Katsutoshi Makino

Increased platelet aggregability in response to shear stress in acute myocardial infarction and its inhibition by combined therapy with aspirin and cilostazol after coronary intervention

Although antiplatelet therapy with a specific inhibitor of phosphodiesterase-3 cilostazol improves stent patency compared with use of aspirin (ASA) alone, the specific role of cilostazol on platelet aggregation in patients with acute myocardial infarction (AMI) is less well understood. Thirty-six patients with AMI who were successfully treated with primary angioplasty were randomized to 3 antiplatelet regimens: ASA alone (n = 12), ASA + ticlopidine (n = 12), and ASA + cilostazol (n = 12). We measured shear stress-induced platelet aggregation (SIPA) using a modified cone-plate viscometer on admission and on day 7, and evaluated the inhibitory effects of combination therapy with ASA + cilostazol on SIPA. Compared with cases of stable coronary artery disease, significant increases in SIPA and plasma von Willebrand factor activity were observed in patients with AMI before they received antiplatelet therapy. On day 7 after primary angioplasty, ASA did not inhibit SIPA (65 +/- 15% vs 57 +/- 11%, p = 0.086), whereas both combination therapies of ASA + ticlopidine and ASA + cilostazol significantly inhibited SIPA in patients with AMI (ASA + ticlopidine: 61 +/- 15% vs 45 +/- 13%, p <0. 0001; ASA + cilostazol: 64 +/- 14% vs 43 +/- 9%, p <0.005). There was a significant correlation of SIPA with adenosine diphosphate (ADP)-induced platelet aggregation (r = 0.412, p = 0.003) and with plasma von Willebrand factor activity (r = 0.461, p = 0.0008). These data suggest that patients with AMI have increased platelet aggregability in response to high shear stress. Combined antiplatelet therapy with ASA + cilostazol appears to be as effective as therapy with ASA + ticlopidine for reducing SIPA in patients with AMI who are undergoing primary angioplasty.

Isolated Congenital Left Ventricular Diverticulum in an Adult: A Case Report

A sixty-three-year-old man presented himself with atrial flutter and congestive heart failure. Cardiac catheterization revealed that left ventricular diverticulum was located on the anterobasal wall with narrow connection to the left ventricular cavity. Coronary angiography revealed normal coronary arteries. The patient had been asymptomatic until adult life with no other thoracoabdominal or cardiac anomalies. This is an extremely rare finding in the adult population.

Diagnostic value of late gadolinium-enhanced MRI and first-pass dynamic MRI for predicting functional recovery in patients after acute myocardial infarction

PurposeThe aim of this study was to determine the comparative diagnostic values of late gadolinium-enhanced magnetic resonance imaging (MRI) and first-pass dynamic MRI for predicting functional recovery of regional myocardial contraction in patients early after acute myocardial infarction.Materials and methodsFirst-pass and late-enhanced MRI were performed in 18 patients 5.5 ± 2.5 days after the onset of myocardial infarction. Images analysis was performed using a 12-segment model. Regional systolic wall thickening (SWT) was measured on cine-MRI obtained 273 ± 130 days later.ResultsLate-enhanced MRI revealed hyperenhancement in all patients, whereas hypoenhancement on first-pass MRI was observed in 67% (12/18) of the patients. The area under the receiver operating characteristics curve was 0.86 for late-enhanced MRI and 0.74 for first-pass MRI (P = 0.27). First-pass MRI was useful for predicting functional recovery of the segments that showed hyperenhancement of >50% of tissue on late-enhanced MRI. In these segments, preserved SWT was observed in 15 of 33 segments (45%) with first-pass hypoenhancement of ≤50% of tissue, but in only 2 of 22 segments (9%) with first-pass hypoenhancement of >50% of tissue.ConclusionWhereas the diagnostic capability of first-pass MRI alone is limited, complementary use of first-pass MRI can enhance the diagnostic performance of late-enhanced MRI because hypoenhancement during first-pass imaging is more specific to nonviable myocardium.

