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

Abstract Renal denervation is a promising new non-pharmacological treatment for resistant hypertension. However, there is a lack of data from Asian patients. The REQUIRE trial investigated the blood pressure-lowering efficacy of renal denervation in treated patients with resistant hypertension from Japan and South Korea. Adults with resistant hypertension (seated office blood pressure ≥150/90 mmHg and 24-hour ambulatory systolic blood pressure ≥140 mmHg) with suitable renal artery anatomy were randomized to ultrasound renal denervation or a sham procedure. The primary endpoint was change from baseline in 24-hour ambulatory systolic blood pressure at 3 months. A total of 143 patients were included (72 renal denervation, 71 sham control). Reduction from baseline in 24-hour ambulatory systolic blood pressure at 3 months was not significantly different between the renal denervation (−6.6 mmHg) and sham control (−6.5 mmHg) groups (difference: −0.1, 95% confidence interval −5.5, 5.3; p = 0.971). Reductions from baseline in home and office systolic blood pressure (differences: –1.8 mmHg [p = 0.488] and −2.0 mmHg [p = 0.511], respectively), and medication load, did not differ significantly between the two groups. The procedure-/device-related major adverse events was not seen. This study did not show a significant difference in ambulatory blood pressure reductions between renal denervation and a sham procedure in treated patients with resistant hypertension. Although blood pressure reduction after renal denervation was similar to other sham-controlled studies, the sham group in this study showed much greater reduction. This unexpected blood pressure reduction in the sham control group highlights study design issues that will be addressed in a new trial. Clinical trial registration NCT02918305 (http://www.clinicaltrials.gov).

Takotsubo syndrome (TTS) is a transient cardiomyopathy that is often associated with cerebrovascular diseases. Earlier studies have supported the concept that the cardiovascular system is regulated by a central autonomic network (CAN) consisting of the insular cortex (IC), anterior cingulate gyrus and amygdala. We report the case of a 79‐year‐old female diagnosed with a mid‐ventricular variant of TTS concomitant with right IC ischaemic stroke. After 12 h of hospitalization, she experienced a sudden collapse. Rapid cardiopulmonary resuscitation resulted in a return of spontaneous circulation. Subsequent left ventriculography revealed akinesis in the mid‐portion of the left ventricle with vigorous contraction of the basal and apex segment. Two weeks after admission, cardiac ultrasound showed improved left ventricular contraction. Right IC ischaemia in this patient might have been associated with a dysregulation of the CAN and subsequent increased sympathetic nervous system activity that triggered TTS.

Although short and long sleep duration are both risk factors of cardiovascular disease (CVD), the recent meta‐analyses have been shown that long sleep duration was closely associated with CVD mortality. While the specific mechanism underlying the association between long sleep duration and CVD remains unclear, long sleep duration was shown to be associated with arterial stiffness and blood pressure variability (BPV) in many Asian populations. This review article will focus on the pathophysiology of long sleep duration, arterial stiffness, BPV and their effects on CVD. To set the stage for this review, we first summarize the current insights for the relationship between long sleep duration and CVD in relation to arterial stiffness and BPV.

