Search

International audience; BACKGROUND: Scarce data are available regarding the electrocardiographic (ECG) and echocardiographic changes in athletes of Asian origin. DESIGN: We investigate the ECG and echocardiographic patterns in Japanese (J) compared with African-Caribbean (AC) and Caucasian (C) athletes. METHODS: A total of 282 professional soccer players (68 J, 96 AC and 118 C) matched for age, gender, sport and level of achievement was examined. RESULTS: ECGs were without alterations in 62% of J (versus 69% of C, p = non significant and 44% of AC, p < 0.001). The most common alterations in J were sinus bradycardia (69%), incomplete right bundle branch block (RBBB; 43%), early repolarization (18%), isolated increase in R/S-wave (10%), Q-waves (9%). Remarkably, no J athlete showed deeply T-wave inversion, in contrast to 6% of AC (p < 0.05). Occasionally, J showed J-point upward/domed ST-elevation with inverted/biphasic T-wave (6% versus 16.5% in AC, p < 0.01). J demonstrated larger left ventricular (LV) cavity compared with AC and C players (55.2 ± 3.3 versus 52.2 ± 3.8 and 53.9 ± 3.7 mm, respectively, p < 0.01), with an important subset ( > 4%) presenting a markedly enlarged cavity (>60 mm), in the presence of normal systolic/diastolic function and no segmental abnormalities. Therefore, J showed a more eccentric remodelling compared with AC and C (relative wall thickness: 0.31 ± 0.05, 0.38 ± 0.06 and 0.36 ± 0.06, respectively, p < 0.01). CONCLUSION: J players show the most eccentric LV remodelling compared with C and AC players. In association, certain training-related ECG patterns, i.e. sinus bradycardia and isolated increase in R/S-wave voltage, are present in a larger proportion of J players than previously described in C players. Conversely, no J athlete showed deeply T-wave inversion, as commonly found in AC and occasionally in C.

SummaryObjectiveIt is usually suggested that life expectancy of top athletes especially in endurance sports is longer than that of sedentary people. On the other hand, heart rate recovery (HRR) after exercise is an independent risk factor for cardiovascular disease and mortality, but differences in HRR between various top athletes are unclear. We examined HRR in various top athletes to clarify a role of HRR that may affect their life expectancy.MethodsHRR was defined as the difference between the heart rate at peak exercise and that at 2min after the finish of exercise using symptom-limited maximal graded bicycle ergometer exercise testing. The relationships between HRR with the grade of static and dynamic component of classification of sports, age, and body mass index (BMI) were estimated.SubjectsThe subjects were 720 male athletes participating in the National Sports Festival Japan in 2005–2008 and age-matched 28 sedentary controls.ResultsHRR was significantly correlated (p

Objectives The goal of our study was to define the structural characteristics of the heart in Japanese 100-km ultramarathon runners. Background During screening of participants in a 100-km ultramarathon, we found some participants who had larger cardiac chambers than had ever been previously reported. Methods A total of 291 male participants in a 100-km ultramarathon age from 20 to 73 years were examined using echocardiography. Results The mean heart rate (HR) was 50.6 ± 5.6 beats/min (38 to 79 beats/min), the systolic blood pressure (SBP) was 110.5 ± 5.6 mm Hg (94 to 138 mm Hg), the diastolic blood pressure (DBP) was 65.9 ± 6.6 mm Hg (58 to 90 mm Hg), the left ventricular end-diastolic diameter (Dd) was 61.8 ± 6.9 mm (42 to 75 mm), the left ventricular end-systolic diameter (Ds) was 39.6 ± 6.0 mm (23.0 to 55.0 mm), the interventricular septal thickness (IVS) was 10.2 ± 1.9 mm (5 to 19 mm), the posterior wall thickness (PW) was 10.0 ± 1.4 mm (5 to 15 mm), the aortic diameter (Ao) was 38.5 ± 4.0 mm (27 to 50 mm), the left atrial diameter (LA) was 40.2 ± 4.8 mm (26 to 49 mm), and the systolic wall stress (WS) was 221.5 ± 52.9 kdyne/cm2(108.0 to 537.6 kdyne/cm2). Significant predictors of these parameters were the monthly running distance for HR, SBP, DBP, Dd, Ds, Ao, LA, and WS, as well as the age for IVS, PW, and Ao. Conclusions Thirty-three participants had a Dd larger than 70 mm. Moreover, some athletes had a larger aorta and left atrium than had ever been previously reported. The oldest runner was 73 years old.

The relationship between the location and size of an infarction and QT dispersion was investigated in 84 Japanese patients with chronic myocardial infarction (54 with anteroseptal infarction and 30 with inferior infarction). The control group consisted of 23 subjects without ischemic heart disease (13 normal subjects and 10 hypertensive patients). Corrected QT dispersion (maximum corrected QT interval minus minimum corrected QT interval: QTc dispersion), was significantly larger in the anterior infarction group than in the control group (69.9+/-21.5 msec vs 53.0+/-17.6 msec), while the inferior infarction group showed no significant difference from control subjects. QTc dispersion was significantly greater in the patients with large anterior infarcts than in those with small anterior infarcts (80.5+/-20.5 msec vs 61.9+/-18.8 msec). In patients with chronic myocardial infarction, QT dispersion is influenced by the infarct location and size. Accordingly, interpretation of QT dispersion data should take these factors into consideration.

