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Reportedly, approximately 9.9%-12.4% of patients with Takotsubo syndrome (TTS) are complicated with cardiogenic shock (CS) and its prognosis remains poor even with the support of conventional mechanical circulatory assist devices including intra-aortic balloon pumping and venoarterial extracorporeal membrane oxygenation. Impella, a novel percutaneous left ventricular assist device, provides strong circulatory support together with the unloading of the left ventricle, and it is theoretically a promising mechanical circulatory assist device for TTS. In this case study, we report four consecutive patients with TTS complicated with CS who were successfully resuscitated using the Impella support.

Fatty liver index (FLI), a predictor of nonalcoholic fatty liver disease, has been reported to be associated with several metabolic disorders. This study aimed to evaluate the relationship between FLI and new onset of diabetes mellitus (DM). We investigated the association of FLI with new onset of DM during a 10-year period in subjects who received annual health examinations (n = 28,990). After exclusion of subjects with DM at baseline and those with missing data, a total of 12,290 subjects (male/female: 7925/4365) who received health examinations were recruited. FLI was significantly higher in males than in females. During the 10-year period, DM was developed in 533 males (6.7%) and 128 females (2.9%). Multivariable Cox proportional hazard models with a restricted cubic spline showed that the risk of new onset of DM increased with a higher FLI at baseline in both sexes after adjustment of age, fasting plasma glucose, habits of alcohol drinking and current smoking, family history of DM and diagnosis of hypertension and dyslipidemia at baseline. When the subjects were divided into subgroups according to tertiles of FLI level at baseline (T1–T3) in the absence and presence of impaired fasting glucose (IFG), hazard ratios after adjustment of the confounders gradually increased from T1 to T3 and from the absence to presence of IFG in both male and female subjects. In conclusion, a high level of FLI predicts new onset of DM in a general population of both male and female individuals.

Purpose Since December 2019, coronavirus disease 2019 (COVID-19) has spread rapidly across the world. During the pandemic, physicians in our hospital have had to respond both to the issue of treating the patients and the increasing domestic burden associated with social disruption. The purpose of this study was to assess how much the burden on our doctors, especially female doctors, was increasing. Material and methods The Physicians’ Career Support Committee in Sapporo Medical University conducted a questionnaire survey. The questionnaire inquired about a wide range of subjects with regard to working style and family life during the first and second waves of the COVID-19 pandemic, and was sent to all medical/dental physicians working in Sapporo Medical University. Results A total of 266 (42.7%) physicians in our hospital responded to our questionnaire and the data for 264 data were analyzed. The total numbers of males, females, and others, including those who did not want to specify, were 178 (67.4%), 82 (31.0%), and 4 (1.5%), respectively. Among them, 62 (23.5%) and 23 (8.7%) answered that their domestic burden was slightly or markedly increased. The increase in the domestic burden showed a significant difference between genders (p = 0.04). Even after correction for background differences using multivariate analysis, being female (p Conclusion Physician-mothers are caught in a dilemma between an increased home burden and clinical duties in the hospital, with a significantly higher ratio than physician-fathers during the pandemic. As we showed, female doctors could have not continued their careers and take responsible positions in the same way as male doctors. This is a social risk in the timing of a crisis, such as a pandemic.

BACKGROUND How the time sequence of cardiopulmonary resuscitation (CPR) procedures is related to clinical outcomes in patients with out-of-hospital cardiac arrest (OHCA) remains unclear. This study examined the impact of the time interval from collapse to start of CPR (no-flow time, NF time) and the time interval from start of CPR to implementation of extracorporeal CPR (ECPR) (low-flow time, LF time) on neurological outcomes.Methods and Results:During the period from 2010 to 2015, we enrolled 85 patients who received ECPR. Fourteen patients (16.5%) showed favorable 30-day neurological recovery. NF time was shorter in the favorable neurological recovery group than in the unfavorable recovery group (1.4±3.0 vs. 5.2±5.8 min, P

Which combination of clinical parameters improves the prediction of prognosis in patients with pulmonary arterial hypertension (PAH) remains unclear. We examined whether combined assessment of pulmonary vascular resistance and right ventricular function by echocardiography is useful for classifying risks in PAH. In 41 consecutive patients with PAH (mean age of 48.9 ± 17.3 years, 31 females), a 6-min walk test, pulmonary function test, and echocardiography were performed at baseline and during PAH-specific therapies. The study endpoint was defined as a composite of cardiovascular death and hospitalization for PAH and/or right ventricular failure. During a follow-up period of 9.2 ± 8.7 months, 18 patients reached the endpoint. Multivariate regression analysis showed that the ratio of tricuspid regurgitation pressure gradient to the time-velocity integral of the right ventricular outflow tract (TRPG/TVI) and tricuspid annular plane systolic excursion (TAPSE) during PAH-specific treatment were independent prognostic predictors of the endpoint. Using cutoff values indicated by receiver operating characteristic analysis, the patients were divided into four subsets. Multivariate analyses by Cox's proportional hazards model adjusted for age, sex and body mass index indicated that subset 4 (TRPG/TVI ≥ 3.89 and TAPSE ≤ 18.9 mm) had a significantly higher event risk than did subset 1 (TRPG/TVI 3.89 and TAPSE 18.9 mm): HR = 25.49, 95% CI 4.70-476.97, p 0.0001. Combined assessment of TRPG/TVI and TAPSE during adequate PAH-specific therapies enables classification of risks for death and/or progressive right heart failure in PAH.

Activity of mTOR complex 1 (mTORC1) has been shown to be up-regulated in animal models of heart failure. Here, we investigated the change and role of mTORC1 in human nonischemic dilated cardiomyopathy (NICM).Endomyocardial biopsy specimens were obtained from patients with NICM (n=52) and from Brugada syndrome patients with normal LVEF as controls (n=10). The specimens were stained for phospho-ribosomal protein S6 (p-Rps6) and phospho-p70S6K (p-p70S6K), and the area with p-Rps6 signal was used as an index of mTORC1 activity. Using median mTORC1 activity, patients were divided into a high mTORC1 activity (H-mTOR) group and a low mTORC1 activity (L-mTOR) group.The ratio of p-Rps6-positive area in biopsy samples was 10-fold larger in patients with NICM than in controls (2.0±2.2% vs. 0.2±0.2%, p0.01). p-p70S6K signal level was higher in the H-mTOR group than in the L-mTOR group. The proportion of patients with a family history of cardiomyopathy was higher and the proportion of patients on ACE inhibitors or angiotensin receptor blockers was lower in the H-mTOR group than in the L-mTOR group. The p-Rps6-positive area was correlated with extent of myocardial fibrosis (r=0.46, p0.01). The cardiac event-free survival rate during a 5-year follow-up period tended to be lower in the H-mTOR group than in the L-mTOR group (52.9% vs. 81.6%, P=0.10).Aberrant activation of mTORC1 in cardiomyocytes was associated with myocardial fibrosis and a trend for worse prognosis in patients with NICM, indicating that persistently activated mTORC1 contributes to progression of human heart failure.