Influence of age on left ventricular performance during exercise in normal Japanese subject: Assessment by radionuclide ventriculography

To assess the effects of age on left ventricular performance, multistage supine ergometer exercise radionuclide ventriculography (RNV) was performed in 92 normal subjects. The subjects ranged in age from 24 to 86 years and were free of cardiopulmonary disease and diabetes. Age-related changes in exercise duration, left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV), cardiac output (CO) left ventricular ejection fraction (LVEF), left ventricular dv/dt, systolic and diastolic time indexes of dv/dt, and peak systolic pressure/left ventricular end-systolic volume (PSP/LVESV) were analyzed at rest and during the peak exercise stage.Age-related decrease in LVEDV and peak diastolic dv/dt were significant at rest. The time indexes of ECG R to peak systolic dv/dt and time of end-systole to peak diastolic dv/dt also were prolonged with age. Both maximum heart rate and exercise duration were shown to decline with age. No age-related difference was observed in LVESV, LVEF or PSP/LVESV either at rest or during exercise. However, the change of LVEF and LVESV during exercise was less in subjects aged 60 or more. These results indicate decreased left ventricular function during exercise in elderly subjects.

Kidney-protective effects of azelnidipine versus a diuretic in combination with olmesartan in hypertensive patients with diabetes and albuminuria: a randomized study

BACKGROUND A thiazide diuretic used in combination with benazepril is superior to amlodipine plus benazepril in reducing albuminuria in hypertensive patients with diabetes. However, calcium channel blockers have diverse characteristics. Thus, we investigated whether combining an angiotensin receptor blocker with either azelnidipine or a thiazide diuretic produced similar reductions in albuminuria in hypertensive diabetic patients for the same levels of blood pressure achieved. METHODS Hypertensive patients with type 2 diabetes and albuminuria (30-600 mg/g creatinine) under antihypertensive treatment (mean age 67.0±7.6 years) were instructed to stop all antihypertensive treatment and take a combination of olmesartan (20 mg/day) and amlodipine (5 mg/day) for 3 months (run-in period). Then, patients were randomly assigned to receive either olmesartan plus azelnidipine (16 mg/day; n=71) or olmesartan plus trichlormethiazide (1 mg/day; n=72) for an additional 6 months. The primary end point was urinary excretion of albumin at 6 months after randomization. RESULTS At the time of randomization, urinary albumin was 116.0 and 107.8 mg/g creatinine (geometric mean) in the azelnidipine and diuretic arms, respectively, and was reduced to a similar extent [79.8 (95% confidence interval 66.4-96.0) and 89.7 (74.6-107.7) mg/g creatinine, respectively, after adjustment for baseline values]. Blood pressure did not differ between the two groups throughout the study period. CONCLUSIONS Azelnidipine is equally effective as a thiazide diuretic in reducing urinary albumin when used in combination with olmesartan.

Multiple Life-threatening Coronary Artery Spasms after Percutaneous Coronary Intervention for Acute Coronary Syndrome

A 69-year-old man who had been hospitalized with acute coronary syndrome (ACS), underwent urgent percutaneous coronary intervention. In the subacute phase, he developed sudden chest pain and hemodynamic deterioration, and urgent coronary angiogram showed multiple coronary artery spasms. The discontinuation of beta-blocker treatment and the administration of a calcium antagonist helped prevent angina attacks. In Japanese patients who tend to have coronary artery spasm, the routine administration of beta-blockers for post-ACS patients with a preserved left ventricular systolic function should be considered carefully.

Trousseau's Syndrome Causing Refractory Deep Venous Thrombosis

A 66-year-old man, who had been diagnosed with deep venous thrombosis (DVT), and who was treated with a vitamin K antagonist (VKA) and who had undergone the implantation of an inferior vena cava filter, was admitted due to an exacerbation of DVT. VKA was administered again; however, the patients DVT worsened. Further examinations revealed colon cancer, which led to a diagnosis of Trousseaus syndrome. The regression of the thrombi was confirmed after the administration of heparin and the resection of the tumors. Trousseaus syndrome should always be kept in mind when patients present with refractory venous thrombosis. The administration of heparin, and cancer control are necessary for the effective treatment of thrombosis in such cases.

