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Background: Amyloid transthyretin (ATTR) cardiac amyloidosis has now been recognized as one of the major causes of heart failure, especially in elderly patients. The purpose of the present study was to validate the usefulness of technetium-99 m (99 mTc)-pyrophosphate (99 mTc-PYP) scintigraphy in the screening diagnosis for ATTR amyloidosis in daily clinical practice. Methods and Results: Ninety-eight patients underwent 99 mTc-PYP scintigraphy in the previous 3 years (PYP positive/negative, 18/80), of whom 29 underwent concomitant endomyocardial biopsy (ATTR positive/negative, 9/20). The sensitivity and specificity of 99 mTc-PYP scintigraphy for the diagnosis of biopsy-proven ATTR amyloidosis were 0.889 and 0.950, respectively. Age, gender, N-terminal prohormone of brain natriuretic peptide (NT-proBNP) level, or electrocardiogram findings did not differ significantly between PYP-positive and PYP-negative patients. Left ventricular (LV) wall thickness was significantly greater in PYP-positive than in PYP-negative patients, but LV ejection fraction or prevalence of atrial fibrillation was similar between groups. In the PYP-positive patients, higher uptake of PYP correlated with younger age and lower NT-proBNP. Conclusions: 99 mTc-PYP scintigraphy was useful, with high sensitivity and specificity in the screening diagnosis for ATTR cardiac amyloidosis, which is difficult to diagnose on clinical characteristics alone. 99 mTc-PYP scintigraphy should be considered to elucidate the underlying causes of heart failure, especially in elderly patients based on the higher prevalence of ATTR cardiac amyloidosis in this population.

We recently reported that the early initiation of tolvaptan in congestive heart failure shortened the hospital stay and reduced the rate of in-hospital death. However, whether or not these results apply to elderly patients with congestive heart failure is unclear. We performed a sub-analysis of our previous study. Among the 102 patients in that study, we retrospectively analyzed the elderly patients >75 years of age treated with tolvaptan. First, we analyzed the efficacy of early tolvaptan use in these patients. We then compared the efficacy and the safety of all tolvaptan use between elderly and younger patients. There were no significant differences in the baseline clinical parameters between the early- and late-tolvaptan-use elderly patients, except for the serum blood nitrogen urea. However, the early use of tolvaptan was also associated with the earlier initiation of ambulatory cardiac rehabilitation, a shorter hospital stay, and a lower rate of in-hospital death in elderly congestive heart failure patients. Furthermore, there were no significant differences in the occurrence of worsening renal failure and hypernatremia. The early use of tolvaptan in elderly patients was also associated with a shorter hospital stay and reduced mortality. We also confirmed the safety of tolvaptan in elderly patients. It might, therefore, be beneficial to consider administering tolvaptan early in elderly patients with heart failure, just as in younger patients.

Cardiac magnetic resonance imaging (MRI) is a useful tool for detecting the arrhythmogenic substrate in cardiac sarcoidosis. We herein present a case of bipolar radiofrequency catheter ablation for ventricular tachycardia (VT) complicated with cardiac sarcoidosis, guided by pre-procedural cardiac MRI. Neither echocardiography nor endocardial voltage mapping suggested a septal VT substrate. However, MRI alone detected intramural lesions in the septum. Although application of endocardial energy failed to treat the VT, bipolar ablation targeting the potential substrate identified by MRI successfully eliminated the VT. Even when no abnormalities are depicted on echocardiography and endocardial voltage mapping, intramural scar tissue identified by cardiac MRI could be critical for VT.

An 86‐year‐old woman suffering from repeated methicillin‐resistant Staphylococcus aureus (MRSA) bacteremia underwent percutaneous lead extraction using an excimer laser. Since negative blood cultures were confirmed three times after lead extraction under intravenous infusion of anti‐MRSA drugs, a Micra transcatheter pacing system (Micra TPS) was implanted 7 days after the lead extraction. Although infusion of anti‐MRSA drugs was continued for 5 weeks, MRSA was isolated in four separate samples of blood cultures 3 weeks after the discontinuation of the anti‐MRSA therapy. The micra TPS was successfully retrieved using a steerable sheath and snare at 8 weeks after implantation.

