Kazuhiro Takeda

Underestimation of Vasodilator Effects of Nitroglycerin by Upper Limb Blood Pressure

To determine why upper limb blood pressure measurement underestimates the vasodilator effects of nitroglycerin on lowering ascending aortic systolic pressure, we studied 24 patients (58 +/- 11 years, mean +/- SD). Ascending aortic pressure and radial artery pulse calibrated by cuff blood pressure measurement at the brachial artery were recorded simultaneously before and 5 minutes after sublingual administration of 0.3 mg nitroglycerin. Waves were analyzed by a signal processor, and the fourth derivative wave was used to find the early (S1) and late (S2) systolic shoulders (S1 corresponds to the second zero crossing and S2 to the third zero crossing). Before nitroglycerin administration, maximal systolic pressure in the ascending aorta (141 +/- 21 mm Hg) coincided with the late systolic peak in all patients, and in most patients (21 of 24) maximal systolic pressure in the radial artery (140 +/- 19 mm Hg) coincided with the early systolic peak. Maximal systolic pressure decreased more in the ascending aorta than in the radial artery (22 +/- 13 and 11 +/- 11 mm Hg, respectively; P < .001). However, the reduction in the shoulder of late systolic pressure in the radial artery (24 +/- 13 mm Hg) clearly indicated the reduction in maximal systolic pressure (late systolic peak) in the ascending aorta. The augmentation index of the ratio of the height of late systolic pressure to early systolic pressure fell proportionally (r = .74, P < .001) in the radial artery (from 0.88 +/- 0.13 to 0.60 +/- 0.11) and in the ascending aorta (from 1.57 +/- 0.25 to 1.26 +/- 0.24), which indicated the reduction in late systolic pressures.(ABSTRACT TRUNCATED AT 250 WORDS)

Workplace hypertension is associated with obesity and family history of hypertension.

Job strain, which is a risk for hypertension and increased left ventricular mass, is thought to cause masked hypertension during work even if blood pressure (BP) is normal at health examinations. To study the prevalence of and factors related to workplace hypertension, 265 public officials (mean age, 41.4±10.7 years) measured their own BP at their workplace using semiautomated BP measurement devices. Factors related to workplace hypertension were assessed with multiple regression analysis. Workplace hypertension, defined as a BP no less than 140/90 mmHg, was observed in 23% of subjects (n=61). Compared with subjects without workplace hypertension (n=204), subjects with workplace hypertension were older (48.5±10.0 vs. 39.3±10.0 years), more likely to be men (69% vs. 46%), and had a higher body mass index (BMI) (23.4±2.7 vs. 21.6±3.2 kg/m2), higher cholesterol levels (214±33 vs. 194±36 mg/dl), and a higher Brinkman index (134±228 vs. 59±148). Subjects with workplace hypertension had higher BPs at checkup than did those without it (125±11/79±9 vs. 110±11/68±9 mmHg). The increases in BPs at the workplace were independently and significantly correlated with BMI, and a family history of hypertension. BP no less than 130/85 mmHg at health checkup was a good detector of workplace hypertension (sensitivity, 49%; specificity, 91%), suggesting that subjects with high-normal BPs at health checkup might have workplace hypertension. In conclusion, workplace hypertension was found to be associated with age, BMI, a family history of hypertension, and high-normal BPs at health checkup.

Two Case Reports of Group B Streptococcal Infective Endocarditis Complicated by Embolism.

Streptococcus agalactiae (Group B streptococcus, GBS) is the major pathogen encountered in the perinatal period, although the incidence of GBS infection has recently increased among non-pregnant adults. Nevertheless, GBS infective endocarditis (IE) is uncommon and often accompanies aortic embolism. We experienced two cases of GBS IE. In Case 1, mobile vegetation of the aortic valve caused an infective cerebral aneurysm. In Case 2, the patient experienced an acute aortic embolic episode. Generally, early surgery for large mobile sites of vegetation is recommended as a class IIb therapy in the guidelines. GBS IE often exhibits a severe clinical course and specificity of vegetation. Therefore, early surgery should be considered in such cases.

Transcatheter aortic valve implantation using Evolut R in quadricuspid aortic valve with severe stenosis and regurgitation

