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Background: Cardiopulmonary exercise testing (CPET) variables represent central and peripheral factors and combined factors in the pathology of patients with cardiac disease. The difference in end‐tidal oxygen partial pressure from resting to anaerobic threshold (ΔPETO2) may represent predominantly peripheral factors. This study aimed to verify the prognostic significance of ΔPETO2 for major adverse cardiac and cerebrovascular events (MACCE) in cardiac patients, including comparison with the minute ventilation–carbon dioxide production relationship (VE/VCO2 slope), and peak oxygen uptake (VO2). Methods: In total, 185 patients with cardiac disease who underwent CPET were consecutively enroled in this retrospective study. The primary endpoint was 3‐year MACCE. The ability of ΔPETO2, VE/VCO2 slope, and peak VO2 to predict MACCE was examined. Results: Optimal cut‐off values for predicting MACCE were 2.0 mmHg for ΔPETO2 (area under the curve [AUC]: 0.829), 29.8 for VE/VCO2 slope (AUC: 0.734), and 19.0 mL/min/kg for peak VO2 (AUC: 0.755). The AUC of ΔPETO2 was higher than those of VE/VCO2 slope and peak VO2. The MACCE‐free survival rate was significantly lower in the ΔPETO2 ≤ 2.0 group versus the ΔPETO2 > 2.0 group (44.4% vs. 91.2%, p < 0.001). ΔPETO2 ≤ 2.0 was an independent predictor of MACCE after adjustment for age and VE/VCO2 slope (hazard ratio [HR], 7.28; p < 0.001) and after adjustment for age and peak VO2 (HR, 6.52; p < 0.001). Conclusion: ΔPETO2 was a strong predictor of MACCE independent of and superior to VE/VCO2 slope and peak VO2 in patients with cardiac disease. [ABSTRACT FROM AUTHOR]

Aim: Worsening renal function (WRF) induced by acute myocardial infarction (AMI) is a strong predictor of cardiovascular events and mortality. Peak oxygen uptake may contribute to prognosis in AMI patients with WRF, however, the impact of WRF on peak oxygen uptake is unclear. Methods: Among 154 patients with AMI who underwent emergency percutaneous coronary intervention and participated in phase II cardiac rehabilitation, those who underwent cardiopulmonary exercise testing were consecutively enrolled. WRF was defined as a ≥20% decrease in estimated glomerular filtration rate (eGFR [ml/min/1.73 m2]) from admission to that at cardiopulmonary exercise testing. The association of WRF with peak oxygen uptake was evaluated by multivariate regression analysis. The non‐WRF group was divided into two subgroups according to eGFR <60/≥60 at cardiopulmonary exercise testing, and eGFR at cardiopulmonary exercise testing and peak oxygen uptake of all three groups were compared. Results: Ninety‐four patients were enrolled in the final analysis. Multiple linear regression analysis showed that WRF was associated with peak oxygen uptake (p =.003). Comparing the non‐WRF group with eGFR at cardiopulmonary exercise testing <60 and the WRF group, although eGFR at cardiopulmonary exercise testing was similar (p = 1.000), peak oxygen uptake in the WRF group was significantly lower (p =.026). Conclusion: WRF, not eGFR at cardiopulmonary exercise testing was significantly associated with peak oxygen uptake in patients with AMI. This result suggests that when considering the relationship between renal function and peak oxygen uptake, WRF must be taken into account. SUMMARY AT A GLANCE: This is a retrospective cohort study on 94 patients followed for up to 6 months in Japan showing that worsening of kidney function after acute myocardial infarction (MI) is associated with peak oxygen uptake on exercise test, and this association is independent of baseline kidney function. Thus a decline is kidney function post MI may have implications for worse outcomes than the absolute level of kidney function. [ABSTRACT FROM AUTHOR]

Summary: Context: The current Endocrine Society Guideline suggests that patients aged <35 years with marked primary aldosteronism (PA) and unilateral adrenal lesions on adrenal computed tomography (CT) scan may not need adrenal vein sampling (AVS) before proceeding to unilateral adrenalectomy. This suggestion is, however, based on the data from only one report in the literature. Objective: We sought to determine the accuracy of CT findings in young PA patients who had unilateral adrenal disease on CT with hypokalaemia and elevation of aldosterone. Design and patients: We retrospectively studied 358 PA patients (n = 30, aged <35 years; n = 39, aged 35‐40 years; n = 289, aged ≥40 years) with hypokalaemia and elevation of aldosterone and unilateral disease on CT who had successful AVS. Main outcome measure: Accuracy of CT findings is determined by AVS findings and/or surgical outcomes in patients aged <35 years. Results: Concordance of the diagnosis between CT and AVS was 90% (27/30) in patients aged <35 years, 79% (31/39) in patients aged 35‐40 years and 69% (198/289) in those aged ≥40 years (trend for P < .01). Surgical benefit was confirmed in three patients aged <35 years and in three patients aged 35‐40 years with the available surgical data who had discordance between CT and AVS findings. Collectively, the diagnostic accuracy of CT findings was 100% (30/30) if aged <35 years and 87% (34/39) if aged 35‐40 years. Conclusion: Primary aldosteronism patients aged <35 years with hypokalaemia and elevation of aldosterone and unilateral disease on adrenal CT could be spared AVS. [ABSTRACT FROM AUTHOR]