Cardiac perforation by a transvenous lead is an uncommon but serious complication. We herein present a case of very late perforation of a Riata implantable cardioverter‐defibrillator lead, which occurred 8 years after implantation. The patient was successfully treated with percutaneous lead extraction using an excimer laser. Lead perforation should be considered, even after years from implantation.

Tolvaptan is an oral antagonist of arginine vasopressin receptor 2 that has been approved in Japan to reduce congestive symptoms in patients with heart failure refractory to loop diuretics. However, it is unknown whether the early use of tolvaptan results in better clinical outcomes. We retrospectively analyzed 102 consecutive patients with decompensated heart failure treated with tolvaptan at our hospital. A given patient was defined as a responder when the maximum urine volume was greater than 150 % of that observed before tolvaptan use. A logistic regression analysis revealed that the early use of tolvaptan (within 3 days after admission) was an independent factor associated with tolvaptan responsiveness. There were no significant differences in the baseline clinical parameters between the early and late tolvaptan use groups. However, the early use of tolvaptan was associated with higher tolvaptan responsiveness, a shorter duration of carperitide infusion, earlier initiation of ambulatory cardiac rehabilitation, shorter hospital stay, lower rate of in-hospital death. The early use of tolvaptan was associated with a shorter hospital stay and reduced mortality in our retrospective cohort. It might therefore be beneficial to consider administering tolvaptan earlier in patients with heart failure.

SUMMARY This paper presents the application of multiobjective optimization methods to network expansion planning. Distribution network expansion planning minimizes system cost and distribution loss while satisfying the constraints. Problem formulation yields combinatorial optimization problems that are difficult to solve due to their complexity. This research applies a genetic algorithm, which is a meta-heuristics method. The present study proposes a new method of multiobjective optimization: NSGA-II, SPEA2, and Controlled NSGA-II are assumed to be the best methods now. The proposed method introduces the concept of a linkage identification genetic algorithm, enabling more efficient searching than methods hitherto known. In the past, most research on network expansion planning did not include the load curve. This research demonstrates that the investigation must include the load curve. It also proposes a new method of search including the load curve.

Nodular calcification is sometimes detected in the native coronary artery. However, it is very rare to find in a saphenous vein graft (SVG). We herein report a rare case of stable angina pectoris (AP) due to nodular calcification. A 75-year-old man who had previously undergone coronary artery bypass grafting was admitted to our hospital due to stable AP. On angiography, significant stenosis was detected in the proximal SVG. Based on the findings of coronary angiography and optical coherence tomography, a red thrombus was suspected at the culprit lesion. However, nodular calcification was also suspected, as there were calcifications around the lesion. As intravascular ultrasound showed the protruding calcification, which we judged to be a nodular calcification, the calcified SVG lesion was successfully treated by percutaneous coronary intervention without any complications. Nodular calcification should be considered as a potential cause of AP, even when located in a SVG.

BackgroundCoronary risk factors for the onset of acute coronary syndrome (ACS), including polyunsaturated fatty acids (PUFAs), in younger adult patients may be different from those in older patients.Methods and resultsWe enrolled 578 patients who underwent coronary angiography at Fukuoka Saiseikai Hospital, and divided them into a younger adult group (YG) (

SummaryCoarctation of the aorta with aortic dissection is sometimes seen in cases of Turner syndrome, and most cases are type A aortic dissection, whereas coarctation of the aorta with type B aortic dissection is unusual. Only two cases of coarctation of the aorta presenting as aortic dissection have been reported in Japan, and only a few cases have been reported worldwide. We report here a case of coarctation of the aorta with some collaterals presenting as aortic dissection (type B) detected by 64-multidetector row computed tomography (MDCT). A 36-year-old man was brought to the emergency room complaining of sudden chest pain and back pain. Since he showed highly developed collaterals, he might never have exhibited symptoms or any limits on movement. Three-dimensional image reconstruction enabled detection of the coarctation of the aorta with some collaterals and aortic dissection in the best projection, and enabled assessment of precise anatomical relationship. In the present case, MDCT gave more useful information than cardiac catheterization for planning the surgical repair of coarctation of the aorta with some collaterals presenting as aortic dissection.

