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Left ventricular (LV) diastolic filling and left atrial (LA) contribution have been investigated in patients with heart disease. However, many of these studies were not conducted at a constant heart rate, and the effects of heart rate remain unclear. The purpose of this study was to clarify the effects of the heart rate on left atrial contractile performance and left ventricular filling during atrial systole. The changes in LA and LV dimensions and pulmonary venous (PV) flow were determined in 9 open-chest dogs by a sonomicrometer and an electromagnetic flowmeter. With a stepwise decrease in the pacing rate from 110 beats/minute to 70 beats/minute, the LA dimension just before atrial contraction increased from 21.4 +/- 0.6 mm to 23.1 +/- 0.7 mm (p0.01), and the LA systolic shortening increased from 1.6 +/- 0.1 mm to 2.1 +/- 0.1 mm (p0.01). However, the calculated LV filling volume during atrial systole decreased from 1.9 +/- 0.3 ml to 1.4 +/- 0.2 ml (p0.01). The PV flow during atrial systole was directed toward the LA, and the LA influx volume from PV decreased from 0.6 +/- 0.1 ml to 0.2 +/- 0.04 ml (p0.01). With a decrease in the pacing rate, the LA Frank-Starling mechanism operated. However, LV filling during atrial systole decreased because of the decrease in PV flow to the LV via the LA. Thus, LA contractile performance cannot always be evaluated from LV filling.

A 74-year-old woman with hypertension and bronchial asthma had chest discomfort at rest and 4 days later was admitted to her nearby hospital because of the sudden onset of right hemiparesis. The hemiparesis had almost disappeared within 24 h of onset, but because an electrocardiogram showed sinus tachycardia and diffuse symmetrical T-wave inversion, she was referred for cardiac examination. Coronary angiography did not reveal any significant coronary artery stenosis, but left ventriculography revealed severe hypokinesis of the left ventricular apical region, which contained a 4×4-mm solid thrombus moving freely with a wavy motion. Moreover, the activity of both protein C and protein S had decreased. The thrombus disappeared after 2 weeks of anticoagulant treatment with warfarin. Her clinical course suggested that the transient cerebral ischemic attack was caused by embolism of the left ventricular thrombus associated with `tako-tsubo-like left ventricular dysfunction'. (Circ J 2003; 67: 556 - 558)

Background— Extracorporeal membrane oxygenation (ECMO) and percutaneous coronary intervention (PCI) may be useful in cardiopulmonary resuscitation. However, little is known about the combination of ECMO and intra-arrest PCI. This study investigated the efficacy of rapid-response ECMO and intra-arrest PCI in patients with cardiac arrest complicated by acute coronary syndrome who were unresponsive to conventional cardiopulmonary resuscitation. Methods and Results— This multicenter cohort study was conducted with the use of the database of ECMO in Hiroshima City, Japan. Between January 2004 and May 2011, rapid-response ECMO was performed in 86 patients with acute coronary syndrome who were unresponsive to conventional CPR. The median age of the study patients was 63 years, and 81% were male. Emergency coronary angiography was performed in 81 patients (94%), and intra-arrest PCI was performed in 61 patients (71%). The rates of return of spontaneous heartbeat, 30-day survival, and favorable neurological outcomes were 88%, 29%, and 24%, respectively. All of the patients who received intra-arrest PCI achieved return of spontaneous heartbeat. In patients who survived up to day 30, the rate of out-of-hospital cardiac arrest was lower (58% versus 28%; P =0.01), the intra-arrest PCI was higher (88% versus 70%; P =0.04), and the time interval from collapse to the initiation of ECMO was shorter (40 [25–51] versus 54 minutes [34–74 minutes]; P =0.002). Conclusions— Rapid-response ECMO plus intra-arrest PCI is feasible and associated with improved outcomes in patients who are unresponsive to conventional cardiopulmonary resuscitation. On the basis of these findings, randomized studies of intra-arrest PCI are needed.