Introduction: In patients with initial shockable rhythms had favor outcomes than those with non-shockable rhythms, and those of asystole had worst outcomes. Purpose: The purpose of the study is to investigate the predictors of favorable outcomes in specific in the asystole rhythms. Method: Patients who were resuscitated after out-of-hospital cardiac arrest and were underwent targeted temperature management were enrolled in this study. Patients were divided into 3 groups according to initial recorded rhythms after indexed cardiac arrest. Favorable outcomes were defined as cerebral performance category of 1 or 2 after 90 days of indexed cardiac arrest. The logistic regression analysis was performed to assesses independent predictor of favorable outcomes. Results: Among the 305 study patients, 57 (19%) patients had initially recorded asystole rhythms, 149 (49%) patients had shockable rhythms, and 99 (32%) patients had pulseless electrical activity (PEA). The patients of PEA were elder (median 62 y [interquartile range 49 y - 72 y], 65 [57 - 75], and 62 [49 - 74], P = 0.03 in the patients of shockable, PEA, and asystole), the rate of male was higher in the shockable (86%, 58%, and 72%, P < 0.001), the time interval from collapse to return of spontaneous circulation (ROSC) were longer in the asystole (28 min [17 - 48], 37 [24 - 53], and 46 [39 - 61], P < 0.001), and the lactate of hospital arrival were higher in the asystole (10.1 mmol/l [6.1 mmol/l - 13.6 mmol/l], 12.0 [8.6 - 15.4], and 13.3 [9.6 - 18.3], P = 0.002). The rate of acute coronary syndrome as the cause of arrest were similar between the groups (45%, 34%, and 28%, P = 0.06). The rate of favorable outcome was 53%, 21%, and 12% (P < 0.001), respectively. The time interval from collapse to ROSC were independently associated with favorable outcomes in the patients of all initial recorded rhythms. Conclusions: The cardiac arrest patients who were witnessed arrest or shorter interval from collapse to ROSC with initial recorded asystole rhythms had favor outcomes than those not. We could not find specific predictors in the patients with asystole.

Funding Acknowledgements Type of funding sources: None. Background Thrombus in left atrial appendage (LAA) is associated with cardiogenic ischemic stroke, and anticoagulation therapy is utilized to prevent thromboembolism. Purpose This study is to investigate the incidence of thrombus in left atrial appendage detected by transoesophageal echocardiography (TOE) under anticoagulation therapy with warfarin or direct oral anticoagulants (DOAC). Methods Between 2005 and 2016, the patients who underwent TOE under anticoagulation therapy due to atrial fibrillation more than one month were enrolled in this study. The patients were divided into 2 groups according to whether treated with warfarin or DOAC and baseline characteristics and incidence of LAA thrombus were assessed. Results Among the 313 study patients, 243 (78%) were treated with warfarin. The patients treated with warfarin were elder (median 73 y vs. 67 y [interquartile range 66 – 78 y vs. 58 – 72 y], P < 0.01), the body mass index was lower (23.2 vs. 24.0 [21.0 – 25.4 vs. 21.3 – 26.9], P = 0.03). The prevalence of male sex (64% vs. 71%, P = 0.26) were similar between the 2 groups. The previous history of hypertension (69% vs. 59%, P = 0.10), diabetes (24% vs. 19%, P = 0.32), vascular disease (30% vs. 26%, P = 0.52), and ischemic stroke were similar between the 2 groups (30% vs. 23%, P = 0.22). The prevalence of CHA2DS2-VASc score > 1 (84% vs. 59%, P < 0.01) and the d-dimer level (0.7 vs. 0.5 mcg/ml [0.5 – 1.8 vs. 0.5 – 0.5 mcg/ml], P < 0.01) were higher in the warfarin groups than those of the DOAC. The velocity of LAA was slower in the warfarin group than those of DOAC (35 vs. 55 cm/s [21 – 54 vs. 38 – 68 cm/s], P < 0.01). The incidence of detection of LAA thrombus was 19% in the warfarin group and 3% in the DOAC group (P < 0.01). In the warfarin group, the PT-INR were lower in the patients with LAA thrombus (1.38 vs. 1.66 [1.11 – 1.92 vs. 1.34 – 2.03], P = 0.03). Conclusions The higher risk of ischemic stroke and out of range PT-INR may be the cause of the higher incidence of LAA thrombus in the patients treated with warfarin than those with DOAC. Abstract Figure.