Typical angioid streaks were found on routine ophthalmologic examination in a 42-year-old female with yellowish, coalescing papules on her neck without any symptoms. Biopsy of the cutaneous lesion showed degeneration and fragmentation of the elastic fibers and many basophilic-stained calcifications in mid-dermis, which are consistent with pseudoxanthoma elasticum. Twenty-four-hour Holter electrocardiography (ECG) showed sinus arrest for 2.5 seconds, and an electrophysiological study revealed sinus nodal dysfunction (sick sinus syndrome), whereas all of the coronary arteries were intact, despite a treadmill stress ECG test showing significant ST depressions. The association of pseudoxanthoma elasticum and sick sinus syndrome is very rare. One possible explanation for this association here is that the degeneration of elastic fiber in endomysium of the sino-atrial node may have affected heart conduction systems, resulting in sick sinus syndrome.

SummaryRight ventricular rupture is a rare complication of cardiopulmonary resuscitation and could be fatal. We report a survival case of right ventricular rupture induced by cardiopulmonary resuscitation in a patient with acute myocardial infarction. A 57-year-old man was admitted to our hospital with ventricular fibrillation. Although chest compression and defibrillation were performed, ventricular fibrillation continued. We inserted a percutaneous cardiopulmonary system and performed coronary angiography, which revealed occlusion of the left anterior descending artery. After coronary stenting and intra-aortic balloon pumping, we succeeded in defibrillation and vital signs became stable. Twenty hours after the intervention, systolic blood pressure dropped to 60mmHg. Ultrasonic cardiogram at that time revealed massive pericardial effusion. We diagnosed cardiac tamponade, and 8Fr drainage tube was placed in the pericardial space. We determined that emergent operation was necessary because we suspected left ventricular rupture due to acute myocardial infarction or coronary rupture induced by percutaneous coronary intervention. However, operative findings revealed right ventricular free wall rupture, which could have been induced by chest compression. In these cases, we should consider the possibility of not only the rupture of left ventricle and coronary artery but also the rupture of right ventricle induced by cardiopulmonary resuscitation.

A 51-year-old woman with a large uterine myoma suffered from acute pulmonary throm boembolism. Venography revealed thrombosis in the right common iliac vein and almost complete obstruction of the left common iliac vein. The ascending lumbar vein showed collateral drainage. Treatment was initiated with continuous intravenous heparin sodium, and a Greenfield filter was inserted to prevent the extension of the pulmonary embolism during and after hysterectomy. After a total hysterectomy, venography revealed restora tion of patency in the bilateral common iliac veins, and no flow was seen in the ascending lumbar vein. Thorough clinical examinations failed to identify any other prothrombotic conditions. These results suggest that a large uterine myoma compressed veins in the pelvis, and the resulting impaired blood flow caused deep venous thrombosis and pulmonary thromboembolism.

The association of the severity of coronary atherosclerosis with hypertension and dyslipidemia, independent of other known coronary risk factors, was examined in 313 men and 155 women who underwent coronary angiography. The severity of coronary atherosclerosis was quantified using Gensini's scoring system. The following criteria were used to define dyslipidemia : hypercholesterolemia (total serum cholesterol concentration ≥220 mg/dl), hypertriglyceridemia (serum triglyceride concentration ≥150 mg/dl), and low HDL-cholesterolemia (serum HDL-cholesterol concentration

This paper presents the application of multi-objective optimization method for Network Expansion Planning. The Distribution Network Expansion Planning (DNEP) aims to minimize the cost and distribution loss while satisfying the constraints. The problem formulation results in combinatorial optimization problems which in practice are quite hard to solve due to their complexity. Therefore, in this paper Genetic Algorithm which is a meta-heuristics method was applied. The present study proposed the new method of multi-objective optimization methods. NSGA-II and SPEA2 is assumed to be the best method now. The proposed method introduces the concept of linkage identification genetic algorithm into that method. As a result, new method was possible to search more efficiently than existing methods.

The authors describe a patient who died of cardiac tamponade due to rupture of the free wall of the left ventricle sixteen years after a myocardial infarction. Examination at autopsy showed total discontinuation of the transmural fibrosis with calcification and fresh bleeding.