Background Whether the short-term effect of cardiac rehabilitation (CR) in elderly patients with heart failure (HF) is influenced by nutritional status is uncertain, so the present study investigated the effect of nutritional status on functional recovery after CR in elderly HF inpatients.Methods and Results:We enrolled 145 patients admitted for treatment of HF who were aged ≥65 years and had a low functional status defined as a Barthel index (BI) score ≤85 points at the commencement of CR. Nutritional status was assessed by the Mini Nutritional Assessment Short Form (MNA-SF) and total energy intake per day. The primary endpoint was functional status determined by the BI score at discharge. The median CR period was 20 days (interquartile range: 14-34 days), and 87 patients (60%) were functionally dependent (BI score ≤85) at discharge. Multivariate logistic regression analysis showed that MNA-SF score (odds ratio [OR]: 0.76, P=0.02) and total energy intake at the commencement of CR (OR: 0.91, P=0.02) were independent predictors of functional dependence after CR. MNA-SF score ≤7 and total energy intake ≤24.5 kcal/kg/day predicted functional dependence at discharge with moderate sensitivity and specificity. Conclusions MNA-SF score and total energy intake at the commencement of CR are novel predictors of the extent of functional recovery of elderly HF inpatients after in-hospital CR.

Objective Although risk factors of atrial fibrillation (AF) in the general population have been characterised, their impacts on patients with specific diseases are unclear. Our aim was to determine whether risk factors of AF are different in patients with and those without coronary artery disease (CAD). Methods We enrolled 1871 consecutive patients who underwent coronary angiography for evaluation of symptoms suggestive of CAD in the BOREAS-CAG Registry between August 2014 and January 2015. After exclusion of patients with valvular heart disease or a history of PCI/cardiac surgery, 1150 patients contributed to multivariate logistic regression analysis to identify risk factors of AF. We also retrieved data for 361 consecutive patients with CAD admitted to Sapporo Medical University Hospital between April 2013 and July 2014 and analysed data for 166 patients using the same inclusion and exclusion criteria as those in the BOREAS-CAG Registry. Results Unexpectedly, CAD was independently associated with the absence of AF. The patients were then divided into a non-CAD group (n=576) and a CAD group (n=574) for further analysis. The brain natriuretic peptide level showed a strong association with AF regardless of the presence or absence of CAD. In the non-CAD group, lack of statin use was independently associated with AF, whereas high serum uric acid level was an independent explanatory variable of AF in the CAD group. The association of AF with uric acid was confirmed in a separate group of patients (n=166) enrolled in the CAD cohort in Sapporo Medical University Hospital. Conclusions Major risk factors of AF are different in patients with CAD and those without CAD. Patients with CAD are more likely to develop AF when the serum uric acid level is high, whereas no statin administration predicts development of AF in patients without CAD.

Whether different patterns of ventricular ballooning in takotsubo cardiomyopathy (TCM) reflect differences in trigger mechanisms or clinical outcomes is unclear. Here we examined differences in the clinical characteristics of typical and atypical forms of TCM. TCM patients (n = 251) in the BOREAS Registry were enrolled for comparison of TCM with apical ballooning (type A, n = 217) and TCM with non-apical ballooning (type non-A, n = 34). The percentage of females was significantly lower in the type non-A group (58.8 vs. 75.6 %), while other demographic parameters and triggers of TCM were similar in the two groups. Rate of mid-ventricular obstruction (MVO) was lower (2.9 vs. 14.3 %) in the type non-A group than in the type A group, though left ventricular ejection fractions in the two groups were comparable. During a follow-up period of 2.6 ± 2.8 years, TCM recurred in 2.9 % of the patients and cardiac death occurred in 4.0 %. Cox proportional hazard analysis indicated that body mass index (hazard ratio [HR]: 0.75, 95 % confidence interval [CI] 0.54-0.99) and MVO (HR: 14.71, CI 1.87-304.66) were determinants of TCM recurrence and that advanced age (HR: 1.09, CI 1.02-1.17) and cardiogenic shock (HR: 4.27, CI 1.07-18.93) were significantly associated with cardiac death. In conclusion, approximately 20 % of TCM patients show non-apical left ventricular ballooning, and female sex and MVO are less frequent in this type than in apical ballooning type TCM. Low body mass index and MVO are risk factors of recurrence, and advanced age and cardiogenic shock are risk factors of cardiac death in TCM.

Background Visceral injury is a life-threatening complication of cardiopulmonary resuscitation (CPR); however, the clinical significance has been masked by the lethal outcome of out-of-hospital cardiac arrest (OHCA). Objective The objective is to share our experience of successful treatment of OHCA patients with serious, CPR-related visceral complications. Case Reports We report two cases of cardiac-origin OHCA with liver injury exacerbated by heparinization during mechanical circulatory support. Although both patients presented with delayed massive liver bleeding (intrahepatic or peritoneal) that compromised hemodynamic status, one patient was successfully treated by selective transcatheter arterial embolization and the other by a surgical procedure. Conclusion Preventive measures such as careful CPR, as well as interventional or surgical repair after the early diagnosis of visceral injury, are required to improve the outcome in some cases of OHCA.

An iterative reconstruction method in combination with resolution recovery, attenuation and scatter corrections (IR-RASC) can improve image quality. It, however, is undetermined whether this technique can improve the detection of coronary artery disease (CAD) when automated quantitative analysis is used. This study evaluated diagnostic values of IR-RASC in combination with automated quantitative analysis in stress myocardial perfusion imaging (MPI) in the CAD detection. This study enrolled consecutive 64 patients (mean age 66.2 ± 17.3 years, 39 males) who had undergone both 99mTc-labeled tetrofosmin stress MPI and coronary angiography within 3 months. Stress MPI abnormalities quantified as summed stress score (SSS), summed rest score (SRS) and summed difference score (SDS) by Heart Risk View-S (HRV-S) and Quantitative Perfusion SPECT (QPS) softwares using IR-RASC images were compared with those by using conventional filtered back-projection method (FBP) images and angiographic findings. Based on expert visual assessment, SSS and SRS by HRV-S/QPS softwares with IR-RASC were significantly lower than those by HRV-S/QPS softwares with FBP at mid- and basal left ventricular segments. Receiver-operating characteristics analysis showed that areas under the curve assessed by HRV-S (0.687) and QPS (0.678) with IR-RASC were nearly identical to those (0.717–0.724) by expert assessment with FBP, and were significantly (P

