Search

Objectives The aim of this AFIRE (Atrial Fibrillation and Ischemic Events With Rivaroxaban in Patients With Stable Coronary Artery Disease) trial subgroup analysis was to examine rivaroxaban monotherapy benefits and their relation to the time between stenting and enrollment among patients after coronary stenting. Background Of 2,215 patients with atrial fibrillation and stable coronary artery disease in the AFIRE trial, rivaroxaban monotherapy was noninferior to rivaroxaban plus antiplatelet therapy (combination therapy) in terms of efficacy and superior for safety endpoints. However, thrombotic risk after antiplatelet therapy cessation remained a concern among 1,444 patients who had undergone coronary stenting >1 year before enrollment. Methods The benefits of rivaroxaban monotherapy in coronary stenting subgroups were assessed for efficacy (a composite of stroke, systemic embolism, myocardial infarction, unstable angina requiring revascularization, or death of any cause), safety (major bleeding defined according to International Society on Thrombosis and Haemostasis criteria), ischemic endpoints, net adverse clinical event, and time between stenting and enrollment. Results Efficacy and safety endpoints for monotherapy were superior to combination therapy, with HRs of 0.70 for efficacy (95% CI: 0.50-0.98; P = 0.036) and 0.55 for safety (95% CI: 0.33-0.92; P = 0.019). For ischemic endpoints, the HR was 0.82 (95% CI: 0.58-1.15; P = 0.240). The HR became smaller with longer time between stenting and enrollment (efficacy, P for interaction = 0.158; safety, P = 0.097). Conclusions In patients with atrial fibrillation after coronary stenting, the benefits of rivaroxaban monotherapy for efficacy and safety endpoints were consistent with those in the whole AFIRE trial population. The benefits became apparent with longer time between stenting and enrollment. (Atrial Fibrillation and Ischemic Events With Rivaroxaban in Patients With Stable Coronary Artery Disease Study [AFIRE]; UMIN000016612 , NCT02642419 )

Backgrounds While arterial stiffness and abnormal pressure wave reflection are independent cardiovascular risk, the difference of their association with alcohol intake have not been fully clarified. Aim This prospective observational study, which utilized repeated annual measurements performed over a 9-year period, applied mixed model analyses to examine age-related differences in longitudinal associations between alcohol intake and arterial stiffness, pressure wave reflection, and inflammation. Methods In 4016 middle-aged (43±9 years) healthy Japanese male employees, alcohol intake, brachial-ankle pulse wave velocity (baPWV), radial augmentation index (rAI), and serum C-reactive protein (CRP) levels were measured annually during a 9-year study period. Based on the questionnaire, alcohol intake was classified as non-drinker, mild-moderate drinker (ethanol 1–20 g/day) and heavy drinker (>20 g/day). Results The estimated marginal mean baPWV (non-drinkers = 1306 cm/s, mild-moderate drinkers = 1311 cm/s, and heavy drinkers = 1337 cm/s, P Conclusion In middle-aged male Japanese employees, alcohol intake may attenuate inflammatory activity. While alcohol intake may exacerbate the progression of arterial stiffening in a dose-dependent manner without mediating inflammation, especially in subjects under 50 years of age, it may promote pressure wave reflection abnormalities with aging at earlier ages without further exacerbation at older ages. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Omroncarpis

Background Hypertension and diabetes mellitus frequently coexist; however, it has not yet been clarified if the bidirectional longitudinal relationships between arterial stiffness and hypertension are independent of those between arterial stiffness and diabetes mellitus. Methods In this 16-year prospective observational study, 3960 middle-aged employees of a Japanese company without hypertension/diabetes mellitus at the study baseline underwent annual repeated measurements of the blood pressure, serum glycosylated hemoglobin A1c levels (HbA1c), and brachial-ankle pulse wave velocity (baPWV). Results By the end of the study period, 664, 779, 154, and 406 subjects developed hypertension, prehypertension, diabetes mellitus, and prediabetes, respectively. Increased baPWV at the baseline was associated with a significant odds ratio (per 1 standard deviation increase) for new onset of prehypertension/hypertension with (2.45/3.28, P Conclusions In middle-aged employees of a Japanese company, in contrast to the bidirectional relationships that exist between arterial stiffness and hypertension, increased arterial stiffness preceding the development of diabetes mellitus may represent that associated with the development of hypertension, as it is observed only in cases of diabetes mellitus coexisting with hypertension. Therefore, arterial stiffness may be associated to a greater degree with the development of hypertension than with the development of diabetes mellitus. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Omron Health Care Company (Kyoto, Japan),Teijin Pharma Company (Tokyo, Japan)

Background Recently, the concept of healthy vascular aging (HVA) and early vascular aging (EVA) phenotypes was proposed. Purpose We examined following issues; constancy of the vascular phenotypes over time; validity of assuming that constancy of the vascular phenotypes reflects the progression rate of structural arterial stiffening; and associations of vascular phenotype constancy with cardiovascular risk factors/their treatment, and the heart rate (HR). Methods Data on the brachial-ankle pulse wave velocity (baPWV) measured annually over a 16-year period in 4682 middle-aged Japanese employees were analyzed. Results Of all subjects, 30% showed constancy of the vascular phenotype during the study period. The estimated marginal mean of baPWV values and the slope of the annual increase of the baPWV were higher in the constant EVA group (EVA-EVA) than in the constant HVA group (HVA-HVA) (Figure 1). Elevated serum HbA1c levels, medication for hypertension, and high HR were significantly associated with constancy of the EVA phenotype, whereas a low HR was significantly associated with constancy of the HVA phenotype. Conclusions In middle-aged Japanese employees with the HVA/EVA phenotype at the study baseline, while the phenotype changed over time in most subjects, HVA/EVA phenotype constancy in the remaining subjects reliably reflected a low/high rate of progression of structural arterial stiffening. Hypertension and abnormal glucose metabolism were associated with constancy of the EVA phenotype, but treatment for these conditions failed to improve the phenotype. Low/high HR was a robust marker of the presence/constancy of the HVA/EVA phenotype. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Omron Health CareTeijin Pharma