We present a patient who had a localized myocardial lesion of the left ventricle. Major clinical sequelae were left ventricular tachycardia and heart failure. This case appears to represent a left-sided counterpart of arrhythmogenic right ventricular dysplasia.

Acute aortic dissection (AAD), acute pulmonary embolism (PE) and acute myocardial infarction (AMI) are all emergent diseases with acute chest pain. However, it is sometimes difficult to diagnose these diseases by symptoms, ECG changes and/or cardiac biomarkers, especially immediately after onset. Because these diseases are all thrombogenic diseases, we considered that D-dimer could be helpful to differentiate these diseases. The purpose of this research was to define the D-dimer value for discrimination between AAD, PE and AMI.Plasma D-dimer values of a consecutive series of 35 AAD, 22 PE and 206 AMI patients on admission were analyzed retrospectively.The D-dimer values of patients with AAD (32.9 ± 66.7 g/ml, p0.001) and PE (28.5 ± 23.6 g/ ml, p0.001) were significantly higher than those of AMI patients (2.1 ± 3.7 g/ml). A cutoff value of 5.0 g/ ml was effective in distinguishing AAD and PE from AMI, with a sensitivity of 68% and a specificity of 90%.Our study showed the possibility that D-dimer could enable faster diagnosis and treatment of AAD, PE and AMI patients. We expect that the D-dimer test will be used more often for screening patients with possible AAD, PE or AMI in the emergency room. We would recommend contrast computed tomography first, not coronary angiography, in a patient with a D-dimer level higher than 5.0 g/ml using our diagnostic kit.

The usefulness of the head-up tilt testing (HUT) has heen previously addressed in diagnosing vasovagal neuroregulatory syncope in the teenage population. However, data concerning sensitivity and specificity is deficient due to the lack of control groups. We compared the response to HUT in young patients referred because of syncope or near syncope (n = 44, mean age 16 ± 3 years SD) to healthy young volunteers with a normal physical examination and no previous history of syncope (n = 18, mean age 16 ± 2 years) and io determine the sensitivity and specificity of HUT. The graded tilt protocol was performed at 15°, 30°, and 45° (each for 2 min), and then 60° for 20 minutes. Cuff blood pressure was measured every minute and lead IIECG was continuously monitored. Results; 25 of the 44 patients (57%) developed a vasovagaJ response or became symptomatic after 13.8 ± 5.7 minutes of HUT. Three of the 18 volunteers (17%) had a vasovagal response and became symptomatic after 9 ± 3 minutes of HUT. There was no statistical difference among the four groups (with and without tilt induced vasovagal response) in terms of age and baseline hemodynamic data. The sensitivity of 20 minutes HUT was 57% and its specificity was 83%. The presyncopal hemodynamic response in patients with history of syncope that was characterized by a significant decrease in systolic blood pressure and lack of increase of diastolic blood pressure as compared with baseline and with other groups. Gonclusions: 20 minutes at 60° HUT has a high specificity for the diagnosis of vasovagal syncope. Its limited sensitivity is counterbalanced by the advantage of limiting the incidence of false-positive results in patients without the vasovagal syndrome.

Microgravity effects on human factor were observed through a series of manual control experiments conducted in the First Material Processing Test. The Japanese Payload Specialist, who operated a stick to control a double integral controlled element against pseudo-random disturbance, felt pain in fast eye movement during orbital experiments. He was obliged to fix his line of sight at the center of display and to watch the displayed error movement using peripheral view. He also felt difficulty in supporting his body against reaction force of his hand movement. During two or three days after landing, disturbance was observed in the PS's posture. The operator's input and output data wiIl be analyzed by the cross spectral analysis to obtain the operator describing function and the remnants. Such data wiII be utilized in space man-machine system design. EIectro-myogram of hand and electro-oculogram data will also be analyzed.

Pulmonary embolism (PE) is a fatal disease that is very rare in young people. A 21-year-old man developed PE because of a retroperitoneal tumor. The inferior vena cava (IVC) was obstructed by the tumor, and thrombus existed in the right common iliac vein. Thrombolysis and heparinization improved his symptoms prior to urgent tumor resection. A temporary IVC filter was inserted the day before the operation, but 8 h later fatal massive PE occurred. At autopsy, the retroperitoneal tumor was revealed as a metastatic choriocarcinoma. Prophylactic use of a temporary IVC filter might have paradoxically induced recurrence of massive PE in this case.

