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Background: There is frequently discordance in the interpretation of myocardial single-photon emission computed tomography images using both rest iodine-123 15-(p-iodophenyl)-3-(R,S) methylpentadecanoic acid (BMIPP) and stress thallium-201 ((201)Tl); that is, negative BMIPP vs positive (201)Tl studies. However, little attention has been paid to reverse discordance (ie, positive BMIPP despite negative stress (201)Tl)., Methods and Results: In the present study 105 consecutive patients with suspected coronary artery disease (CAD) who underwent both rest BMIPP and stress (201)Tl imaging were evaluated. No patient with previous myocardial infarction was included. Scintigraphic studies revealed that BMIPP was in concordance with (201)Tl in 71 patients: both were positive in 38 and negative in 33, whereas both were discordant in 20 and reverse discordant in 14. In patients with reverse discordance, the pattern of BMIPP abnormality was segmental in 8 and spotty in 6; the former was related to coronary territory. Based on the BMIPP findings and clinical symptoms, 7 patients with positive BMIPP despite negative (201)Tl underwent coronary angiography: 3-vessel CAD was found in 3 patients, 2-vessel CAD in 1, coronary spasm in 2, and insignificant lesions in 1. In the remaining 7 patients, no cardiac event was observed during 2-year follow-up., Conclusions: In patients showing positive BMIPP despite negative (201)Tl, a segmental BMIPP perfusion abnormality indicates a high likelihood for CAD, despite normal stress (201)Tl imaging. Thus, adding BMIPP to (201)Tl imaging may help to better identify patients with significant CAD, including multivessel disease.

Reduction in cardiac (123)I-metaiodobenzylguanidine (MIBG) uptake is a characteristic feature of Parkinson's disease (PD) and dementia with Lewy bodies (DLB), and is useful in distinguishing them from other neurodegenerative disorders. The aim of this study was to investigate the role of this method of scintigraphy in the differential diagnosis of dementia in our Memory Clinic. We performed MIBG scintigraphy in patients with dementia referred to the Memory Clinic and compared the heart-to-mediastinum (H/M) ratio of MIBG uptake. Thirty out of 32 patients with DLB and all 9 PD with dementia patients had reduced H/M ratios, whereas 37 out of 40 patients with Alzheimer's disease had normal H/M ratios. Most patients with vascular dementia, frontotemporal dementia, and other dementias had normal H/M ratios. The overall sensitivity to positively identify patients with Lewy body disease (including DLB and PD with dementia) was 95%, and the specificity to distinguish them from patients with other types of dementias was 87%. MIBG scintigraphy showed a high sensitivity for the detection of Lewy body disease, and also a high specificity for discrimination from other types of dementia. The scintigraphy may provide a valuable and adjunctive method in the diagnosis of Lewy body disease and a differential diagnostic tool for patients with dementias.

Background: Exercise gated single-photon emission computed tomography (SPECT) using technetium-99m (99mTc)-sestamibi evaluates both myocardial perfusion during stress and wall motion >30 min after the stress, which has the potential to assess not only exercise-induced myocardial ischemia but also the development of myocardial stunning., Methods and Results: To evaluate the incidence of post-stress myocardial stunning, as well as comparing the effects of different stress methods on the development of stunning, 179 consecutive patients with known or suspected coronary artery disease (CAD) underwent (99m)Tc-sestamibi SPECT with either exercise (n=135) or adenosine triphosphate disodium (ATP) (n=44). Electrocardiogram-gated SPECT images were acquired >30 min after the stress and again 4 h later, and perfusion and wall motion were evaluated. Post-stress myocardial stunning occurred in 24 patients (13%): 22 after exercise and 2 after ATP stress. The magnitude of the transient wall motion abnormality after exercise was greater in patients with severe ischemia, compared with those with mild-to-moderate ischemia (p<0.0001). By contrast, with ATP stress, the magnitude of the transient wall motion abnormality was similar, regardless of the severity of perfusion abnormality. Furthermore, a significant correlation between summed difference score and transient wall motion abnormality was found after exercise (r=0.68, p<0.0001). With ATP, however, no such correlation was observed (r=0.28, p=NS)., Conclusions: Using 99mTc-sestamibi gated SPECT, myocardial stunning is frequently observed after exercise and correlates with the severity of myocardial ischemia, but this does not occur with ATP, which is regarded as a specific marker for severe CAD.

Background: Although a very simple method of measuring brachial -- ankle pulse wave velocity (baPWV) has become available in a clinical setting, whether baPWV can predict future cardiovascular events remains uncertain. We examined whether baPWV is a predictor of cardiovascular events in patients with acute coronary syndrome (ACS)., Methods and Results: baPWV measurement was performed in 215 consecutive patients with ACS. During the follow-up period (26+/-10 months), 46 patients experienced post-hospitalization cardiovascular events (18 patients experienced a major event (eg, stroke, re-admission for heart failure or cardiac death), and 28 patients experienced coronary re-intervention). A receiver operating characteristic curve demonstrated that the best cut-off point of a baPWV for predicting a post-hospitalization cardiovascular event was 17.00 m/s and that for predicting a major cardiovascular event was 18.00 m/s. After the adjustment for the conventional risk factors influencing the prognosis, a multivariate Cox proportional hazards model demonstrated that both cut-off points of baPWV had a significant hazard ratio for a post-hospitalization event: 5.47 (2.69-11.09) and for a major cardiovascular event: 9.22 (2.78-30.56)., Conclusions: baPWV is a simple predictor of the prognosis of patients with ACS that is independent of conventional risk factors for ACS.

Background: Aortic surgery is an invasive, high-risk noncardiac procedure and the patients who require it have a high prevalence of coronary artery disease. Therefore, preoperative risk stratification for this subset is essential., Methods and Results: To assess the perioperative risk for aortic surgery, pharmacologic stress single-photon emission computed tomography (SPECT) was performed in 302 patients: aortic dissection in 56, thoracic aortic aneurysm in 124, and abdominal aortic aneurysm in 122. Not only was the presence or absence of perfusion defects analyzed, but also the 20-segment model. Pharmacologic thallium SPECT revealed negative findings in 210 patients and positives in 92. Perioperative cardiac events occurred in 9 patients: 7 occurred in patients with positive SPECT, and in only 2 of those with negative SPECT (2/210 vs 7/92; p<0.05). Multivariate analysis using logistic regression model revealed that a summed stress score>or=14 was the most important factor to identify patients who subsequently had perioperative cardiac events., Conclusions: Pharmacologic stress SPECT has significant value in the risk stratification of patients before aortic surgery. In patients with positive SPECT, an aggressive approach to reduce the preoperative risk is necessary, whereas aortic surgery can be performed safely in patients with negative SPECT.

