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Myocardial ischemia due to narrowing of the right coronary artery (RCA) may result in sinus arrhythmias, which usually present as transient sinus bradycardia with no hemodynamic instability. We report a rare case of sinus arrest with hemodynamic instability, which lasted for several months, and was caused by the occlusion of the sinus node (SN) artery following the RCA stenting. A 78-year-old woman with diabetes mellitus, hypertension, and dyslipidemia was referred to our hospital because of chest pain during activity. In her coronary angiogram, severe diffuse stenosis of the RCA was observed and intracoronary imaging using intravascular ultrasound revealed diffuse atherosclerotic plaque lesions with partial calcification and vulnerability. RCA was treated by inserting three zotarolimus-eluting stents. Immediately after these interventions, the SN artery originating from the RCA proximal to the lesion was occluded, which resulted in SN dysfunction. Significant bradycardia was observed on electrocardiogram along with low blood pressure, suggesting sinus arrest. Along with hemodynamic instability, sinus arrest lasted for several months, and permanent pacemaker implantation was needed. The plaque burden should be taken into consideration when choosing the appropriate percutaneous coronary intervention strategy because of the potential complication of sinus arrest after RCA stenting. < Learning objective: Clinicians should be aware of the potential for sinus arrest after right coronary artery stent implantation. In cases with large plaque burden, it might be best to protect a side branch using a catheter or a small diameter balloon. Acute sinus node ischemia is a possible cause of sinus dysfunction after percutaneous coronary intervention. As such the strategy for this intervention should be chosen with care.> [ABSTRACT FROM AUTHOR]

An 89-year-old woman was admitted to our hospital for subacute onset of right upper and lower limb weakness and was diagnosed with acute cerebral infarction. During rehabilitation, close observation revealed that her oxygen saturation decreased in the sitting position and improved in the recumbent position without any subjective symptoms of dyspnea. Transthoracic and transesophageal echocardiography and cardiac catheterization revealed a large patent foramen ovale with an atrial septal aneurysm with right-to-left shunting through the defect, and she was diagnosed with platypnea-orthodeoxia syndrome. Her right hemiplegia caused the trunk to collapse, so the patient slumped when in sitting position, and the trunk tilted to the right forward, resulting in an increased right-to-left shunt. Her peripheral capillary oxygen saturation improved in the upright sitting position supported by therapists. This case suggests that right hemiplegia may exacerbate the symptoms of platypnea-orthodeoxia syndrome. < Learning objective: Platypnea-orthodoxia syndrome (POS) is a rare disease and often not clearly diagnosed. Previous studies have reported POS due to patent foramen ovale (PFO) after the onset of subclinical cerebral infarction. To our knowledge, this is the first case to suggest that trunk collapse during sitting due to right hemiplegia exacerbated the hypoxemia caused by POS. Moreover, 20–30% of adults may have asymptomatic PFO. POS may be detected by examining changes in oxygen saturation in different postures.> [ABSTRACT FROM AUTHOR]