Introduction: Malnutrition, cognitive decline and heart failure (HF) frequently coexist in the elderly. A recent systematic review revealed that malnutrition was a possible contributing factor of cognitive impairment. Although several studies reported the association of malnutrition with poor HF prognosis, the underlying pathophysiology has been unclear. Hypothesis: We assessed the hypothesis that malnutritional status might be associated with cognitive dysfunction in the elderly with HF. In addition, we investigated whether left ventricular ejection fraction (LVEF) moderates that relationship or not. Methods: Nutritional status and cognitive function were evaluated using the geriatric nutritional risk index (GNRI), controlling nutritional status (CONUT) score and mini-mental state examination (MMSE) in 245 elderly inpatients in stable phase of HF (82.9±6.0 years old, male 49.4%). Echocardiography was performed at admission. HF with preserved EF (HFpEF) was defined according to LVEF more than 50% (n=129). Results: According to the quartile of MMSE score (< 19, ≥19 to 27≤, >27), significant associations of MMSE score were observed with GNRI (89.1 vs 95.4 vs 95.5, p=0.004) and CONUT score (3.50 vs 2.71 vs 2.61, p=0.039) among three groups. In the logistic regression analysis adjusted for the confounders including age, gender, LVEF, brain natriuretic peptide level, systolic blood pressure at admission, diuretics and antihypertensive medication use, GNRI (β=0.96, 95%CI:0.93 to 0.99, p=0.008) and CONUT score (β=1.18, 95%CI:1.01 to 1.37, p=0.03) each was significantly associated with cognitive dysfunction (defined as MMSE score Conclusions: In conclusion , lower GNRI and higher CONUT score were shown to be significant indicators of cognitive dysfunction in the elderly HF patients. These results highlight the importance of stratifying by nutritional status for a clinical intervention of cognitive dysfunction in the elderly patients without HFpEF.

Introduction: Idiopathic ventricular fibrillation (IVF) including Brugada syndrome (BS) is one of causes of cardiac arrest without prior overt cardiac dysfunction. Hypothesis: We assessed the hypothesis that patents of IVF had favor outcomes than those of non-IVF after cardiac arrest treated with targeted temperature management (TTM). Methods: Patients who were treated with TTM after cardiac arrest between 2000 and 2019 were enrolled in the study. Patients were divided into 2 groups according to whether the patients were diagnosed as IVF or not. The patients treated with TTM were routinely performed coronary angiography. Results: Among the study patients (N = 306), 35 (11%) patients were IVF and 7 were BS. The patients of the IVF group were significantly younger (median 53 y vs. 64 y) than those of the non-IVF group. The prevalence of initial rhythm was shockable (69% vs. 47%, P = 0.02) was significantly higher in the patients of the IVF group than those of the non-IVF group. Among the patients in the non-IVF group, 114 patients (42%) were diagnosed as acute coronary syndrome and 93 patients (35%) were treated with coronary revascularization. The prevalence of male sex (77% vs 74%, P = 0.70) and witnessed to arrest (80% vs. 81%, P = 0.87), and low-flow time (29 min vs. 38 min [20 - 43 min vs. 21 - 52 min, P = 0.15]) were similar between the 2 groups. The prevalence of performing extracorporeal resuscitation (9% s 43%, P < 0.001) were lower in the patients of the IVF group. The 8-y survival rate were shown in the figure. All of the BS patients were witnessed arrest and were discharged without severe neurological deficit. The IVF as the cause of arrest was independently associated with 8-y survival. Conclusions: The patients of IVF had favor outcomes than those of non-VF. One of causes may be the lower prevalence of requiring extracorporeal circulatory support due to less cardiac dysfunction. The patients of BS had the tendency toward higher survival rate than those of non-BS IVF patients.