Objective -We assessed the reflection pressure wave using noninvasive measurement of wave intensity (WI) in patients with cardiomyopathy. Methods and results - Subjects included 8 patients with hypertrophic cardiomyopathy (HCM group) and 10 patients with dilated cardiomyopathy (DCM group).Twelve healthy subjects were used as a control group. By using a combined Doppler and echo-tracking system, changes in vascular diameter (dD) and blood flow velocity (dV) were recorded simultaneously at the common carotid artery and dD x dV was measured as WI. In the components of WI, the positive component of early systolic phase (FE) and the negative component following FE (B) were significantly reduced in the DCM group. There was a significant positive correlation between FE and B in all 3 groups. The appearance time of B was significantly shorter in the HCM group and significantly longer in the DCM group compared with the control group. Conclusions - It was suggested that the value of the reflection pressure wave was influenced by the left ventricular contractility, and that the effect of the reflection pressure wave appeared earlier in patients with HCM and later in patients with DCM compared with the control subjects.

OBJECTIVES We sought to determine the prevalence of right bundle branch block (RBBB) and ST segment elevation in the working Japanese population, as well as the event rate during a three-year prospective follow-up period. BACKGROUND A poor prognosis of RBBB and ST segment elevation has been reported in Europe and South America, even in asymptomatic patients; however, a large population of asymptomatic patients with sporadic RBBB and ST segment elevation has not been studied. METHODS Ten thousand 12-lead electrocardiograms (ECGs) were obtained during annual check-ups of working adults in the Tokyo area. This three-year prospective follow-up study consisted of 105 patients, including 20 with ventricular fibrillation, 18 with syncope and 67 who were asymptomatic. They were registered from 46 institutions in Japan. RESULTS The prevalence of ECG abnormalities in working adults was 0.16%. A coved-type ST segment elevation was related to a history of cardiac events, and 18% of registered patients had PR prolongation and 9.5% had left-axis deviation. The cumulative cardiac event-free rate was 67.6% in the symptomatic group and 93.4% in the asymptomatic group (p = 0.0004) after three years. CONCLUSIONS The recurrence rate of cardiac events in symptomatic patients was similar to that reported previously, but it was very low in sporadic asymptomatic patients. The ECG findings may help us to select patients for further examination and more accurate evaluation of their prognoses.

A 25-year-old man was found to have an abnormal cardiac contour on a chest radiograph, and was referred. Transesophageal echocardiography suggested herniation of the left atrial appendage (LAA) through a gap in the pericardium, and magnetic resonance imaging indicated congenital partial absence of the pericardium. Cardiac dysfunction was caused by compression from the enlarged left atrium and thrombi were thought to be present in the appendage, so surgery was performed. The intraoperative diagnosis was congenital LAA aneurysm. Although distinguishing between congenital LAA aneurysm and congenital absence of the pericardium is reported to be possible with magnetic resonance imaging, we were unable to so in this case. (Jpn Circ J 2001; 65: 56 - 59)

3チャネルディジタルホルター心電計を用い, Frank XYZ誘導から合成12誘導心電図 (Syn-ECG) を記録する方法を開発した, 本研究では, Syn-ECGがP波, QRS波, T波のみならず虚血性ST偏位も正確に再現することが可能であるかを検討した.対象は, ディジタルホルター心電計を装着時に標準12誘導心電図 (St-ECG) を記録した健常者15名および運動負荷試験を施行した連続72名中虚血性ST下降を認めた15名とした.健常者のSt-ECGとSyn-ECGのP波の形状, QRS波に対するR波およびT波振幅の比率, 運動負荷誘発虚血性ST下降の形状とQRS波に対するST偏位の比率を比較した.健常者臥位時のSyn-ECGは, St-ECGと近似した, さらに, Syn-ECGは運動時の虚血性ST偏位の比率においても近似した.Syn-ECGは, P波, QRS波, T波のみならず虚血性ST偏位に関しても形態的, 量的に近似した.本法は, 虚血性ST偏位の診断にも適応可能と考えられた.

A 61-year-old female, with a history of uterine and cervical cancer treated with radical hysterectomy and 2 years of postoperative chemotherapy, presented to the emergency department with dyspnea on exertion. Computed tomography of the chest revealed a large pericardial effusion and a sacciform aneurysm of the ascending aorta. The patient subsequently underwent emergency pericardiocentesis with drainage of approximately 330 ml of a bloody and turbid effusion. Cultures from the effusion yielded group B streptococcus. Multiple organ failure and disseminated intravascular coagulation syndrome occurred in the acute phase, but gradually improved with continuous antibiotic therapy. On the 194th hospital day, in situ reconstruction of the ascending aorta was successfully performed using a synthetic graft. Although rarely reported, both purulent bacterial pericarditis and mycotic aneurysm can be life-threatening.

The present study investigated the serial changes in serum magnesium (Mg) and erythrocyte concentration of Mg in patients with acute myocardial infarction (AMI) and the relationship between these changes and left ventricular ejection fraction (LVEF) at 1 month after the onset of infarction. The study group comprised 26 patients with AMI (mean age, 57.9+/-8.9 years). Serum Mg and erythrocyte Mg were measured on hospital days 1, 2, 4, 7 and 21. The change in erythrocyte Mg during the acute phase was calculated as a ratio: [(erythrocyte Mg at day 2)-(erythrocyte Mg at day 1)]/(erythrocyte Mg at day 1). The change in serum Mg was calculated similarly. The following results were obtained. (1) Serum Mg tended to increase from the onset of myocardial infarction (day 1: 1.86+/-0.19, day 2: 1.93+/-0.22, day 4: 2.17+/-0.23; day 7: 2.25+/-0.20; day 21: 2.12+/-0.15 mg/dl). (2) Erythrocyte Mg on day 2 and day 4 showed a significant decrease compared with day 1 (day 1: 2.45+/-0.40, day 2: 2.09+/-0.41, day 4: 2.07+/-0.37, day 7: 2.22+/-0.33, day 7: 2.34+/-0.28 mg/dl per 400x10(4)/mm3 cells). (3) A significant positive correlation was observed between the change in serum Mg and LVEF (r=0.55, p

We report a 70-year-old women with Eisenmenger's syndrome. Eisenmenger's syndrome with ventricular septal defect was diagnosed at another hospital when she was 32 years old. Then, she was referred to our hospital at age 60 old and she now is according to the out patient in over clinic. She have mild cardiac function, NYHA classification, was II-M, polycythemia cell blood count 535 x 10(4) and 17.2 g/dl in hemoglobin. Echocardiography suggested serious Eisenmenger's syndrome. The left ventricle was compressed, the blood pressure of the right ventricle exceeded 105 mmHg, and the onset of the right to left shunt flow was thought to be 250 msec bored on the electrocardiogram Q wave. The reason why the progression of complicated obstructive pulmonary artery disease was slow may have been become of the mildness of her polycythemia, and this is presumed to be the reason for her long survival to age 70.