Background Although the presence of 99mTc-sestamibi/123I-BMIPP-mismatch, the reverse redistribution (RR) of 99mTc-sestamibi and RR of 123I-BMIPP in patients with acute myocardial infarction (AMI) are known to significant markers for predicting the improvement of LV wall motion in the infarcted territory in chronic phase, few studies were performed to analyze them by simultaneous dual-isotope imaging using cadmium-zinc-telluride (CZT) SPECT system. Purpose The purpose of this study was to evaluate whether the presence of 99mTc-sestamibi/123I-BMIPP-mismatch or RR of 99mTc-sestamibi, RR of 123I-BMIPP make better prediction of the improvement of LV wall motion in the infarcted territory. Methods We evaluated 42 consecutive patients with AMI who had undergone both dual-isotope SPECT in acute phase and stress myocardial SPECT using 99mTc-tracers in chronic phase by Discovery NM530c. The presence of 99mTc-sestamibi/123I-BMIPP-mismatch, RR of 99mTc-sestamibi and RR of 123I-BMIPP were determined using traditional definition. The improvement of LV wall motion in the infarcted territory from acute phase to chronic phase was assessed using QGS. Results Of 42 patients, the improvement of LV wall motion in the infarcted territory from acute phase to chronic phase was found in 29 patients. The presence of 99mTc-sestamibi/123I-BMIPP-mismatch and RR of 99mTc-sestamibi and RR of 123I-BMIPP were significantly linked to predict the improvement of LV wall motion (p=0.0001, p=0.0001 and p=0.002, respectively). To predict the improvement of LV wall motion in the infarcted territory in chronic phase, the presence of 99mTc-sestamibi/123I-BMIPP-mismatch showed sensitivity of 93%, specificity of 85% and accuracy of 91%, while RR of 99mTc-sestamibi and RR of 123I-BMIPP had sensitivities of 72%, 48%, specificities of 85%, 100% and accuracies of 76%, 64%, respectively. The multivariate discriminant analysis revealed that the combination of 99mTc-sestamibi/123I-BMIPP-mismatch, RR of 99mTc-sestamibi and RR of 123I-BMIPP best predicted the improvement of LV wall motion in the infarcted territory in chronic phase with sensitivity of 93%, specificity of 85% and accuracy of 91% (chi-square=40.6), compared with RR of 99mTc-sestamibi and RR of 123I-BMIPP only (sensitivity 79%, specificity 85% and accuracy of 81%, chi-square=16.9). Conclusions The addition of 99mTc-sestamibi/123I-BMIPP-mismatch on RR of 99mTc-sestamibi and RR of 123I-BMIPP in patients with AMI, help better predict the improvement of LV wall motion in the infarcted territory in chronic phase. Funding Acknowledgement Type of funding sources: None.

Background While arterial stiffness and endothelial dysfunction, which are diffuse vascular damage, are phenotypes of vascular damage, their associations with the progression of atherosclerosis, which is focal vascular damage, has not been fully clarified. The present prospective observational study was conducted to examine whether arterial stiffness and endothelial dysfunction predict the progression of carotid atherosclerosis in subjects medicated for hypertension with/without carotid atherosclerosis. Methods and results In 617 subjects receiving antihypertensive treatment, we conducted flow-mediated vasodilatation (FMD), brachial-ankle pulse wave velocity (baPWV) and common carotid artery intima-media thickness mean and maximal (IMTmean and IMTmax) at the baseline and the end (3 years' later) of study periods. During the study period, FMD was decreased and baPWV, IMTmean and IMTmax were increased significantly. In subjects without carotid atherosclerosis (IMTmax 1.1mm, n=201), both baPWV and FMD were not associated with any markers of carotid atherosclerosis and also their changes during the study period. Conclusion In subjects with hypertension, arterial stiffness rather than endothelial dysfunction may be associated with the progression of carotid atherosclerosis, and this association may be significant in the premature stage of atherosclerosis. Figure 1 Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Omron Healthcare, Asahikasei Calpis

Objectives The objective of this study was to determine the optimal cut-off value of % uptake of simultaneous dual-isotope (99mTc-sestamibi/123I-BMIPP) SPECT in patients with acute myocardial infarction (AMI) for prediction of myocardial viability in chronic phase. Methods We evaluated 30 consecutive patients with AMI who had undergone both dual-SPECT in acute phase and stress myocardial SPECT using 99mTc-tracers in chronic phase by Discovery NM530c. Regional % uptake with a 17-segment model was obtained using QPS software. The presence of myocardial viability was defined when regional % uptake ≥50% in 99mTc SPECT at rest in chronic phase was observed. Receiver operating characteristic (ROC) curves were analyzed to determine the optimal cutoff values of regional % uptake in both left anterior descending artery (LAD) territory and non-LAD coronary territory in acute phase to predict the myocardial viability in chronic phase. Results The cutoff values for prediction of viable myocardium were %uptake ≥47% for 99mTc-sestamibi, %uptake ≥31% for 123I-BMIPP in acute phase in LAD territory and %uptake ≥52% for 99mTc-sestamibi, %uptake ≥48% for 123I-BMIPP in non-LAD territory. The respective sensitivities, specificities and the area under the ROC curve (AUC) values in the prediction of myocardial viability were 92%, 92% and 0.94 with 99mTc-sestamibi, 90%, 85%, 0.92 with 123I-BMIPP in LAD territory, and 81%, 93% and 0.92 with 99mTc-sestamibi, 81%, 90%, 0.92 with 123I-BMIPP in non-LAD territory. There were no significant differences in AUC values between 99mTc-sestamibi and 123I-BMIPP in both LAD territory and non-LAD coronary territory. Conclusions In the simultaneous 99mTc-sestamibi/123I-BMIPP dual-isotope imaging in patients with AMI, these results suggest that not only 99mTc-sestamibi SPECT, but also 123I-BMIPP SPECT may be possible to predict the presence of myocardial viability in chronic phase. But it should be noted that the optimal cutoff values of regional % uptake in acute phase to predict the myocardial viability may differ for LAD territory and non-LAD coronary territory. Funding Acknowledgement Type of funding source: None