Background: The long-term safety and efficacy of drug-eluting stents for patients with acute myocardial infarction (AMI) remain controversial. Methods and Results: A total of 143 consecutive patients who presented between August 2004 and July 2006 with AMI and who underwent primary percutaneous coronary intervention (PCI) using sirolimus-eluting stents (SES), were compared with a historical control cohort of 129 consecutive patients who presented between August 2002 and July 2004 and who underwent primary PCI using bare metal stents (BMS). The rate of major adverse cardiovascular events at 3 years was significantly lower in the SES group than in the BMS group (20.3% vs. 33.1%, respectively; P=0.01). This reduction was mainly driven by a decrease in the rate of target vessel revascularization (12.3% vs. 22.4%, respectively; P=0.02). There was no significant difference in the rate of cardiovascular death (4.5% vs. 5.7%, respectively; P=0.67), non-fatal myocardial infarction (4.5% vs. 9.2%, respectively; P=0.16), coronary artery bypass grafting (2.3% vs. 2.5%, respectively; P=0.93), stroke (2.4% vs. 0.8%, respectively; P=0.35), and stent thrombosis (2.9% vs. 2.3%, respectively; P=0.80) between the 2 groups. Conclusions: SES can be used safely and effectively in patients with AMI. (Circ J 2012; 76: 65-70)

Background: Prodromal angina pectoris (AP) has a cardioprotective effect by the mechanism of ischemic preconditioning, and the QRS score on the admission electrocardiogram (ECG) reflects myocardial damage at presentation. This study was undertaken to investigate the effect of prodromal AP on infarct progression after the onset of acute myocardial infarction (AMI). Methods and Results: The study group comprised 291 patients with a first ST-elevation AMI who underwent coronary angiography within 24 h of symptom onset. QRS score was calculated from the admission ECG. Patients were divided into 3 groups according to elapsed time from onset of AMI to angiography: early group (

Glucose Tolerance Test (GTT) newly detects diabetes (new diabetes) in a substantial number of patients without a history of diabetes (known diabetes) after acute myocardial infarction (AMI). Patients with new diabetes have poor outcomes, despite their lower HbA1c levels.This study consisted of 53 patients with new diabetes and 47 patients with known diabetes who underwent GTT 1 week after AMI. Sixty-eight patients with normal GTT and 78 patients with impaired glucose tolerance served as control. Plasma glucose and insulin were measured at fasting, 30 m, 60 m and 120 m after glucose load. Peak glucose-fasting glucose was used as a measure of glucose fluctuation. Homeostasis model assessment of insulin resistance and the Stumvoll's equations were used to assess insulin sensitivity and ß-cell function, respectively.Fasting glucose (115 ± 20 mg/dl versus 129 ± 41 mg/dl, p=0.02) and hemoglobin A1C (5.7 ± 0.5% versus 6.7 ± 1.4%, p0.001) in new diabetes were significantly lower than known diabetes. Insulin sensitivity was similarly impaired in both new diabetes and known diabetes (3.2 ± 2.2 versus 3.0 ± 1.9, p=0.58). Impairment of insulin secretion was less severe in new diabetes than in known diabetes. Peak glucose-fasting glucose was significantly greater in diabetic patients than inpatients with normal GTT (75 ± 30 mg/dl, p0.001) and impaired glucose tolerance (95 ± 24 mg/dl, p0.001), with no difference between new diabetes and known diabetes (156 ± 36 mg/dl versus 165 ± 57 mg/dl, p=0.36).These findings suggested that insulin resistance and exaggerated glucose fluctuation could be attributable to poor outcomes after AMI in patients with new diabetes.

Background Recent studies have demonstrated that stress-induced Tako-tsubo cardiomyopathy is likely to occur in elderly female patients. Objectives The purpose of this study was to evaluate gender differences in the clinical characteristics of patients with Tako-tsubo cardiomyopathy. Methods This study consisted of 102 patients with Tako-tsubo cardiomyopathy. It was characterized by akinesia/hypokinesia of the mid-to-distal portion of the left ventricular chamber, with normokinesia/hyperkinesia of the basal portion with an ejection fraction of less than 50% on transthoracic echocardiography. Results There were 13 male and 89 female patients. In 10 male patients (77%), Tako-tsubo cardiomyopathy occurred during or immediately after receiving medical treatment or examination for an underlying disease. In 9 male patients (69%), objective symptoms such as abnormality of monitoring or low blood pressure, but not subjective symptoms increased the chance of the patient being diagnosed with Tako-tsubo cardiomyopathy. There was no significant difference in age, body weight, hypertension, or diabetes except for height between male and female patients. The incidence of in-hospital onset was significantly higher in male patients than in female patients (77% vs 17%, P < 0.01). There was no significant difference in in-hospital mortality (15% vs 6%, P = not significant). Conclusions These results suggested that physical stress might have more to do with the occurrence of Tako-tsubo in male than female patients. Copyright © 2010 Wiley Periodicals, Inc.