Background Pulmonary hypertension (PH) is a strong predictor of mortality in patients with interstitial lung disease (ILD). However, patients with ILD often have poor outcomes even in the absence of PH. Pulmonary vascular resistance (PVR) assessed by right heart catheterization is a predictor of mortality in patients with ILD. However, the clinical utility of PVR assessed by Doppler echocardiography (PVRecho) as a predictor of the outcome in patients with ILD remains unclear. The aim of this study was to examine whether PVRecho independently predicts mortality in patients with ILD. Methods Echocardiographic examinations were performed in 133 consecutively enrolled patients with ILD (age, 67 ± 9 years; 53% men). Tricuspid annular plane systolic excursion (TAPSE) was measured, and PVRecho was calculated by the following formula: PVRecho = [TRV × 10/time-velocity integral of right ventricular outflow (RVOT-VTI)] + 0.16. Data for parameters of pulmonary functional tests and for serum biomarkers, which were measured within 3 months before or after the echocardiographic examinations, were collected. Results During a mean follow-up period of 18 ± 7 months, 13 patients died due to respiratory failure (n = 10), heart failure (n = 1), or unknown causes (n = 2). In univariate analysis, body mass index, idiopathic pulmonary fibrosis, use of an antifibrotic drug (AD), RVOT-VTI, PVRecho, percentage of predicted vital capacity (%VC), percentage of predicted forced expiratory volume in 1 second, and percentage of predicted diffusion capacity of the lungs for carbon monoxide (%DLco), but not TAPSE or serum biomarkers, were significantly associated with mortality. Cox proportional hazard multivariate analysis indicated that %VC [hazard ratio (HR): 0.92, p = 0.001], use of AD (HR: 4.05, p = 0.043), and PVRecho (HR: 3.79, p = 0.029) independently predict mortality in patients with ILD. Replacement of %VC with %DLco in the multivariate analysis did not change the results: %DLco (HR: 0.90, p = 0.001), use of AD (HR: 7.53, p = 0.029), and PVRecho (HR: 3.65, p = 0.020). Conclusions In addition to parameters of pulmonary function tests and use of AD, increased PVRecho is an independent predictor of mortality in patients with ILD who were evaluated for screening of PH by echocardiography.

We examined prognostic interactions among cardiac autonomic function assessed by (123)I-labeled metaiodobenzylguanidine ((123)I-MIBG) activity, hemoglobin, and kidney function in chronic heart failure patients. Anemia, chronic kidney disease, and impairment of cardiac sympathetic function have been shown as determinants of prognosis in heart failure patients, but there has been little information on their synergistic correlations with cardiac mortality.After evaluations of hemoglobin and estimated glomerular filtration rate (GFR), 468 heart failure patients with left ventricular ejection fraction less than 50% underwent cardiac (123)I-MIBG imaging before discharge and were then followed up for a mean interval of 60.5 mo with a primary endpoint of cardiac death. Cardiac (123)I-MIBG activity was quantified using heart-to-mediastinum ratio (HMR) and washout rate.For 89 fatal cardiac events documented (19.0%), besides New York Heart Association class, multivariate Cox analysis revealed HMR, hemoglobin, and estimated GFR as significant independent determinants, with hazard ratios of 0.215 (P = 0.0129; 95% confidence interval [CI], 0.064-0.718), 0.821 (P = 0.0062; 95% CI, 0.708-0.946), and 0.984 (P = 0.0243; 95% CI, 0.970-0.998), respectively. Receiver-operating-characteristic analysis determined the thresholds for identifying patients at increased risk for cardiac death to be 1.57 for HMR, 11.9 g/dL for hemoglobin, and 46.4 mL/min/1.73 m(2) for estimated GFR. Combining the 4 independent predictors incrementally (P0.05) improved prognostic powers maximally up to a global χ(2) value of 97.3 compared with sole or other combinations.Hemoglobin, kidney function, and alterations of cardiac sympathetic nerve activity are independently and synergistically associated with increased cardiac mortality in chronic heart failure patients, together with New York Heart Association functional class.

Introduction: Deep vein thrombosis (DVT) develops after lower limb arthroplasty despite the current use of prohylaxis. Thus, accurate risk stratification is warranted to establish new prophylactic strategies. Soleal vein (SV) dilatation is often found by ultrasonography, which is performd for the screeing of the DVT. However, if the SV dilatation is usable for prediction of the DVT after the lower limb arthroplasty remains unclear. Hypothesis: We aimed to examine whether the SV dilatation assessed by ultrasonography predicts the DVT after the lower limb arthroplasty. Methods: Ultrasonography was performed pre- (mean 5 days) and postoperatively (mean 8 days) in 135 osteoarthritic patients (age 66+/-13 years, 76% women) who underwent total hip arthroplasty (THA; n = 99) or knee arthroplasty (TKA; n = 36). The patients with preoperative DVT were excluded. Presence of DVT was diagnosed by ultrasonography, which was performed from the bilateral femoral to lower limb. Increased diameter of SV (>10 mm) assessed by ultrasonography was defined as the SV dilatation. Results: Thirty seven patients (27%) developed the DVT, which was proximal in one (3%) and distal in 36 (97%), after the lower limb arthroplasty. SV dilation was observed in 14 patients (10%). Of these, 11 (79%) had the postoperative DVT. Multivariate logistic regression analysis indicated that age (odds ratio [OR] 1.1, 95% CI 1.01 to 1.11, p=0.016), female (OR 4.9, 95% CI 1.18 to 19.9, p=0.028), TKA (OR 2.7, 95% CI 1.01 to 7.37, p=0.047), and SV dilatation (OR 18.8, 95% CI 4.0 to 88.8, p Conclusions: In addtion to well-known risk factors for postoperative DVT, the SV dilatation assessed by ultrasonography is an independent predictor of the DVT after the THA. Assessment of the SV diameter by ultrasonography is useful for identfying patients with high risk for the postoprtative DVT after the THA.

We sought to compare the prognosis of patients with spontaneous coronary artery dissection (SCAD) and atherosclerosis as the cause of acute myocardial infarction (AMI), especially in young females.A total of 20,195 patients with AMI at 20 institutions between 2000 and 2013 were retrospectively studied. Major adverse cardiac event (MACE: cardiac death, AMI or urgent revascularization) was the endpoint. The overall prevalence of SCAD was 0.31% (n=63; female, 94%). SCAD developed following emotional stress in 29% of patients. Revascularization was performed in 56% (35 of 63 patients), and SCAD recurrence developed in the originally involved vessel in 6 of 35 patients with revascularization, compared to none among 28 patients after conservative therapy (p=0.002). We compared the clinical characteristics of young female AMI patients aged ≤50years in the SCAD (n=45) and no-SCAD groups (atherosclerotic AMI, n=55). During a median follow-up of 50months, SCAD recurred in 27% of patients, of which 42% was in the first 30days. Kaplan-Meier analysis showed a significantly higher incidence of MACE in the SCAD group compared to the no-SCAD group (hazard ratio, 6.91; 95% confidence interval, 2.5 to 24.3; p0.001), although the rate of successful percutaneous coronary intervention for SCAD was as high as 92%.Young female patients with SCAD represent a high-risk subgroup of patients with AMI and require close follow-up.

