Haruyo Yamashita

Concentrations of interleukins, interferon, and C-reactive protein in stable and unstable angina pectoris.

We analyzed the concentrations of interleukins (IL)-6, IL-10, IL-12, and IL-18, interferon (IFN)-gamma, and high-sensitivity C-reactive protein (hsCRP) in 40 patients with unstable angina (UAP), 39 patients with stable angina (SAP), and 52 age- and gender-matched controls. Compared with the control group, IL-12 concentrations were significantly higher in both the SAP and UAP groups, especially in the UAP group, and the IL-18 concentrations tended to be higher in the UAP group. Conversely, IL-10 concentrations were significantly lower in the SAP and UAP groups. Both IL-6 and hsCRP concentrations were significantly higher in the UAP group. The levels of hsCRP were positively correlated with inflammatory or proinflammatory cytokines (IL-6, IL-12, and IL-18), and negatively correlated with anti-inflammatory cytokine (IL-10). Moreover, the levels of IL-12 were positively correlated with IL-18, and negatively correlated with IL-10, and the results revealed the T-helper 1 dominant state. These results suggested that the inflammatory response was strongly associated with coronary atherosclerosis and angina pectoris, and that the T-helper 1 dominance may play an important role in these diseases.

Impact of diabetes on muscle mass, muscle strength, and exercise tolerance in patients after coronary artery bypass grafting

BACKGROUND The impact of diabetes mellitus (DM) on muscle mass, muscle strength, and exercise tolerance in patients who had undergone coronary artery bypass grafting (CABG) has not been fully elucidated. METHODS We enrolled 329 consecutive patients who received cardiac rehabilitation (CR) after CABG (DM group, n=178; non-DM group, n=151) and measured lean body weight, mid-upper arm muscle area (MAMA), and handgrip power (HGP) at the beginning of CR. We also performed an isokinetic strength test of the knee extensor (Ext) and flexor (Flex) muscles and a cardiopulmonary exercise testing at the same time. RESULTS No significant differences in risk factors, including age, gender, number of diseased vessels, or ejection fraction were observed between the 2 groups. The levels of Ext muscle strength, peak oxygen uptake, and anaerobic threshold were significantly lower in the DM group than in the non-DM group (all p<0.05). Both peak oxygen uptake and MAMA correlated with Ext and Flex muscle strength as well as HGP (all p<0.005). The MAMA, HGP, and Ext muscle strength were lower in patients who received insulin therapy than in those who did not. Interestingly, fasting glucose levels significantly and negatively correlated with Ext muscle strength. CONCLUSIONS These data suggest that DM patients had a lower muscle strength and exercise tolerance than non-DM patients. Moreover, a high glucose level may affect these deteriorations in DM patients after CABG.

Usefulness of Prominently Projected Aortic Arch on Chest Radiograph to Predict Severe Tortuosity of the Right Subclavian or Brachiocephalic Artery in Patients Aged >44 Years Undergoing Coronary Angiography With a Right Radial Artery Approach

Although it is well known that certain characteristics, such as older age, female gender, hypertension, and high body mass index, are closely associated with severe arterial tortuosity among patients undergoing transradial coronary angiography, few data are available regarding useful predictors of severe arterial tortuosity among geriatric patients. The purpose of the present study was to evaluate the characteristics of geriatric patients with severe tortuosity of the right subclavian artery or brachiocephalic artery. The coronary angiographic reports of patients with severe tortuosity of the right subclavian artery or brachiocephalic artery and age- and gender-matched control patients were retrospectively evaluated. A total of 847 consecutive patients underwent right transradial coronary angiography. Of these patients, 48 (5.7%) had severe tortuosity (29 women, age 73.4 ± 8.6 years). The factors associated with severe arterial tortuosity were greater body mass index (odds ratio 1.17, p = 0.02), the presence of a prominently projected aortic arch on a chest radiograph (odds ratio 5.62, p <0.01), and lower serum creatinine value (odds ratio 0.05, p <0.01). In conclusion, the presence of a prominently projected aortic arch on the chest radiograph is a useful predictor of severe arterial tortuosity.

Dislodgment of an Atrial Screw‐In Pacing Lead 10 Years After Implantation

Dislodgment of an atrial screw‐in pacing lead is quite rare. This report describes a rare case of an atrial screw‐in lead dislodgment 10 years after implantation. Although it is an uncommon complication, very late dislodgment can occur postoperatively, and careful follow‐up is necessary. (PACE 2004; 27:264–265)

Chronic Aortic Dissection Presenting as Aphasia

Acute aortic dissection (AAD) is a fatal disease and delay in diagnosis results in deteriorated prognosis. A 55‐year‐old man presented to our hospital with aphasia because of a suspected stroke. Although the lack of pain made diagnosis difficult, we diagnosed Stanford type A AD as the underlying cause of his stroke. Two possible explanations were considered for the lack of pain. First, although the stroke was caused by AD, the stroke itself prevented the patient from feeling the pain. Second, the aphasia prevented him from complaining about the pain. Therefore, we believe that physicians require a high clinical index of suspicion for AD considering the possibility of painless AD or miscommunication secondary to aphasia.