A 56-year-old man under right ventricular pacing for atrial fibrillation and bradycardia had congestive heart failure. He received a cardiac resynchronization pacemaker with a defibrillator. Four months later, follow-up transthoracic echocardiography showed a right atrial mass although he had no symptom. Transesophageal echocardiography showed a large immobile round-shaped mass on the defibrillation lead, which was attached to the free wall of the right atrium. One month after the initiation of anticoagulant therapy, the mass disappeared, suggesting that it was thrombotic. During the 5 month follow-up, he remained in good condition without the recurrence of right atrial thrombosis.

Background: Early reperfusion improves left ventricular (LV) function and survival after acute myocardial infarction (MI). Thrombolytic therapy achieves early patency of the infarct artery in about two-thirds of patients. In nearly half of the remaining patients, in whom early reperfusion was not achieved with thrombolytic therapy, the infarct artery might reopen by the time of predischarge angiography. However, the impact of such late spontaneous reperfusion after failed thrombolytic therapy on LV function and long-term survival remained unclear. Hypothesis: This study was undertaken to assess implication of late spontaneous reperfusion after failed thrombolytic therapy on LV function and long-term survival after acute MI. Methods: The study consisted of 198 patients with anterior acute MI who underwent thrombolytic therapy and predischarge angiography: 160 patients with infarct artery patent early and late after therapy (persistent patency), 17 patients with infarct artery occluded early after therapy but patent at predischarge angiography (late spontaneous reperfusion), and 21 patients with infarct artery occluded early and late after therapy (persistent occlusion). Results: Persistent patency was associated with enhanced improvement in LV ejection fraction (7.7 ± 11.8%) compared with late spontaneous reperfusion (0.0 ± 9.6%, p = 0.03) and persistent occlusion (-1.4 ± 9.7%, p = 0.003). Persistent patency was associated with better long-term survival than with late spontaneous reperfusion (p < 0.001) and persistent occlusion (p < 0.001). Multivariate analysis comparing persistent patency and late spontaneous reperfusion showed that early reperfusion was an independent predictor of long-term survival. Conclusion: Late spontaneous reperfusion after failed thrombolytic therapy was associated with poor LV function and long-term survival, emphasizing the importance of early reperfusion.

The effects of volume loading on the left atrial preejection period (LAPEP) and left atrial ejection time (LAET) were examined in 24 patients with various heart diseases using pulsed Doppler echocardiography. In response to volume loading, the left atrial dimension before atrial contraction significantly increased from 30.6 mm +/- 5.8 mm to 32.4 mm +/- 5.4 mm and the change in the left atrial dimension during atrial contraction tended to increase. The peak velocity in the atrial contraction phase significantly increased from 58 cm/s +/- 14 cm/s to 63 cm/s +/- 13 cm/s, and the integral of the atrial contraction phase tended to increase. LAPEP significantly decreased from 114 ms +/- 16 ms to 104 ms +/- 14 ms and LAET significantly decreased from 128 ms +/- 15 ms to 124 +/- 12 ms. The relation between LAET and left ventricular end-diastolic pressure, and that between LAPEP and mean pulmonary capillary wedge pressure, shifted downward to the right after volume loading. Thus, left atrial ejection is augmented by volume loading according to the Frank-Starling mechanism, while LAPEP decreases due to an increase in preload and LAET decreases due to an increase in afterload.

To evaluate the responsible factors for left atrial ejection, the left atrial preejection period (LAPEP), i.e., the time interval between atrial pacing pulse and onset of atrial ejection, and left atrial ejection time (LAET), i.e., the duration of atrial ejection, were determined from mitral inflow velocity patterns in 35 patients with various heart diseases using pulsed Doppler echocardiography. LAPEP ranged from 75 to 157 (mean 110 +/- 18) msec and LAET from 80 to 169 (mean 124 +/- 19) msec. The left atrial dimension before atrial contraction showed no significant correlation with LAPEP or LAET. Peak velocity during atrial contraction was negatively correlated with LAPEP (r = -0.42, p less than 0.05) and positively with LAET (r = 0.56, p less than 0.01). Left ventricular end-diastolic pressure (LVEDP) indicated a significant negative linear correlation with LAET (r = -0.44, p less than 0.05). LAPEP showed no significant linear correlation with LVEDP, but a significant curvilinear relationship was observed between them (LAPEP = 169 - 9.LVEDP + 0.28.LVEDP2, r = 0.63, p less than 0.001). Mean pulmonary capillary wedge pressure (mPCWP) was curvilinearly related to LAPEP (LAPEP = 168 - 11.mPCWP + 0.42.mPCWP2, r = 0.72, p less than 0.001) and LAET (111 + 4.1.mPCWP - 0.22.mPCWP2, r = 0.63, p less than 0.001). Although LAPEP decreased and LAET increased with increase in mPCWP up to about 15 mmHg, the reverse situation was noted for greater mPCWP. Thus, the major determinants of left atrial systolic time intervals are left atrial and ventricular pressures, and peak velocity during atrial contraction.