Background: Two-dimensional speckle tracking imaging (2DS) enables quantitative measurement of left ventricular strain. However, application of 2DS for measurement of circumferential carotid arterial strain (CAS) is not fully elucidated. We investigated the feasibility and reproducibility of measuring CAS by 2DS and determinants of CAS in healthy subjects. Methods: Fifty-one healthy subjects (20 men and 31 women) with a mean age of 29 ± 11 years were enrolled. Ultrasound examination of bilateral common carotid arteries (CCAs) was performed and short axial views were recorded. The mean intima-media thickness (IMT) of bilateral CCAs was measured using semiautomated edge-detection software. Bilateral peak CAS at systole and time to peak CAS in each region were measured by 2DS. Stiffness parameter β of bilateral CCAs was measured and bilateral cardio-ankle vascular index (CAVI) was recorded. Intraobserver and interobserver variabilities for mean CAS were calculated in 15 subjects. Results: Of the 612 regions, 577 (94%) had adequate waveforms for measurement of CAS. The mean value of CAS was 6.7 ± 2.1%. Required time for CAS analysis was 128 ± 12 seconds per subject. Multiple regression analysis identified age (P < 0.001) and pulse pressure (P < 0.05) as independent significant determinants of mean CAS. Corrected CAS, which was calculated as mean CAS/pulse pressure, correlated with age, mean IMT, and stiffness parameter β and systolic pressure (P < 0.001), age (P < 0.01), and stiffness parameter β (P = 0.02) were identified as independent significant determinants of corrected CAS. Coefficient of variance (CV) of intraobserver and interobserver variabilities for mean CAS were 8.8% and 5.9%, respectively. Conclusions: 2DS in the CCAs is simply and quickly performed with high feasibility and excellent reproducibility. In healthy subjects, age and pulse pressure are the most important determinants of mean CAS. (Echocardiography 2011;28:899-906)

Systolic reserve is an important compensatory mechanism against increasing afterload. Although longitudinal systolic dysfunction with preserved ejection fraction has been reported in hypertensive hearts, radial and circumferential function has not been fully examined. The aim of this study was to investigate three-directional systolic function and its relationships with left ventricular geometry in asymptomatic hypertensive patients using two-dimensional speckle-tracking imaging.Echocardiographic evaluations were performed in 74 hypertensive patients and 55 age-matched control subjects.Longitudinal strain was significantly reduced in the hypertrophy groups compared with that in control subjects (concentric, -15.1 ± 4.0%; eccentric, -15.9 ± 4.4%; control, -18.9 ± 3.3%; P.05). Conversely, radial strain was significantly higher in the normal geometry group than in control subjects (53.8 ± 19.4% vs 40.3 ± 15.1%, P.05). However, this augmentation was attenuated in the other geometries.Hypertrophic remodeling attenuates compensatory augmentation of radial systolic function and is associated with latent longitudinal systolic dysfunction.

Background— The prognosis of patients with saddleback or noncoved type (non–type 1) ST-elevation in Brugada syndrome is unknown. The purpose of this study was to clarify the long-term prognosis of probands with non–type 1 ECG and those with coved (type 1) Brugada-pattern ECG. Methods and Results— A total of 330 (123 symptomatic, 207 asymptomatic) probands with a coved or saddleback ST-elevation ≥1 mm in leads V 1 –V 3 were divided into 2 ECG groups—type 1 (245 probands) and non–type 1 (85 probands)—and were prospectively followed for 48.7�15.0 months. The absence of type 1 ECG was confirmed by drug provocation test and multiple recordings. The ratio of individuals with a family history of sudden cardiac death (14%) was lower than previous studies. Clinical profiles and outcomes were not notably different between the 2 groups (annual arrhythmic event rate of probands with ventricular fibrillation; type 1: 10.2%, non–type 1: 10.6%, probands with syncope; type 1: 0.6%, non–type 1: 1.2%, and asymptomatic probands; type 1: 0.5%, non–type 1: 0%). Family history of sudden cardiac death at age P =0.005; hazard ratio, 2.66; 95% confidence interval, 1.06 to 6.71; P =0.03, respectively, by multivariate analysis), although spontaneous type 1 ECG and ventricular fibrillation inducibility by electrophysiological study were not reliable parameters. Conclusions— The long-term prognosis of probands in non–type 1 group was similar to that of type 1 group. Family history of sudden cardiac death and the presence of early repolarization were predictors of poor outcome in this study, which included only probands with Brugada-pattern ST-elevation.

Previous studies have reported that acute hyperglycemia is associated with high mortality after acute myocardial infarction (AMI). However, optimal plasma glucose level may be different between diabetic and nondiabetic patients. The purpose of this study was to assess the relation between admission glucose and in-hospital mortality after AMI in patients with and without diabetes. This study consisted of 3,750 patients who were admitted to the 35 hospitals participating to the Japanese Acute Coronary Syndrome Study (JACSS) group within 48 hours after the onset of AMI. Plasma glucose was measured at the time of hospital admission. In patients without a history of diabetes, there was a linear relation between admission glucose and in-hospital mortality. Nondiabetic patients with a glucose level6 mmol/L had the lowest mortality (2.5%). As admission glucose increased by 1 mmol/L, mortality increased by 17% (13% to 21%, p0.001). In patients with a history of diabetes, however, there was a U-shape relation between glucose and mortality. Diabetic patients with glucose 9 to 10 mmol/L had the lowest mortality (1.9%); not only severe hyperglycemia (glucoseor =11 mmol/L, 9.1%, p0.001) but also euglycemia (glucose7 mmol/L, 9.4%, p = 0.009) were associated with higher mortality compared to moderate hyperglycemia (glucose 9 to 11 mmol/L, 3.2%). Diabetic patients with admission glucose 9 to 10 mmol/L had the lowest mortality, whereas lower glucose was better in nondiabetic patients. In conclusion, optimal glucose level on admission may be different between diabetic and nondiabetic patients with AMI.

The purpose of this study was to clarify the clinical characteristics and prognostic implications of left atrial (LA) dilation evaluated echocardiographic volume in patients with normal LA dimension (LAD). A total of 140 consecutive patients (81 men, mean age: 57 ± 18 years) with normal LAD (

Although high white blood cell (WBC) count and plasma glucose (PG) and low glomerular filtration rate (GFR) on admission have been associated with poor outcomes after acute myocardial infarction (AMI), the combined prognostic utility of these 3 variables was unclear. The association of WBC count, PG, and GFR on admission to in-hospital outcomes was examined in 2,633 patients who underwent primary stent placement for ST-segment elevation AMI within 48 hours after symptom onset. In-hospital mortality progressively increased as the number of the variables of high WBC count (or =11,120/microl; upper tertile), high PG (or =10.4 mmol/L; upper tertile), and low GFR (or =60 ml/min/1.73 m(2); lower tertile) increased. Patients with all 3 variables had a strikingly higher in-hospital mortality rate (25.9%). After adjusting for baseline characteristics, multivariate analysis showed that compared with patients who had none of these variables, odds ratios for in-hospital mortality were 1.63 (95% confidence interval [CI] 0.88 to 3.03, p = 0.12) in patients with only 1 variable, 2.33 (95% CI 1.28 to 3.96, p = 0.047) in those with 2 variables, and 6.16 (95% CI 2.98 to 12.6, p0.001) in those with all 3 variables. In conclusion, combined evaluation of WBC count, PG, and GFR on admission was a simple and useful method for the early prediction of risk of in-hospital death in patients undergoing primary stent placement for ST-segment elevation AMI.