Background: Although iodine 123 15-(p-iodophenyl)-3-(R , S) methylpentadecanoic acid (BMIPP) can assess abnormal utilization of fatty acid in the diseased myocardium, the prognostic value of BMIPP imaging at rest in patients with known or suspected coronary artery disease (CAD) remains unclear., Methods and Results: A total of 270 patients were included by a retrospective search of the existing databases of 4 institutions. In addition to hard events, consisting of cardiac death and nonfatal myocardial infarction, any significant events including death, nonfatal myocardial infarction, coronary revascularization, heart failure, and unstable angina were assessed. During a median follow-up of 3.9 years, 33 patients had significant events, among whom 10 had hard events. Kaplan-Meier survival estimates revealed a hard event-free survival rate of 98% at 3 years in patients with a BMIPP defect score lower than 5 but 93% in those with a defect score of 5 or greater ( P = .03). With regard to significant events, the analysis showed an event-free survival rate of 92% at 3 years in patients with a BMIPP defect score lower than 5 but 80% in those with a defect score of 5 or greater ( P = .0003)., Conclusions: These results indicate that resting BMIPP imaging has prognostic value and may have a role in the risk stratification of patients with known or suspected CAD.

Background: Although the simultaneous measurement of brachial and ankle blood pressure is a simple method of evaluating atherosclerosis, its diagnostic value for coronary artery disease (CAD) is undetermined., Methods and Results: To evaluate the diagnostic value of ankle-brachial pressure index (ABI) and brachial-to-ankle pulse wave velocity (baPWV), 334 consecutive patients with suspected CAD were evaluated. Patients with a previous myocardial infarction or coronary intervention were not included. The magnitude of myocardial ischemia was evaluated by myocardial perfusion imaging. Using a 20-segment model, the percent of ischemic segments to total segments was expressed as %myocardium ischemic. In patients with < or =1, 2 and > or =3 coronary risk factors, %myocardium ischemic was 2.7+/-0.4, 4.0+/-0.5, 7.9+/-0.8%, respectively (p<0.0001 for trend). Performing ABI with a cutoff of 1, the %myocardium ischemic was similar in patients with < or =1 or 2 risk factors. In patients with > or =3 coronary risk factors, however, an ABI <1 reflected greater %myocardium ischemic than an ABI > or =1 (10.1+/-1.3, 6.6+/-1.0%; p=0.03). No such additional value was observed with baPWV., Conclusions: The addition of simultaneous brachial and ankle blood pressure measurements will help further stratify patients with multiple risk factors. Although this approach is simple, it facilitates the identification of high-risk patients who require aggressive treatment because >10% myocardium ischemic is regarded as a scintigraphic indicator for coronary revascularization.

To stratify perioperative cardiac risk for endovascular surgery, pharmacologic stress single-photon emission computed tomography (SPECT) was performed in 206 patients. Of 8 patients who had cardiac events, 7 occurred in 67 patients with positive SPECT results, whereas only 1 occurred in 139 patients with negative SPECT results (7 of 67 vs 1 of 139, p <0.002). Furthermore, a scintigraphic marker of a summed stress score >/=14 was the most important factor identifying patients who subsequently had cardiac events by multivariate analysis.

Background: Although the development of a coronary guidewire mounted with a pressure sensor has facilitated the measurement of pressure-derived fractional flow reserve (FFR) to assess the functional severity of coronary artery stenoses, the theoretical limitations include diabetes mellitus because of the associated microvascular abnormalities., Methods and Results: In the present study 304 vessels and their coronary territories in 96 diabetic and 149 nondiabetic patients were evaluated by pressure-derived FFR and thallium-201 single photon emission computed tomography (SPECT) to determine the applicability of measuring FFR in diabetic subjects. The best cut-off value for FFR to detect myocardial ischemia, as demonstrated by (201)Tl SPECT, was 0.725 in the diabetic and 0.745 in the nondiabetic patients. Sensitivity and specificity were similar for the 2 groups (83% and 75% (diabetic) vs 79% and 83%). However, diabetic patients with homoglobin (Hb) A(1c) >or=7.0% showed lower specificity in comparison with those having HbA(1c) <7.0% (64 vs 88%; p=0.045); however, sensitivities were similar (83 vs 83%; p=NS)., Conclusions: The cut-off value of 0.75 for FFR can detect myocardial ischemia in diabetic patients, although the adequacy of glycemic control should be taken into consideration when assessing the FFR measurements.

Objectives: Development of the coronary pressure wire has facilitated the measurement of fractional flow reserve (FFR) to assess the functional severity of coronary artery stenoses., Methods: This study evaluated the correlations between FFR and myocardial direct counts of technetium-99m(99mTc)-sestamibi in 20 patients (16 men, 4 women, mean age 66 +/- 8 years) who underwent 99mTc-sestamibi single-photon emission computed tomography (SPECT) with the 2-day protocol using 740 MBq of 99mTc-sestamibi each day. Visual assessment of myocardial imaging and quantitative analysis with the measurement of percent uptake and direct count of 99mTc-sestamibi were performed., Results: Visual assessment of myocardial imaging revealed that reversibility of 99mTc-sestamibi perfusion defects was correlated with FFR of < 0.75, which is regarded as functionally important stenosis (17/20 vs 3/20, kappa = 0.71, p < 0.002). Regional reversibility score did not correlate with FFR (r = -0.40, p = NS). Quantitative analysis revealed that the change in 99mTc-sestamibi percent uptake with pharmacologic stress using adenosine triphosphate disodium (ATP) also did not correlate with FFR (r = 0.35, p = NS). In contrast, percent increase in 99mTc direct counts with ATP was lower in patients with FFR of < 0.75 than in those with FFR of > = 0.75 (-4 +/- 16% vs 24 +/- 30%, p < 0.01). In addition, a significant correlation (r = 0.70, p < 0.001) was observed between percent increase in 99mTc direct counts with ATP and FFR., Conclusions: These results suggest that quantitative analysis of 99mTc-sestamibi scintigraphy enables the assessment of the magnitude of functional significance of coronary stenosis.