Among 95 patients with Tako-tsubo cardiomyopathy, left ventricular (LV) apical thrombus was documented in 5 (5.3%) patients. The thrombus was mural in 2 (40%), and protruding in 3 (60%) patients. In 4 patients, LV apical thrombus disappeared after anticoagulant therapy. In one patient with protruding thrombus, brain infarction occurred. LV dysfunction was resolved during follow-up in all patients.

Several studies have shown that both chronic kidney disease (CKD) and diabetes mellitus are risk factors for mortality in patients with acute myocardial infarction (AMI). This study was undertaken to investigate influence of CKD on the prognostic significance of diabetes in patients with AMI. Between January 1996 and December 2005, 888 patients with AMI underwent coronary angiography within 24 hours after the onset of chest pain. CKD was difined estimated glomerular filtration rate (eGFR) of less than 60.0 ml/minute/1.73 m 2 of body-surface area (stage3–5). Kaplan-Meier method was used to compare 5-year survival of diabetic and non-diabetic patients, in the presence (n=337) or absence (n=551). Kaplan-Meier curves for 5-year survival rate are shown in Figure . In the absence of CKD, there was no significant difference in 5-year survival rate between patients with diabetes and those without (93 % v.s. 94 %, p=0.82). In patients with CKD, however, diabetes was associated with lower 5-year survival rate (65 % v.s. 87 %, p

A 56-year-old man was admitted to our hospital after successful resuscitation for out-of-hospital cardiac arrest. Electrocardiogram on admission showed right bundle branch block and ST segment elevation in leads V1-3. Subsequent intravenous infusion of isoproterenol rapidly resolved ST segment elevation, suggesting Brugada syndrome. Therapeutic hypothermia, that was performed with a target temperature of 34.0 degrees C did not induce ST segment elevation in leads V1-3. The J-ST segment elevation rather became much more normal, suggesting a beneficial effect of mild therapeutic hypothermia. Serial ECG showed the temporal variation of ST segment elevation, and pilsicainide challenge test showed the occurrence of ST segment elevation, confirming the diagnosis of Brugada syndrome. Clinical observation suggested that mild therapeutic hypothermia reversed the Brugada phenotype through the prevention of fever as well as being indicated for cerebral protection after cardiac arrest. In conclusion, therapeutic hypothermia with a temperature of 34.0 degrees C can be used safely in Brugada syndrome.

We studied the factors determining the extent of myocardial damage induced by catheter electrical ablation in 23 mongrel dogs and evaluated the efficacy and safety of catheter electrical ablation in 6 patients with medically refractory ventricular tachycardias (VT). Electrical shocks were delivered on the epicardium (EPI) and endocardium (END) of the ventricular wall of open-chest anesthetized dogs through a 6F USCI electrode catheter. Effect of the extent of electrode contact pressure was examined by the presence or absence of monophasic action potential using the contact electrode technique. The former was defined as the hard touch condition and the latter was defined as the soft touch condition. The myocardial lesion induced by EPI fulguration was larger than that by END fulguration (EPI-100 J soft touch: 10.2 +/- 2.9 mm in diameter, 6.6 +/- 1.6 mm in depth vs END-100 J soft touch: 7.7 +/- 1.7 mm in diameter, 5.0 +/- 1.2 mm in depth; p less than 0.05, p less than 0.05). The lesion diameter and lesion depth were enlarged by increasing the amount of delivered energy. The lesion depth by the hard touch condition was significantly greater than by the soft touch condition. The transmural perforation was observed in all EPI fulguration in the hard touch condition of the right ventricular wall. In the clinical study, one to three shocks (mean 1.8 +/- 0.7) of 60 to 200 J (mean 151 +/- 48 J) were delivered per session in 6 patients with medically refractory VT.(ABSTRACT TRUNCATED AT 250 WORDS)