Despite widespread use of implantable cardioverter defibrillators (ICDs), their cost and the fact that only a certain group of patients fully benefits from the devices require appropriate risk stratification of patients. This study investigated whether altered cardiac autonomic function is associated with the occurrence of ICD discharge or lethal cardiac events. Methods: Fifty-four ICD-treated patients were prospectively followed after assessment of cardiac metaiodobenzylguanidine (MIBG) activity, quantified as the heart-to-mediastinum ratio (HMR), plasma concentration of brain natriuretic peptide (BNP), and left ventricular ejection fraction (LVEF). Patients were divided into 2 groups based on the presence (group A, n = 21) or absence (group B, n = 33) of appropriate ICD discharge during a 15-mo period. Results: Group A had a significantly lower level of MIBG activity and a higher plasma BNP level than did group B. Univariate analysis revealed BNP level, any medication, and late HMR to be significant predictors, and multivariate analysis showed late HMR to be an independent predictor. An HMR of less than 1.95 with a plasma BNP level of more than 187 pg/mL or an LVEF of less than 50% had significantly increased power to predict ICD shock: positive predictive values, 82% (HMR + BNP) and 58% (HMR + LVEF); negative predictive values, 73% (HMR + BNP) and 77% (HMR + LVEF); sensitivities, 45% (HMR + BNP) and 67% (HMR + LVEF); and specificities, 94% (HMR + BNP) and 70% (HMR + LVEF). Conclusion: When combined with plasma BNP concentration or cardiac function, cardiac MIBG activity is closely related to lethal cardiac events and can be used to identify patients who would benefit most from an ICD.

Insulin resistance (IR) is now considered to be a risk factor for coronary arterial atherosclerosis and is likely to be involved in a limited endothelium-dependent vasodilatory function in peripheral circulation. We investigated whether IR impairs endothelial vasodilator function in the noninfarcted coronary artery. In 14 nondiabetic patients (10 males, 66 +/- 6 years) who were selected from 214 patients underwent IR evaluation by glucose clamp, a Doppler flow wire was used to measure coronary flow changes (percent volume flow index, %VFI) during intracoronary administration of papaverin (10 mg) and stepwise administration of acetylcholine (Ach; 1, 3, 10 microg/ml per minute) into the non-infarcted left circumflex coronary artery. Insulin resistance was comparatively evaluated by an euglycemic hyperinsulinemic glucose clamp (M value, mg/m(2) per minute) or by a 75g-oral glucose tolerance test (120-min immunoreactive insulin; 120' IRI, pmol/l). Eight patients (57%) were defined as having IR on the basis of results obtained by both the glucose clamp method (M values167 mg/m(2) per minute) and 120' IRI (384 pmol/l). There was no difference between papaverin-induced %VFI increases in IR and non-IR subjects (328% +/- 43% vs. 361% +/- 87%). However, IR subjects showed significantly lower Ach-induced %VFI increases in a dose-dependent manner (P0.05), especially when low (1 microg/ml per minute) and moderate (3 microg/ml per minute) doses of Ach were used (165% +/- 18% or 248% +/- 29% in non-IR subjects vs. 130% +/- 20% or 183% +/- 41% in IR subjects, P0.001, respectively). Moreover, %VFI increase at a low dose of Ach infusion significantly correlated with M values or 120' IRI ([%VFI Ach 1 microg] = 85.9 + 0.35 [M values], r = 0.58, P = 0.038; [%VFI Ach 1 microg] = 176.8 - 0.47.[120' IRI], r = -0.57, P = 0.035). Insulin resistance limits endothelium-dependent coronary vasodilation in association with the severity of IR in non-diabetic patients.

Background The degree to which abnormal glucose tolerance contributes to the development of coronary artery disease (CAD) has not been clarified in Japanese. The relationship between abnormal glucose tolerance and severity of coronary artery stenosis, as well as the contributions of hypertension, diabetes and other risk factors for CAD to recurrence of the disease, were investigated in the present study. Methods and Results The subjects were 474 consecutive patients (mean age: 63.8±11.3 years) with suspected CAD who were admitted to Sapporo Medical University Hospital during April 1, 1997 to March 31, 2004. The coronary index and stenosis score were higher in subjects with diabetes mellitus (DM) and in subjects with impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) than in subjects with normal glucose tolerance (NGT). Ischemic episodes recurred during the observation period (mean 2.5 years) in 61 of 341 patients diagnosed as having CAD. In the follow-up subjects, systolic blood pressure (SBP) was significantly higher in the recurrence group than in the non-recurrence group, and SBP was a significant variable in logistic regression analysis after adjustment for age, gender, hemoglobin A1c, total cholesterol, body mass index, smoking history, family history and stenosis score. The relative risk of recurrence became 1.7-fold higher with a rise in SBP of 10 mmHg (95% confidence interval: 1.252-2.250). Analysis of the relationship between glucose tolerance and recurrence showed that the rate of recurrence was higher in patients with IFG + IGT + DM than in those with NGT. Conclusions CAD progresses not only in patients with DM but also in those with IGT. The rate of recurrence of ischemic episodes increases in individuals with IGT or DM, and suggesting that hypertension is a risk factor for recurrence of ischemic episodes. Management of glucose tolerance and blood pressure is therefore important for prevention of CAD in Japanese. (Circ J 2007; 71: 20 - 25)

Background The impact of body mass index (BMI) on outcomes after primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) remains unclear. Methods and Results A total of 3,076 patients undergoing PCI for AMI within 48 h after symptom onset were studied. Patients were divided into 4 groups according to baseline BMI: lean (, 出版者照会後に全文公開

Background There is conflicting information about whether nitrate treatment aggravates long-term prognosis, so the present retrospective study was designed to determine the effects of long-term nitrate therapy on major adverse events after acute myocardial infarction (AMI) in the coronary interventional era. Methods and Results Using the Japanese Acute Coronary Syndrome Study database, 1,236 consecutive patients who were hospitalized within 48 h of onset of symptoms of AMI from January to December 2003 were evaluated. All-cause mortality, cardiac events and cardiovascular events were lower in patients treated with nitrates than in the untreated controls. However, these crude comparisons included several confounding factors on nitrate prescription. To minimize the effect of selection bias on outcomes, the technique of propensity score matching for clinical characteristics was used and distortion of effective nitrate treatment was excluded as much as possible. The results of propensity score matching showed that nitrate therapy had no impact on all-cause mortality, cardiac events and cardiovascular events at 30, 60 or 90 days, 6 months, 1 year, and 2 years follow-up. Conclusions Long-term nitrate therapy after AMI neither improves nor aggravates prognosis. Prospective randomized clinical trials are warranted to determine the effects of long-term nitrate therapy for secondary prevention of AMI. (Circ J 2007; 71: 301 - 307)

Background Studies from North America indicate that patients admitted during the weekend with acute myocardial infarction (AMI) have a worse outcome than weekday-admitted patients, probably reflecting a lower rate of invasive procedures. However, it is unclear whether the same is true in Japan, which has a different healthcare system. Methods and Results Using the Japanese Acute Coronary Syndrome Study (JACSS) database, this study included 4,805 consecutive patients who were admitted within 48 h of onset of AMI (3,526 [73.4%] patients with weekday onset [Monday through Friday] and 1,279 [26.6%] with weekend onset [Saturday and Sunday]). There were no significant differences between the 2 groups in patient background and clinical features. The proportions of patients who underwent emergency catheterization (88.4% vs 88.0%) and reperfusion therapy (81.5% vs 81.4%) were also similar. There were no differences between the 2 groups in the in-hospital, 30-day, and 1-year mortality rates. Even after various adjustments, there was no difference in the risk of death associated with weekend versus weekday onset of AMI. Conclusion There were no obvious differences in outcome for Japanese AMI patients in the weekday- or weekend-onset group, suggesting the quality of the Japanese healthcare system is similar for the entire week. (Circ J 2007; 71: 1841 - 1844), 出版者照会後に全文公開