The aim of the present study was to evaluate whether necrosis of the right bundle branch is responsible for development of right bundle branch block in acute myocardial infarction. Twenty patients with acute anteroseptal myocardial infarction were studied--10 with right bundle branch block (group A) and 10 without (group B)--to evaluate by serial sectioning the pathological extent of myocardial infarction surrounding the right bundle branch and also that of right bundle branch necrosis. Myocardial infarction reached the right bundle branch more than 8 mm above the moderator band in all of group A, whereas myocardial infarction reached the right bundle branch less than 3 mm above the moderator band in only three patients in group B. Nine hearts in group A showed significant necrosis of the right bundle branch. In group B and in one case with transient right bundle branch block no necrosis was found. The occurrence of right bundle branch block was almost entirely explained by necrosis of the right bundle branch, but transient right bundle branch block did develop without necrosis of the right bundle branch.

これまでに著者らは二つの方法でメチルシラザン類を得てきた。一つは,ヘキサメチルシクロトリシラザンの開環反応により得られたメチルシラザソオリゴマー,他は,MeSiCI3/Me2SiCI12混合系の共アンモノリシスにより得られるメチルシラザンオリゴマーである。これらを前駆体として繊維や薄膜など特殊形状の成形体製造の可能性を検討してきた,これらメチルシラザンオリゴマー類は生成初期には比較的低分子量であるが,いずれも分子末端に官能性のアミノ基をもち,そのため室温においても自己縮合し,時間の経過とともに高分子化することが可能である。しかしながら0長時間を必要とするうえ,最終段階で急激に分子量増加をきたすため利用適正条件を把握することがはなはだ困難であった。そこで,メチルシラザンオリゴマーの縮合時間の短縮を図るとともにその縮合物の主に軟化温度の把握に焦点を置き,初期分子量の異なるオリゴマー類に対して,処理温度,処理時間を変えた熱処理を行い,セラミックス前駆体として有効な熱変成メチルポリシラザンへの変換をはかった。この熱処理により原料オリゴマーは三つの領域,すなわち流動性領域,熱可塑性領域,熱硬化性領域を示す熱変成メチルポリシラザンに変換される。これら三領域中,特に熱可塑性領域にある試料を熱可塑性メチルポリシラザソとし・熱可塑性を与える処理温度範甲の確定と生成の再現性を求め,さらに与えられた軟化温度を指標として熱可塑性メチルポリシラザンを定義し,また特殊形状のセラミックス成形体への前駆体としての可能性を検討し効果のあることを確認した。

Introduction: trans radial intervention (trI) is less invasive. However, percutaneous coronary intervention (PcI) operators may be concerned that trans femoral approach (tFI) is better than trI according to the state of the patients, for example the patients with acute coronary syndrome (Acs) under the shock state, with severe winding subclavian artery and with the spasming radial artery. case report: We herein report a case of an unstable angina and acute heart failure. coronary angiography (cAG) revealed evidence of 90% ostial stenosis of the left main trunk (LMt). but we were unable to engage a 6 Fr guiding catheter (Gc) because of severe tortuosity of the left subclavian artery. therefore, we attempted intracoronary passage of a 4 Fr JL3.5 catheter exchange the 4 Fr diagnostic catheter with a 6 Fr Gc using an

Although thinning of the ventricular wall due to infarct expansion (septal aneurysm) may contribute to ventricular septal rupture (VSR), spatial factors predisposing to this mechanical complication have not been fully demonstrated. To identify the morphologic predictors of VSR, a retrospective postmortem study was performed on 17 hearts with acute anteroseptal myocardial infarction, comprising 7 with VSR and 10 without rupture. Infarct size and the extent of wall thinning were quantified. Wall thinning was defined as a decrease of less than 50% of thickness of the noninfarcted wall. The total infarct size did not differ among the groups. In the free wall (FW), the infarct was smaller in hearts with VSR than in those with a ruptured FW (p