Background: Sirolimus-Eluting Stent (SES) is effective in reducing restenosis. Although several studies have reported the usefulness of SES in patients with acute myocardial infarction (AMI), the current major concerns of the use of SES in AMI are over-suppression of neointimal formation and late thrombosis. Coronary angioscopic examination provides an opportunity to assess neointimal coverage over stent and adherent thrombus in patients. Method: This study consisted of 18 patients who underwent primary angioplasty with SES for AMI. A mean average of 7.6 ± 2.5 months after SES implantation, coronary angioscopic examination was performed. Neointimal coverage of the SES was assessed by the grading as: grade 0 = complete exposure of the stent struts, grade 1 = dull light reflex from stent struts, grade 2 = no light reflex, but slightly visible stent struts, and grade 3 = complete coverage. Because the grade of neointimal coverage may vary from struts to struts, both maximum and minimum grade of neointimal coverage were assessed. The presence of thrombus was also evaluated. Results: All but one patient had at least 2 different grades of neointimal coverage; one patient had only grade 0. When the maximum grade of neointimal coverage was assessed, grade 0 was observed in 1 patient, grade 1 in 4 patients, grade 2 in 8 patients, and grade 3 in 5 patients. As to minimum grade, grade 0 was observed in 11 patients and grade 1 in 7 patients, however, grade 2 and 3 was not observed. Thrombus adherent to uncovered stent struts (grade 0 or 1) was observed in 8 patients (44%). Conclusion: The process of neointimal coverage over SES was heterogeneous. Even 7 months after SES implantation for AMI, most of the stent struts were not covered by neointimal with high incidence of adherent thrombus. Long-term aggressive anti-platelet therapy should be advocated for patients with AMI who were treated with SES.

Aims To investigate whether admission hyperglycaemia in non-diabetic patients with acute myocardial infarction (AMI) is a surrogate for previously undiagnosed abnormal glucose tolerance. Methods and results Two hundred non-diabetic patients with AMI were divided into three groups: 81 patients with admission glucose

Prodromal angina occurring shortly before the onset of acute myocardial infarction (MI) has a cardioprotective effect in patients with acute MI by the mechanism of ischaemic preconditioning.1,2 However, it has been reported that several conditions, including aging and diabetes mellitus, may abolish the beneficial effect of prodromal angina.3,4 Recent experimental studies have reported that the cardioprotective mechanism of preconditioning is impaired by post-MI left ventricular (LV) remodelling.5 Patients with prior MI have an increased risk of developing acute MI. Once acute MI has occurred, the prognosis is worse than that for patients without prior MI. This study was undertaken to investigate the influence of prior MI on the effect of prodromal angina in patients with acute MI. This study enrolled 1076 patients with acute MI who underwent coronary angiography within 24 hours after the onset of chest pain. Acute MI was diagnosed by chest pain persisting longer than 30 minutes and concomitant ECG changes. Serum creatine kinase was measured every three hours. Peak creatine kinase concentration had to be more than twice the normal upper limit. Immediately after coronary angiography, reperfusion therapy was performed, if appropriate. Most (84%) of the patients underwent primary coronary angioplasty with (n = 584) or without coronary stents (n = 315). Contrast left ventriculography was performed before reperfusion therapy (n = 635) and at predischarge catheterisation (n = 656). Prodromal …

A 26-year-old man was admitted to our hospital because of acute pericarditis. The current patient had a saddle-back type ST-segment elevation shortly after the onset of acute pericarditis. Interestingly, it converted into a coved type ST-segment elevation, subsequently regressed gradually as acute inflammation improved. After 3 months, right ventricular rapid pacing induced ventricular fibrillation, and intravenous sodium channel blocker induced a coved type ST-segment elevation. The current case implies that a Brugada-type ST-segment elevation, which is thought to be false in acute pericarditis, may be true in some patients with asymptomatic Brugada syndrome.

To assess the usefulness of directional coronary atherectomy (DCA) in acute myocardial infarction (AMI), 139 consecutive patients with anterior wall AMI undergoing successful catheter intervention were studied. The reocclusion rate was significantly lower in the last 70 patients who underwent DCA as aggressively as possible compared with the first 69 patients treated with coronary balloon angioplasty (12.1% vs 3.0%, p0.05).