Aim: The prevalence of asymptomatic coronary artery stenosis in relation to carotid artery stenosis is influenced by the underlying disease and has yet to be clarified., Methods: A total of 124 consecutive Japanese patients with aortic aneurysm, but without symptoms of coronary artery stenosis, were divided into 2 groups on the basis of carotid ultrasonography: the carotid stenosis group (>or=50% luminal diameter narrowing) and the non-stenosis group. Myocardial imaging was performed using thalium-201 chloride and adenosine triphosphate disodium., Results: The mean age and incidence of both cerebrovascular disease and peripheral artery disease were significantly higher in the stenosis group (n=24) than the non-stenosis group (n=100). Defining both fixed and reversible hypoperfusion as positive on the basis of myocardial imaging, a significantly higher number of positive findings were found in the stenosis group (15/24; 62.5%) than in the non-stenosis group (32/100, 32.0%), (Odds ratio: 3.54; p<0.01). The distributions of hypoperfusion defects in the stenosis group were similar to those in the non-stenosis group, but fixed hypoperfusion was more frequently seen in the stenosis group., Conclusion: The high prevalence of positive findings in the stenosis group indicates that carotid artery stenosis is frequently associated with coronary artery stenosis even in asymptomatic patients, and could be an indicator for advanced atherosclerosis of the coronary artery. The results confirm that stress myocardial imaging is invaluable in the detection of coronary artery stenosis, particularly in patients with carotid arteriosclerosis.

In 167 patients with suspected coronary artery disease, 74 of whom had myocardial infarction (MI), measurement of myocardial fractional flow reserve (FFR) in previous infarction territories, using a cut-off point of 0.75, showed a sensitivity of 79% and a specificity of 79% for myocardial ischemia as demonstrated by thallium-201 myocardial imaging. This sensitivity and specificity were similar to a sensitivity of 79% and a specificity of 72% observed in territories not related to MI. In addition, a receiver-operating characteristic curve analysis revealed that the best predictability of FFR for myocardial ischemia was between 0.74 and 0.76, regardless of the presence or absence of MI.

Recently, it has been reported that hypertension causes not only cerebro-cardiovascular diseases, but also a decline of cognitive function in the elderly. However, it is not clear whether or not aging and hypertension have a latent effect on the cognitive-neurobehavioral and cardiac functions in healthy elderly whose scores of basic activities of daily living (ADL) are fully maintained. We evaluated the effect of aging and hypertension on cognitive-neurobehavioral and cardiac functions in 25 healthy community-dwelling elderly subjects (mean age: 69 y.o.) whose scores of basic ADL were fully maintained. Subjects were followed over a 5-year period, and the following examinations were performed before and after a 5-year follow-up: echocardiography, 24-hr ambulatory blood pressure monitoring (ABPM), and cognitive-neurobehavioral function test. Left ventricular mass index was significantly increased in the hypertensive (HT) subjects relative to the normotensive (NT) subjects over the 5 years (% change: 3% for HT vs. -0.8% for NT, p = 0.03). The number of non-dippers significantly increased over the 5 years in the HT group (initially: 20% [2/10] vs. follow-up: 58% [7/12], p = 0.04). Visuospatial cognitive performance scale scores for evaluation of higher cognitive-neurobehavioral functions significantly deteriorated in the HT subjects (initially; 2,344 +/- 110 vs. 2,380 +/- 102, ns, and follow-up: 2,149 +/- 181 vs. 2,356 +/- 159, p = 0.04). Hypertension contributes to the impairment of the cognitive-neurobehavioral function in the elderly by latently affecting the functions of multiple organs. This occurs even if basic ADL is maintained for 5 years. Therefore, it is important to control BP not only to prevent cardiovascular events, but also to preserve the neurobehavioral function.

The development of quantitative gated single-photon emission computed tomography (SPECT) has enabled the assessment of left ventricular perfusion, function and wall thickness in a single examination. Accordingly, the present study used gated SPECT to assess the benefit of coronary artery bypass grafting (CABG) in patients with coronary artery disease; 47 of those patients were evaluated before and 5 months after CABG. As a result of coronary revascularization, a significant improvement was observed in global ejection fraction (50+/-12 --> 53+/-11%; p<0.05). In 107 revascularized territories, the average regional reversible defect score (0.8+/-0.5 --> 0.2 +/-0.3; p<0.0001), average regional perfusion score at rest (0.6+/-0.6 --> 0.3+/-0.4; p<0.0001), average regional wall motion score (0.9+/-0.7 --> 0.7+/-0.5; p<0.05), and end-diastolic wall thickness (8.1+/-1.3 --> 8.6+/-1.5 mm; p<0.0005) all improved significantly. Even in 34 non-revascularized territories, the average regional reversible defect score (0.5+/-0.7 --> 0.2+/-0.5; p<0.03), average regional wall motion score (0.8+/-1.1 --> 0.5 +/-1.0; p<0.03) and end-diastolic wall thickness (8.0+/-1.4 --> 9.1+/-2.0 mm; p<0.03) all improved significantly. These results indicate that improvement in myocardial ischemia, hibernation and left ventricular function with CABG can be assessed in detail with gated SPECT.

The present study was conducted to evaluate the influences of age and gender on the results of noninvasive brachial-ankle pulse wave velocity (baPWV). In 12517 subjects who had no medication and no history of cardiovascular diseases, multiple regression analysis demonstrated that age, blood pressure, body mass index, triglycerides, blood glucose, and uric acid were significant variables for baPWV in both genders. From this population, we extracted 7881 "healthy subjects" (4488 males and 3393 females, 25-87 years) without any of the atherogenic risk factors, and the results of baPWV were analyzed chronologically in 5-year age intervals. baPWV was lower in females than in males until age 60, and became similar in both genders over age 60. Multiple regression analysis demonstrated that not only the value of R(2) but also the coefficient of the effect of age on baPWV are larger in females than in males. In the estimation of the regression curve, the relationship between age and baPWV demonstrated a quadratic curve in both genders. Thus, aging influences baPWV, and its effect is more prominent in female. Menopause seems to be the crucial phenomenon to explain the augmented increase in arterial stiffness with aging in females.

