Kazumi Akasaka

Repolarization characteristics in early repolarization and brugada syndromes: insight into an overlapping mechanism of lethal arrhythmias.

We reported impaired QT‐rate dependence in early repolarization syndrome (ERS); however, contemporary data have shown peak incidence of sudden cardiac death (SCD) in ERS and Brugada syndrome (BrS) at mid‐night and early morning. Taken together, we analyzed the nocturnal QT‐rate dependence in both syndromes.

Malnutrition, renal dysfunction and left ventricular hypertrophy synergistically increase the long-term incidence of cardiovascular events

Although malnutrition indicates an unfavorable prognosis in some clinical settings, the synergistic impact of nutritional state, renal dysfunction and left ventricular hypertrophy (LVH) on cardiovascular events is unknown. Among 338 patients aged 40–80 years who underwent echocardiographic evaluation between 2003 and 2005, 161 patients who were followed for >7 years were recruited. Malnutrition was defined as a geriatric nutritional risk index (GNRI) of ⩽96. The mean patient age was 63.5±9.2 years; the mean estimated glomerular filtration rate (eGFR) was 72.9±18.7 ml min−1 per 1.73 m2; the mean LV mass index was 114±33 g m−2; and the mean GNRI was 100.4±6.0. Among the patients, 25% (n=40) had an eGFR of <60 ml min−1 per 1.73 m2, 29% (n=46) exhibited chronic kidney disease (CKD) and 37% (n=59) had LVH. During the follow-up period (median: 96 months), cardiovascular events were observed in 15 patients (9%). Kaplan–Meier curves showed a significantly higher incidence of cardiovascular events in patients with an eGFR of <60 ml min−1 per 1.73 m2 (log-rank P=0.007), a GNRI of ⩽96 (P=0.003) or LVH (P=0.010). In a Cox regression analysis, eGFR, LVH and GNRI were independent determinants of cardiovascular event incidence after adjusting for age, gender and the presence of hypertension and diabetes. Furthermore, the combination of LVH and lower GNRI was significantly associated with a higher rate of cardiovascular events not only in all patients but also in patients with CKD. In conclusion, malnutrition, low eGFR and LVH were independent determinants of cardiovascular event incidence; they synergistically increased rates of these events in the long term. The evaluation and management of LVH progression and the improvement of nutritional status are critical for preventing cardiovascular complications even in non-dialysis patients.

The balance of fetuin-A and osteoprotegerin is independently associated with diastolic dysfunction in hemodialysis patients

Fetuin-A and osteoprotegerin (OPG) are arterial calcification regulators, which are related to cardiovascular survival in hemodialysis patients. We hypothesized that a balance of these calcification regulators might mediate the progression of left ventricular (LV) diastolic dysfunction in hemodialysis patients. We recruited 63 hemodialysis patients and measured their serum fetuin-A, OPG, arterial stiffness, aortic calcification and echocardiographic parameters, including the transmitral early diastolic velocity/tissue Doppler mitral annular early diastolic velocity ratio (E/E′), and analyzed the relationships between these variables. Fetuin-A levels were significantly and negatively correlated with the ankle–brachial pulse wave velocity (baPWV), aortic calcification score (AOCS), left atrial volume index (LAVI), LV mass index (LVMI) and E/E′. OPG levels and the ratio of OPG to fetuin-A levels were significantly and positively correlated with the baPWV, AOCS, LAVI and E/E′. A stepwise multiple regression analysis revealed that E/E′ was independently correlated with fetuin-A levels (β=−0.334, P=0.02), OPG levels (β=0.367, P=0.01) and the ratio of OPG to fetuin-A (β=0.295, P=0.04). Categorizing the patients according to their serum fetuin-A and OPG levels revealed that patients with low fetuin-A and high OPG levels had the highest LAVI, LVMI and E/E′ values after adjusting for potential confounders. Serum fetuin-A levels negatively reflected, whereas OPG levels and the ratio of OPG to fetuin-A positively reflected an increase in vascular and ventricular stiffness, leading to the aggravation of diastolic dysfunction. Therefore, based on our results, the balance of the tissue calcification regulators fetuin-A and OPG could mediate the progression of LV diastolic dysfunction in hemodialysis patients.