A-55-year-old man with diabetes mellitus was admitted to hospital because of chest pain. He was diagnosed as anterior acute myocardial infarction and treated with stent placement. After 7 days, ventricular fibrillation occurred because of a subacute reocclusion and balloon angioplasty was performed. Despite reperfusion therapy, intraaortic balloon pumping, antiarrhythmic drugs and beta-blocker, ventricular tachycardia or fibrillation relapsed and cardioversion was performed 29 times during 32 h. Temporary overdrive atrioventricular sequential pacing was initiated and the malignant arrhythmia finally disappeared. Even after stoppage of 25 h overdride pacing, it never recurred. Temporary overdrive pacing is an easy and feasible therapy for a drug-resistant electrical storm associated with AMI and should be performed in the early stage.

Background It remains unclear whether spontaneous anterograde flow preserves myocardial fatty acid metabolism in patients with acute myocardial infarction (AMI). Methods and Results The present study comprised 129 patients with a first anterior AMI in whom Thrombolysis in Myocardial Infarction (TIMI) 3 flow was obtained on the final angiogram: 28 patients with spontaneous anterograde flow and 101 patients with total occlusion on the initial angiogram. Thallium-201 (201Tl) and iodine-123-β-methyl-p-iodophenyl penta-decanoic acid (123I-BMIPP) dual-isotope myocardial single-photon emission computed tomography (SPECT) was performed at 6.5±4.2 days after onset. The SPECT image was divided into 17 segments, and each segment was graded with scores between 0 and 4 (0, normal uptake; 4, defective). The sum of each score was defined as the total defect score (TDS). TDS values for 201Tl (9.0 ±7.4 vs 16.8±12.2, p

A 28-year-old man was admitted because of chest pain. Emergency coronary angiography showed a massive thrombus in the proximal segment and another occlusive thrombus in the distal segment of the left anterior descending artery. He was treated with thrombolytic therapy. Repeat coronary angiography showed disappearance of the thrombi in the proximal and distal segments and obvious myocardial bridging in the mid segment. Intravascular ultrasound revealed an atherosclerotic plaque in the segment immediately proximal to the myocardial bridging, but did not reveal any plaque within or distal to the site. He was discharged 12 days later.

A 64-year-old man with a history of previous coronary intervention of the left anterior descending artery was admitted to hospital because of recurrent chest pain at rest. Coronary angiography revealed no significant coronary artery stenosis. During preparation for the second shot of the right coronary artery, chest pain occurred unexpectedly, represented by ST segment elevation in leads II, III and aV(F). Immediate right coronary angiography revealed no significant coronary artery stenosis, but markedly delayed contrast medium washout. Intracoronary administration of nicorandil attenuated this phenomenon, and the patient was diagnosed as having angina pectoris caused by microvascular spasm with ST segment elevation.

Our data suggest that a high coronary wedge pressure is associated with improved left ventricular function after reperfusion for AMI. A combination of angiographic collaterals and coronary wedge pressure permits further evaluation of coronary collateral circulation in patients with AMI.

The time course of the electrocardiographic (ECG) changes in patients with tako-tsubo syndrome remains unknown.In the present study, 16 patients with tako-tsubo syndrome and 15 patients with anterior acute myocardial infarction with minimal enzymatic release (minimal AMI) were evaluated. Left ventricular dysfunction dramatically resolved approximately 2 weeks later in both groups. In the patients with tako-tsubo syndrome, the admission ECG usually showed ST segment elevation, especially in leads V(3-6). T wave inversion deepened progressively to its first negative peak, which occurred at approximately 3 days. The T wave was shallow for several days and then deepened again, the second negative peak occurring at approximately 2-3 weeks. The QT interval was prolonged as the T wave deepened, and shortened as the T wave became shallow. In the patients with minimal AMI, a similar time course of ECG changes was observed after reperfusion. In general, at 3 days or later during the early phase, T wave inversion was deeper and the QTc interval was longer in tako-tsubo syndrome than in minimal AMI.Because the time course of the ECG changes, as well as that of the left ventricular dysfunction, is similar between tako-tsubo syndrome and minimal AMI, these 2 cardiac disorders must be carefully differentiated.