Background/Introduction Although both the presence of 99mTc-sestamibi/123I-BMIPP mismatch and the reverse redistribution of 99mTc-sestamibi in patients with acute myocardial infarction (AMI) are known to significant markers for predicting the improvement of left ventricular (LV) wall motion in the infarcted territory in chronic phase, few studies evaluated them by simultaneous dual-isotope (99mTc-sestamibi/123I-BMIPP) imaging using cadmium-zinc-telluride (CZT) SPECT system. Purpose The purpose of this study was to evaluate whether the presence of 99mTc-sestamibi/123I-BMIPP mismatch or the reverse redistribution of 99mTc-sestamibi make better prediction of the improvement of LV wall motion in the infarcted territory. Methods We evaluated 30 consecutive patients with AMI who had undergone both dual-isotope (99mTc-sestamibi/123I-BMIPP) SPECT in acute phase and stress myocardial SPECT using 99mTc-tracers in chronic phase by Discovery NM530c. Both 99mTc-sestamibi/123I-BMIPP mismatch and reverse redistribution of 99mTc-sestamibi were determined using traditional definition. The improvement of LV wall motion in the infarcted territory from acute phase to chronic phase was assessed using QGS. Results Of 30 patients, the improvement of LV wall motion in the infarcted territory from acute phase to chronic phase was found in 20 patients. Both the presence of 99mTc-sestamibi/123I-BMIPP mismatch and reverse redistribution of 99mTc-sestamibi were significantly linked to predict the improvement of LV wall motion (p=0.0001, p=0.011, respectively). The respective sensitivities, specificities and accuracies in the prediction of the improvement of LV wall motion in the infarcted territory were 90%, 90% and 90% with 99mTc-sestamibi/123I-BMIPP mismatch, and 60%, 90%, 70% with reverse redistribution of 99mTc-sestamibi. Conclusions In the simultaneous 99mTc-sestamibi/123I-BMIPP dual-isotope imaging using CZT SPECT system, both the presence of 99mTc-sestamibi/123I-BMIPP mismatch and the reverse redistribution of 99mTc-sestamibi in acute phase are useful for predicting the improvement of LV wall motion in chronic phase, but the presence of 99mTc-sestamibi/123I-BMIPP mismatch is superior to the reverse redistribution of 99mTc-sestamibi for it. Funding Acknowledgement Type of funding source: None

This prospective observational study was conducted to examine the longitudinal associations of early/late cardiac systolic load (ESL/LSL) with decline of preserved cardiac systolic function, and also to examine the age-related differences in their associations. In 3679 middle-aged Japanese healthy men (43±9 years), brachial-ankle pulse wave velocity (baPWV) which related to ESL, radial augmentation index (rAI) which related to LSL and pre-ejection period/ejection time (PEP/ET) were measured annually during a 9-year study period. In subjects aged 50 years old (n=1093), baPWV and PEP/ET, but not rAI, were annually increased. Then, the PEP/ET at both the start and end of study period were increased among the tertile ranges of baPWV but not in those of rAI (Figure). In the mixed model linear regression analysis, while the baPWV (estimate = 7.2x10–5, p50 years old. Thus, in Japanese healthy men, age-related differences in the progression of vascular functional abnormalities may result in a difference in their effect on the decline of preserved cardiac systolic function. Namely, while age-related increase in ESL related with arterial stiffness may decrease preserved cardiac systolic function in subjects of all ages, age-related increase in LSL related with pressure wave reflection may decrease this parameter only in subjects under 50 years of age. Figure 1 Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Omron Health Care, Asahi Calpis Wellness

In addition to both pulse wave velocity (PWV; a marker of arterial stiffness) and augmentation index (AI; a marker of central hemodynamics), not only the decrease of ankle-brachial pressure index (ABI) but also its increase predict the future cardiovascular events. While arterial stiffness and central hemodynamics have been proposed to affect the increase in ABI logically, their effects on increase in ABI have not been fully clarified. The present cross-sectional and longitudinal studies were conducted to examine the associations of arterial stiffness and central hemodynamics with increase in ABI and also examine the age-related difference of those associations. In 4016 men (42±9 years old), ABI, brachial-ankle PWV (baPWV) and radial AI (rAI) were measured annually for 9 years' observation period. In the cross-sectional analyses adjusted with age, heart rate and mean blood pressure, both baPWV and rAI were associated with ABI in men aged 50. As shown in Figure, ABI was annually increased in subjects aged 50 (n=1146) during the follow-up period. The mixed model linear regression analysis (MMA) conducted in 9 years' annual repeated measurement data demonstrated that increased baPWV (estimate = 0.017, p50. In conclusion, the arterial stiffness and central hemodynamics may individually affect the increase in ABI in men aged 50. Thus, further studies are needed to clarify whether ABI, arterial stiffness, and central hemodynamics individually predicts future cardiovascular events, and their age-related difference of their predictabilities. figure1 Funding Acknowledgement Type of funding source: Private hospital(s). Main funding source(s): Tokyo Medical University