It is controversial whether treatment with an angiotensin II receptor blocker (ARB) or a calcium channel blocker (CCB) improves prognosis of hemodialysis (HD) patients. This study was designed as a multicenter prospective cohort study. HD patients (n = 1071) were enrolled from 22 institutes in January 2009 and followed up for 3 years. Patients with missing data, kidney transplantation or retraction of consent during the follow-up period (n = 204) were excluded, and 867 patients contributed to analysis of mortality. Propensity score (PS) for use of ARB and that for CCB was calculated using a multiple logistic regression model. ARB and CCB were prescribed in 45.6 and 54.7 % of patients at enrollment. During the 3-year follow-up period, all-cause mortality and cardiovascular mortality rates were 18.8 and 5.1 %, respectively. Kaplan–Meier curves showed that all-cause and cardiovascular mortality rates were lower in the ARB group than in the non-ARB group, though the mortality rates were similar in the CCB group and non-CCB group. In PS-stratified Cox regression analysis, ARB treatment was associated with 34 and 45 % reduction of all-cause death and cardiovascular death, respectively. In PS matching analysis, ARB treatment was associated with a significant reduction (46 % reduction) in the risk of all-cause death. A significant impact of CCB treatment on all-cause or cardiovascular mortality was not detected in PS analysis. The use of an ARB, but not a CCB, is associated with reduced all-cause and cardiovascular mortalities in patients on HD.

Background Whether an intervendor discordance of myocardial velocities determined by tissue Doppler echocardiography (TDE) can be generalized remains unclear. We compared intervendor variabilities of left ventricular (LV) and right ventricular (RV) myocardial velocities among three TDE systems. Methods Examinations with TDE were performed in 41 healthy subjects and 11 patients with cardiovascular risk factors (CVR) using α-7 (V1, Hitachi Aloka Medical), Artida (V2, Toshiba Medical Systems), and Vivid E9 (V3, GE Healthcare) on the same day. Peak systolic (s′), early diastolic (e′), and late diastolic (a′) myocardial velocities at medial and lateral sites of the mitral annulus and lateral site of the tricuspid annulus were measured using both pulsed-wave TDE and color TDE. Intra-observer and inter-observer variabilities were determined in 10 subjects and test–retest variability in 14 subjects. Results As for test–retest variability, reproducibilities of LV and RV myocardial velocities determined by pulsed-wave TDE and color TDE were relatively low but comparable between V1, V2, and V3. Myocardial velocities in healthy subjects determined by both pulsed-wave TDE and color TDE were significantly different among the three TDE systems. Myocardial velocities by pulsed-wave TDE in V3 were 2–12% lower (P

Background: Quantitative assessment of left ventricular ejection fraction (LVEF) is technically difficult in patients with poor image quality (IQ). Mitral annulus velocity assessed by pulsed tissue Doppler imaging (TDI) and mitral annulus motion assessed by M-mode echocardiography has been shown to correlate with LVEF. Furthermore, mitral annulus sites are easy to identify even in patients with poor IQ. The purpose of this study was to determine whether these methods are useful for estimating LVEF in patients with poor IQ. Methods: One hundred ten patients underwent TDI and M-mode echocardiography simultaneously. Mitral annulus velocity and mitral annulus motion were obtained from each of the four mitral annulus sites. Mean mitral annular peak systolic velocities (Sm) and mean mitral annular motions (MAM) were calculated by averaging at each site. IQ was defined according to a previous report. Results: Both Sm and MAM were successfully measured in all patients. Mean Sm and mean MAM correlated with LVEF. These correlations were observed not only in patients with good IQ (p < 0.001, r = 0.61 for mean Sm; p < 0.001, r = 0.61 for mean MAM) or fair IQ (p < 0.001, r = 0.58 for mean Sm; p < 0.001, r = 0.68 for mean MAM) but also in patients with poor IQ (p < 0.05, r = 0.42 for mean Sm, p < 0.001, r = 0.61 for mean MAM). Using optimal cutoff values of mean Sm and mean MAM in each IQ group, sensitivity and specificity for identifying LVEF < 50% were comparable among three IQ groups. Conclusions: Assessment of long-axis systolic function by TDI and M-mode echocardiography enables estimation of LVEF even in patients with poor IQ.

Admission white blood cell (WBC) count and plasma glucose (PG) have been associated with adverse outcomes after acute myocardial infarction (AMI). This study investigated the joint effect of WBC count and PG on predicting in-hospital outcomes in patients with AMI. WBC count and PG were measured at the time of hospital admission in 3,665 patients with AMI. Patients were stratified into tertiles (low, medium, and high) based on WBC count and PG. Patients with a high WBC count had a 2.0-fold increase in in-hospital mortality compared with those with a low WBC count. Patients with a high PG level had a 2.7-fold increase in mortality compared with those with a low PG level. When a combination of different strata for each variable was analyzed, a stepwise increase in mortality was seen. There was a considerable number of patients with a high WBC count and low PG level or with a low WBC count and high PG level. These patients had an intermediate risk, whereas those with a high WBC count and high PG level had the highest risk, i.e., 4.8-fold increase in mortality, compared with those with a low WBC count and low PG level. Multivariate analysis was performed to assess the predictor for in-hospital mortality using WBC count and PG level as continuous variables and showed that WBC count and PG level were independently associated with in-hospital mortality. These findings suggested that a simple combination of WBC count and PG level might provide further information for predicting outcomes in patients with AMI.

Background Measurement of circulating biomarkers has enabled early diagnosis and risk assessment of acute coronary syndrome. This study sought diagnostic values of the first single-point data of biomarkers obtained soon after patient arrival by comparing with scintigraphically quantified myocardial injury in patients presenting with acute chest pain at an emergency room. Methods and Results Serial blood samples were taken soon after arrival in an emergency department in 74 patients with suspected acute coronary syndrome to quantify blood levels of troponin-T (TnT), heart-type fatty acid-binding protein (H-FABP), myocardial-bound creatine kinase (CK-MB), and myoglobin. Myocardial perfusion and metabolic defects were scintigraphically quantified. The first single-point data had high positive predictive values for detecting the defects (80-100%) but low negative predictive values (15-41%). CK-MB and TnT had higher specificities (73-100%) but significantly lower positive rates (22-27%) than the others (61-68%), resulting in greater sensitivities of H-FABP and myoglobin (75-80%) than those of CK-MB and TnT (29-35%). Among biomarkers, TnT peak concentrations most closely correlated with scintigraphic abnormalities. Conclusion H-FABP can contribute to early detection of myocardial injury and TnT is most likely to correlate with injured myocardial mass. The differential features of biomarkers are complementary in patients with acute chest pain presenting at an emergency room. (Circ J 2006; 70: 419 - 425)