OBJECT The purpose of this study was to elucidate differences in readmission rates and late outcome in outpatients with chronic heart failure treated in different clinical settings. PATIENTS AND METHODS This study included 65 consecutive patients who were admitted to our CCU due to acute heart failure for the first time and discharged from our institution. After their discharge, 31 were cared for by a cardiologist in the outpatient clinic of our institution (group A) and the other 34 were cared for by a general practitioner in a clinic (group B). The various findings during the acute phase and the follow-up period were retrospectively compared between the two groups. In addition, the incidence of unexpected readmission and prolonged outcomes were compared between the two groups. RESULTS The patients in group B were older than those in group A, but no other differences were noted in patient characteristics. More patients in group A required more than one hospitalization within 6 months from discharge (group A, 35.5%; group B, 8.9%, p

This study was undertaken in patients with heart failure to investigate the relation between plasma norepinephrine (NE) concentration and Mg dynamics. The study subjects comprised 16 patients with chronic heart failure (mean age 64.9±10.0 years). Cardiopulmonary exercise testing was performed on all patients, and anaerobic threshold (AT), peak oxygen uptake (peak VO2) and peak exercise time were measured. Resting and peak values of plasma NE concentration and serum and erythrocyte magnesium concentration were also measured. The results were as follows: the serum Mg concentration was increased significantly immediately after exercise (p

The purpose of this study was to evaluate cardiopulmonary responses during submaximal cycle exercise at various angles of backrest inclination. Ten healthy Japanese men of mean age 25.9 yrs, height 170.6 cm, and body mass 66.1 kg, performed cycle exercises at a constant workload which reached the anaerobic threshold, at 20 degrees, 40 degrees, and 60 degrees of backrest inclination from the vertical plane, but the angle between the seat and back rest was kept at 110 degrees. The results were as follows: 1) Both cardiac output and stroke volume showed a higher value at the resting control state and during exercise as the backrest angle increased. 2) Oxygen consumption, carbon dioxide output, heart rate, gas exchange ratio, and oxygen pulse were not affected by the angle of backrest inclination. 3) Tidal volume at 20 degrees of backrest inclination was higher than at 60 degrees. 4) No significant differences were found in minute ventilation between each backrest angle. These findings suggest that changes in the backrest angle significantly alter cardiopulmonary parameters at rest and during exercise; in particular, an angle difference of 40 degrees may be enough to alter tidal volume, cardiac output and stroke volume, but not the minute ventilation.

Recent observations have shown that plasma levels of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) correlate with cardiac function or prognosis in heart failure patients. However, relatively little is known about changes in their plasma concentration during commonly occurring physiological states such as fatigue. Therefore, this study was designed to examine the physiological changes of plasma ANP and BNP concentrations using a chronic sleep-deprivation model. Bicycle ergometer cardiopulmonary exercise tests were performed in 10 healthy volunteers (mean age: 22.7 years). Blood samples for measuring ANP and BNP were drawn during the resting state and immediately after each exercise test. Cardiac output (CO) was measured during the exercise test by the impedance method. The study conditions were designed as follows: (A) a day following a period of normal sleep (control state) and (B) a day preceded by 1 month during which sleep lasted

The basal part of the interventricular septum (IVS) is known to show different hypertrophic features from those observed in the other parts of the left ventricular wall. These are considered to reflect physiological changes that occur with normal aging. However, these changes have not been carefully evaluated, and their clinical significance has not been defined. We assessed these changes echocardiographically. The subjects were patients at least 70 years of age in whom localized hypertrophy in the basal part of the IVS was seen during the whole cardiac cycle on echocardiography. The prevalence was 6.3% among 96 consecutively studied patients. All 6 patients had a history of hypertension. Echocardiographic findings were as follows: 1) the left atrium was mildly or moderately dilated, 2) there was no evidence of either dilatation or narrowing of the left ventricular cavity, 3) the left ventricular wall motion appeared normal and indices of systolic function were within normal limits in all subjects except one who had a history of myocardial infarction, 4) the angle formed by the aorta and the IVS averaged 106.7 degrees (range: 95 to 120 degrees), 5) Doppler examination showed increases in the ratio of the peak flow velocity during atrial systole to the peak flow velocity early in diastole, and 6) prolongation of the deceleration time of the flow velocity early in diastole. The last of these findings suggested left ventricular diastolic dysfunction, but peak flow velocity at the left ventricular outflow tract was normal. There was no evidence of stenosis of the left ventricular outflow tract. Localized hypertrophy in the basal part of the IVS in elderly patients could be a type of cardiac hypertrophy caused by hypertension. On echocardiography, the basal part of the IVS seemed to protrude toward the left ventricular cavity, but there was no evidence of stenosis in the left ventricular outflow tract.