Background Hypertrophic cardiomyopathy (HCM) is a most prevalent primary myocardial disorder with heterogeneous clinical features. However, there have been few studies on clinical features of HCM as a prospective cohort. In 2015, we established a large-scale registration survey of patients with HCM throughout Japan, named J-HCM registry study. Purpose The aim of this study was to clarify the clinical features of Japanese patients with HCM. Methods J-HCM registry study is a prospective, multicenter investigation, consisting of 24 hospitals. This time, we present the baseline clinical characteristics in this survey. Results Total 1484 patients were registered. The ages at registration and at diagnosis were 65±15 and 56±17 years, respectively, and 806 patients (54%) were men. Majority of the patients (95%) was NYHA class I or II. With regard to subtypes of HCM, there were 526 patients (36%) in the HCM with left ventricular (LV) outflow tract obstruction, 126 patients (8%) in the mid-ventricular obstruction, 57 patients (4%) in the end-stage phase characterized by LV ejection fraction Conclusions In this multicenter registration survey of patients with HCM, the baseline clinical characteristics were almost similar to several retrospective large-scale cohorts in Western countries except older age and less symptomatic state. This study will provide important knowledge regarding management of HCM. Figure 1 Funding Acknowledgement Type of funding source: None

The score based on the office systolic blood pressure, age, fasting blood glucose level, and estimated glomerular filtration rate (SAGE score) has been proposed as a useful marker to identify elevated values of carotid-femoral pulse wave velocity (PWV). The present cross-sectional study was conducted to examine whether the SAGE score is also a useful marker to identify subjects with elevated brachial-ankle PWV values in Japanese subjects with hypertension. We measured the brachial-ankle PWV and calculated the SAGE score in a total of 1019 employees of a Japanese company with hypertension and 817 subjects with hypertension derived from a multicenter study cohort. The analyses in this study were based on data from these two study groups as well as on a composite population of the two (n = 1836). The receiver operating characteristic curve analysis showed that the area under the curve to identify subjects with brachial-ankle PWV values of ≥1800 cm/s was over 0.70 in each of the three study groups. Even after adjustments, a SAGE score ≥7 had a significant odds ratio for identifying subjects with brachial-ankle PWV values ≥1800 cm/s in the 1836 study subjects from the composite occupational and multicenter study cohort (odds ratio = 2.1, 95% confidence interval = 1.4–3.0, P < 0.01). Thus, in Japanese subjects with hypertension, the SAGE score may be a useful marker for identifying subjects with elevated brachial-ankle PWV values. © 2020, The Japanese Society of Hypertension.

Background Blood flows through healthy hearts form optimal flow structures; they store flow kinetic energy (KE) that can be used for ejection. In contrast, in failing hearts, intracardiac flows become disorganized so that they may be energetically inefficient. However, it remained unknown whether left ventricular (LV) flow energetics prognosticates in heart failure. Methods This study included 61 patients with dilated cardiomyopathy (DCM). The temporal change in KE during early diastole (ED), atrial contraction (AC) and isovolumic contraction (IVC) was measured using Vector Flow Mapping particle tracking (Hitachi, figure top). LV inflow (total flow) were divided, based on whether they were ejected (direct flow, DF) or stayed in LV (retained flow, RF) in the following systole. KE of DF can be made use of for ejection, whereas KE of RF is supposed to be wasted. Diastolic function was graded, according to current EACVI/ASE guidelines. The patients were followed up for three years. Primary endpoint was hospitalization for worsening heart failure (WHF). Results 12 patients had hospitalizations for WHF in the follow-up period. KE of total flow did not show any significant difference through the cardiac cycle between patients with and without WHF. KE of DF was slightly, but not significantly, smaller (ED: p = 0.252, AC: p = 0.119, IVC: p = 0.122), and KE of RF was slightly, but not significantly, larger (ED: p = 0.971, AC: p = 0.085, IVC: p = 0.134) in patients with WHF than those without events. The ratio of DF and RF (DF/RF ratio) showed significant differences between these two groups, especially from AC through IVC (figure, bottom-left). Cox proportional hazard analyses demonstrated that DF/RF ratio during IVC showed a significant correlation with clinical outcomes (p = 0.033, hazard ratio = 0.067). It remained significant even after adjusted for diastolic function grade (p = 0.046, hazard ratio = 0.074). Kaplan-Meier analysis confirmed the above results (figure, bottom-right). Conclusion: Efficiency of KE recruitment for LV ejection during IVC is associated with clinical outcomes in DCM. Abstract P893 Figure. LISA

Background Although the patient's characteristics and outcome of acute myocardial infarction (AMI) have been sufficiently investigated and primary percutaneous coronary intervention (PCI) has been recognized as established treatment strategy, those of recent myocardial infarction (RMI) have not been fully evaluated. Purpose The purpose of the present study was to clarify clinical characteristics and in-hospital outcomes of RMI patients from the database of the Tokyo CCU network multicenter registry. Methods In Tokyo CCU network multicenter registry database from 2013 to 2016, 15788 consecutive patients were registered as AMI (within 24 hours from onset) and RMI (within 2–30 days from onset). However 1246 patients were excluded because of inadequate data. And we excluded 66 cases because of out of onset period and 129 cases that strongly suspected of involvement of vasospastic events. Therefore, remaining 14347 patients were categorized to RMI group (n=1853) and AMI group (n=12494), and analyzed. Results Compared with AMI group, average age was older (70.4±12.9 vs 68.0±13.4 years, p Kaplan-Meier analysis Conclusions RMI patients had distinctive clinical features in backgrounds and treatment strategies compared with AMI patients, and the major cause of death of RMI patients was different from that of AMI patients. Furthermore, even though treatment during hospitalization of RMI patients was well done, death due to mechanical complications continued to increase.