Transcatheter aortic valve implantation (TAVI) for aortic stenosis (AS) is widely spread but is controversial in bicuspid or quadricuspid aortic valve (QAV) because of calcification or raphes which may affect on device expansion [1]. We report TAVI for QAV with severe AS and aortic valve regurgitation (AR). An 83-year-old man was repeatedly hospitalized because of heart failure due to severe ASR. He had reduced left ventricular function due to coronary artery disease and rejected surgery. Echocardiogram showed that peak aortic velocity was 4.68 m/s and aortic valve area was 0.82 cm2 with severe AR (Fig. 1a). Cardiac computed tomography (CT) showed QAV of three equal cusps and one small cusp regarded as type B by the Hurwitz’s classification [2]. The accessory cusp was situated between right and non-coronary cusp (Fig. 1b). The longitudinal CT showed strong calcification of left coronary cusp (LCC) protruding to left ventricular outflow tract (Fig. 1c), so self-expandable valve is appropriate rather than the balloon-expandable one for fear of annulus rupture. The annular perimeter and its area was 79.1 mm and 483.7 mm2, so we selected 29 mm Evolut R. Coronary height was 11.8 mm in left coronary artery and 16.1 mm in right one, so we did not do coronary protection. The vascular diameters of femoral access sites were about 7 mm, so we could insert 18French sheath. Balloon valvuloplasty (BAV) using 20 mm balloon was done as preparation (Fig. 1d) and LCC was sufficiently spread. Then, Evolut R was deployed in the supra-annular position so that its distal end was put on the edge of the calcification of LCC (Fig. 1e). The mean pressure gradient decreased from 51.5 to 3.0 mmHg and diastolic blood pressure increased from 35 to 51 mmHg (Fig. 1f). There was trivial paravalvular leak after procedure (Fig. 1g). BAV made them possible to grasp how expandable calcified cusps are, to crimp Evolut R to the annulus properly and to minimize paravalvular leak. In TAVI for QAV, although insufficient valve expansion or paravalvular leak may be expected, it made possible to perform sufficient treatment in the proper preparation. TAVI could be a viable option for severe ASR of QAV.

Jarvik 2000 Implantation in Anatomical Right Ventricle on Patient with Corrected Transposition of Great Arteries

The use of durable continuous-flow device for right ventricular (RV) remains limited and is evolving to date. We experienced a patient with corrected transposition of great arteries (CC-TGA) who needed ventricular assist device (VAD) for end-stage heart failure, was properly treated by Jarvik 2000 implantation in anatomical right ventricular.

Impact of age on left ventricular geometry and diastolic function in elderly patients with treated hypertension

Abstract Purpose: Left ventricular (LV) remodelling is observed in numerous patients with hypertension and is a principal cause of heart failure in elderly patients. The aim of this study was to determine the relationships between age and structural/functional LV remodelling observed in elderly hypertensive patients. Methods: A total of 557 elderly hypertensive patients (mean age: 74.0 ± 8.6 years) with preserved LV systolic function underwent echocardiography and 24-hour blood pressure (BP) measurement. Results: Overall, 41.1% of patients had LV hypertrophy, 77.9% had increased relative wall thickness (RWT) defined as RWT >0.42, and 31.8% had both. Logistic analysis of the entire study population showed that increased RWT was associated with both 24-hour systolic BP (odds ratio (OR) 1.38, 95% confidence interval (CI) 1.12 to 1.70) and age (OR 1.32, 95%CI 1.08 to 1.61), whereas increased RWT was associated only with age (OR 1.61, 95%CI 1.23 to 2.11) after excluding patients with LV hypertrophy. Univariate and multivariate linear regression analyses of all patients showed that LV diastolic echocardiographic parameters were consistently associated with age (p ≤ .001) alone, even considering LV structural changes. Conclusions: Age was independently correlated with LV concentric/functional changes regardless of LV hypertrophy, suggesting that ageing is independently involved in the progression of LV remodelling.

114 GRADE I HYPERTENSION IS ASSOCIATED WITH MYOCARDIAL INFARCTION, WHILE KIDNEY SIZE IS ASSOCIATED WITH CEREBRAL INFARCTION IN THE VERY ELDERLY PATIENTS; ANALYSIS FROM 3100 CONSECUTIVE AUTOPSY CASES

Purpose: Even after HYVET showed efficacy of antihypertensive treatment in octogenarians, target blood pressure (BP) remains to be examined. Methods: We studied 3100 autopsy cases (1589 men, median 81yrs) at a general geriatric hospital. We related BP to myocardial (MI) and cerebral infarction (CI). Results: Averaged BPs were 141±1/80±0mmHg. 21% of the cases had MI and 66% had CI. Ages of death, systolic BP, heart weight, and kidney weight were related to MI and CI. In logistic regression analysis, the hazard of MI after adjustment for age and sex was 1.67 (95%CI, 1.24 to 2.26, *p<0.001) for the highest (>156mmHg) versus the lowest systolic BP quartile (<119mmHg), and 1.53 (95%CI, 1.13 to 2.07; p=0.005) for the second highest (140–155mmHg) versus the lowest quartile. Among those who deceased >81 years old, the hazard of MI was 1.48 (95%CI, 0.97 to 2.27, p=0.07) for the highest quartile, and 1.59 (95%CI, 1.04 to 2.43, p<0.05) for the second highest quartile. In contrast, the hazard of CI was 2.42 (95%CI, 1.78 to 3.29*) for the highest versus the lowest BP quartile, and 1.69 (95%CI, 1.26 to 2.26*) for the second highest versus the lowest quartile. In octogenarians, CI was not significantly associated with systolic BP, while the hazard was 1.76 (95%CI, 1.22 to 2.55, p=0.003) for the lowest versus the highest tertile of kidney weight. Conclusion: Grade I hypertension was associated with MI and CI in the elderly. In octogenarians, grade I hypertension was associated with MI, while kidney atrophy was associated with CI.