Brain natriuretic peptide (BNP) secretion increases after myocardial infarction (MI); its plasma level may reflect the degree of left ventricular dysfunction. This study examines how aerobic exercise therapy for MI influences BNP secretion. Subjects included 70 patients (mean age, 62.0±11.3 years) who were divided into four groups: (1) 20 patients with an anterior MI and exercise training; (2) 20 patients with an anterior MI and no exercise training; (3) 15 patients with an inferior MI and exercise training; and (4) 15 patients with an inferior MI and no exercise training. The training groups performed aerobic exercise 3 times a week for 2 months. Exercise intensity was defined as a heart rate of anaerobic threshold (AT), derived from the treadmill cardiopulmonary exercise testing at 1 month after the onset of MI. The subjects underwent cardiopulmonary exercise testing again at 3 months after the onset of MI. To measure BNP, blood samples were obtained in the resting state and immediately after the peak exercise. AT and peak oxygen uptake increased in the training group with anterior MI and in both the training and nontraining groups with inferior MI. Significant serial change in plasma BNP level was not observed in the inferior MI groups. Plasma BNP level decreased longitudinally only in the nontraining anterior MI group. It was concluded that exercise training in patients with an anterior MI could delay the recovery of left ventricular function, but will increase exercise tolerance. (Jpn Circ J 1998; 62: 658 - 664)

We have previously reported that chronic sleep deprivation causes a deficiency of intracellular magnesium (Mg) and decreased exercise tolerance. The aim of this study was to clarify whether oral administration of Mg could be effective in restoring the exercise tolerance that is decreased by chronic sleep deprivation. A bicycle ergometer cardiopulmonary exercise test was performed by 16 healthy volunteers (mean age 21.9 years). They were divided into 2 groups: 8 received doses of 100 mg of Mg orally per day for 1 month (Mg group) and the remaining 8 received no Mg and served as the control group. The study conditions were designed as follows: (1) the usual state (good sleep); and (2) the sleep-deprived state (sleeping time up to 60% less than the usual state for 1 month). The ratio of intracellular Mg content of the sleep-deprived state to the usual sleep state was significantly higher in the Mg group (p

Outcomes of primary angioplasty in 6 elderly patients with acute myocardial infarction who were admitted to the hospital between July of 1994 and June of 1997 were reviewed retrospectively. Emergency coronary angiography was done in 7 of 16 patients (44%) who were at least 85 years old and primary angioplasty was done in 6 patients (38%). Dilatation was successful in all 6 patients. Congestive heart failure occurred in 4 patients and cardiogenic shock occurred in 1 patient, but no patient died during hospitalization. Blood transfusion and surgical resection were done in 1 patient because of a giant hematoma and pseudoaneurysm at the puncture site. Although the creatinine level increased after angioplasty in all 6 patients, dialysis therapy was not needed. All patients were alive and none had angina at follow-up (mean follow-up period = 16.5 months). Primary angioplasty was successful in patients at least 85 years old; both short-term and long-term outcomes were good. Primary angioplasty should be considered to be an effective treatment for acute myocardial infarction in people 85 years old and older.

The long-term relative benefits of thrombolysis and mechanical reperfusion therapy following acute myocardial infarction (AMI) have not been established. The purpose of this study was to compare left ventricular function, left ventricular remodeling and late outcome after AMI for different reperfusion therapies. Thirty consecutive patients suffering their first anterior wall myocardial infarction with coronary stenoses limited to the left anterior descending coronary artery were studied. They included 10 patients who underwent intracoronary thrombolysis (ICT), 10 who underwent PTCA and 10 who underwent noninterventional medical treatment. All patients underwent coronary angiography (CAG) during the acute phase of AMI and also during the follow-up period, and left ventriculography during the follow-up period and clinical follow-up was performed (mean clinical follow-up period: 53 +/- 31 months). No significant difference in global ejection fraction was noted among the groups, although the end-diastolic volume index (EDVI) in the PTCA group (79.4 +/- 17.5 ml/m2) was significantly smaller than in the noninterventional (106.1 +/- 25.1 ml/m2) and ICT (107.9 +/- 28.3 ml/m2) group (p0.05). The regional wall motion index (RWMI) for the anterior region in the PTCA group (-2.7 +/- 0.8) was greater (p0.05) than in the noninterventional (-3.4 +/- 0.6) and ICT (-3.3 +/- 0.6) groups. A significant linear correlation was found between EDVI and % diameter stenosis and also between RWMI and % diameter stenosis following reperfusion (p = 0.01). There was no difference in the incidence of cardiac death, nonfatal reinfarction, bypass surgery or congestive heart failure among the groups. Disturbed left ventricular regional wall motion and remodeling benefit most from angioplasty because of prompt restoration of adequate blood flow. However, there was no difference in late outcomes following AMI among the three groups.

症例は62歳の男性. 輸血歴なく, 飲酒歴なし. 昭和61年, 肝障害で近医に入院歴あり. このときHBs抗原は陰性であった. 肝庇護療法のみで肝機能は改善し, 以後7年間自他覚症状なく経過していた. 通院観察中もトランスアミナーゼは正常値を持続した. 平成6年2月, GPT164IU/lと肝障害再燃を認め当科入院. HBs抗原陰性, HCV抗体 (第二世代) 陰性で, 抗核抗体は20, 480倍と高力価を, Ig-Gは3, 458mg/dlと高値を示した. 腹腔鏡下肝生検では肝表面は軽度不整を認め, 組織像では形質細胞浸潤を伴う慢性肝炎, 活動性の像を呈した. 上記より自己免疫性肝炎と診断し, プレドニゾロン投与にて肝機能は速やかに改善した. 本症は当初, 非B型肝障害と診断され, 無治療にも拘らず7年もの長期間, 無症候性に経過した後に再燃したと考えられた. 自己免疫性肝炎の発症様式を考える上で, また男性例であることから示唆に富むと思われ報告した.