To evaluate cardiac complications associated with electrical injury, 7 patients with high-tension electrical injury (6,600 V alternating current) underwent 201Tl and 123I-metaiodobenzylguanidine (MIBG) imaging in addition to conventional electrocardiographic and echocardiographic assessments. Electrocardiography showed transient atrial fibrillation, second degree atrioventricular block, ST-segment depression, and sinus bradycardia in each patient. Echocardiography showed mild hypokinesis of the anterior wall in only 2 patients, but 201Tl and 123I-MIBG myocardial scintigraphy showed an abnormal scan image in 6/7 and 5/6 patients, respectively. Decreased radionuclide accumulation was seen primarily in areas extending from the anterior wall to the septum. Decreased radionuclide accumulation was smaller in extent and milder in degree in 123I. MIBG than in 201Tl imaging. These results suggest that even in patients without definite evidence of severe cardiac complications in conventional examinations, radionuclide imaging detects significant damage due to high-tension electrical injury, in which sympathetic nerve dysfunction might be milder than myocardial cell damage.

Although a relationship between the coronary pressure-derived fractional flow reserve (FFR) and the presence of myocardial ischemia as demonstrated by radionuclide imaging has been reported in a select group of patients, it remains to be established whether this relation also holds true in actual clinical settings with a heterogeneous group of patients. Accordingly, 194 coronary vessels and their supply territories were evaluated in 165 consecutive patients with suspected or known coronary artery disease. An FFR <0.75, which is regarded as indicative of functionally important stenosis, showed a significant correlation with the redistribution of (201)Tl (p<0.0001), with a sensitivity of 79% and specificity of 73%. In 70 infarct-related coronary arteries, the sensitivity and specificity were 79% and 75%, respectively, whereas in the 124 remaining vessels that were not related to the myocardial infarct, the sensitivity and specificity were 80% and 72%, respectively. In addition, the FFR exhibited a significant inverse correlation with the (201)Tl reversibility score (r=-0.62; p<0.0001). These results suggest that the FFR has a significant relationship with scintigraphic evidence of myocardial ischemia and can be regarded as a marker of its presence or absence in patients in actual clinical settings.

Objectives: To assess the clinical significance of iodine-123 beta-methyl-p-iodophenyl-pentadecanoic acid(BMIPP) single photon emission computed tomography(SPECT), the predictive value of BMIPP imaging in patients with angina pectoris was evaluated., Methods: One hundred seventy-four patients who underwent BMIPP imaging in our institution were aged 61.8 +/- 11 years. One hundred thirty-five patients had stable angina and 39 had unstable angina at the time of examination. Patients with previous myocardial infarction or myocardial disorders were excluded. Early and delayed images were acquired in BMIPP SPECT, and the images were analyzed visually. Cardiac events were classified into hard and soft events: the former consisted of cardiac death and nonfatal myocardial infarction, and the latter included coronary revascularization and heart failure., Results: The findings of BMIPP imaging were normal in 82 patients and abnormal in 92. During follow-up of 15.5 +/- 9.5 months, hard events were observed in 4 patients and soft events in 53. In patients with normal BMIPP imaging, soft events were observed in nine patients, but no hard event was encountered. Furthermore, in patients with both normal BMIPP and stress thallium imagings, no cardiac event was observed during 2 years. In contrast, 4 hard events and 44 soft events occurred in patients with abnormal BMIPP imaging. Patients with abnormal BMIPP imaging had a higher incidence of soft events than those with normal BMIPP imaging, regardless of the type of angina(16/62 vs 3/73, p < 0.0005 for stable angina; 28/30 vs 6/9, p < 0.0001 for unstable angina)., Conclusions: The finding of BMIPP imaging correlates well with the mid-term prognosis of patients with angina pectoris. Since BMIPP SPECT is performed without stress to the patient, this imaging modality is important in evaluating patients with stable or unstable angina.

To elucidate clinical features of infective endocarditis in the elderly, 20 elderly patients aged > or = 60 years were compared in detail with 30 others aged < 60 years retrospectively. Twelve of the 20 elderly patients had a calcific aortic valve or an artificial device as a predisposing heart disease, whereas 16 middle-aged patients had mitral valve prolapse or congenital heart disease (p = 0.001). The prevalence of major extracardiac disorders such as neurological disease were higher in the elderly than in the middle (9/20 vs 3/30; p < 0.01). The frequency of infected valve was similar; mitral in 8, aortic in 11 and other valves or congenital defect in 2 in the elderly versus 14, 11 and 6, respectively in the middle. Among 39 patients in whom causative microorganisms were identified, staphylococcus epidermidis was most frequently identified in the elderly (5/20), whereas streptococcus species was found in the middle (12/30). Time from the onset of symptoms to correct diagnosis was usually delayed in the entire group; the delay was longer particularly in the elderly than in the middle-aged patients (72 +/- 87 vs 36 +/- 32 days; p < 0.1). Maximal body temperature was less in the elderly than in the middle-aged patients (38.5 +/- 0.7 vs 39.3 +/- 1.1 degrees C; p < 0.01), whereas peak level of C-reactive protein (10.4 +/- 6.1 vs 13.0 +/- 7.9 mg/dL), the incidences of heart failure (9/20 vs 10/30), and embolic complications (7/20 vs 10/20) were similar in the 2 groups. Cardiac operation was performed less in the elderly than in the middle-aged patients (9/20 vs 21/30; p < 0.08). Five elderly patients had disease-related mortality, whereas only one middle-aged patient died (p = 0.02). These results suggest that although predisposing heart disease and causative microorganism in infective endocarditis are different between the elderly and middle-aged patients, the incidence of major complications are similar. However, due to the delay of correct diagnosis in the elderly who usually have major extracardiac disorders, the prognosis of infective endocarditis in the elderly is poor.

Eighteen patients with heart failure were studied to clarify whether angiotensin-converting enzyme inhibitor treatment improves excess ventilation during exercise. Treatment with angiotensin-converting enzyme inhibitors had a beneficial effect on excess ventilation during exercise, without significant improvement in exercise capacity in patients with moderate congestive heart failure.