Introduction: Acute aortic dissection is a disease of high mortality. The symptoms may mimic other conditions and misdiagnosed, such as acute coronary syndrome, coronary involvement complicates the clinical scenario and increases mortality. Case Report: We herein report a case of an acute myocardial infarction caused by acute aortic dissection. Without noticing the aortic dissection, we performed emergent coronary angiography, which showed severe stenosis of the proximal right coronary artery. Intravascular ultrasound scan led us to suspect aortic dissection. However, we performed balloon angioplasty because the patient's hemodynamic status was unstable. ECG-gated coronary computed tomography angiography provided a definitive diagnosis, and the patient underwent successful surgical repair of the aortic dissection. Conclusion: Acute coronary syndrome associated with acute aortic dissection is not rare. However, the management of these conditions depends on the details of each case. This case demonstrates the difficulty of treating such cases in the real world. Herein, we describe educational imaging findings and briefly discuss the management of cases involving acute coronary syndrome associated with acute aortic dissection.

The authors report a patient with silent dissecting aortic aneurysm in whom three-dimen sional spiral computed tomography (CT) angiography (3D-CTA) provided important imaging data. Images obtained by 3D-CTA were compared with the results of both conventional angiography and CT. They conclude that 3D-CTA was a powerful diagnostic modality for this patient, in addition to conventional CT and angiography.

Background Although molecular biological studies suggest a pathogenic link between enterovirus infection and dilated cardiomyopathy (DCM), the frequency of detection of enteroviral RNA is not consistently high in myocardial tissue from patients with DCM. A recent study has suggested that hepatitis C virus (HCV) may also be involved in the development of DCM. Methods and Results We performed genomic analysis for HCV in three patients with chronic active myocarditis. In all three patients, serum aminotransferase activities remained within normal ranges until the terminal stage of heart failure. At necropsy, all three livers showed evidence of tissue damage caused by chronic congestion, and one liver had evidence of chronic hepatitis. Routinely processed, paraffin-embedded tissue blocks of myocardium and liver were analyzed. Renal specimens were also analyzed to exclude the possibility of myocardial contamination with HCV material from the circulating blood. RNA extracted from the heart, liver, and kidney was subjected to strand-specific reverse transcription and amplified by semi-nested polymerase chain reaction. The target nucleotide sequence was a 178-bp fragment of the highly conserved 5′-noncoding region. Both positive- (genomic) and negative-strand RNA (replicative intermediates) were present in myocardial and liver tissue samples from all three patients. However, negative-strand RNA was undetectable in renal tissue from one patient. Conclusions These findings suggest that HCV replicated in myocardial tissue of these patients with myocarditis. Thus, HCV infection may contribute to the development of this unusual form of myocarditis.

We present here a patient with the unusual combination of a newly developed right bundle branch block (RBBB) and an acute posterior myocardial infarction (MI). A dissecting MI with interventricular septal (IVS) rupture was initially thought to have caused RBBB. However, histologic examination revealed that the right bundle branch (RBB) had no ischemic involvement, but did show fibrosis, which suggests that this chronic damage of the RBB was a major contributor to the development of RBBB. This case confirms that the RBB is rarely involved by a posterior MI even in the presence of a dissecting IVS rupture.

We prepared the Bi 2 Sr 2 Ca n −1 Cu n O y (Bi-based) whiskers by a method of Al 2 O 3 -seeded quenched glassy platelets, changing atmospheres of growth. It is very important to seed Al 2 O 3 particles on the surface of the glassy platelets in order the whiskers to grow at higher rate. From the results, we found that the growth rates and the critical temperatures of the whiskers were independent of oxygen gas flow rates, whereas the critical current density was dependent on such parameters. In addition, the superconducting property of the whiskers was affected by oxygen partial pressures, and the whiskers did not grow in Ar gas.