To investigate the time sequence of glomerular cell proliferation in acute human glomerulonephritis, renal biopsy tissues were examined from 15 acute post-streptococcal glomerulonephritis (APSGN) patients (who were biopsied 1-31 days after onset), using an immunoperoxidase technique with monoclonal antibodies against proliferating cell nuclear antigen (PCNA) and various cell surface markers. Few, if any, PCNA+ cells were observed in normal glomeruli, but many cells were positive for PCNA in the acute phase of APSGN. Glomerular PCNA+ cells were observed either within glomerular tufts, or lining Bowman's capsule (parietal epithelial cells); the number of positive cells tended to decrease exponentially as the disease duration increased (r = -0.91, P < 0.0001). PCNA+ cells within glomerular tufts were further identified by double immunostaining. PCNA was not found in PMN or T cells, but a small proportion of macrophages were PCNA+. Most of the remaining PCNA+ cells were resident glomerular cells; the proportion of PCNA+ endothelial cells (CD31+) was over 80 per cent in the early phase, but as the disease continued the proportion of mesangial cells (alpha-smooth muscle actin+) increased to about half of the total PCNA+ cells within the tuft. These data indicate that the hypercellular glomeruli in APSGN are due not only to immune cell infiltration, but also to resident glomerular cell proliferation, probably induced by locally produced growth factors.

Impaired cardiac function after strenuous exercise, such as an ultramarathon or triathlon, has been ascribed to “cardiac fatigue.” However, a reduction of cardiac function in strenuous sports in the absence of coronary artery disease might also be based on myocardial injury because of excess catecholamines. We studied the cardiac injury in runners of a 100-km ultramarathon by determination of levels of serum troponin T, which is highly specific for myocardial injury. Blood was collected from 13 healthy adult men before, immediately after, and the next morning after participation in a 100-km ultramarathon. Creatine kinase (CK), isozyme of CK with muscle and brain subunits (MB), and cardiac troponin T levels were determined. Creatine kinase levels were 207 ± 108 IU/L before the marathon, 10,313 ± 10,273 IU/L immediately after, and 10,799 ± 6593 IU/L on the next day. Creatine kinase MB levels at the same time points were 12 ± 14 IU/L, 197 ± 170 IU/L, and 166 ± 108 IU/L, respectively. Cardiac troponin T level was ⩽0.1 ng/mL in all subjects before the marathon and increased significantly to a mean of 0.68 ± 0.73 ng/mL immediately after, exceeding the normal limit in seven subjects. It then returned to normal (0.15 ± 0.07 ng/mL) on the next day, while CK, which referred to skeletal muscle damage, was still elevated at a high level. Because cardiac troponin T levels increased after the ultramarathon, myocardial injury was considered to have occurred.

16歳の若年女性でtoxic epidermal necrolysis (TEN) 治療中に, 高度な急性肝内胆汁うっ滞を発症. 種々内科的治療に抵抗性にて, 難治性慢性肝内胆汁うっ滞へ移行し, 約3年の短期間に続発性胆汁性肝硬変症に進展し, 死亡した極めて稀な例を経験した. 本症例はSherlockらの提唱するthe disappearing intrahepatic bile ductsの範躊にはいるが, 臨床的にprimary biliary cirrhosis (PBC), Alagille病, Byler病などは否定的であった. アセトアミノフェンの服用歴とLST陽性やTEN様の皮疹, ステロイドの中止後胆汁うっ滞の悪化を認めたことより, 薬剤アレルギーが病態の背景にあり, 肝内胆管の潜在的なhypoplasiaやprimary screlosing cholangitis (PSC) の存在が病態の増悪因子となった可能性が示唆された, 残された治療選択は肝移植のみと考えられたが, 高度な胆汁うっ滞を主とした病態においては, 経過中にその適応および時期の適切な判断を下すことは難しく, 類似症例の参考となると考えられ報告した.

日本心電学会「運動負荷心電図の標準化に関する委員会」では, 同学会の抗狭心症薬判定小委員会のトレッドミル試験による薬効評価基準を実際の労作狭心症例180人 (平均年齢59.9±9.2歳) について検討した.投与薬剤は各種抗狭心症薬であり, Bruce法によるトレッドミル負荷試験をおこなった.この基準は同一運動時間のST下降度と運動耐容時間を個別に判定するものである.同一運動時間のST下降度の「やや改善」以上は60.9%, 運動耐容時間の「やや改善」以上は62.2%であった.運動負荷試験による薬効評価に適した症例は, 観察期に運動誘発胸痛があり, 2mm以上のST下降があり, 運動耐容時間が6分前後の症例と考えられた.同一運動時間のST下降度と運動耐容時間による総合判定は, 改善度が高くなる傾向にあった.

脳血栓症急性期において, エンドセリン-1 (ET-1) は経時的に低下し, 組織プラスミノーゲンアクチベーター (t-PA) は鏡像的に増加する.今回はそのメカニズムの解析を目的に基礎的, 臨床的検討を行った.培養血管内皮細胞へのオザグレルナトリウム添加で培養液中の両因子濃度は非添加対照と差が認められない.トロンビン添加で両因子とも対照より有意の高値を示した.このことから両因子の脳血栓症急性期の変化に治療薬剤や凝固の直接的関与は否定される.急性期1～7病日のET-1とt-PAの各変化量が逆相関を示した “逆相関群” では相関しない “非相関群” に比してt-PAのインヒビターPAI-1の遊離型 (free) PAI-1の相対的高値が認められた.t-PAはET-1放出を抑制する既報の成績からt-PA増加がET-1放出を主導的に抑制し, 急性期の血栓抵抗性をfree PAI-1高値例においては誘導しているものと考えられた.すなわち, 脳血栓症治療に際しては抗血小板・抗凝固だけではなく, このt-PA・PAI-1の線溶系を考慮すべきである.