The clinical benefit of cholesterol-lowering treatment is unknown in the Japanese elderly in whom the prevalence of morbidity and mortality related to coronary artery disease are known to be low. To evaluate the efficacy of cholesterol-lowering treatment with 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor in Japanese elderly patients with documented coronary artery disease, 121 patients with serum cholesterol > or = 150 mg/dl prospectively received HMG-CoA reductase inhibitor, and 271 patients undergoing cholesterol-lowering treatment based on dietary therapy alone served as historical controls. The 143 elderly patients age > or = 65 years in the 2 groups had similar baseline serum total cholesterol level (201 +/- 30 vs 202 +/- 31 mg/dl), age (71 +/- 4 vs 70 +/- 4 years), proportion of men (37/53 vs 64/90), number of diseased vessels (1.7 +/- 0.9 vs 1.5 +/- 1.0), and incidences of other classical coronary risk factors, including hypertension, diabetes mellitus, smoking, obesity and family history of coronary artery disease. In all 392 patients, similar trends were observed, including serum total cholesterol level (208 +/- 33 vs 201 +/- 34 mg/dl). With HMG-CoA reductase inhibitors, serum total cholesterol level was reduced by 14% in the elderly subjects and by 13% in all patients. During the follow-up of approximately 3 years, cardiac events occurred in 5 patients (one elderly) in the treatment group and 38 patients (12 elderly) in the control group. Kaplan-Meier survival estimates revealed a higher event-free survival rate with HMG-CoA reductase inhibitors in the elderly subjects (98% vs 85%, p < 0.05) and in all patients (94% vs 86%, p < 0.05). Cox proportional hazard modeling also demonstrated a significant reduction in risk for cardiac events with drug therapy (relative risk 0.32, p < 0.05), in addition to the number of diseased vessels (relative risk 1.8, p < 0.01). In contrast, no additional risk was observed with advancing age. Cholesterol-lowering treatment with HMG-CoA reductase inhibitors is effective to improve the prognosis of Japanese elderly patients, including those with normal serum cholesterol level.

To evaluate the functional recovery after coronary bypass surgery in patients with severe left ventricular (LV) dysfunction (ejection fraction (EF) < or = 35%), 100 consecutive patients with viable myocardium in the territory supplied by the left anterior descending artery (LAD) underwent coronary bypass grafting. In addition, cardiac catheterization and single-photon emission computed tomography (SPECT) perfusion imaging with thallium-201 were repeated 1-year postoperatively. Although 12 patients with severe LV dysfunction were preoperatively in a worse New York Heart Association functional class (3.1+/-0.7 vs 2.4+/-0.8; p<0.01), had a higher incidence of heart failure (10/12 vs 14/88; p<0.001) and had a worse LVEF (29+/-5 vs 61+/-14%; p<0.001) compared with 88 patients without severe LV dysfunction, the operative mortality was similar in the 2 groups (1/12 vs 2/88; p=NS). The postoperative NYHA functional class in the patients with severe LV dysfunction was similar to that in the patients without such dysfunction (1.6+/-0.7 vs 1.3+/-0.6; p=NS). In addition, the 1-year postoperative study revealed a significant improvement in the thallium defect score in both the LAD territory (1.7+/-1.2 to 0.7+/-1.0, p=0.01) and all the territories (5.2+/-2.2 to 3.2+/-1.9, p=0.002) in patients with severe LV dysfunction, whereas no improvement in defect score was found in either of these territories in those without severe LV dysfunction (LAD: 0.6+/-1.4 to 0.4+/-1.2, p=NS; All: 1.9+/-2.2 to 1.8+/-2.0, p=NS). Furthermore, a marked 1-year postoperative improvement (15-24%; 95% confidence interval) in LVEF (29+/-5 to 48+/-10%, p<0.001) was demonstrated in patients with severe LV dysfunction, but not in those without such dysfunction (60+/-13 to 61+/-11%, p=NS). These results indicate that myocardial viability in the LAD territory, as demonstrated by thallium-201 SPECT perfusion imaging, predicts a significant improvement in functional class and LVEF of at least 10% or more after coronary artery bypass grafting in patients with severe LV dysfunction.

Although the aVL lead in exercise electrocardiography is reported to be helpful in identifying a significant narrowing of the left anterior descending coronary artery (LAD), its role in exercise testing has not been fully evaluated. Accordingly, 821 patients who underwent both standard exercise testing and coronary angiography were evaluated. In patients with aVL lead ST elevation, the incidence of a significant narrowing of the LAD (124/165 vs 348/656; p<0.001) was higher than in those without. Multiple logistic regression analysis revealed that the 2 most important variables that correlated with aVL lead ST elevation were a greater number of leads with ST depression in the inferior leads and a smaller amplitude of R wave in the aVL lead. In contrast, variables correlating with aVL lead ST depression in the majority of cases were a greater number of leads with ST depression in all leads and the presence of inferior lead ST elevation. The results of this study indicate that although aVL lead ST elevation could be a marker for LAD narrowing, more important factors such as inferior lead ST-segment depression and the R-wave amplitude of the aVL lead should be taken into consideration. In contrast, ST depression in the aVL lead mostly represents exercise-induced myocardial ischemia of greater extent and severity.

To detect a significant narrowing of the left anterior descending artery in patients with inferior/posterior myocardial infarction, 200 patients underwent standard exercise testing. Age, gender, and grade of stenosis of the left anterior descending artery were similar in 138 patients with inferior myocardial infarction and 62 with posterior myocardial infarction. In patients with left anterior descending artery stenosis, there were more lateral leads with ST-segment depression (1.8+/-1.0 vs 1.1+/-1.1; p<0.01) and fewer anterior leads with ST-segment depression (2.1+/-1.4 vs 2.9+/-1.4; p=0.02) in those with inferior myocardial infarction than in those with posterior myocardial infarction. Applying the criterion of exercise-induced ST-segment depression > or = 0.1 mV, sensitivities and specificities in detecting left anterior descending artery stenosis were 98% and 21% respectively in inferior myocardial infarction and 94% and 26% respectively in posterior myocardial infarction. In contrast, discriminant analysis revealed sensitivities and specificities of 77% and 91% respectively in inferior myocardial infarction and 71% and 81% respectively in posterior myocardial infarction using the variables related to severity of inducible ischemia and lateral and anterior lead ST-segment depression. These results indicate that a multivariate approach underscoring the site of myocardial infarction can help in identifying stenosis of the left anterior descending artery in patients with inferior/posterior myocardial infarction.