Introduction: Mortality in patients with acute coronary syndrome (ACS) due to unprotected left main coronary artery (LMA) occlusion is high. Extracorporeal membrane oxygenation (ECMO) could rapidly provide circulatory support. Hypothesis: This study aimed to verify the hypotheses that the patient who required circulatory support with ECMO in acute phase of LMA-ACS had greater cardiac function deterioration and had higher mortality in the chronic phase than those who did not require ECMO. Methods: Patients with LMA-ACS who underwent percutaneous coronary revascularization between 2000 and 2020 were enrolled in this study. The patients were divided into two groups based on whether or not they received ECMO. Thirty-day (acute phase) and 30-day to 6-year (chronic phase) survival curves were constructed by Kaplan-Meier method. The cause of death in acute and chronic phase were examined. Results: Among the 85 study patients, 23 (27%) were in the ECMO-group. Median age was younger in the ECMO-group (65 y [57 - 72] vs. 73 y [69 - 83], p < 0.01), and male sex (67% vs. 63%) were similar in ECMO group and non-ECMO groups respectively. The prevalence of ST elevation myocardial infarction (STEMI), non-STEMI, unstable angina were 52%, 48%, and 0% vs. 15%, 42%, and 44% in the ECMO group and non-ECMO group, respectively. The 30-day mortality was significantly higher in ECMO group (61% vs. 15%, p < 0.01); however, the 30-day to 6-year mortality was similar between the two groups (41% vs. 33%, p = 0.59) (Figure). The cause of death in the acute phase were cardiac failure (79% and 67%) and those in chronic phase were cardiac failure (50% and 25%), malignancy (0% and 13%), and infection (50% and 36%). Conclusions: The mortality in chronic phase in LMA-ACS patients who survived up to 30 days were similar in ECMO group and non-ECMO group. Moreover the patients whose cardiac function deteriorated severely and required ECMO in acute phase had similar prognosis to those that did not require ECMO.

Introduction: While clinical predictors of plaque erosion (PE) in patients with acute coronary syndromes (ACS) were reported, PE was more frequently observed in the population with normal kidney function. On the other hand, earlier studies indicated that spotty calcification related to plaque rupture on the culprit site in ACS. However, the morphological features of coronary calcification on culprit site have not been investigated in relation to PE. Hypothesis: We assessed the hypothesis that the morphology of calcification on culprit site was associated with PE in ACS patients without chronic kidney disease (CKD). Methods: In the 166 ACS patients (66.9±10.7 years old, male 83 %), based on Optical Coherence Tomography/ Optical Frequency Domain Imaging, existence of PE on culprit site was investigated. In the morphological features of coronary calcification, the maximum thickness, maximum area, maximum angle, minimum depth from the lumen in axial sections, and the length in longitudinal image were determined. Results: There were the 73 patients with PE, 58 patients with calcification and 38 patients with CKD. A marginal significant difference in thickness (300 vs 190μm, p=0.07) and significant difference in angle (60 vs 23degree, p=0.001), area (0.89 vs 0.43mm 2 , p=0.001) and length (2.34 vs 1.12 mm, p=0.03) were observed between the patients with PE and the patients without PE. In the multiple regression analysis adjustment for age, gender, region location, maximum creatine phosphokinase, STEMI or not, diabetes mellitus, angiotensin receptor blockers use, statin use and systolic blood pressure on admission, angle (OR: 1.01, 95%CI: 1.002 to 1.013, p=0.005) and area (OR: 1.46, 95%CI: 1.02 to 2.1, p=0.04) each had significant associations with PE. Specifically, only in the patients without CKD, thickness (p=0.025), angle (p=0.003) and area (p=0.013) were significant indicators of PE. Conclusions: In conclusion, morphology of calcification on culprit site was a significant indicator of PE in the patients with ACS. Specifically, larger calcification might serve as a pathophysiology underlying in the phenotype of plaque vulnerability in ACS patients with normal kidney function.