Objective Although corticotropin is a representative secretagogue of aldosterone, the utility of the cosyntropin stimulation test (C- ST) in diagnosing primary aldosteronism ( PA) has not been elucidated. Aim of the study was to evaluate the clinical utility of C- ST for confirmatory testing and subtype classification of PA. Design, Setting and Patients In this retrospective study, we identified patients with hypertension and positive case-detection results for PA who underwent C- ST and saline infusion testing ( SIT) between 2006 and 2013 at eight referral centres in Japan. PA and essential hypertension ( EH) were distinguished based on SIT results. PA subtype classification was determined by adrenal venous sampling ( AVS). Plasma aldosterone concentration ( PAC) was measured before and 30 and 60 min after intravenous cosyntropin administration. The ability of C- ST to distinguish PA from EH and to distinguish unilateral from bilateral disease was assessed by the area under the receiver operating characteristic curve. Results Of 205 patients with hypertension and positive case-detection results, 139 (68%) had PA based on SIT results. Eighteen patients in whom AVS was unsuccessful were excluded from analysis. The baseline PAC before C- ST was significantly higher ( P < 0·01) in patients with PA than in those with EH. However, the degree of difference in PAC between patients with PA and EH was not enhanced by the administration of cosyntropin. In addition, the administration of cosyntropin did not improve the distinction between bilateral and unilateral PA subtypes. Conclusions C- ST has no utility as a confirmatory and subtype testing of PA when the diagnosis of PA is based on the positive results in SIT. [ABSTRACT FROM AUTHOR]

Context In adrenal vein sampling (AVS) for patients with primary aldosteronism, the contralateral ratio of aldosterone/cortisol (A/C) between the nondominant adrenal vein and the inferior vena cava is one of the best criteria for determining lateralized aldosterone secretion. Despite successful cannulation in some patients, the A/C ratios in the adrenal veins are bilaterally lower than that in the inferior vena cava (bilateral aldosterone suppression; BAS). Objectives To investigate the prevalence of BAS in AVS and how to resolve this condition. Design and setting Retrospective study involving nine referral centres. Patients Four hundred and ninety-one patients who were confirmed as having primary aldosteronism and had an AVS between January 2006 and December 2013. Measurements The prevalence of BAS before and after ACTH stimulation was compared. In addition, we investigated other methods for overcoming BAS. Results In 304 patients with successful AVS before ACTH stimulation, BAS was observed in 29 (9·5%). BAS was resolved after ACTH stimulation in 22 patients. In 276 patients with successful AVS both before and after ACTH stimulation, the frequency of BAS was significantly reduced after ACTH (8·7% vs 2·5%, P < 0·01). In a few patients, BAS was also resolved by adding a sampling point at the common trunk of the left adrenal vein and by an alternative drainage vein from the adrenal tumour. Conclusions BAS sometimes occurs in AVS without ACTH stimulation. ACTH stimulation significantly reduces BAS with a single AVS procedure. [ABSTRACT FROM AUTHOR]

Context Although adrenal vein sampling (AVS) is the standard method for subtype diagnosis in primary aldosteronism (PA), protocol details including the sampling position in the adrenal vein are not standardized. Objective To establish the optimum sampling position in the left adrenal vein based on postoperative outcome in PA patients. Design and Setting Retrospective study in nine referral centres. Participants Of 496 consecutive PA patients who underwent AVS between 2006 and 2013, 217 with successful AVS under cosyntropin stimulation, and with concomitant data from two positions: proximal (common trunk) and distal (central vein) to the junction with the inferior phrenic vein, were included. Main outcome measures Discordant rate of subtype diagnosis between common trunk and central vein, and postoperative outcomes in patients with discordant results. Results Subtype diagnosis using common trunk and central vein was discordant in 10 (4.6%) of the 217 patients (κ = 0.87, P < 0.05). Of these 10 patients, eight with left unilateral subtype and two with bilateral subtype using common trunk data showed bilateral subtype and unilateral subtype, respectively, using central vein data. Five patients with left unilateral subtype and one with bilateral subtype by common trunk data underwent unilateral adrenalectomy. All six patients were cured of PA after adrenalectomy, resulting in false-negative rates of 17% (1/ 6) by common trunk data, and 83% (5/6) by central vein data. Conclusion In view of its better potential diagnostic accuracy, technical ease, lower cost and lower risk of vein rupture, blood sampling from the common trunk of the left adrenal vein may be preferable as the standard method of AVS in patients with PA, although additional studies in a larger number of cases are required. [ABSTRACT FROM AUTHOR]

Objectives Adrenal vein sampling ( AVS) is the standard criterion for the subtype diagnosis in primary aldosteronism ( PA). Although lateralized index ( LI) ≥4 after cosyntropin stimulation is the commonly recommended cut-off for unilateral aldosterone hypersecretion, many of the referral centres in the world use LI cut-off of <4 without sufficient evidence for its diagnostic accuracy. Aim The aim of the study was to establish the diagnostic significance of contralateral ( CL) aldosterone suppression for the subtype diagnosis in patients with LI <4 in AVS. Design and patients A retrospective multicentre study was conducted in Japan. Of 124 PA patients subjected to unilateral adrenalectomy after successful AVS with cosyntropin administration, 29 patients with LI < 4 were included in the study. The patients were divided into Group A with CL suppression ( n = 16) and Group B ( n = 13) without CL suppression. Three outcome indices were assessed after 6 months postoperatively: normalization/significant improvement of hypertension, normalization of the aldosterone to renin ratio ( ARR) and normalization of hypokalaemia. Results The normalization/significant improvement of hypertension was 81% in Group A and 54% in Group B ( P = 0·2). The normalization of ARR was 100% in Group A and 46% in Group B ( P = 0·004). Hypokalaemia was normalized in all patients of both groups. The overall cure rate of PA based on meeting all the three criteria was 81% in Group A and 31% in Group B ( P = 0·01). Conclusions In patients with PA, where the LI is <4 on AVS, CL suppression of aldosterone is an accurate predictor of a unilateral source of aldosterone excess. CL suppression data should be interpreted in conjunction with computed tomographic adrenal imaging findings to guide surgical management. [ABSTRACT FROM AUTHOR]