全国107施設の運動負荷試験に関するアンケート調査により, 推定累積運動負荷試験1, 779, 352件 (マスター2階段試験951, 512件, エルゴメーター法215, 972件, トレッドミル法611, 868件) における事故について検討を行った.死亡事故6件, 入院を要する重篤事故37件であり, 検査10, 000件当たりの事故率は, 死亡0.034, 心筋梗塞発症0.129であった.死亡を含む重篤事故の基礎疾患が明らかであったのは31件であり, 内訳としては心筋梗塞13%, 不安定狭心症13%, 狭心症32%であり, 肥大型心筋症, 拡張型心筋症, 弁膜症などその他が42%であった.事故の内容 (総数40件) は, 心筋梗塞発症57.5%, 不安定狭心症12.5%, 持続性ST上昇10%, その他20%であった.事故の原因としては, 報告のあった33件の中で過度の虚血6%, 過度の負荷15%, 不安定狭心症に負荷を行った6%, その他15%であり, 原因不明が58%を占めた.過去に事故の経験の有無による運動中止基準の比較では, 運動中止心拍数および収縮期血圧が事故の経験ある施設において年齢別推定最大心拍数85%以上や収縮期血圧250mmHg以上の設定など中止基準の設定が高い傾向を認めたが, 運動中止STレベルには差を認めなかった.本邦における運動負荷試験に伴う事故の発生頻度は, 過去の諸外国の報告よりは少ない傾向であったが, 事故の原因として不安定狭心症に負荷を行った例や過剰負荷の例が認められ, 事故の防止のため負荷試験の適応と禁忌, 運動中止基準の遵守がより必要と考えられた.

A previously healthy 64-year-old woman attended our hospital with chest pain, facial edema, and general fatigue. A chest radiograph revealed cardiomegaly, small bilateral pleural effusions, and hilar congestion--findings that improved after early therapy with furosemide and methyldigoxin. A chest radiograph recorded 7 years earlier had revealed no dilation of cardiac shadow. There were no findings suggesting atrial septal defect (ASD) or valvular heart disease. Echocardiography revealed a tumor-like mass adhering to the posterior wall of the left atrium. Color-flow Doppler echocardiography revealed a left-to-right shunt at the atrial level. The Qp/Qs ratio as measured by cardiac catheterization was 2.0. Coronary angiography revealed abnormal dilated arteries from the atrioventricular nodal branch and several feeding arteries from the left circumflex branch. We hypothesized that the left-to-right shunt could be due to the tumor, which extended to the rim of the patent foramen ovale, or to the very small, previously unrecognized, ASD. This patient died 6 months after her first admission and an autopsy was performed. Light microscopic examination of the tumor revealed spindle-shaped fibroblast-like cells arranged in a storiform or fascicular pattern. The immunohistochemical findings were consistent with malignant fibrous histiocytoma (MFH). In the literature, left-to-right shunt at the atrial level has not been reported in patients with cardiac MFH.

A 91-year-old male patient was admitted to hospital with acute myocardial infarction complicating cardiogenic shock. An emergency coronary arteriogram showed 99% stenosis at the mid-section of the right coronary artery, and in order to achieve an early recovery direct percutaneous transluminal angioplasty (PTCA) was performed through the brachial artery using a 6 french catheter. The lesion was successfully dilated up to 25% residual stenosis. Hypointention had been sustained during the admission; however, it gradually improved and he was discharged on the 31st hospital day. He has been followed up for 6 months after discharge at the out-patient clinic and has not recurrent ischemic episodes. According to other reports on the use of direct PTCA in the elderly, the postdischarge mortality rate is lower than that with medical therapy or thrombolysis. When cardiogenic shock occurs even in the elderly, direct PTCA should be selected as the first choice of treatment.

目的: 1992年, Brugadaらは特発性心室細動群の中に心電図上, 右脚ブロックパターンにST上昇 (RB-ST) を伴う一群のあることを報告した.この心電図波形が, 心室細動を予知する情報になる可能性があるとして, 現在注目されている.しかし, この心電図所見の疫学的情報はなく, 本報告が世界で初めての報告である.対象: 健康診断の目的で心電図を記録した小, 中学生 (9, 569人) と成人 (4, 092人) , および当科受診者 (8, 366人) の計22, 027人を対象に疫学調査を行なった.結果: (1) RB-ST型心電図は, 小, 中学生の0.01% (1人) , 成人の0.07% (3人) , 受診者の0.09% (8人) , 全体の口.05% (12人) であった. (2) RB-ST型はいずれも男性で, 年齢は14～71歳と層が広く, 明らかな基礎心疾患はなかった. (3) 失神の既往は12人中4人 (33%) で内3例は心室細動 (Vf) を認め, 1例は原因不明であり, Vfと診断し得た例は全例40歳以下であった.総括: RB-ST型心電図はきわめてまれであるが, 広い年齢層に認められ, また, 男性に多く, Vfとの関連は比較的若年者に見られた.

The effect of body position on cardiopulmonary response was assessed by the following protocols: 1) Cardiopulmonary exercise testing with a bicycle ergometer (20 W/min) was performed on nine healthy men (mean age; 19.9 years) in a sitting and a supine position. Oxygen uptake, heart rate and blood pressure were measured during the test. Noradrenaline and Angiotensin II were analyzed at rest and after exercise. 2) Single-level exercise testing at 100 W was performed. The cardiac index was computed from the cardiac output, which was measured using the dye-dilution technique at rest and during exercise. The results were as follows: 1) Anaerobic threshold was lower in the supine than in the sitting. 2) Noradrenaline and Angiotensin II were slightly lower in the supine than in the sitting. 3) The cardiac index at rest was slightly greater in the supine, and that during 100 W exercise was the same in both positions. It is concluded that the blood flow to active muscle during 100 W exercise is lower in the supine than in the sitting. The etiology of lower anaerobic threshold in the supine is thought to be due to lowered blood flow to active muscle.