• Cancer-related cardiovascular disease is reported in the era of oncocardiology. • Dasatinib has improved survival but sometimes is accompanied by fluid retention. • Tolvaptan may be useful to manage dasatinib-induced fluid retention. Cancer treatment has been developing significantly and cancer-related cardiovascular disease treatments such as various anticancer agents and molecular target drugs have been reported often in the era of oncocardiology. Chronic myeloid leukemia (CML) is a hematopoietic stem cell malignancy. Dasatinib is a novel tyrosine-kinase inhibitor approved for CML with Philadelphia (Ph) chromosome and the most common adverse effects of dasatinib are peripheral edema and pleural effusion, which sometimes impose the interruption or reduction of dosage of dasatinib treatment, accompanied by diuretic and steroid use. The goal of CML treatment is maintaining hematological control in the long term by controlling these side effects. The aim of this study is to clarify the efficacy of tolvaptan in treating dasatinib-induced fluid retention. We retrospectively analyzed six CML patients who received tolvaptan for dasatinib-induced fluid retention. The mean age of patients was 60.5 ± 11.5 years old, and the mean dosage of dasatinib and tolvaptan were 58.3 ± 20.4 mg/day and 5.0 ± 1.9 mg/day, respectively. Tolvaptan was introduced 564.5 ± 369.9 days after dasatinib was introduced. Ejection fraction (EF) by echocardiography and brain natriuretic peptide (BNP) levels did not change. However, the diastolic function significantly changed [E/e′ of the septal side: from 20.3 ± 2.3 to 16.5 ± 4.2, of the lateral side: from 15.0 ± 2.1 to 12.5 ± 3.8 (p < 0.05, respectively)]. New York Heart Association functional class was improved from 3.3 ± 0.5 to 1.5 ± 1.2 (p < 0.01) and the grades of fluid retention were also improved. Three patients discontinued dasatinib, and two patients could restart the administration of dasatinib after controlling fluid retention. Five patients could control fluid retention and they could continue with dasatinib therapy without any complications. Tolvaptan may be useful in fluid control in patients with CML treated with dasatinib. [ABSTRACT FROM AUTHOR]

It is difficult to manage the symptoms of patients who are dying of end-stage heart failure (HF). Opioids are sometimes required to relieve their symptoms in addition to oxygen therapy and medical management. Oxycodone is a μ receptor agonist that is known to be a safer opioid than morphine in patients with chronic kidney disease (CKD) because its metabolites have weak pharmacological activity. We treated a 99-year-old woman who had end-stage HF (secondary to severe aortic stenosis) and CKD. It was also difficult to maintain an intravenous line because of severe edema. We administered oxycodone subcutaneously and successfully alleviated her severe symptoms without severe adverse effects of opioids until a few days before her death. We report this case and discuss the possibility of using subcutaneous oxycodone as a new palliative care strategy in patients with end-stage HF. < Learning objective: We report the management of chest symptoms of an elderly patient with end-stage heart failure (HF) due to severe aortic stenosis by subcutaneous infusion of oxycodone. This method has a possibility to alleviate chest symptoms of end-stage HF with less severe adverse effects until a few days before death than morphine, and may be useful to manage the symptoms even in patients with severe edema. Further investigation will be required to compare subcutaneous oxycodone with intravenous morphine.> [ABSTRACT FROM AUTHOR]

Background We attempted to evaluate whether the relationship between the QTc interval and mortality (including sudden cardiac death) is linear or J-shaped in the general Japanese population, who tend to be at greater risk of strokes than cardiac events. Methods We classified 10,804 subjects according to their Bazett QTc interval quartiles (determined by electrocardiography) at the baseline and followed them up for a mean period of 141.9 ± 28.3 months (127,712 person-years). Results In total, 878 subjects died during the study period, including 104 from cardiovascular events, 100 from stroke, and 46 from sudden cardiac death. In a Cox proportional hazards regression model adjusted for conventional cardiovascular risk factors, the risk of cardiovascular mortality increased progressively with the QTc interval quartile [Q2, hazard ratio (HR) = 0.94 (0.43–2.03); Q3, HR = 1.11 (0.53–2.34); Q4, HR = 2.21 (1.12–4.36); HR are vs. Q1]. A parallel analysis found that the risk of stroke mortality was marginally increased in the highest Bazett QTc interval quartile [HR = 1.93 (0.97–3.85)]. On the other hand, the risk of sudden cardiac death exhibited a J-shaped relationship with the Bazett QTc interval quartile [Q1, HR = 8.58 (1.07–69.05); Q3, HR = 7.17 (0.88–58.73); Q4, HR = 13.18 (1.72–101.03); HR are vs. Q2]. Conclusion In the general Japanese population, cardiovascular and stroke mortality increase progressively with the Bazett QTc interval quartile, while the risk of sudden cardiac death exhibits a J-shaped relationship with the latter variable. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: To clarify the implications of the home arterial stiffness index (HASI), we compared HASI with other arterial stiffness measures and investigated the association between HASI and hypertensive target organ damage (TOD). Methods: We assessed brachial–ankle pulse wave velocity (baPWV) and the carotid augmentation index (cAIx) as measures of arterial stiffness and wave reflection, and the left ventricular mass index (LVMI), carotid intima-media thickness (IMT) using ultrasonography, and the urinary albumin/creatinine ratio (UACR) as measures of TOD in 356 never-treated hypertensive subjects. Home blood pressure (BP) was taken in triplicate in the morning and evening, respectively, for 14 consecutive days with a memory-equipped device. HASI was defined as 1 minus the respective regression slope of diastolic on systolic BP. Results: HASI was significantly correlated with age (r =0.32, P <0.001), home pulse pressure (r =0.36, P <0.001), morning–evening difference in home systolic BP (r =−0.29, P <0.001), baPWV (r =0.18, P <0.001), cAIx (r =0.16, P =0.002), carotid IMT (r =0.26, P <0.001), and UACR (r =0.24, P <0.001), but not with LVMI (r =0.05, P =0.38). After adjustment for age and sex, the significant correlation between HASI and baPWV/cAIx was lost. In multivariate regression analyses, HASI and baPWV were significantly associated with carotid IMT (standardized β =0.21, P <0.001; β =0.14, P =0.014) and UACR (β =0.13, P =0.018; β =0.21, P <0.001), independently of age, sex, and home mean arterial pressure. On the other hand, cAIx was independently associated only with LVMI (β =0.24, P <0.001). Conclusion: These findings indicate that HASI adds nothing to the existing measures of arterial stiffness, but might be a BP component that can aid in the detection of carotid atherosclerosis and renal damage, similar to PWV. [Copyright &y& Elsevier]