Background Thrombus in left atrial appendage (LAA) is associated with cardiogenic ischemic stroke; however, little is known about prognosis of patients with LAA thrombus detected by transoesophageal echocardiography (TOE). Purpose This study is to investigate the prognosis of patients with LAA thrombus and their cause of death. Methods Between 2005 and 2016, the patients who were performed TOE in our hospital were enrolled in this retrospective observational study. Five-year stroke free and survival curves were constructed by Kaplan-Meir method and cause of death were assessed. Results Among the 1263 study patients, LAA thrombus was detected in 146 (12%) patients. The patients with LAA thrombus were elder (74 y [66–79 y] vs. 70 y [62–76 y], P Conclusions The patients who were detected thrombus in the LAA had higher incidence of ischemic stroke; however, the 5-y survival were similar. The ischemic stroke was not major cause of death in the patients with and without LAA thrombus. The higher rate of receiving anticoagulation therapy may be one of the causes of the discrepancy. Figure 1 Funding Acknowledgement Type of funding source: None

Background Regardless of patients’ baseline renal function, worsening renal function (WRF) during hospitalization is associated with poor outcomes. In individuals with acute heart failure (AHF), one predictor of WRF is an early drop in systolic blood pressure (SBP). Few studies have investigated WRF in elderly AHF patients or the influence of these patients’ heart rate (HR) at admission on the relationship between an early SBP drop SBP and the AHF. Methods We measured the SBP and HR of 245 elderly AHF inpatients (83 ± 6.0 years old, females 51%) at admission and another six times over the next 48 h. We defined ‘WRF’ as a serum creatinine increase ≥0.3 mg/dL by Day 5 post-admission. We calculated the ‘early SBP drop’ as the difference between the admission SBP value and the lowest value during the first 48 h of hospitalization. Results There were significant differences between the 36 patients with WRF and the 209 patients without WRF: early SBP drop (51 vs. 33 mmHg, p p p p Conclusions In these elderly AHF patients, exaggerated early SBP drop and lower HR at admission were significant independent predictors of WRF, and these factors were additively associated with WRF.

Background: Regardless of patients' baseline renal function, worsening renal function (WRF) during hospitalization is associated with poor outcomes. In individuals with acute heart failure (AHF), one predictor of WRF is an early drop in systolic blood pressure (SBP). Few studies have investigated WRF in elderly AHF patients or the influence of these patients' at-admission heart rate (HR) on the relationship between an early SBP drop SBP and the AHF. Methods: We measured the SBP and HR of 245 elderly AHF inpatients (82.9±6.0 years old, females 50.6%) at admission and another six times over the next 48 hr. We defined 'WRF' as a serum creatinine increase ≥0.3 mg/dL by Day 5 post-admission. We calculated the 'early SBP drop' as the difference between the admission SBP value and the lowest value during the first 48 hr of hospitalization. Results: There were significant differences between the 36 patients with WRF and the 209 patients without WRF: early SBP drop (51.3 vs. 32.5 mmHg, pConclusions: In these elderly AHF patients, exaggerated early SBP drop and lower at-admission HR were significant independent predictors of WRF, and these factors were additively associated with WRF.