Background Heart failure (HF) is a heterogeneous condition. The reduced liver blood flow and hepatic congestion associated with HF causes liver damages leading to liver sclerosis. Fibrosis 4 score (FIB-4 score), a marker of liver sclerosis, is easily calculated from age, serum aspartate aminotransferase (AST), alanine aminotransferase (ALT) level and blood platelet count (PLT). Liver stiffness is known to be associated with vascular damages, including arterial stiffness and central hemodynamics. These vascular damages also cause the new onset of HF. However, it remains to be clarified whether liver stiffness is a direct risk factor for HF or whether its association with HF is mediated by vascular damage. We conducted cross-sectional and prospective longitudinal studies to examine whether FIB-4 score is directly associated with the serum NT-pro-BNP levels or the association is mediated by arterial stiffness and/or abnormal central hemodynamics. Methods and results In 3,040 health Japanese subjects with serum NT-pro-BNP levels Conclusion Liver stiffness may have a significant direct association with the development of HF from the early stage, without the mediation of arterial stiffness and/or abnormal central hemodynamics. Therefore, the FIB-4 score appears to serve as a direct risk factor for HF from the early stage, and its association with HF may not be mediated by vascular damages.

The prevalence of asymptomatic coronary artery stenosis in relation to carotid artery stenosis is influenced by the underlying disease and has yet to be clarified.A total of 124 consecutive Japanese patients with aortic aneurysm, but without symptoms of coronary artery stenosis, were divided into 2 groups on the basis of carotid ultrasonography: the carotid stenosis group (or=50% luminal diameter narrowing) and the non-stenosis group. Myocardial imaging was performed using thalium-201 chloride and adenosine triphosphate disodium.The mean age and incidence of both cerebrovascular disease and peripheral artery disease were significantly higher in the stenosis group (n=24) than the non-stenosis group (n=100). Defining both fixed and reversible hypoperfusion as positive on the basis of myocardial imaging, a significantly higher number of positive findings were found in the stenosis group (15/24; 62.5%) than in the non-stenosis group (32/100, 32.0%), (Odds ratio: 3.54; p0.01). The distributions of hypoperfusion defects in the stenosis group were similar to those in the non-stenosis group, but fixed hypoperfusion was more frequently seen in the stenosis group.The high prevalence of positive findings in the stenosis group indicates that carotid artery stenosis is frequently associated with coronary artery stenosis even in asymptomatic patients, and could be an indicator for advanced atherosclerosis of the coronary artery. The results confirm that stress myocardial imaging is invaluable in the detection of coronary artery stenosis, particularly in patients with carotid arteriosclerosis.

To assess the clinical significance of iodine-123 beta-methyl-p-iodophenyl-pentadecanoic acid(BMIPP) single photon emission computed tomography(SPECT), the predictive value of BMIPP imaging in patients with angina pectoris was evaluated.One hundred seventy-four patients who underwent BMIPP imaging in our institution were aged 61.8 +/- 11 years. One hundred thirty-five patients had stable angina and 39 had unstable angina at the time of examination. Patients with previous myocardial infarction or myocardial disorders were excluded. Early and delayed images were acquired in BMIPP SPECT, and the images were analyzed visually. Cardiac events were classified into hard and soft events: the former consisted of cardiac death and nonfatal myocardial infarction, and the latter included coronary revascularization and heart failure.The findings of BMIPP imaging were normal in 82 patients and abnormal in 92. During follow-up of 15.5 +/- 9.5 months, hard events were observed in 4 patients and soft events in 53. In patients with normal BMIPP imaging, soft events were observed in nine patients, but no hard event was encountered. Furthermore, in patients with both normal BMIPP and stress thallium imagings, no cardiac event was observed during 2 years. In contrast, 4 hard events and 44 soft events occurred in patients with abnormal BMIPP imaging. Patients with abnormal BMIPP imaging had a higher incidence of soft events than those with normal BMIPP imaging, regardless of the type of angina(16/62 vs 3/73, p0.0005 for stable angina; 28/30 vs 6/9, p0.0001 for unstable angina).The finding of BMIPP imaging correlates well with the mid-term prognosis of patients with angina pectoris. Since BMIPP SPECT is performed without stress to the patient, this imaging modality is important in evaluating patients with stable or unstable angina.

The clinical benefit of cholesterol-lowering treatment is unknown in the Japanese elderly in whom the prevalence of morbidity and mortality related to coronary artery disease are known to be low. To evaluate the efficacy of cholesterol-lowering treatment with 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor in Japanese elderly patients with documented coronary artery disease, 121 patients with serum cholesterolor = 150 mg/dl prospectively received HMG-CoA reductase inhibitor, and 271 patients undergoing cholesterol-lowering treatment based on dietary therapy alone served as historical controls. The 143 elderly patients ageor = 65 years in the 2 groups had similar baseline serum total cholesterol level (201 +/- 30 vs 202 +/- 31 mg/dl), age (71 +/- 4 vs 70 +/- 4 years), proportion of men (37/53 vs 64/90), number of diseased vessels (1.7 +/- 0.9 vs 1.5 +/- 1.0), and incidences of other classical coronary risk factors, including hypertension, diabetes mellitus, smoking, obesity and family history of coronary artery disease. In all 392 patients, similar trends were observed, including serum total cholesterol level (208 +/- 33 vs 201 +/- 34 mg/dl). With HMG-CoA reductase inhibitors, serum total cholesterol level was reduced by 14% in the elderly subjects and by 13% in all patients. During the follow-up of approximately 3 years, cardiac events occurred in 5 patients (one elderly) in the treatment group and 38 patients (12 elderly) in the control group. Kaplan-Meier survival estimates revealed a higher event-free survival rate with HMG-CoA reductase inhibitors in the elderly subjects (98% vs 85%, p0.05) and in all patients (94% vs 86%, p0.05). Cox proportional hazard modeling also demonstrated a significant reduction in risk for cardiac events with drug therapy (relative risk 0.32, p0.05), in addition to the number of diseased vessels (relative risk 1.8, p0.01). In contrast, no additional risk was observed with advancing age. Cholesterol-lowering treatment with HMG-CoA reductase inhibitors is effective to improve the prognosis of Japanese elderly patients, including those with normal serum cholesterol level.

