic flow: y = 0.80x + 0.11; r = 0.95, tricuspid regurgitation: y = 1.00x - 0.23; r = 0.90)., Conclusions: The new hand-carried ultrasound device (SonoSite 180PLUS equipped with DCPD and CWD) is clinically useful for evaluating valvular regurgitations and flow velocities. Further studies are needed to determine the mechanism of the underestimation of high flow velocities by CWD.

Objectives: Hand-held ultrasound devices are becoming available for clinical examination, but the accuracy and precision of such devices are unclear. This study compared the accuracy of a hand-held echo device to a standard echo system., Methods: Twenty-two patients were examined with the OptiGo (Phillips Medial Systems) hand-held ultrasound system with a 2.5 MHz transducer and SONOS 5500 (Phillips Medial Systems) standard ultrasound system with a 2 to 4 MHz wideband transducer. Patients with cardiac arrhythmia and tachycardia were excluded. Image quality, chamber size (left ventricle, left atrium), global and regional left ventricular function, valve morphology and severity of valve regurgitation were assessed., Results: There was good agreement between the two imaging devices for image quality (77.3%), left ventricular ejection fraction (90.5%), regional wall motion score (> 90%), valve morphology (> 90%), severity of valve regurgitation (> 81.0%) and there was good correlation and agreement for left ventricular and left atrial size., Conclusions: Although the OptiGo has limitations, the hand-held examination appropriately estimates global and regional left ventricular function, valve morphology, valve regurgitation and chamber size.