Background Left atrial appendage (LAA) thrombus is one of causes of cardiogenic stroke and detection of LAA thrombus by transoesophageal echocardiography (TOE) strongly suggest cardiogenic stroke. It was reported that cardiogenic stroke patients had higher in-hospital mortality about 19%; however, little is known about LAA thrombus and mortality after indexed detection of LAA thrombus. We investigated LAA thrombus detection and their prognosis including ischemic stroke and survival. Methods The patients who were performed TOE between 2005 and 2016 in our hospital were enrolled in this study. Patients were divided into 2 groups based on thrombus detection in the LAA, and baseline characteristics and outcomes including prevalence of 5-y stroke-free and survival from the indexed TOE were compared. Results Among the 1260 study patients, the follow-up duration was median 971 d (interquartile range 345 d – 2017 d), and 67% of the patients were performing TOE for atrial fibrillation (AF), 20% for cerebral infarction, and 14% for valvular heart disease. Non-valvular AF was seen in 64% of the study patients and rheumatic AF was in 2%. The age (74 y [66 y – 79 y] vs 70 y [62 y – 76 y], p < 0.001), the prevalence of male sex (67% vs 69%, p = 0.63), and hemoglobin level (13.9 g/dl [12.5 – 15.1 g/dl] vs 13.8 g/dl [12.4 – 14.9 g/dl], p = 0.49) were similar between the patients with LAA thrombus and those without. The CHA2DS2-VASc score (p = 0.008), the prevalence of receiving anticoagulation before TOA (34% vs 24%, p = 0.01), those of after TOA (98% vs 66%, p < 0.001), serum creatinine (0.92 mg/dl [0.80 – 1.10 mg/dl] vs 0.85 mg/dl [0.71 – 1.00 mg/dl], p < 0.001), d-dimer level (1.7 mcg/ml [0.9 – 3.5 mcg/ml] vs 0.8 mcg/ml [0.5 – 2.2 mcg/ml], p < 0.001), and plasma brain natriuretic peptide (315 pg/ml [128 – 515 pg/ml] vs 126 pg/ml [47 – 284 pg/ml], p < 0.001) were higher in the patients with LAA thrombus than those without. The 5-y ischemic stroke-free rate was lower in the patients with LAA thrombus than those without (p < 0.001) (Figure, Panel A); however, the 5-y survival was similar between the 2 groups (p = 0.93) (Panel B). Conclusions The patients who were detected thrombus in the LAA had higher incidence of ischemic stroke, but the survival rate were similar. The higher rate of receiving anticoagulation therapy in the patients with LAA thrombus may be the cause of this discrepancy. Further studies are necessary to clarify this issue. Abstract P765 Figure

Introduction Paradoxical cerebral infarction is a mechanism of acute ischemic stroke; however, definitive images to diagnose paradoxical embolism are not often obtained. We report a case of paradoxical cerebral embolism complicated with cardiac arrest due to massive pulmonary embolism. Case report A 40-year-old man presented due to sudden-onset chest pain, and was admitted to our hospital. He was restless and had cold sweat; we could not measure blood pressure. Electrocardiography showed wide QRS complex with right bundle branch block, and T wave inversion in leads V1 and III. Transthoracic echocardiography showed diffuse severe left ventricular hypokinesis, with slightly better inferior wall motion compared to other segments. Few minutes after arriving, he experienced cardiac arrest; chest compression was initiated. He was transported to the catheter laboratory, and veno-arterial extracorporeal membrane oxygenation was initiated subsequently. To diagnose the cause of arrest, we performed coronary angiography, which revealed no occluded coronary artery. Pulmonary angiograms showed bilateral proximal pulmonary artery occlusion with massive thrombi (panel A). Surgical embolectomy was performed after cardiac team discussion. After ICU admission post-surgery, pericardial effusion was increased, and the blood drained continuously from the chest tube; a large amount of blood transfusion was required. Reopen chest haemostasis was utilised. After the second ICU admission, anisocoria was observed; subsequent computed tomography showed low density and midline shift in almost the entire left cerebral hemisphere (Panel B). Carotid duplex ultrasound revealed a large thrombus saddled at the left carotid artery bifurcation (Panel C and D). We rechecked the transthoracic echocardiogram at arrival to reveal the cause of the cerebral infarction, which showed the thrombus to be at the ascending aorta (Panel E). We thought that the thrombi had moved from the lower limb to the right atrium. The massive pulmonary embolism increased the pulmonary artery and right atrial pressure, resulting in the lower pressure of the left atrium compared to that of the right atrium. The thrombi passed through the patent foramen ovale into the left atrium, moved into the left ventricle, and embolised the left internal carotid artery (Panel F). He expired due to severe neurologic injury from brain herniation. Conclusion In this case, although the pulmonary embolism was massive and led to cardiac arrest, the deteriorated haemodynamics improved by extracorporeal cardiopulmonary resuscitation and surgical embolectomy. However, we could not rescue the patient because of the severe neurological injury due to paradoxical embolism. Paradoxical cerebral infarction in pulmonary embolism is rare; however, we should pay careful attention to early detection of paradoxical cerebral infarction in pulmonary embolism and treatment for return of the patient to the former lifestyle. Abstract P684 figure