In this double-blind study, the authors compared the safety and efficacy of the investigational oral agent midodrine, a specific alpha 1-sympathomimetic agent, with ephedrine, a nonspecific alpha- and beta-adrenergic receptor agonist. Eight patients (4 men and 4 women) with refractory orthostatic hypotension resulting from autonomic failure were studied. This study was based on the notion that neurogenic orthostatic hypotension results from attenuation of adrenergic nerve traffic and not from alpha-adrenergic receptor dysfunction. Although arteriolar vasoconstrictors seem to be appropriate therapeutic agents, their success has been limited, and the search for an ideal drug is ongoing.The authors employed a blocked, double-blind, randomized crossover design. The single-blind placebo run-in period was 2 days. The double-blind titration period with either midodrine or ephedrine was 3 to 5 days; the titration end point was to increase standing systolic blood pressure toor = 80 mm Hg and to maintain a supine pressure below 180/100 mm Hg. The maintenance period was 3 to 5 days. A 4-day placebo washout period was interposed at the crossover point.The ability to stand improved in patients treated with midodrine but not with ephedrine. Midodrine significantly increased both systolic (P0.001) and diastolic (P0.001) standing blood pressure over placebo (P0.001) and ephedrine (P0.05). In contrast, ephedrine-induced changes in standing pressures did not significantly differ from placebo (P0.05). Midodrine treatment improved the frequency of the ability to stand as compared with ephedrine, and was associated with a significantly higher incidence of standing systolic pressures80 mm Hg than was placebo (P0.001). Both midodrine and ephedrine significantly increased supine systolic and diastolic blood pressures over placebo (P0.001, P0.01, P0.01, P0.01, respectively), but were not significantly different from each other. Ephedrine significantly increased (P0.05) the pulse rate as compared with placebo and midodrine, whereas midodrine produced a statistically significant (P0.05) but clinically minimal decrease in pulse rate compared with placebo. Neither drug affected clinical laboratory variables.Midodrine safely and effectively improved orthostatic hypotension caused by autonomic failure. Our data suggest that the ability to stand is improved better by midodrine than by ephedrine.

The purpose of the present study is to elucidate the difference in extent of myocardial infarction (MI) between those cases with and those without right bundle branch block (RBBB) occurring during the course of acute MI. We examined postmortem hearts from 20 patients with acute anteroseptal MI; 10 with (group A) and 10 without RBBB (group B). The extent of MI was studied pathologically in the interventricular septum (IVS) and reconstructed. The longitudinal extent of MI did not distinctly differ between groups A and B. In 5 hearts of group B, the anterior limit of the MI extended as high, or as close to the cardiac base, as in group A hearts. Transmural MI was relatively common and seen more frequently in group A than in group B. However, the MI did not always extend evenly to the left and right ventricular sides in the IVS. Left-sided predominance in extent of the MI was more frequently observed in group B than in group A. Right-sided predominance in the extent of septal MI was relatively rare and was seen in 5 cases at the portion where the right bundle branch came down. Four of these were group A patients. Thus, involvement of the right bundle branch might partly depend on the unevenness of the mural extent of the MI as well as the height of extension of the MI in the IVS.

We report three patients with a particular form of myocarditis characterized by numerous clusters of lymphocytes. Their common clinical manifestation was progressive and fatal heart failure with a 3- to 6-year duration. Atrioventricular and intraventricular conduction disturbances were observed in two patients. At necropsy, the hearts weighed 480, 530, and 430 gm, respectively, and showed marked dilatation of the bilateral ventricles and atria, with frequent mural thrombi. Histologic examination revealed numerous lymphocytic clusters and scattered foci of acute myocardial cell damage on a background of extensive fibrosis. We propose the term "chronic active myocarditis" to denote clinicopathologic characteristics of the present cases.

A transient complete coronary occlusion due to spasm was induced by the cold pressor test in a 51-year-old man with variant angina. Arteriography before the test revealed a normal left coronary artery and only minor irregularities of the mid-portion of the right coronary artery. Three minutes after cold stimulation, angina pectoris accompanied by ST-segment elevation was observed in lead II ECG. Simultaneous coronary arteriography during the attack showed a complete occlusion of the proximal right coronary artery due to spasm. The anginal attack together with spastic occlusion disappeared after administration of 0.8 mg of nitroglycerin. Thus, the cold pressor test can trigger coronary artery spasm and may even lead to a total occlusion in patients with variant angina. Individuals with variant angina may be subjected to additional risk when exposed to cold temperatures.