To predict exercise tolerance in the chronic phase of myocardial infarction (MI), cardiopulmonary exercise testing was performed using a ramp treadmill protocol in 25 patients at 1 and 3 months after the onset of MI. Oxygen uptake, heart rate and O2 pulse were estimated at rest, during a warm-up period, and at the levels of anaerobic threshold (AT), respiratory compensation (RC) and peak exercise. Results were as follows: 1) AT and peak oxygen uptake at 3 months after the onset of MI were 14.1 +/- 2.8 and 21.8 +/- 5.2 ml/min/Kg, respectively. 2) The subjects were divided into 2 groups according to peak oxygen uptake at 3 months: one showing peak oxygen uptake > 22 ml/min/Kg and the other < 22 ml/min/Kg. The former group (n = 13) was referred to as the good tolerance group, and the latter group (n = 12) was referred to as the poor tolerance group. Oxygen uptake at AT, RC and peak exercise was lower in the poor tolerance group than in the good tolerance group (11.2 vs 14.7, 15.1 vs 20.4, 17.1 vs 23.4 ml/min/Kg, respectively). 3) The increases in oxygen uptake from AT to RC and from AT to peak exercise were less in the poor tolerance group than in the good tolerance group. 4) O2 pulse at rest, warm-up, AT, RC and peak exercise were also lower in the poor tolerance group.2+ tolerance in the chronic phase of MI.

Aims: Despite the clinical usefulness of transcutaneous oxygen tension (TcPO2) to assess the severity of limb ischemia, the factors determining TcPO2 in patients with peripheral arterial disease (PAD) have not been fully clarified. We therefore examined the regions of arterial stenosis and clinical factors affecting lower-extremity TcPO2.Methods: Resting TcPO2 (REST-TcPO2) and postexercise TcPO2 (Ex-TcPO2) in the calf region and the dorsalis pedis were measured simultaneously in 66 patients (132 limbs) with clinically suspected PAD, in whom angiography was also performed.Results: The peripheral arteries of the lower extremities were divided into five segments, and the impact of significant stenosis in each segment on ipsilateral TcPO2 was evaluated by multiple regression analysis. In the calf region, significant stenosis of the proximal arteries (common-external iliac artery) revealed stronger involvement determining Ex-TcPO2 than the peripheral segment (posterior tibial artery). In the dorsalis pedis, the peripheral segment (anterior tibial artery) more strongly determined Ex-TcPO2 and REST-TcPO2 than proximal segments. Age, creatinine, and diabetes were associated with REST-TcPO2 of the calf region independent of arterial stenoses, while those of the dorsalis pedis were independently associated with age, and creatinine. In contrast, Ex-TcPO2 in both regions was not independently associated with clinical factors, except for stenosis of the perfusing arteries.Conclusion: The vascular lesions affecting TcPO2 differ between the calf region (proximal > peripheral) and the dorsalis pedis (proximal < peripheral). In addition postexercise TcPO2 is solely determined by stenosis of the perfusing arteries, while TcPO2 at rest is affected by multiple clinical factors.

SummaryObjectiveHeart rate recovery (HRR) after exercise is an independent risk factor for cardiovascular disease and mortality, and it is well known to be modifiable by weight loss. We investigated whether HRR was mainly improved by better cardiopulmonary function or by alteration of the metabolic profile.MethodsThe weight loss program included 2h of group exercise per week and individual dietary instruction by a qualified dietician every week. Clinical assessment (including HRR) was done before and after the 3-month program.PatientsThe subjects were 125 obese persons without a past history of stroke, cardiovascular events, or use of medications who participated in and completed our exercise plus weight loss program.ResultsHRR (35.61±12.83 to 45.34±13.6 beats/min, p

Summary Background and hypothesis: Genetic influence on development of athlete’s heart is uncertain. This study investigated whether angiotensin-converting enzyme (ACE) gene polymorphism influenced development of athlete’s heart. Methods: Forty-three participants in a 100-km ultramarathon were classified on the basis of ACE gene polymorphism into a deletion group (n = 26) and an insertion group (n = 17). Echocardiograms were recorded to determine left ventricular end-diastolic and end-systolic diameters, interventricular septal thickness, left ventricular posterior wall thickness, left ventricular mass, and ejection fraction. Results: Left ventricular end-diastolic diameter (65.5 k 4.0 mm) and left ventricular mass (369.5 k 73.9 g) were significantly larger in the subjects with deletion than in those with insertion (57.4 f 4.2 mm, 306.5 k 93.7 g). However, no significant differences in the other parameters were noted. Conclusions: In long-distance runners, ACE gene polymorphism of the D/D and DA genotypes has a stronger influence on left ventricular hypertrophy than polymorphism of the I/I genotype.

Background and hypothesis: Genetic influence on cardiac remodeling is uncertain. The purpose of this study is to determine the effects of polymorphism of the angiotensin-converting enzyme (ACE) gene on cardiac remodeling after myocardial infarction. Methods: The subjects were 43 patients with old anteroseptal myocardial infarction. Based on the polymorphism of the ACE gene, they were classified into a deletion group of 25 patients (D/D genotype in 4 and D/I genotype in 21) and an insertion group of 18 patients (all I/I genotype). Echocardiograms were used to determine left ventricular end-diastolic and end-systolic diameters, interventricular septal and posterior wall thicknesses, left ventricular mass, left atrial diameter, and left ventricular ejection fraction. Blood concentrations of atrial and brain natriuretic peptide were also measured. Results: Left ventricular end-systolic and end-diastolic dimensions, left ventricular mass, and levels of both atrial and brain natriuretic peptide were significantly higher in the deletion group. in contrast, septal thickness, posterior wall thickness, and ejection fraction showed no differences between the two groups. Conclusions: in patients with old anteroseptal infarction, ACE gene polymorphism of the D/D and D/I genotypes has a stronger influence on left ventricular remodeling than polymorphism of the I/I genotype.