Although the aVL lead in exercise electrocardiography is reported to be helpful in identifying a significant narrowing of the left anterior descending coronary artery (LAD), its role in exercise testing has not been fully evaluated. Accordingly, 821 patients who underwent both standard exercise testing and coronary angiography were evaluated. In patients with aVL lead ST elevation, the incidence of a significant narrowing of the LAD (124/165 vs 348/656; p0.001) was higher than in those without. Multiple logistic regression analysis revealed that the 2 most important variables that correlated with aVL lead ST elevation were a greater number of leads with ST depression in the inferior leads and a smaller amplitude of R wave in the aVL lead. In contrast, variables correlating with aVL lead ST depression in the majority of cases were a greater number of leads with ST depression in all leads and the presence of inferior lead ST elevation. The results of this study indicate that although aVL lead ST elevation could be a marker for LAD narrowing, more important factors such as inferior lead ST-segment depression and the R-wave amplitude of the aVL lead should be taken into consideration. In contrast, ST depression in the aVL lead mostly represents exercise-induced myocardial ischemia of greater extent and severity.

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

To elucidate whether atherosclerotic aortic plaque detected by transesophageal echocardiography can be a clinically useful marker for coronary artery disease in the elderly.Atherosclerotic aortic plaque detected by transesophageal echocardiography has been reported to be a marker for coronary artery disease. Its significance may be important particularly in the elderly population, although to our knowledge, there are no data yet available.We performed transesophageal echocardiography on 84 patients who had previously undergone coronary arteriography. The criteria used to diagnose atherosclerotic plaque on transesophageal echocardiography were the presence of focally or linearly increased echodensity of the aortic intima with lumen irregularity and thickening or ulceration.Significant coronary artery disease (or = 50% stenosis) was detected in at least one major coronary artery in 27 of the 84 patients. Aortic plaques were detected by transesophageal echocardiography in 25 of the 27 patients (93%) with coronary artery disease and in 30 of 57 patients (53%) without coronary disease (p0.001). Among 24 patients 70 years or older, aortic plaques were present in 13 of 14 (93%) patients with coronary artery disease and 9 of 10 patients (90%) without coronary disease. Among 60 patients younger than 70 years, aortic plaques were present in 12 of 13 patients (92%) with coronary artery disease and 21 of 47 patients (45%) without coronary disease (p0.01). The independent association between coronary artery disease and the presence of aortic plaque, age, gender, and other coronary risk factors was examined by multiple logistic regression analysis. In patients 70 years or older, the presence of aortic plaque failed to be a predictor of significant coronary artery disease, although it was indeed a strong predictor of coronary artery disease in patients younger than 70 years (p0.05).In elderly patients, atherosclerotic aortic plaque detected by transesophageal echocardiography is not useful in predicting significant coronary artery disease. It is useful only in a relatively younger population.

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

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

Patients with myocardial infarction (MI) and triple vessel coronary disease generally have poor prognoses. However, it is not known whether there are particular angiographic variables associated with the poor prognosis in MI patients with triple vessel disease. The angiographic variables for poor prognosis were investigated in 43 MI patients with triple vessel disease (32 men and 11 women, mean age 63 +/- 9 years) who were followed medically for a mean of 32 +/- 28 months. There were 13 cardiac deaths (30%) and 10 late-coronary artery bypass grafting (23%). Twenty patients were alive and well. The patients who died of cardiac causes had lower ejection fractions (42 +/- 18% vs 49 +/- 15%, p0.05), a higher prevalence of two vessel occlusion (77% vs 40%, p0.05), and a higher prevalence of coronary occlusion opposite the MI site (69% vs 25%, p0.01) when compared to survivors, although there were no significant differences in age, MI sites, or the prevalence of occlusion in the infarct-related artery. Multivariate analysis with the Cox proportional hazards model revealed that coronary occlusion opposite the MI site (hazards ratio 16.36) and an age ofor = 65 years (4.46) indicated a significantly high ratio. The hazard ratio of the ejection fraction and two vessel coronary occlusion were not significant. The poor prognosis of MI patients with triple vessel coronary disease may be related to impaired left ventricular function and to coronary occlusion opposite the MI site and greater age. This may have important clinical implications in the initial decision for interventional therapy.

Noninvasive evaluation of coronary artery disease is difficult in elderly patients because of their limited exercise-capacity. The diagnostic and prognostic value of dipyridamole perfusion scintigraphy was assessed in 147 patients aged 65 years and older. All patients underwent coronary angiography. Initially, 32 patients had percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG). The other 115 patients were first treated medically and followed for a mean of 29 +/- 22 months. Nine patients (7.9%) had cardiac events including cardiac death and coronary intervention (PTCA or CABG) during the follow-up. Dipyridamole perfusion scintigraphy was performed safely in all patients, whereas treadmill exercise testing could not be adequately performed in 24 patients, 18 of whom had multivessel disease. Multiple regression analysis showed that: fixed defect and reversible defect were powerful detectors of coronary lesions (p = 0.0001, p = 0.0027, respectively), all patients with fixed disease and 94% of patients with only reversible defect had significant coronary lesion; Diffuse slow washout and ST depression were statistically significant for detecting multivessel coronary lesions in patients with fixed disease (p = 0.0001, p = 0.017, respectively), the sensitivity and specificity of diffuse slow washout and/or ST depression for detecting multivessel coronary lesions ware 85% and 74%, respectively, and ST depression was statistically significant for detecting multivessel coronary lesions (p = 0.0002) in patients with only reversible defect, the sensitivity and specificity of ST depression were 88% and 64%, respectively. Cox survival analysis identified diffuse slow washout as the best predictor of future cardiac events among the scintigraphic variables.(ABSTRACT TRUNCATED AT 250 WORDS)