The objective of the present prospective multicenter case-control study was to investigate the long-term clinical outcome (5 years) of primary stenting compared to primary percutaneous transluminal coronary angioplasty (PTCA) without stenting (POBA) in patients with acute myocardial infarction at 7 cardiovascular centers in Hokkaido, Japan. Forty-one patients with acute myocardial infarction treated with successful primary stenting (stent group: case) and paired with 41 matched control subjects with acute myocardial infarction treated by successful primary PTCA without stenting (POBA group: control) were analyzed. After 1 year, the stent group had a lower incidence of the combined clinical endpoint (death, rehospitalization due to congestive heart failure, nonfatal myocardial infarction, repeat angioplasty, CABG, or cerebrovascular events) compared to the POBA group (17.1% versus 39.0%, P = 0.049). After 5 years, the incidences of congestive heart failure and cardiac death were the same in both groups. However, compared to the POBA group, the stent group had a lower combined clinical endpoint (34.1% versus 61.0%, P = 0.027). The Kaplan-Meier event-free survival curves of the stent group showed a significantly lower occurrence of clinical events compared to the POBA group (P = 0.0116). Multiple logistic regression analysis of clinical events identified age > or = 69 years (P = 0.0092, odds ratio = 4.179) and stenting (P = 0.0158, odds ratio = 0.279) as explanatory factors. Compared with POBA, primary stenting for acute myocardial infarction results in a better long-term clinical outcome.

Background Limited information exists regarding the impact of gender on in-hospital outcome after primary stenting for acute myocardial infarction (AMI). Methods and Results A total of 2,981 patients (790 women and 2,191 men) participated in the study who were admitted within 24 h after symptom onset and underwent emergency primary stenting for AMI. Compared with men, women were significantly older; had higher incidences of hypertension, diabetes mellitus, hyperlipidemia, Killip class ≥2, and cardiogenic shock; had a higher blood glucose level and a lower serum creatinine level on admission. Other baseline characteristics, including the incidences of ST-segment elevation AMI, anterior infarction, 3-vessel disease, initial or final Thrombolysis in Myocardial Infarction (TIMI) flow grade did not significantly differ between the sexes. The in-hospital mortality rate was significantly higher in women than in men (9.4% vs 5.2%, p

BACKGROUND: There is considerable interest in the pleiotropic pharmacological action of sarpogrelate hydrochloride, a novel selective serotonin 2A receptor antagonist. In the present study the persistent insulin-sensitizing effects of sarpogrelate were investigated in non-diabetic and non-medicated diabetic patients with peripheral artery disease (PAD). METHODS AND RESULTS: Indices of insulin resistance (IR) (fasting immunoreactive insulin (IRI) and calculated homeostasis model assessment (HOMA-R)) and adiponectin were measured before and after 2 weeks of sarpogrelate administration (300 mg/day) in 24 patients (19 men, 76+/-9 years) with PAD. Sixteen of the 24 patients were examined after 3 months of treatment for assessment of the chronic effect of sarpogrelate on IR. After 2 weeks of treatment, significant decreases in fasting IRI (p=0.03) and HOMA-R (p=0.024), but not in adiponectin, were observed. After 3 months of treatment, significant decreases in fasting IRI (16.0+/-10.3 vs 9.2+/-2.0 microU/ml, p=0.03) and HOMA-R (4.30+/-2.83 vs 2.40+/-0.74, p=0.025) were maintained. Furthermore, adiponectin was significantly increased (8.11+/-4.13 vs 9.64+/-4.37 microg/ml, p=0.027). All of the examined HOMA-R had a significant correlation with all of the examined adiponectin (p

Background Little is known about the long-term outcome of implantable cardioverter defibrillator (ICD) therapy in survivors of out-of-hospital cardiac arrest (OHCA). Methods and Results The frequency of lethal ventricular arrhythmias and whether ICD implantation can prevent recurrence of cardiac arrest were examined. Long-term (24.4±11.9 months) outcome was examined in 23 patients with OHCA who were treated with an ICD (OHCA group) and 35 patients without OHCA (non-OHCA group) who were treated with an ICD. Patients in both groups had same clinical backgrounds; however, those in the OHCA group showed a significantly lower incidence of induced ventricular arrhythmias (71%) than the non-OHCA group (96%). In the follow-up period, patients in the OHCA group had almost the same incidence of ICD discharge (30%) as patients in the non-OHCA group (40%). The rate of recurrence of ventricular fibrillation in the OHCA patients was 13%, and it was difficult to estimate the rate by induced ventricular arrhythmia. Conclusion The results suggest that ICD implantation for survivors of OHCA with favorable neurological recovery might be effective for preventing recurrence of cardiac arrest. (Circ J 2006; 70: 1128 - 1132)

Background: Few studies have examined if two score systems of coronary stenosis, SYNTAX score and Gensini score, are different as predictors of prognosis in patients with coronary artery disease (CAD). Here we examined this issue in patients with stable CAD after percutaneous coronary intervention (PCI). Methods: We retrospectively analyzed 795 consecutive patients who underwent coronary angiography for suspected stable CAD from January 2007 to August 2012. One hundred fifty-nine patients received PCI according to consensus of the Heart Team in our institute and patients’ consents. Overall severity of coronary stenosis and complexity in each patient was quantified by both the SYNTAX score and Gensini score, and patients were divided into high score group and low score group by the mean of the score in overall patients. Follow-up period was 15.9 ± 14.4 months, and MACE was defined as a composite of cardiac death, myocardial infarction, target vessel revascularization and/or congestive heart failure. Results: The mean SYNTAX score and Gensini score were 19.0 ± 12.4 and 47.8 ± 26.9, respectively. Long-term MACE in a group with high SYNTAX score (≧19, n=71) tended to be higher than a group with low SYNTAX score ( Conclusion: Gensini score is not inferior to SYNTAX in prediction of the clinical outcome after PCI in patients with stable CAD. Prognosis after PCI is favorable in patients with low Gensini score (especially those with GS

Introduction: Spontaneous coronary artery dissection (SCAD) is an unusual cause of acute myocardial infarction (AMI). It is postulated that the patients with SCAD have good clinical prognosis because they have few coronary risk factors (CRF). However, a recent report studying the US patients with SCAD aged 18~78 years suggested that the rate of recurrence was higher than we expected. In the present study, we therefore have focused on prognostic impact of SCAD on younger female populations. Methods: A total of 16,233 AMI patients registered by 10 institutes from 1991 to 2012 were retrospectively studied. The definition of SCAD was based on the presence of medial dissection or intramural hematoma that was recognized by angiography before any catheter intervention. Results: There were 27 patients diagnosed as SCAD (male/female 1/26, age 45±9 [SD] years). The overall prevalence of SCAD was 0.17% of AMI patients. SCAD developed after physical or emotional stress in 11 patients (40.7%). The left anterior descending artery was involved in 17 patients (62.9%), among whom 4 patients had multi-vessel SCAD (14.8%). Recurrences of SCAD were shown in 9 patients (33.3%). In 4 of 9, recurrence was seen in previously unaffected coronary arteries. In young population of AMI patients (age Conclusions: The present multicenter study demonstrated that younger female AMI patients with SCAD, characterized as minimum accumulation of CRF, seem to be prone to cardiac events.