The clinical significance of silent myocardial ischemia (SMI) in the elderly was assessed in 91 patients with Q wave infarction who showed ischemic ST depression during treadmill stress testing, as well as reversible defect (RD) during dipyridamole thallium imaging. They were divided into two groups (47 patients with silent ST depression and 44 patients with painful ST depression) and compared for scintigraphic and coronary arteriographic features, and prognosis. There was no significant difference in age, gender and site of infarction between the two groups. The prevalence of single and double vessel coronary stenosis was higher in patients with SMI (66%) than in those with painful ischemia (p < 0.05). The results of treadmill stress testing showed a longer exercise duration (4.7 +/- 1.7 vs. 4.1 +/- 1.8 min) and higher maximal heart rate (138 +/- 15/vs. 126 +/- 20/min) in patients with SMI than in those with painful ischemia (p < 0.01). Dipyridamole thallium imaging revealed a larger infact (18.8 +/- 9.1 vs. 14.6 +/- 10.2 segments) in patients with SMI than in those with painful ischemia (p < 0.05). The prevalence of RD in the area of infarction was also higher in patients with SMI (74%) than in those with painful ischemia (45%) (p < 0.05). Although a higher proportion of the patients with painful ischemia (42%) underwent CABG or PTCA as their initial therapy, compared with those with SMI (25%) (ns), there was no difference in the cardiac event rate between the two groups who were initially treated medically. Dipyridamole thallium imaging is useful in the assessment of SMI in elderly patients with Q wave myocardial infarction. Those with SMI may have a larger infarct and a higher prevalence of ischemia localized within the infarction than those with painful ischemia.

An autopsy case of a 58-year-old woman with massive cardiac involvement of adult T cell leukemia/lymphoma (ATLL) is reported. She developed cardiac failure due to aortic and mitral regurgitation with cardiac infiltration of ATLL cells, and underwent replacement of both aortic and mitral valves. Studies of the cut-surfaces revealed diffuse thickening of the subendocardial wall of the left chamber with widespread whitish-brown tumor infiltrates. In the regions surrounding the replaced aortic and mitral valves there was also massive tumor cell infiltration. The tumor cells infiltrating the cardiac muscle wall were T cell in origin and exhibited Leu-3a (CD4)-positive immunoreaction. Ultrastructurally, tumor cells contained markedly indented nuclei and some were attached directly to the muscle cells. These findings suggest that this was an unusual form of ATLL with widespread involvement of the heart.

To assess the clinical significance of silent myocardial ischemia (SMI) in the elderly, 113 patients with stable angina who showed ischemic ST depression during treadmill stress testing were studied by dipyrimadole thallium imaging and coronary arteriography. They were divided into two groups: 44 patients with silent ST depressions and 69 patients with painful ST depressions. The groups were compared for scintigraphic and coronary arteriographic features as well as prognosis. There was a significantly greater proportion of older patients (> or = 65 years) in the group with SMI (64%) than in the group with painful ischemia (38%) (p < 0.01), although there was no difference in the mean ages of the two groups. The prevalence of multivessel coronary stenosis was not significantly different between the two groups (45% in the SMI group and 61% in the group with painful ischemia). Treadmill stress testing showed no differences in exercise duration, maximal heart rate, maximal systolic blood pressure, or maximal ST depression between the two groups. Dipyrimadamole thallium imaging revealed similar results in the site of reversible defects (RD), i.e. 76% in the anterior area and 24% in the inferior area in patients with SMI, and 83% in the anterior area and 17% in the inferior area in patients with painful ischemia. However, the size of RD was significantly smaller in patients with SMI, i.e. 14.6 +/- 6.1 segments in patients with SMI and 18.7 +/- 8.3 segments in patients with painful ischemia (p < 0.05). Although a significantly higher proportion of patients with painful ischemia (48%) underwent PTCA or CABG as their initial therapy as compared to those with SMI (16%), there was no significant difference in the cardiac event rate between the two groups initially treated medically. Among patients with stable angina, those with SMI may have a smaller amount of ischemic myocardium and may be older in a greater proportion than those with painful ischemia. Dipyrimadole thallium imaging is useful in the assessment of SMI in the elderly.

To evaluate the relation between blood pressure and diastolic function in the elderly, 28 apparently healthy volunteers underwent blood pressure measurements, echocardiographic examinations, and radionuclide angiography acquired in list mode. Casual blood pressure did not correlate with diastolic indices measured either by echocardiography or by a radionuclide method, except for peak filling rate during atrial contraction assessed by radionuclide angiography (r = 0.39, p < 0.05). Ambulatory blood pressure monitoring revealed significant correlations between peak filling rate during atrial contraction assessed by radionuclide angiography and blood pressure measured over 24 hours, while awake and during sleep. The time to peak filling rate and the velocity of early diastolic filling were found to correlate with blood pressure, but the best correlation was between blood pressure during sleep and peak filling rate during atrial contraction (r = 0.53, p < 0.005). These results show a direct relation between blood pressure and diastolic function in the elderly, which is stronger during sleep than during wakefulness.

The autonomic nervous system importantly regulates coronary arterial tone and vascular resistance. To evaluate a role of autonomic nervous activity and the effects of calcium antagonist in patients with vasospastic angina (VSA), 13 VSA patients with patent coronary arteries (58+/-8 years) and 8 normal subjects (58+/-12 years) were studied. Arterial pressure and electrocardiogram were continuously recorded with the patient in a supine position under controlled respiration (0.2 Hz). Low-frequency (LF) and high-frequency (HF) components of the beat-to-beat variabilities of systolic arterial pressure and RR interval were then estimated by autoregressive power spectral analysis. The LF power (normalized unit) of both systolic arterial pressure (0.53+/-0.17 vs 0.30+/-0.17, p < 0.01) and RR variabilities (0.51+/-0.20 vs 0.31+/-0.16, p < 0.05) in patients with VSA were greater than that in normal subjects. There was no significant difference in the HF power. Seven patients with VSA who were treated with diltiazem (60 to 200 mg/day) had normalized LF power (normalized unit) of both systolic arterial pressure (0.62+/-0.12 vs 0.33+/-0.16, p < 0.01) and RR variabilities (0.55+/-0.23 vs 0.36+/-0.14, p < 0.05), together with clinical improvement. An increased sympathetic vasomotor tone and cardiac sympathetic predominance may play an important role in patients with VSA. Diltiazem improves these sympathetic hyperactivities.

A 32-year-old woman presented with a rare case of tricuspid valve endocarditis causing inflammatory reopening of the spontaneously closed ventricular septal defect (VSD), associated with aortic valve malformation. She was admitted to our hospital because of fever lasting 4 weeks. Severe aortic regurgitation was revealed by color Doppler echocardiography. Blood culture identified Microccus faecalis. Antibiotics were administered over 3 weeks, but serial echocardiography showed a developing vegetation in the right ventricle and left-to-right shunt flow. The diagnosis was infective endocarditis complicated by aortic ring abscess and interventricular septal fistula. Surgery performed on the 22nd hospitalized day found a vegetation of the tricuspid valve, a membranous type of VSD, and aortic valve malformation. Aortic valve replacement, patch closure of VSD, and tricuspid valvuloplasty achieved a successful outcome.