The diagnostic value of dipyridamole thallium scintigraphy for the noninvasive identification of left main (LM) and triple vessel (TV) coronary artery disease (CAD) was evaluated in 615 consecutive patients with known or suspected CAD. One hundred thirty-nine patients had LM or TVCAD; the remaining 476 patients had limited CAD (double vessel CAD in 112, single vessel CAD in 235, insignificant lesions in 129). Patients with LM or TVCAD, compared to those with limited CAD, had a higher incidence of diffuse slow washout (58 vs 20%, p0.0001), extensive fixed defects (21 vs 6%, p0.0001) and extensive reversible defects (32 vs 8%, p0.0001). During dipyridamole loading, the incidence of chest pain was higher (65 vs 41%, p0.0001), and the magnitude of ST depression was greater (0.16 +/- 0.14 vs 0.04 +/- 0.07 mV, p0.001) in patients with LM or TVCAD than in those with limited CAD. Stepwise discriminant analysis using scintigraphic imaging achieved a sensitivity of 69%, a specificity of 79%, and an accuracy of 77% for diagnosing patients with LM or TVCAD. After including clinical markers of ischemia during dipyridamole loading, multivariate analysis revealed an improved diagnosis with a sensitivity of 71%, a specificity of 85%, and an accuracy of 82%. These results clearly show the usefulness of scintigraphic imaging as well as the significance of careful assessment of clinical markers of ischemia during dipyridamole loading for the noninvasive identification of LM and TVCAD.

Studies of normal aging in the cardiovascular system in humans are affected by the study population. Besides intrinsic biological aging, extrinsic factors including overt or latent cardiovascular diseases as well as life style variables such as physical activity, diet, alcohol and smoking may influence the age-related changes of cardiovascular function. We have recruited "normal" elderly subjects from community-dwelling volunteers by extensive health screening procedures including treadmill maximum exercise tests. Some of their cardiovascular functions, such as various cardiovascular regulatory functions, were altered compared to normal young subjects, while others such as resting hemodynamics were not. Interrelationships among various autonomic functions in the elderly were not recognized. Although general effects of life styles on circulatory regulatory functions were not clearly indicated, variables such as sodium intake or body mass index appeared to affect some of the sympathetic nervous functions. Furthermore, hypertension in the elderly had much less impact on cardiovascular functions than is generally expected, based on the results from young or middle-aged subjects. To identify factors which either modify (accelerate) or do not affect the aging of the cardiovascular functions is important not only to achieve a good aging process but also to establish therapeutic goals in elderly subjects.

Objectives: We sought to evaluate whether the measurements of pressure-derived fractional flow reserve (FFR) is applicable in diabetic patients. Background: Although the development of a coronary pressurewire facilitates the measurement of FFR to assess the functional severity of coronary-artery stenoses, theoretical limitations include diabetes mellitus due to microvascular abnormalities. Methods: We studied 245 patients with 304 vessels and their coronary territories with a coronary pressurewire and thallium-201 single-photon emission computed tomography (SPECT). The cut-off point in FFR for detecting myocardial ischemia was evaluated using receiver operating characteristic (ROC) curve analysis. Results: In 96 diabetic and 149 nondiabetic patients, the best cut-off point in FFR to detect myocardial ischemia as demonstrated by thallium SPECT was 0.725 in diabetics and 0.745 in nondiabetics. In addition, the areas under these 2 curves were similar (0.833 vs 0.831). Sensitivity of 83% and specificity of 75% in diabetic patients were also similar to nondiabetics (sensitivity 79% and specificity 83%). However, diabetic patients with HbA1c≥7.0% showed lower specificity in comparison to diabetic patients with HbA1c

Background: Since cardiac disease is a major cause of death in renal failure patients receiving hemodialysis, the assessments of cardiac function and coronary artery disease are of particular concern in this high-risk population. Methods: To evaluate the usefulness of the cardiac risk stratification using stress single photon emission computed tomography (SPECT) in patients receiving hemodialysis, stress SPECT was performed in 79 such patients. In addition to clinical profile, the presence or absence of perfusion defects including semi-quantitative analysis with the 20-segment model was evaluated. Results: Stress SPECT revealed negative findings in 37 patients and positives in 36. In addition, reduced ejection fraction measured by gated SPECT or echocardiography was observed (48.7±16.0 %). During a mean follow up of 18.7 months in 73 patients, after excluding 6 patients who underwent coronary revascularization within 60 days of SPECT study, cardiac events occurred in 14 patients: cardiac death in 1, myocardial infraction in 3, congestive heart failure in 3 and unstable angina in 7. Univariate analysis revealed the history of myocardial infraction, the duration of hemodialysis and summed stress score (SSS) >8 were significant predictors of cardiac events. Multivariate analysis using Cox proportional hazards model revealed that SSS8 was the single best factor to identify patients who had cardiac events (hazard ratio 4.0; 95% confidence interval, 1.3–12.3; p Conclusion: Stress myocardial SPECT has a significant value in the risk stratification of renal failure patients receiving hemodialysis. In patients with moderate to severe myocardial perfusion defects, further cardiac evaluation including coronary angiography is necessary.

Background: Not only patients with aortic disease have a high prevalence of coronary artery disease, but also aortic surgery itself is highly invasive. Therefore, preoperative risk stratification for this high-risk subset is essential. We evaluated the usefulness of the perioperative cardiac risk stratification using pharmacologic single photon emission computed tomography (SPECT) in patients undergoing aortic surgery. Methods: Pharmacologic stress SPECT using ATP or dipyridamole was performed in 302 patients: aortic dissection in 56, TAA in 124, and AAA in 122. Open vascular surgery was performed in 75, and endovascular surgery by stent-graft placement in 227. Not only the presence or absence of perfusion defects, but also the 20-segment model analysis was performed. Results: Pharmacologic thallium SPECT revealed negative findings in 210 patients and positive findings in 92. Among 92 patients with positive tests, 33 patients were evaluated by catheterization; 25 out of these 33 patients revealed to have CAD. Of these 25 patients, 9 underwent successful revascularization prior to or during surgery. Perioperative cardiac events occurred in 9 patients; 7 occurred in patients with positive SPECT, whereas only 2 occurred in those with negative SPECT (2/210 vs 7/92; p 13 was the most important factor to identify patients who subsequently had perioperative cardiac events. Conclusions: Pharmacologic stress SPECT has a significant value in the risk stratification of patients before aortic surgery. In patients with positive SPECT, especially extensive myocardial perfusion defects, aggressive approach for preoperative risk reduction is necessary, whereas aortic surgery can be performed safely in patients with negative SPECT.