Background Renal dysfunction is a frequent finding in patients hospitalized for acute heart failure (AHF). Worsening renal function (WRF) during hospitalization was found to be related with a poor outcome independently of baseline renal function. Early drop in systolic blood pressure (SBP) has shown to predict WRF in AHF. However, there have been few studies that reported the impact of on-admission heart rate (HR) on the relationship between early SBP drop and WRF in the elderly AHF. Purpose We assessed the hypothesis that early SBP drop predict WRF in the elderly patients with AHF, and investigated that on-admission HR might have an interaction with that relationship. Methods SBP and HR were measured on admission and 6 times during 48 hours in the 245 elderly AHF inpatients (82.9±6.0 years old, male 49.4%). WRF was defined as a serum creatinine increase of ≥0.3 mg/dL by Day 5. Early drop in SBP was calculated as the difference between admission and the lowest value measured during the first 48 hour of hospitalization. Results Early SBP drop (51.3 vs 32.5mmHg, p Conclusions In the elderly AHF patients, exaggerated early SBP drop and lower on-admission HR were shown as significant independent predictors of WRF. These two factors were additively associated with WRF. Too much reduction in SBP and that in HR might be harmful to renal circulation in AHF.

Takotsubo syndrome (TTS) is a poorly recognized heart disease that was initially regarded as a benign condition. Recently, it has been shown that TTS may be associated with severe clinical complications including death and that its prevalence is probably underestimated. Since current guidelines on TTS are lacking, it appears timely and important to provide an expert consensus statement on TTS. The clinical expert consensus document part I summarizes the current state of knowledge on clinical presentation and characteristics of TTS and agrees on controversies surrounding TTS such as nomenclature, different TTS types, role of coronary artery disease, and etiology. This consensus also proposes new diagnostic criteria based on current knowledge to improve diagnostic accuracy. ispartof: EUROPEAN HEART JOURNAL vol:39 issue:22 pages:2032-2046 ispartof: location:England status: published

The cardiovascular system is regulated by a central autonomic network (CAN) consisting of the insular cortex, anterior cingulate gyrus, and amygdala. Because the insular cortex often tends to be damaged in patients with herpes simplex virus (HSV) encephalitis, the autonomic instability observed in these patients was suggested to be moderated by an insular cortex lesion. Here, we report the case of a 51-year-old Japanese male who was hospitalized following a collapse 5 days earlier; he was diagnosed as herpes encephalitis. Diffusion-weighted MRI revealed asymmetric right greater hyperintensity throughout his insular cortex and anterior cingulate gyrus. At 1 week after admission, transthoracic echo showed diffuse hypokinesis in the left ventricle (LV). Cardiac 123I-meta-iodobenzylguanidine uptake (123I-MIBG) scintigraphy revealed reduced uptake in the inferior and posterior wall. Electrocardiograhy at rest showed that the coefficient variation of RR intervals (CVR-R) was reduced, and the corrected QT (QTc) interval length was prolonged. In this HSV encephalitis patient, signs of a right insular cortex lesion and autonomic instability were observed: LV hypokinesis, regional reduced 123I-MIBG uptake, decreased CVR-R, and QTc interval prolongation. Our patient’s autonomic instability may thus be derived from disrupted autonomic balance due to the right insular cortex lesion.

