Hiromi Yoshimura

Coronary Vasomotor Response to Intracoronary Acetylcholine Injection, Clinical Features, and Long-term Prognosis in 873 Consecutive Patients With Coronary Spasm: Analysis of a Single-Center Study Over 20 Years

Background The aim of this study was to elucidate the correlation between angiographic coronary vasomotor responses to intracoronary acetylcholine (ACh) injection, clinical features, and long‐term prognosis in patients with vasospastic angina (VSA). Methods and Results This is a retrospective, observational, single‐center study of 1877 consecutive patients who underwent ACh‐provocation test between January 1991 and December 2010. ACh‐provoked coronary spasm was observed in 873 of 1637 patients included in the present analysis. ACh‐positive patients were more likely to be older male smokers with dyslipidemia, to have a family history of ischemic heart disease, and to have a comorbidity of coronary epicardial stenosis than were ACh‐negative patients. ACh‐positive patients were divided into 2 groups: those with focal (total or subtotal obstruction, n=511) and those with diffuse (severe diffuse vasoconstriction, n=362) spasm patterns. Multivariable logistic regression analysis identified female sex and low comorbidity of coronary epicardial stenosis to correlate with the ACh‐provoked diffuse spasm pattern in patients with VSA. Kaplan–Meier survival curve indicated better 5‐year survival rates free from major adverse cardiovascular events in patients with diffuse spasm pattern compared with those with focal spasm pattern (P=0.019). Multivariable Cox hazard regression analysis identified diffuse spasm pattern as a negative predictor of major adverse cardiovascular events in patients with VSA. Conclusions ACh‐induced diffuse coronary spasm was frequently observed in female VSA patients free of severe coronary epicardial stenosis and was associated with better prognosis than focal spasm. These results suggest the need to identify the ACh‐provoked coronary spasm subtypes in patients with VSA.

Clinical features and prognosis of patients with coronary spasm-induced non-ST-segment elevation acute coronary syndrome.

Background The prevalence, clinical features, and long‐term outcome of patients with non–ST‐segment elevation acute coronary syndrome (NSTE ACS) associated with coronary spasm are not fully investigated. Methods and Results This observational multicenter study enrolled 1601 consecutive patients with suspected NSTE‐ACS who underwent cardiac catheterization between January 2001 and December 2010. A culprit lesion was found in 1152 (72%) patients. In patients without a culprit lesion, the acetylcholine provocation test was performed in 221 patients and was positive in 175 patients. In the other patients, coronary spasm was verified in 145 patients during spontaneous attack. Spasm‐induced NSTE‐ACS was diagnosed in 320 (20%) patients. Multivariable analysis identified age <70 years (odds ratio [OR] 2.19, 95% CI 1.58 to 3.04), estimated glomerular filtration rate >60 mL/min per 1.73 m2 (OR 1.72, 95% CI 1.16 to 2.56), and lack of hypertension (OR 2.55, 95% CI 1.90 to 3.41), dyslipidemia (OR 2.76, 95% CI 2.05 to 3.73), diabetes mellitus (OR 2.49, 95% CI 1.78 to 3.48), previous myocardial infarction (OR 5.37, 95% CI 2.89 to 10.0), and elevated cardiac biomarkers (OR 2.84, 95% CI 2.11 to 3.83) as significant correlates of spasm‐induced NSTE‐ACS (P<0.01 for all variables). Transient ST‐segment elevation during spontaneous attack (variant angina) was observed in 119 patients with spasm‐induced NSTE‐ACS. Variant angina was more common in nondyslipidemic men among patients with spasm‐induced NSTE‐ACS. Conclusions The study showed frequent involvement of coronary spasm in the pathogenesis of NSTE‐ACS. Variant angina was observed in one third of patients with spasm‐induced NSTE‐ACS. Coronary spasm should be considered even in patients with less coronary risk factors and nonobstructive coronary arteries.

Utility of postural change in differentiating sludge from thrombus in the left atrial appendage: A case report

We detected symptomatic atrial fibrillation in a 64‐year‐old man who had undergone mitral valvuloplasty. While performing transesophageal echocardiography (TEE) in the left lateral decubitus position, we detected an isoechoic mass lesion at the bottom of the left atrial appendage (LAA). After changing the patients position from left to right, the mass lesion dropped down from the bottom of the LAA, spread out into the left atrium, and appeared as a spontaneous echocardiographic contrast with mobility. We therefore diagnosed the mass lesion as not a thrombus but sludge. Changing the patients position during TEE is useful for distinguishing sludge from thrombi.

Tailored Adjunctive Cilostazol Therapy Based on CYP2C19 Genotyping in Patients With Acute Myocardial Infarction ― The CALDERA-GENE Study ―

BACKGROUND Patients with reduced-function CYP2C19 genotypes on dual antiplatelet therapy (DAPT) with aspirin and clopidogrel show higher clinical risk for acute myocardial infarction (AMI). We investigated the effect of CYP2C19 genotype-tailored adjunctive cilostazol therapy on treatment of AMI.Methods and Results:The study group of 138 patients with suspected AMI were screened for CYP2C19 genotype immediately after percutaneous coronary intervention (PCI) using a SPARTAN RX point-of-care device. Carriers of the CYP2C19 reduced-function allele were randomized into DAPT (Carrier/DAPT) and DAPT plus 14-day cilostazol (Carrier/DAPT+Cilostazol) groups, while noncarriers were treated with DAPT (Noncarrier/DAPT). After exclusion of 10 patients, the remaining 128 patients were analyzed for P2Y12 reaction unit (PRU) using VerifyNow®P2Y12 system, and levels of biomarkers immediately after, and 1, 14, and 28 days after PCI. DAPT+Cilostazol reduced PRU levels in carriers (n=46) to those found in the Noncarrier/DAPT group (n=40), and significantly lower than those of the Carrier/DAPT group (n=42) at 14 days post-PCI. Discontinuation of cilostazol for 14 days was associated with a significant rise in PRU levels to those of the Carrier/DAPT group at 28 days post-PCI. Plasma B-type natriuretic peptide levels at 14 days post-PCI were lower in Carrier/DAPT+Cilostazol than in the other 2 groups, and the levels increased to those of the other groups at 28 days post-PCI after withdrawal of cilostazol. CONCLUSIONS Adjunctive cilostazol therapy tailored to CYP2C19 genotype seemed useful in AMI patients with the CYP2C19 reduced-function allele.

Pulmonary Tumor Thrombotic Microangiopathy ― Antemortem Diagnosis With Pulmonary Artery Wedge Blood Cell Sampling in a Recurrent Breast Cancer Patient ―

years earlier, and adjuvant chemotherapy (fluorouracil, epirubicin and cyclophosphamide followed by docetaxel), then endocrine therapy for 5 years because of clinical stage IIA invasive carcinoma of the left breast. At the present admission the patient had sinus tachycardia A 46-year-old woman with a 2-week history of progressive exertional dyspnea and dry cough was admitted to hospital with a diagnosis of severe hypoxia. She had a history of operation for breast cancer (left mastectomy and axillary lymph node dissection) 6