To elucidate which clinical features produce U-wave inversion, 339 patients with severe narrowing of the left anterior descending artery were evaluated. In patients with anterior myocardial infarction, extensive coronary artery disease and protected left anterior descending arterial territory are essential in the development of U-wave inversion, whereas electrocardiographic changes at rest in addition to anterior lead ST depression, rather than coronary anatomy, are important in those without anterior myocardial infarction.

Patients suspected of having coronary artery disease (CAD) underwent dipyridamole thallium scintigraphy, exercise electrocardiography, and coronary angiography. Of the 500 patients studied, 163 were at least 65 years old, and 337 were less than 65 years old. Both CAD and multivessel CAD were more common in elderly than in younger patients (81% vs 69%, p < 0.01 for CAD; and 43% vs 26% p < 0.01 for multivessel CAD). In patients without myocardial infarction, the specificity of exercise electrocardiography was lower among elderly patients than among younger patients (52% vs 61%), but the sensitivity was higher (87% vs 75%). In contrast, both the sensitivity and the specificity of dipyridamole thallium scintigraphy were similar in the two age groups (86% vs 87% and 79% vs 74%). Among patients with myocardial infarction and a positive exercise test, reversible defects were equally common in the two age groups (60% vs 58%). The reversible defects were in areas remote from the area of infarction in half of the patients in both groups. Among patients with negative exercise-test results, reversible defects were more common in elderly patients than in younger patients (57% vs 38%). The reversible defects were in the infarcted area in 71% and 79% of these patients, respectively. These results indicate that dipyridamole thallium scintigraphy is a sensitive and specific method for detecting CAD, independent of age. It is particularly useful in identifying myocardial viability in the infarcted area.

Objectives: To elucidate whether atherosclerotic aortic plaque detected by transesophageal echocardiography can be a clinically useful marker for coronary artery disease in the elderly., Background: Atherosclerotic aortic plaque detected by transesophageal echocardiography has been reported to be a marker for coronary artery disease. Its significance may be important particularly in the elderly population, although to our knowledge, there are no data yet available., Methods: We performed transesophageal echocardiography on 84 patients who had previously undergone coronary arteriography. The criteria used to diagnose atherosclerotic plaque on transesophageal echocardiography were the presence of focally or linearly increased echodensity of the aortic intima with lumen irregularity and thickening or ulceration., Results: Significant coronary artery disease (> or = 50% stenosis) was detected in at least one major coronary artery in 27 of the 84 patients. Aortic plaques were detected by transesophageal echocardiography in 25 of the 27 patients (93%) with coronary artery disease and in 30 of 57 patients (53%) without coronary disease (p<0.001). Among 24 patients 70 years or older, aortic plaques were present in 13 of 14 (93%) patients with coronary artery disease and 9 of 10 patients (90%) without coronary disease. Among 60 patients younger than 70 years, aortic plaques were present in 12 of 13 patients (92%) with coronary artery disease and 21 of 47 patients (45%) without coronary disease (p<0.01). The independent association between coronary artery disease and the presence of aortic plaque, age, gender, and other coronary risk factors was examined by multiple logistic regression analysis. In patients 70 years or older, the presence of aortic plaque failed to be a predictor of significant coronary artery disease, although it was indeed a strong predictor of coronary artery disease in patients younger than 70 years (p<0.05)., Conclusions: In elderly patients, atherosclerotic aortic plaque detected by transesophageal echocardiography is not useful in predicting significant coronary artery disease. It is useful only in a relatively younger population.

Thirty-four patients with idiopathic dilated and ischemic cardiomyopathy underwent a symptom-limited cardiopulmonary exercise testing to evaluate the significance of postexercise blood pressure (BP) response. The postexercise BP response was useful in assessing the impaired exercise capacity and increased sympathetic activity in patients with heart failure.

To evaluate the clinical significance of silent myocardial ischemia in elderly patients with coronary artery disease, 147 patients (aged 65 years and older) underwent coronary angiography and dipyridamole thallium scintigraphy. Seventy-four patients (44 men, 30 women) who showed reversible defects (RD) and ischemic ST depression during scintigraphy were divided into two groups: 13 with silent RD (18%, 12 men, 1 woman), and 61 with painful RD (82%, 32 men, 29 women). Most patients with silent RD were men. The prevalence of myocardial infarction was similar in patients with silent RD (62%) and in patients with painful RD (49%). The prevalence of multivessel disease was also similar in the two groups: 85% in patients with silent RD and 82% in patients with painful RD. Among 38 patients with infarction, 8 had silent RD and 30 had painful RD. The prevalence of RD in the area of infarction was greater in patients with silent RD (63%) than in patients with painful RD (47%), but the difference was not statistically significant. The prevalence of extensive infarction (fixed defects) was greater in patients with silent RD (75%) than in patients with painful RD (30%, p < 0.05). Among 36 patients without infarction, there was no scintigraphic parameter which showed significant difference. Bypass grafting and angioplasty were initially performed in 23% of the patients with silent RD and in 36% of the patients with painful RD (ns). When the two groups were treated medically during the follow-up period of 29 +/- 22 months, the incidences of cardiac events were similar: 10% in patients with silent RD and 13% in patients with painful RD. The prevalence of silent RD is not high in elderly patients with significant coronary artery disease. Compared with the patients with painful RD, those with silent RD were more likely to have an old and extensive myocardial infarction, and they tended to have RD in the area of the infarct.

To determine the prognostic value of serum cholesterol level in Japanese patients with established coronary artery disease, we followed 330 consecutive patients with a left ventricular ejection fraction of > or = 50%. Over a period of 4.0 +/- 2.5 years, 53 patients (16%) experienced cardiac events. Multivariate analysis using Cox proportional hazard modeling revealed that obesity (risk ratio 4.3; p = 0.0001), the number of diseased vessels (risk ratio 1.9; p = 0.0001) and a serum cholesterol level > or = 220 mg/dl (risk ratio 2.3; p = 0.01) or > or = 200 mg/dl (risk ratio 2.1; p < 0.02) increase the risk of cardiac events. These results suggest that patients with established coronary artery disease and a serum cholesterol level > or = 200 mg/dl have a similar risk of experiencing a cardiac event as patients without left ventricular dysfunction and a serum cholesterol level > or = 220 mg/dl. Although the prevalence of coronary artery disease is low in Japan, the serum cholesterol level should be strictly controlled in subjects with established coronary artery disease to avoid future cardiac events.