Rho-associated kinases play an important role in a variety of cellular functions. Although Rho-associated kinase activity has been shown to be an independent predictor for future cardiovascular events in a general population, there is no information on Rho-associated kinase activity in patients with acute coronary syndrome. We evaluated leukocyte Rho-associated kinase activity by Western blot analysis in 73 patients with acute coronary syndrome and 73 age- and gender-matched control subjects. Rho-associated kinase activity within 2 hours of acute coronary syndrome onset was higher in patients with acute coronary syndrome than in the control subjects (0.95±0.55 versus 0.69±0.31; P P =0.03 and P =0.03, respectively) and then gradually decreased to 0.83±0.52 after 7 days, 0.78±0.42 after 14 days, and 0.72±0.30 after 6 months ( P =0.22, P =0.29, and P =0.12, respectively). During a median follow-up period of 50.8 months, 31 first major cardiovascular events (death from cardiovascular causes, myocardial infarction, ischemic stroke, and coronary revascularization) occurred. After adjustment for age, sex, cardiovascular risk factors, and concomitant treatment with statins, increased Rho-associated kinase activity was associated with increasing risk of first major cardiovascular events (hazard ratio, 4.56; 95% confidence interval, 1.98–11.34; P

Left atrial appendage (LAA) thrombus is one of causes of cardiogenic stroke and detection of LAA thrombus by transesophageal echocardiography (TEE) strongly suggest cardiogenic stroke; however, little is known about detection of LAA thrombus and long-term prognosis. We investigated LAA thrombus

The Takotsubo cardiomyopathy is often considered autochthonous to the heart, although the primary problem may be not in the heart muscle itself. Instead, similar to several Takotsubo‐like cardiac pathologies seen in acute neurological diseases, it may reflect the capacity of the nervous system to injure the heart. Persuasive evidence exists that shocking emotional stress promotes direct heart injuries. Moreover, clinical and laboratory research shows that cardiac structural damage can occur in the presence of a normal heart, especially in the context of seizures, stroke, and traumatic brain injury or under conditions of psychological stress. The aim of this review is to summarize the clinical implications of these observations, several of which focus on the pivotal role of the insula of Reil in the brain‐heart connection, to unravel the mystery of Takotsubo cardiomyopathy pathogenesis.

The clinical expert consensus statement on takotsubo syndrome (TTS) part II focuses on the diagnostic workup, outcome, and management. The recommendations are based on interpretation of the limited clinical trial data currently available and experience of international TTS experts. It summarizes the diagnostic approach, which may facilitate correct and timely diagnosis. Furthermore, the document covers areas where controversies still exist in risk stratification and management of TTS. Based on available data the document provides recommendations on optimal care of such patients for practising physicians. ispartof: EUROPEAN HEART JOURNAL vol:39 issue:22 pages:2047-2062 ispartof: location:England status: published

Background Coronary computed tomography angiography (CCTA) not only provides information regarding luminal stenoses but also allows for visualization of mural atheromatous changes (coronary plaques). Objective We sought to elucidate whether plaques seen on CCTA enable prediction of 2-year outcomes in patients with suspected and known coronary artery disease (CAD). Methods Of 3015 patients who underwent CCTA, the images and 2-year clinical courses of 2802 patients were independently analyzed. The primary endpoint was the composite of all-cause death and acute coronary syndrome. Results During the 2-year observation period, 49 (1.7%) patients developed the primary outcome. The 2-year rates of the primary outcome in the normal (n = 515, no mural lesions), calcium (n = 654, calcified lesion alone), and plaque groups (n = 1633, presence of noncalcified or partially calcified plaques) were 0.2%, 2.0%, and 2.1%, respectively (P = 0.0028). Adverse plaque features such as low attenuation, positive remodeling, spotty calcification, and the napkin-ring sign (low-attenuation core with a higher-attenuation rim) were assessed by an independent core laboratory. Stepwise multivariate Cox proportional hazard analysis showed that a plaque with two or more characteristics (adjusted hazard ratio, 1.98; 95% confidence interval, 1.09–3.60; P = 0.0254), age of ≥67 years (mean), statin treatment after CCTA, and obstructive stenosis remained independent predictors of the primary outcome. Conclusions Plaque imaging in CCTA has predictive value for the 2-year outcome and is a useful identifier for high-risk patients among those with known and suspected CAD.