Abstract: Objective: Morning blood pressure surge (MBPS) has been shown to be a risk factor for cardiovascular disease and is associated with vascular remodeling. This study investigated whether the cerebrovascular risk of MBPS is modified by low-grade inflammation. Methods: We evaluated ambulatory BP, high sensitivity C-reactive protein (hsCRP), and brain MRI at baseline in 514 Japanese hypertensive patients, and followed them for the incidence of stroke for an average of 41 months (range: 1–68 months, 1751 person-years). Results: MBPS was significantly correlated with the hsCRP level in patients with the highest quartile of MBPS, but not in the other quartiles. The odds ratio for silent cerebral infarcts (SCIs) was significantly higher only in patients in the highest quartile of MBPS with higher (above median) hsCRP [odds ratio 2.74, 95% confidence interval (CI) 1.42–5.30] in comparison with those in other quartiles of MBPS and with lower (below median) hsCRP. Conversely, being in the highest quartile of MBPS and having a higher hsCRP were independently and additively associated with an increased risk for clinical stroke events (both the highest quartile of MBPS and the higher hsCRP; hazard ratio [HR] 5.77, 95%CI 2.11–15.81, only the highest quartile of MBPS; HR 3.03, 95%CI 0.89–10.33, only the higher hsCRP; HR 2.89, 95%CI 1.12–7.47), even after adjusting for confounding factors. Conclusion: Exaggerated MBPS and increased low-grade inflammation independently increase the risk of stroke, while the relationship between exaggerated MBPS and the presence of SCIs is slightly affected by low-grade inflammation. [Copyright &y& Elsevier]

Abstract: Recently, visit-to-visit variability in systolic blood pressure (SBP) has been shown to be a predictor of stroke. In this study, we investigated the relationship of visit-to-visit blood pressure (BP) variations (based on 12 visits once a month) with intima-media thickness (IMT) and stiffness in common carotid artery among the 201 high-risk elderly (female 75%) at cardiovascular disease. Max-IMT was significantly positively correlated with age, smoking, renin-angiotensin system inhibitor use, coefficient of variation (CV), and delta (maximum-minimum) in SBP, and CV in diastolic BP (DBP) but was significantly negatively correlated with female, high-density lipoprotein (HDL), and minimum in SBP. Stiffness parameter β was significantly positively correlated with age, standard deviation (SD), CV, maximum, and delta in SBP, and SD, CV, and delta in DBP but was significantly negatively correlated with smoking, HDL, average, and minimum in DBP. In a multiple regression analysis, delta SBP (P < .001) was associated with max-IMT independently of average SBP. CV (P < .05) and delta (P < .05) in SBP, and CV (P < .001) and delta (P < .01) in DBP were associated with stiffness parameter β independently of average BP. In the high-risk elderly, exaggerated visit-to-visit BP fluctuations were significant indicators for carotid artery atherosclerosis and stiffness independently of average BP. [Copyright &y& Elsevier]