Objective This study was undertaken to assess the relationship between acute hyperglycemia and left ventricular function after reperfusion therapy for acute myocardial infarction (AMI). Methods This study consisted of 529 patients with a first anterior wall AMI who underwent coronary angiography followed by coronary angioplasty or thrombolysis within 12 hours after the onset of chest pain. Plasma glucose was measured at the time of hospital admission. Acute hyperglycemia was defined as plasma glucose >10 mmol/L. Results Although acute hyperglycemia was associated with both lower acute left ventricular ejection fraction (LVEF) (46% ± 12% vs 48% ± 10%, P = .026) and lower predischarge LVEF (51% ± 15% vs 56% ± 15%, P = .001), the difference was more pronounced in the latter and the change in LVEF was significantly smaller in patients with acute hyperglycemia (4.8% ± 11.2% vs 8.0% ± 13.8%, P = .022). Multivariable analysis showed that there was a significant correlation between plasma glucose and impaired predischarge LVEF, even after adjustment of acute LVEF ( r = −0.13, P = .005). Thirty-day mortality tended to be higher in patients with acute hyperglycemia than in patients without (7.1% vs 3.5%, P = .06). Multivariable analysis showed that plasma glucose (per 1 mmol/L increase) was an independent predictor of 30-day mortality after AMI (odds ratio 1.12, 95% CI 1.03-1.22, P = .009). Conclusion Acute hyperglycemia was independently associated with impaired left ventricular function and higher 30-day mortality after AMI. These results may provide a potential explanation for poor outcomes of patients with AMI and acute hyperglycemia.

A 67-year-old man, who was previously diagnosed with vasospastic angina and treated with standard therapy, was admitted to our hospital because of recurrent chest pain refractory to sublingual nitroglycerin. Admission electrocardiography revealed ST segment elevation in II, III and aV(F), and his symptoms were relieved by intravenous bolus administration of nicorandil. He was diagnosed to have active variant angina, and remained symptomatic even after treatment with calcium antagonists and nitrates at optimal doses. Intravenous bolus administration of nicorandil was consistently effective to relieve his symptoms. Anginal attack was finally prevented by massive oral nicorandil in addition to conventional treatment.

The purpose of the present study was to assess the impact of intraaortic balloon pumping (IABP) in patients with persistent ST elevation who underwent revascularization within 6 h of their first acute anterior myocardial infarction (AMI). Persistent ST elevation after revascularization was defined as being > or =50% of the initial value on return to the coronary care unit. Twenty-four patients were treated without IABP (control group) and 27 patients were treated with IABP (IABP group). There was no significant difference between the 2 groups in pretreatment left ventricular ejection fraction (LVEF), end-diastolic volume index or end-systolic volume index. After 137+/-46 days, the change in the LVEF was significantly higher in the IABP group than in the control group (5+/-13% vs 13+/-15%, p=0.04). However, the left ventricular end-diastolic volume index was similar between the 2 groups during follow-up (pretreatment: 77+/-19 ml/m(2) vs 74+/-13 ml/m(2), p=0.54; follow-up: 86+/-22 ml/m(2) vs 83+/-18 ml/m(2), p=0.60). These data suggest that IABP enhances the improvement in LVEF independent of remodeling in AMI patients with persistent ST elevation after revascularization.

Object Although previous studies reported that late reperfusion might prevent left ventricular dilation after acute myocardial infarction (AMI), implication of persistent ischemic chest pain on admission remains to be investigated. This study was undertaken to assess the implication of persistent ischemic chest pain on in-hospital outcome and left ventricular function after late reperfused AMI. Methods and Patients We studied 63 patients with a first anterior AMI who underwent percutaneous coronary intervention 6 to 24 hours (11.2±4.5 hours) after the onset. Of 63 patients, 48 (76%) had persistent ischemic chest pain on admission. Results Incidence of in-hospital death, reinfarction or congestive heart failure was similar between the 2 groups. Pretreatment left ventricular ejection fraction and end-diastolic volume were similar between the 2 groups. Predischarge angiography was performed at 17±5 days after the onset. Late reperfusion prevented the dilation of left ventricular end-diastolic volume in patients with chest pain (78±12 to 75±17 ml/m2, p=0.15), but did not in those without (75±20 to 93±28 ml/m2, p=0.03). A multivariate analysis revealed that absence of persistent ischemic chest pain was an independent predictor of predischarge left ventricular end-diastolic volume >100 ml/m2 (odds ratio 0.10, p=0.04). Conclusions Our data demonstrated that absence of persistent ischemic chest pain appears to be a simple and reliable marker which predicts left ventricular dilation after late reperfused AMI.(Internal Medicine 41: 920-924, 2002)

The impact of coronary stenting on microvascular circulation in the infarct area was compared with that of balloon angioplasty in 94 patients with acute myocardial infarction (AMI) who underwent coronary revascularization within 6h of onset: 49 patients were treated with balloon angioplasty alone, and 45 were treated with coronary stenting. Microvascular circulation after revascularization was assessed by Thrombolysis in Myocardial Infarction (TIMI) flow grade analysis and ST segment analysis. TIMI flow grade was assessed on the final angiographic image after coronary intervention, and the ST segment was assessed on the 12-lead electrocardiogram recordings just before revascularization and on return to the coronary care unit. The distributions of TIMI flow grade and change in sigmaST (5.1 +/- 10.8 vs 5.1 +/- 9.9mm) were similar between the 2 groups. Predischarge left ventricular ejection fraction (54 +/- 14 vs 54 +/- 15%) and in-hospital outcome were also similar between the 2 groups. The data suggest that coronary stenting did not influence microvascular circulation (improvement or detriment) in patients with reperfused AMI.