Background: The development of quantitative gated SPECT (QGS) facilitates a wide application of functional evaluation during myocardial imaging with the use of not only Tc-99m-labeled radioisotopes but also using Tl-201. However, the feasibility of gated SPECT using Tl-201, in comparison to Tc-99m-labeled radioisotopes, has not been validated. Methods: A set of gated SPECT studies performed on the same patient using Tc-99m sestamibi and Tl-201 was evaluated. Mean interval between the 2 studies was 10.0 ± 5.7 months. Patients who underwent coronary intervention or drug adjustment before the second study were excluded. Using the QGS software, left ventricular end-diastolic volume (LVEDV), end-systolic volume (LVESV) and ejection fraction (LVEF) were measured in 61 patients. In addition, left ventricular regional wall motion was assessed visually by a 3-dimensional display image using a 7-segment model. Results: Significant correlations were observed in LVEDV (r = 0.85, p Conclusion: In the assessment of cardiac function using gated SPECT with Tl-201, LVEF was similar to the measurements made with Tc-99m sestamibi, though LV volumes tended to be smaller. In addition, caution is necessary in the analysis of regional wall motion, particularly of the inferior wall.

The age as an important factor influencing the prognosis of mitral valve prolapse (MVP) was assessed by comparing two age groups; 26 cases whose ages were younger than 49 years, and 27 cases more than 50 years. 1. The aged group had higher incidence of dyspnea and enlarged heart most probably due to insidious heart failure. 2. The aged group frequently had an apical pansystolic murmur and enlarged left atrium, indicating the progress of mitral regurgitation. These observations suggest that the careful follow-up observation is mandatory for patients with MVP of advanced age.

To assess the indication for percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG), we studied 93 patients with angina pectoris but without myocardial infarction. All patients had significant stenosis (greater than 50%) in at least one coronary artery, including the left anterior descending artery. Fifty-eight patients received medical treatment (Group I), 12 had PTCA (Group II) and 23 had CABG (Group III). Findings of coronary angiography, treadmill exercise tests and dipyridamole perfusion scintigraphy as well as the frequency of cardiac events during follow-up were assessed in each group. 1. Coronary angiography revealed 1 vessel disease in 38% of the patients in Group I, 58% in Group II, and 13% in Group III; 2 vessel disease in 33%, 25% and 61%; and 3 vessel disease in 29%, 17% and 26%, respectively. 2. Exercise duration with the treadmill test was 4.7 min in Group I, 4.0 min in Group II and 3.7 min in Group III. ST depression (greater than or equal to 1 mm) was induced in 75%, 83% and 95%, respectively. Exercise duration improved from 4.0 to 6.0 min after PTCA and from 3.7 to 4.5 min after CABG. Exercise-induced ST depression also became less frequent; from 83% to 25% after PTCA and from 95% to 32% after CABG. Dipyridamole perfusion scintigraphy showed reversible defects in 86% of the patients in Group I and in all patients in Groups II and III. Reversible defects were observed in 17% of the patients after PTCA and in 21% after CABG. 3. During a mean follow-up period of 26 months, cardiac deaths occurred in one patient (2%) in Group I and 2 (7%) in Group III. Nonfatal cardiac events (myocardial infarction and unstable angina or those necessitating revascularization--late PTCA or CABG) were observed in 12 patients (21%) in Group I, 4 (24%) in Group II and 10 (36%) in Group III. Anginal attacks at least once weekly remained in 12% of the patients in Group I, 19% in Group II and 14% in Group III at the last follow-up. In conclusion, PTCA and CABG appear to be effective methods for improving ischemia and exercise tolerance. However, preventive PTCA and CABG may not be indicated in patients with mild angina, because the prognosis is also excellent in medically-treated patients with angina but without myocardial infarction or left main coronary artery disease.

To evaluate the prognostic significance of perfusion abnormalities, particularly large defects, in dilated cardiomyopathy (DCM), we performed thallium-201 myocardial scintigraphy and 24-hour ambulatory ECG monitoring in 27 patients. The abnormal scintigraphic patterns and the presence of ventricular tachycardia (VT) were correlated with causes of death during a follow-up period of 30.0 +/- 19.4 months. Eight patients had large defects (LD), 11 had multiple small defects (MSD), and eight had no defects (NL). The patients with LD had extensive ventricular akinesis in the region of the perfusion defect, significantly elevated LVEDP (LD 20.6 +/- 7.4 mmHg, MSD 15.5 +/- 7.6 mmHg, NL 10.3 +/- 2.3 mmHg: LD vs NL; p less than 0.01, MSD vs NL; p less than 0.05), and reduced ejection fraction (LD 23.9 +/- 9.1%, MSD 32.7 +/- 7.2%, NL 40.3 +/- 7.7%: LD vs MSD; p less than 0.05, MSD vs NL; p less than 0.01). VT was detected in 11 patients; among whom three had LD, six had MSD, and two had no defects. Among seven patients who died during follow-up (five of heart failure, one sudden death, and one non-cardiac death), five had LD and two had MSD. There were no deaths among patients without defects. Among 11 patients with VT, only one died suddenly. In conclusion, large scintigraphic defects correlated well with severe LV dysfunction, and this is an important variable in predicting outcomes in DCM.