Serum uric acid (UA) levels reflect circulating xanthine oxidase activity and oxidative stress production. Hyperuricemia has been identified in patients who have congestive heart failure and is a marker of poor prognosis in such patients. We investigated the relation between serum UA levels and Killip's classification suggestive of the severity of heart failure and whether hyperuricemia influences mortality of patients who have acute myocardial infarction (AMI). Using the Japanese Acute Coronary Syndrome Study database, we evaluated 1,124 consecutive patients who were hospitalized within 48 hours of onset of symptoms of AMI from January to December 2002. There was a close relation between serum UA concentration and Killip's classification. Patients who developed short-term adverse events had high UA concentrations. Serum UA levels, Killip's class, age, and peak creatine phosphokinase level were significant predictors of long-term mortality. The hazard ratio for patients in the highest quartile of UA was 3.7 compared with those in the lowest quartile for death after AMI after adjustment for independent factors that were related to mortality. The combination of the best UA cutoff (447 micromol/L) for predicting survival based on receiver-operating characteristics analysis and Killip's class significantly predicted the prognosis of acute and long-term AMI-related complications. In conclusion, our results suggest that hyperuricemia after AMI is associated with the development of heart failure. Serum UA level is a suitable marker for predicting AMI-related future adverse events, and the combination of Killip's class and serum UA level after AMI is a good predictor of mortality in patients who have AMI.

Strain rate (SR) imaging enables quantitative measurement of left ventricular (LV) function independent of cardiac translation. However, whether SR imaging is applicable for detection of left atrial (LA) dysfunction remains unknown. The purpose of this study was to assess the feasibility of measuring LA function by SR imaging, focusing on the effects of aging and LA dilatation during atrial fibrillation (AF). Echocardiographic evaluation including SR imaging was performed in 50 controls (29 males and 21 females; mean age, 41 +/- 14 years) and in 27 patients with AF (15 males and 12 females; mean age, 62 +/- 12 years; 8 with persistent AF and 19 with paroxysmal AF) from 3 apical views and analyzed off-line. Peak SR was measured at each LA segment (septum, lateral, posterior, anterior, and inferior), and mean peak systolic SR (SR-LAs), early diastolic SR (SR-LAe), and late diastolic SR (SR-LAa) were calculated by averaging the results for each segment. LA dimension, peak mitral and pulmonary velocities at late diastole, LA fractional shortening, and atrial filling fraction were calculated as parameters of LA function. Normal values for mean SR-LAs, SR-LAe, and SR-LAa were 3.4 +/- 1.0 s -1 , -3.9 +/- 1.7 s -1 , and -3.1 +/- 1.0 s -1 , respectively, and they were successfully measured in more than 95% of the LA segments. In controls, both mean SR-LAs and mean SR-LAe correlated with age, LA dimension, and early to late diastolic mitral flow velocity ratio. Conversely, mean SR-LAa did not show significant correlation with age or parameters of LA function. In AF patients, mean SR-LAs was correlated inversely with age. The mean SR-LAs was significantly lower in persistent AF patients than in age-matched controls (1.7 +/- 0.8 vs 2.9 +/- 0.9 s -1 ; P.01). Based on our findings, we conclude that noninvasive quantification of LA function using SR imaging enables evaluation of LA dysfunction due to aging and LA dilatation.

Background Preinfarction angina improves survival after acute myocardial infarction (AMI) in nonelderly but not elderly patients in the thrombolytic era. However, it remains unclear whether preinfarction angina has a beneficial effect on clinical outcome in elderly patients undergoing percutaneous coronary intervention (PCI). Methods and Results The study group comprised 484 anterior AMI patients who were admitted within 24 h of onset and underwent emergency PCI. Patients were divided into 2 groups: those aged

Background Early defibrillation and cardiopulmonary bypass have been postulated to be a promising intervention against out-of-hospital cardiac arrest (OHCA); however, little is known about the long-term prognosis. The effects of early recovery of circulation (ROC) on neurological recovery and the long-term outcome in patients with OHCA were examined. Methods and Results Functional recovery and long-term (22.0±15.3 months) outcome were examined in 100 patients with definite diagnosis of OHCA. Spontaneous circulation recovered in 79% of the patients (using on-site counter shock in 20% of the patients). Cardiopulmonary bypass was performed in 38 of the OHCA patients. The total survival and favorable neurological recovery rates were 40% and 25%, respectively. The patients with favorable recovery obtained early ROC (28.2±16.0 min). Receiver-operating characteristic analysis showed that a period of less than 35 min for ROC was the optimal period for achieving a favorable recovery, with sensitivity of 68% and specificity of 73%. The patients with a prior history of heart failure or reduced left ventricular ejection fraction exhibited more frequent, exacerbated heart failure and ventricular arrhythmias. Conclusions Early ROC using on-site counter shock or cardiopulmonary bypass might result in better long-term outcome in patients with OHCA of cardiac origin. (Circ J 2005; 69: 1302 - 1307)

Background: The concentration of heart-type fatty acid-binding protein (hFABP), a promising novel marker for detection of acute or persistent myocardial damage, is significantly influenced by renal clearance and thus has limitations to its usefulness in patients with renal dysfunction. We evaluated whether the serum ratio of hFABP to myoglobin (F/M) might be a useful marker for assessing cardiac damage in hemodialysis patients. Methods: Serum hFABP and myoglobin were measured, and the value of F/M was calculated in 21 hemodialysis patients. Cardiac markers (cardiac troponin T [cTnT], atrial natriuretic peptide [ANP], and brain natriuretic peptide [BNP]) and echocardiographic indices (left ventricular end-diastolic dimension [LVDd], left ventricular mass index [LVMI], and inferior vena cava [IVC] dimension) were examined and compared with hFABP, myoglobin, and F/M ratios. Results: Serum hFABP and myoglobin levels were significantly elevated in hemodialysis patients and reduced by 30–40% during hemodialysis. The value of F/M after hemodialysis, but not the concentration of hFABP or myoglobin, had significant linear correlations with ANP, BNP, cTnT, LVDd, LVMI, and IVC. Conclusion: The value of F/M after hemodialysis, but not the concentration of hFABP itself, might be a newly useful marker for estimation of cardiac damage and volume overload in hemodialysis patients.

Although heart-type fatty acid-binding protein (H-FABP) can be a marker of sarcolemmal injury due to acute myocardial ischemia, the diagnostic or prognostic value is not established in patients with acute chest pain. This multicenter prospective study aimed to determine the diagnostic and prognostic values of H-FABP in 133 patients presenting to an emergency room with suspected acute coronary syndrome (ACS) by comparing with those of conventional biomarkers. H-FABP and myoglobin had greater positive results than did creatine kinase-MB or troponin T. Receiver operating characteristics analysis revealed that H-FABP was the most reliable for detection of ACS and that H-FABP had the greatest sensitivities for identification of patients requiring emergency hospitalization, coronary angiography, and interventional therapy within 7 days among the biomarkers. Thus, H-FABP can be an early diagnostic and prognostic biochemical marker, particularly within the first 6 h from the onset of chest symptoms, in patients with chest pain at an emergency department.