BACKGROUND AND HYPOTHESIS: The mechanism of sudden cardiac death occurring in patients with chronic fatigue is controversial. This study was designed to define a hypothesis that coronary arterial spasm and thrombus formation can occur during chronic fatigue. METHODS: For evaluating the feasibility of coronary arterial spasm, erythrocyte magnesium (Mg) was measured. Blood coagulability was evaluated by the change of prostaglandin concentration. Subjects included 16 healthy male volunteers (mean age 21.6 +/- 2.5 years). Test conditions were as follows: (A) control state: a day following a night of good sleep; (B) temporary sleep deprivation: a day preceded by < 3 h of sleep; (C) chronic sleep deprivation: a day preceded by a month during which sleep lasted < 60% of that in condition (A) above. The erythrocyte Mg concentration was measured by the atomic absorption method. The plasma concentration of thromboxane B2 and 6-keto-prostaglandin F1 alpha were measured in eight subjects by radioimmunoassay method. RESULTS: (1) Mean erythrocyte Mg concentration was significantly less in chronic sleep deprivation (1.1 +/- 0.4 mg/dl) than in the control state (1.8 +/- 0.4 mg/dl, p < 0.01) or in temporary sleep deprivation (1.6 +/- 0.4, p < 0.01). (2) The level of thromboxane B2 was significantly higher during chronic sleep deprivation than under control conditions (104.4 +/- 78.0 vs. 20.4 +/- 9.0 pg/ml, p < 0.05). (3) There were no significant intergroup differences in 6-keto-prostaglandin F1 alpha level. CONCLUSION: These findings could support the hypothesis that coronary arterial spasm and thrombus formation occur in chronic sleep deprivation.

In chronic case of myocardial infarction (OMI), alternation of a daily total energy consumption (DTEC) between in OMI and in the pre-infarction stage was investigated. The limiting factors of DTEC, including functional classification according to New York Heart Association (NYHA) subset, Forrester's hemodynamic subset (FS) in the stage of acute myocardial infarction (AMI), numbers of significant coronary arterial stenosis (NCAG), cardiac function at rest in OMI, for example; cardiac index (CI), pulmonary capillary wedge pressure (PCW), left ventricle end-diastolic pressure (EDP) and exercise tolerance in OMI, were considered. Subjects, consisting of 191 OMI cases, were classified into the younger group less than 59 years old (79 males and 10 females) and the older group greater than 60 years old (102 males and 23 females). Daily physical activity was examined by questionnaires from these patients and DTEC was calculated based on daily physical activity. Results in the younger group and older group were investigated separately. Reduction of DTEC after myocardial infarction was recognized in all ages and both sexes, however, reduction of DTEC in the older group was less than in the younger group, especially in males. Concerning the limiting factors of the older group, exercise tolerance in OMI was related to reduction of DTEC. NYHA category, FS in the AMI stage, NCAG, CI, PCW and EDP had no significant relation to DTEC. In addition, the effects of social limiting factors, for instance retirement, and mental limiting factors were considered to be important.

An optimal target of exercise therapy for the chronic stage of myocardial infarction (OMI) was proposed by investigating a daily total energy consumption (DTEC) in 172 outpatients (142 males and 30 females) with OMI. DTEC was significantly lower in OMI than in the preinfarction state: 2005.8 +/- 487.8 vs. 2451.6 +/- 631.7 Kcal (p less than 0.01) in the male, 1389.9 +/- 367.4 vs. 1626.2 +/- 426.0 Kcal (p less than 0.01) in the female. Limiting factors of a daily physical activity (DPA) in OMI were selected from various non-cardiac and cardiac factors by using multifactorial analysis (Hayashi III). Non-cardiac limiting factors included; age of greater than 60, house-wife, joblessness and female, sex, and cardiac limiting factors included; NYHA class II, III, low anaerobic threshold (AT), treadmill exercise tolerance of less than 6 min, Forrester subset III, IV, heart failure in OMI and the recurrence of MI. Eighty percent of patients without cardiac limiting factors restricted DPA by 25% of DTEC of the preinfarction state. Our optimal target of exercise therapy for OMI was set to resume DTEC up to the level before MI. For patients without exercise habits, activities requiring 100 to 150 Kcal a day were requested. Also, this regimen had an educational purpose to obtain self-confidence both mentally and physically and was expected to raise the level of DPA to that of preinfarction state.

Holter心電図の普及とともに症状を伴わない心筋虚血が日常生活において高頻度に発生しており,また虚血性心疾患の予後は症状とは無関係で,冠動脈病変と左室機能障害の重症度と調連することがわかってきた.無症候性心筋虚血には痛覚閾値の上昇機序によるもの,有痛性発作にまで至らない軽症虚血発作など,異なった機序によるものが含まれているが,それらすべてが治療の対象となるところに本病態の臨床的意義がある.

A case of vietnamese immigrant with tuberculous mediastinopericarditis was reported and the literature was reviewed. A 39 year-old man was admitted to our hospital with chief complaints of dyspnea and weakness. Blood chemistry suggested the existence of congestive liver dysfunction. Chest X-ray film revealed marked cardiomegaly and a abnormal mass in the anteriorly superior area which was confirmed as anterior mediastinum on CT scan. Echocardiogram disclosed a large volume of pericardial effusion and thickened pericardium. Tuberculin test was positive. Firstly, this mediastinal mass was believed to be malignant tumor and the pericardial effusion had originated from it. Finally, tuberculous mediastinopericarditis was diagnosed by detecting tuberculous mycobacterium from the cultured pericardial effusion and also the biopsied lymph nodes. Although occurrence of tuberculous mediastinopericarditis is rare at the present time in Japan, this disease has not been exterminated and should be kept in mind.