Background: Cardiovascular prognostic significance of relative wall thickness (RWT) in patients with diabetes has not been reported although concentric hypertrophy is common in diabetic patients. Purpose: This study was conducted to test the hypothesis that the prognostic significance of different measures of left ventricular (LV) geometric change, principally LV mass index (LVMI) and RWT, would be different in diabetic patients compared with nondiabetic individuals among Japanese hypertensive subjects. Methods: Ambulatory blood pressure monitoring and echocardiography were performed in 400 uncomplicated hypertensive individuals at baseline, of whom 379 (157 with diabetes and 222 without diabetes; mean age 67.8 ± 8.8 years) were successfully followed up for 63 ± 26 months to document cardiovascular events. We dichotomized LVMI and RWT to the highest quartile vs other 3 quartiles for further categoric analyses in diabetic and nondiabetic patients. Results: Fifty-three cardiovascular events occurred during the follow-up period. With Kaplan-Meier analysis, both diabetic and nondiabetic patients with the highest quartile of LVMI showed a significantly higher incidence of cardiovascular vents. However, the highest quartile of RWT was associated with cardiovascular events only in diabetic subjects. With Cox regression analyses controlling for age, sex, body mass index, serum creatinine, triglycerides, and clinic systolic blood pressure, RWT (per 0.01 change), but not LVMI, was associated with cardiovascular events in diabetic patients (relative risk: 1.06, 95% confidence interval 1.02–1.11; P = .008), whereas LVMI (g/m2), but not RWT, was associated with cardiovascular events in nondiabetic patients (relative risk: 1.02, 95% confidence interval 1.01–1.03; P = .005). Conclusion: In hypertensive subjects with type 2 diabetes mellitus, echocardiographic LV RWT is a predictor of cardiovascular events independent of LV mass and other confounders. [Copyright &y& Elsevier]

Abstract: Objective: Excess aldosterone has a detrimental effect on large artery stiffness. We aimed to investigate the association of the change in plasma aldosterone concentration (PAC) by antihypertensive medication with the change in aortic pulse wave velocity (aPWV). Methods: We conducted a prospective, randomized, open-label, blinded end-point study in 207 hypertensive patients. Patients received olmesartan monotherapy for 12 weeks, followed by add-on use of hydrochlorothiazide (HCTZ; n =104) or azelnidipine (n =103) for 24 weeks after randomization. The aPWV, which was determined by measuring the carotid to femoral PWV, and laboratory data were assessed at baseline and 24 weeks later. Results: PAC in the HCTZ group increased more than that in the azelnidipine group, while aPWV and mean arterial pressure in the azelnidipine group decreased more than those in the HCTZ group. In univariable analyses, the change in PAC was significantly and positively correlated with the change in aPWV in the total population (r =0.26, P <0.001) and the HCTZ group (r =0.28, P =0.004), but not in the azelnidipine group (r =0.17, P =0.09). In multivariable analyses, a positive association of the change in PAC with the change in aPWV was observed in the total population (standardized regression coefficient β =0.18, P <0.001) and the HCTZ group (β =0.23, P =0.004), independently of the changes in covariates, but not in the azelnidipine group (β =0.13, P =0.06). Conclusion: The change in PAC was significantly and positively associated with the change in aPWV in patients treated with HCTZ. These findings may partly explain why thiazide diuretics have little effect on large artery stiffness. [Copyright &y& Elsevier]