Tracheal stenosis caused by severe tortuosity of the brachiocephalic artery

A 94-year-old woman admitted to Juntendo Tokyo Koto Geriatric Medical Center located in Tokyo, Japan, with impaired consciousness was diagnosed with seizures on electroencephalography and treated with an anticonvulsant. During hospitalization, she developed transient desaturation. Chest computed tomography, magnetic resonance imaging and chest radiograph showed tracheal stenosis caused by severe tortuosity of the brachiocephalic artery (BCA; Fig. 1a–c). The desaturation improved with the administration of a beta-adrenergic stimulant and an expectorant. We inferred that the desaturation was caused by tracheal stenosis, which deteriorated by viscous sputum. On account of the patient’s advanced age, we opted for conservative rather than invasive management; this comprised inhalation of salbutamol sulfate and bromhexine, oral ambroxol, and a tulobuterol patch. The conservative approach was effective and desaturation did not recur. Although we discussed tracheal stenting, it was considered too invasive. Advanced age is listed as one of the factors associated with arterial tortuosity, which can become so severe that it causes tracheal stenosis in super-elderly patients, as observed in the present case. Apart from advanced age, the presence of a prominently projected aortic arch, as observed on chest radiography, can reportedly function as a predictor of severe tortuosity of the BCA. A prominently projected aortic arch is confirmed when the distance from the neck of the aortic arch to the left edge of the aortic arch is at least 10 mm. In the present case, a chest radiograph showed a prominently projected aortic arch, which is indicated by an arrow in Figure 1c. In conclusion, in super-elderly patients such as the present patient, tracheal stenosis caused by severe tortuosity of the BCA should be included in the differential diagnosis of desaturation. Physicians should suspect possible tracheal stenosis when a prominently projected aortic arch is discovered on a chest radiograph.

Aortic and mitral valvular calcification in patients undergoing hemodialysis for 10 years or more and their prognosis

Valvular disease in hemodialysis (HD) patients occurs at a younger age and progresses faster compared with valvular changes due to aging in the general population [1]. The following can be involved in the mechanism of valvular calcification: parathyroid abnormality, aging, long-term HD, and calcium deposits in valves due to calciumbased drug or phosphate binder [2]. Valvular calcification can develop due to hypertension, diabetes mellitus (DM), dyslipidemia, renal anemia, blood access, and infective endocarditis [3]. In this study, we examined aortic valvular calcification (AVC) and mitral valvular calcification (MVC) in patients undergoing HD for 10 years or more. Computed tomography (CT) and echocardiography were used to detect calcification. Comparison was made between valvular calcification and risk factors for arteriosclerosis. In addition, prognosis of valvular disease was examined. The subjectswere 41patients undergoingoutpatientHD for 10 years ormore. Theywere 29men and 12women (mean age: 60±8 years and meandurationofHD: 20±7 years). Theunderlyingdiseasewas chronic glomerulonephritis (CGN) in 28 patients (mean duration of hemodialysis: 23±7 years), DM in 10 patients (12±1 years), and polycystic kidney disease in 3 patients (22±1 years). Non-contrast enhanced cardiac CT was performed with a 0.5-second scan time and 1 cm scan width to examine the presence or absence of AVC and MVC. Visual assessmentwasperformed to evaluate the density of calcification. In the same period, the followingwasmeasured just before HD in the two-day break between HD sessions: total cholesterol, high density lipoprotein cholesterol (HDLC), triglyceride, postprandial glucose, hemoglobin A1c, calcium (Ca), phosphorus (P), Ca-P product, and parathyroid hormone. Echocardiography was also performed. All numerical data were expressed as means±standard deviation. Comparison of measurements between groups was performed using Students unpaired t test. A p-value of less than 0.05 was defined to be statistically significant. Table 1 shows patient characteristics by underlying disease. AVCwas difficult to differentiate from aortic calcification and MVC from left circumflex artery calcification. In both AVC and MVC, the motion of the heart caused plus and minus density artifacts. Thus, the apparent density of calcification differed from the actual density, and determination of severity of valvular calcificationwas difficult using CT. Therefore, accurate comparison could not be performed between the results of blood tests and the degree of calcification. CTexamination revealed AVC in 38 of 41 patients, andMVCwas seen in all patients.When the density was examined in each patient, the visually assessed density tended to International Journal of Cardiology 164 (2013) 123–128

Massive Pericardial Effusion in a Case of Acute Pericarditis with Slight ST-Segment Elevation of Short Duration.

We present the case of a 77-year-old woman who suffered from chest pain. Her white blood cell count was 10,200/μL and C-reactive protein level was 5.5 mg/dL. There was no electrocardiogram abnormality up to 5 hours after admission. At 15 hours, slight ST-segment elevation occurred, but this disappeared on day 4. Imaging revealed slight pericardial effusion. Nonsteroidal anti-inflammatory drugs and antibiotics were administered. However, the pericardial effusion, inflammatory response, and bilateral heart failure worsened. Pericardiotomy on day 6 released 350 mL of fluid, and symptoms improved. Viral pericarditis was assumed. Massive pericardial effusion is rare in cases of acute viral pericarditis, as is slight, short-duration ST-segment elevation.

Acute Myocardial Infarction with Severe ST Segment Elevation Treated with Percutaneous Coronary Intervention More than Two Days after Onset: A Case with Remarkable Recovery

The patient was a 65-year-old man with marked ST-elevation myocardial infarction. Cardiac catheterization revealed an occluded middle portion of the left anterior descending artery and no collateral circulation. Percutaneous coronary intervention (PCI) was performed, and ST elevation improved 5 days after PCI. Almost all electrocardiogram (ECG) findings were normal 6 months later. Echocardiographic findings were also normal. This case was very successful and unusual in that no ventricular aneurysm formed despite ST elevation continuing for a few days and that ECG and left ventricular function were nearly normal after PCI performed days after the onset in a case without collateral circulation.