A 73-year-old man was admitted because of progressive dyspnea. Echocardiography revealed a markedly dilated right sinus of Valsalva and severe aortic regurgitation. Coaptation loss of the aortic valve leaflets was thought to be the cause of regurgitation and congestive heart failure, a rare complication of the unruptured sinus of Valsalva aneurysm. Surgical treatment should be considered to prevent life-threatening heart failure and rupture of the aneurysm even in patients without overt heart failure.

A prominent U wave induced by exercise testing in patients with anterior wall myocardial infarction is a highly specific but insensitive marker for the narrowing of the left circumflex or right coronary artery, although a U-wave increase alone with or without ST-segment depression may help better identify these coronary artery narrowings. In patients with inferior and/or posterior myocardial infarction, a prominent U wave is regarded as a simple electrocardiographic marker for inferior and/or posterior residual ischemia.

Two cases of Candida endocarditis are reported. The first case was of a 63-year-old man who had a positive blood culture for Candida albicans during treatment for liver abscess and early gastric cancer. He was transferred to our department, and aortic and tricuspid regurgitation due to Candida endocarditis was diagnosed. The patient was successfully treated with aortic valve replacement, tricuspid valve plasty and anti-fungal agents. The second case was of a 65-year-old man who complained of fever. Despite a diagnosis of common bile duct cancer and resection of the tumor, the fever persisted. He was transferred to our department and was diagnosed having aortic regurgitation due to Candida endocarditis, complicated by heart failure. Although intense medical therapy including antifungal agents, diuretics, catecholamines and digoxin was initiated, the patient died from multiple embolisms 9 days later. In the treatment of Candida endocarditis, early diagnosis and early decision-making for either surgical or medical therapy is indispensable. Although the prevalence of Candida endocarditis is low, the differentiation of this disease should be taken into account in febrile elderly patients with long-standing therapy with antibiotics.

The autonomic nervous system may play an important role in regulating coronary arterial tone. To evaluate the role of autonomic nervous activity in patients with vasospastic angina (VSA), we studied 10 VSA patients with patent coronary artery (mean; 56 yr, range; 44-66 yr) and 8 normal subjects (mean; 58 yr, range; 35-71 yr). ECG and arterial pressure were continuously recorded for 4 min in a supine position at 7:30 am, 10:30 am, and 4:30 pm. Low-frequency (LF; 0.04-0.15 Hz) and high-frequency (HF; 0.20 Hz) components of the beat-to-beat variabilities of the R-R interval (RRI) and systolic arterial pressure (SAP) were then estimated by autoregressive power spectral analysis. The LF-Normalized Power (LF-NP; [LF Power]/[Total Power]-[Direct Current Power]) of both the RRI and SAP variabilities were greater in VSA patients than in normal subjects (RRI: 0.51 +/- 0.07, 0.51 +/- 0.07, 0.53 +/- 0.06, vs 0.25 +/- 0.04, 0.31 +/- 0.05, 0.31 +/- 0.06, at 7:30 am, 10:30 am, and 4:30 pm respectively: p = 0.010, 0.044, 0.018. SAP: 0.62 +/- 0.06, 0.53 +/- 0.06, 0.57 +/- 0.06 vs 0.37 +/- 0.04, 0.30 +/- 0.06, 0.26 +/- 0.07, respectively: p = 0.006, 0.017, 0.003.). The LF-power of SAP variability also tended to be greater in VSA patients. There was no difference in the HF-component coefficient of variance (CCV (%) = 100 x (component power) (1/2)/ mean RR intervals) of the RRI variabilities between the 2 groups. These results indicate that increased sympathetic vasomotor tone and cardiac sympathetic predominance may play an important role in patients with VSA.

A 64-year-old man, who had had bilateral intermittent claudication and leg pain for five years, was admitted because of sudden onset of severe leg pain, and acute respiratory failure. Laboratory data showed markedly elevated serum CK of 73,050 IU/L, and urinary myoglobin of 430,000 ng/ml. A diagnosis of rhabdomyolysis was made. Renal dialysis was required for the next two days because of acute renal failure. The aortogram was performed on the 32nd day and disclosed complete obstruction of the abdominal aorta immediately distal to the bilateral renal arteries. Good collateral flow was noted to the popliteal arteries. On the 49th day, the patient successfully underwent extra-anatomical bypass surgery (axillo-bifemoral bypass). The mechanism of rhabdomyolysis in this elderly patient was discussed.

A 42-year-old man and a 65-year-old woman with infective endocarditis suffered onset of severe back pain. Magnetic resonance imaging and technetium-99 m bone scanning demonstrated osteomyelitis in the lumbar spine which is an unusual complication of infective endocarditis. The man was treated by antibiotics and finally aortic valve replacement and laminectomy with bone grafting. The woman had small patent ductus arteriosus and developed aortic regurgitation, but was treated by antibiotics and corset application with good result. The possibility of osteomyelitis in the lumbar spine should be considered in a patient with endocarditis complaining of severe back pain. The appropriate antibiotic therapy over a prolonged period is recommended.

Patients with myocardial infarction (MI) and triple vessel coronary disease generally have poor prognoses. However, it is not known whether there are particular angiographic variables associated with the poor prognosis in MI patients with triple vessel disease. The angiographic variables for poor prognosis were investigated in 43 MI patients with triple vessel disease (32 men and 11 women, mean age 63 +/- 9 years) who were followed medically for a mean of 32 +/- 28 months. There were 13 cardiac deaths (30%) and 10 late-coronary artery bypass grafting (23%). Twenty patients were alive and well. The patients who died of cardiac causes had lower ejection fractions (42 +/- 18% vs 49 +/- 15%, p < 0.05), a higher prevalence of two vessel occlusion (77% vs 40%, p < 0.05), and a higher prevalence of coronary occlusion opposite the MI site (69% vs 25%, p < 0.01) when compared to survivors, although there were no significant differences in age, MI sites, or the prevalence of occlusion in the infarct-related artery. Multivariate analysis with the Cox proportional hazards model revealed that coronary occlusion opposite the MI site (hazards ratio 16.36) and an age of > or = 65 years (4.46) indicated a significantly high ratio. The hazard ratio of the ejection fraction and two vessel coronary occlusion were not significant. The poor prognosis of MI patients with triple vessel coronary disease may be related to impaired left ventricular function and to coronary occlusion opposite the MI site and greater age. This may have important clinical implications in the initial decision for interventional therapy.