Large Non-Bacterial Vegetation Causing Acute Aortic Regurgitation ― Unexpected Finding at Autopsy ―

Received October 13, 2017; revised manuscript received January 18, 2018; accepted January 23, 2018; released online February 23, 2018 Time for primary review: 24 days Department of Cardiology (T.S., M. Ikezawa, A.H., S.Y., H.N., K.M.), Department of Gastroenterology (K.T.), Mie Prefectural General Medical Center, Yokkaichi; Department of Cardiology, Mie Heart Center, Meiwa (T.S.); and Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu (M. Ito), Japan Mailing address: Toshiki Sawai, MD, PhD, Department of Cardiology, Mie Heart Center, 2227-1 Oyodo, Meiwa, Taki-gun, Mie 510-8561, Japan. E-mail: tsawai@clin.medic.mie-u.ac.jp ISSN-1346-9843 All rights are reserved to the Japanese Circulation Society. For permissions, please e-mail: cj@j-circ.or.jp Large Non-Bacterial Vegetation Causing Acute Aortic Regurgitation ― Unexpected Finding at Autopsy ―

Antialbuminuric effect of eplerenone in comparison to thiazide diuretics in patients with hypertension

This study investigated the effects and safety of eplerenone or thiazide diuretics in patients with hypertension and albuminuria (pretreatment urinary albumin/creatinine ratio ≥10 mg/gCr) treated with an angiotensin II receptor blocker. The primary end point was the mean percent change in the urinary albumin/creatinine ratio from baseline to 48 weeks. An efficacy analysis was performed in 195 patients (98 in the eplerenone group and 97 in the thiazide group). Systolic and diastolic blood pressures at 48 weeks were similar in the two groups. The mean percent change in the urinary albumin/creatinine ratio from baseline to 48 weeks was similar in the two groups (P=.804). In the safety analysis, the withdrawal rates for adverse events were similar in both groups. The antialbuminuric effects and safety of eplerenone therapy were similar to those of thiazide diuretics when combined with an angiotensin II receptor blocker in patients with hypertension and albuminuria.

MPS 04-07 SHORT AND MID-TERM OUTCOMES OF ACUTE MYOCARDIAL INFARCTION WITH ELEVATED SYSTOLIC BLOOD PRESSURE ON ADMISSION

Objective: Although lower admission systolic blood pressure (SBP) has been established as a poor prognostic factor in patients with acute myocardial infarction (AMI), the impact of preserved admission SBP on short and mid-term outcomes has not been fully evaluated. Design and Method: From January 2013 to March 2015, 1281 consecutive patients with AMI were registered in Mie ACS Registry, a prospective, multicenter registry in Japan. We evaluated 1122 patients (mean age 68 ± 13 years, male 78%) except for 159 patients with admission SBP < 100 mmHg. Patients were divided into three groups according to admission SBP: 100–139 mmHg (normal admission SBP; NBP group, n = 612), 140–179 mmHg (moderately elevated admission SBP; MBP group, n = 419) and ≥180 mmHg (excessively elevated admission SBP; EBP group, n = 91). The clinical characteristics, 30-day and 1-yaer outcomes (follow-up rate 94.7%) were compared among the three groups. Results: The rate of primary percutaneous coronary intervention and the number of diseased coronary vessels were not significantly different among the three groups. The Killip classification and the peak creatine kinase values were lowest in the MBP group. Heart failure, arrhythmia, shock and multi-organ failure during hospitalization were most often in the NBP group, but myocardial rupture was no significant difference in the three groups. The 30-day cumulative mortality was trend to be high in the NBP group (6.5%, 3.3% and 4.4% for NBP, MBP and EBP group, respectively, Log-Rank P = 0.069), and 1-year cumulative mortality after hospital discharge was significantly high in NBP group (5.5%, 1.6% and 2.4% for NBP, MBP and EBP group, respectively, Log-Rank P = 0.007) than other two groups (Figure). Conclusions: Admission SBP of less than 140 mmHg can be a risk of hemodynamic instability during hospitalization and an indicator of poor outcomes after hospital discharge in patients with AMI and preserved admission SBP.