Background Peculiar asynergy, which consists of hypokinesis or akinesis from the mid portion to the apical area and hyperkinesis of the basal area on contrast left ventriculogram, is rare. Because the end-systolic left ventriculogram looks like a "tako-tsubo," which was used for trapping octopuses in Japan, we proposed the term "tako-tsubo-like left ventricular dysfunction." Our aim was to evaluate its clinical features and causes. Methods We studied 30 patients with tako-tsubo-like left ventricular dysfunction without significant coronary artery disease. We assessed its pathophysiologic mechanisms by coronary spasm provocation test, endomyocardial biopsy, measurement of virus titer, and measurement of circulating catecholamine levels. Results Patient age ranged from 55 to 83 years. Twenty-eight were women and 2 were men. Tako-tsubo-like left ventricular dysfunction was dramatically resolved on predischarge left ventriculogram at 11.3 ± 4.3 days. Acute coronary angiography revealed spontaneous multivessel coronary spasm in 3 patients. Among 14 patients, ergonovine or acetylcholine induced epicardial single coronary spasm in 4 patients and multivessel coronary spasm in 6 patients. Spontaneous microvascular spasm occurred at predischarge in 1 patient. An endomyocardial biopsy specimen in 3 patients and measurement of virus titer in 7 patients did not show evidence of acute myocarditis. Circulating norepinephrine was normal or slightly elevated in 6 patients. Conclusions We showed clinical features of a novel cardiac syndrome with tako-tsubo-like left ventricular dysfunction. Although the precise cause remains unclear, simultaneous multivessel coronary spasm at the epicardial artery or microvascular levels may contribute to the onset of tako-tsubo-like left ventricular dysfunction. (Am Heart J 2002;143:448-55.)

OBJECTIVETo assess the influence of diabetes on long term prognosis after reperfusion treatment and its interaction with multivessel disease.DESIGNA retrospective observational study.SETTINGHiroshima City Hospital.PATIENTS1660 consecutive patients with acute myocardial infarction who underwent coronary angiography within 24 hours after the onset of chest pain.MAIN OUTCOME MEASURESInfluence of diabetes on 10 year survival after infarction was assessed using the generalised Wilcoxon test and Cox's proportional hazards regression. Follow up was completed in 1622 patients (98%).RESULTSDiabetic patients had more multivessel disease than non-diabetic patients (53%v 34%, p CONCLUSIONSDiabetes is an independent predictor of long term mortality after infarction in patients with single vessel disease. However, in the presence of multivessel disease, prognosis after infarction is impaired regardless of diabetes, and the influence of diabetes is less obvious.

Although it has been well demonstrated that TIMI grade 3 flow is associated with improved survival after acute myocardial infarction in non-elderly patients, its implication in elderly patients has not been clarified. To assess this issue, 1,115 patients with acute myocardial infarction who underwent coronary angiography within 24 hours after the onset of chest pain were studied: there were 131 elderly patients (ageor = 75 years) and 984 non-elderly patients (age75 years). Follow-up was achieved for 1,092 patients (98%). Elderly patients were associated with more female, Killip classor = 2, 3 vessel disease and non-smokers. Although modality of reperfusion therapy was not different, final TIMI flow grade was less frequently obtained in elderly patients (53% vs 65%, p = 0.005). Elderly patients were associated with higher in-hospital mortality (25% vs 9%, p0.001) and lower 10 years cardiac death free rate (p0.001). Cox proportional hazards model showed that final TIMI flow grade 3 was an independent predictor of 10 years cardiac death free in elderly patients (odds ratio (OR) = 0.39, 95% confidence interval (CI) = 0.20-0.74, p = 0.004) as well as non-elderly patients (OR = 0.41, 95% CI = 0.29-0.58, p0.001). In conclusion, our data suggest that final TIMI grade 3 flow is an important determinant to improve short- and long-term survival after acute myocardial infarction in elderly patients as well as in non-elderly patients.