Late gadolinium enhancement of cardiac magnetic resonance imaging indicates abnormalities of time-domain T-wave alternans in hypertrophic cardiomyopathy with ventricular tachycardia

BACKGROUND The presence of myocardial scar detected by late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) imaging has been described as a good independent predictor of mortality in patients with hypertrophic cardiomyopathy (HCM). Time-domain T-wave alternans (TWA) is also a potential predictor of cardiac mortality in patients with left ventricular dysfunction. OBJECTIVE The purpose of this study was to elucidate the relationship between LGE distribution and TWA in patients with HCM. METHODS CMR and TWA analyses using Holter monitoring were performed in 42 patients with HCM. The average transmural extent of LGE was scored as 1-4 in each segment, and the sum of the LGE scores (total LGE score) was calculated for each patient. The correlation between the maximal time-domain TWA voltage and LGE findings was analyzed, and the differences in time-domain TWA voltage, total LGE score, and cardiac function assessed by CMR imaging in the presence or absence of ventricular tachycardia (VT) were also compared. RESULTS The total LGE score was significantly and positively correlated with the maximal time-domain TWA voltage (r = 0.59; P < .001). Furthermore, the total LGE score and maximal time-domain TWA voltage were significantly greater in patients who had episodes of VT (n = 21) than in those without VT (23 ± 7 vs. 10 ± 8; P < .001 and 87 ± 26 μV vs. 62 ± 12 μV; P < .001, respectively). However, the left ventricular ejection fraction did not statistically differ between patients with VT and those without VT (56% ± 14% vs. 61% ± 7%; P = .102). CONCLUSION The magnitude of the localized LGE was significantly correlated with abnormalities in ventricular repolarization as assessed by TWA and QT dispersion.

Three cases of corticosteroid therapy triggering ventricular fibrillation in J-wave syndromes

We describe three cases of J-wave syndrome in which ventricular fibrillation (VF) was probably induced by corticosteroid therapy. The patients involved were being treated with prednisolone for concomitant bronchial asthma. One of the three patients had only one episode of VF during her long follow-up period (14 years). Two patients had hypokalemia during their VF episodes. Corticosteroids have been shown to induce various types of arrhythmia and to modify cardiac potassium channels. We discuss the possible association between corticosteroid therapy and VF in J-wave syndrome based on the cases we have encountered.

Cerebral Microbleeds Remain for Nine Years: A Prospective Study with Yearly Magnetic Resonance Imaging

BACKGROUND Cerebral microbleeds (CMBs) are refined neuroimaging findings detected on T2*-weighted gradient echo (GRE) magnetic resonance imaging (MRI) and are widely accepted as an important marker of the vulnerability of cerebral small vessels. It is necessary to further clarify the natural history of CMBs by a longitudinal study. This study aimed to reveal the natural history of CMBs and find a better way to track CMBs by a prospective long-term observation. METHODS We performed yearly brain MRI assessments for 7 or more years in 8 nonvalvular atrial fibrillation Japanese outpatients with CMBs detected in the baseline MRI. We began to use a 3.0T MRI scanner from 2012 as well. RESULTS We followed up 3 patients for 9 years, 2 for 8 years, and 3 for 7 years. In all patients, the CMBs at baseline did not disappear during the follow-up period. Importantly, the CMB in 1 patient seemed to disappear during the sixth imaging using 1.5T T2*-weighted GRE but was detected again during the seventh imaging with 3.0T susceptibility weighted imaging and ninth imaging with 3.0T T2* GRE. Moreover, in a patient implanted with a pacemaker, which is only applicable for 1.5T MRI at present, the CMB seemed to disappear and appeared once again with a 1.5T T2*-weighted GRE at a slice thickness of 2.5 mm instead of 5 mm. CONCLUSIONS From this prospective study, we obtained 2 absolutely new findings that CMBs remained for as long as 9 years and a high-field or thin-slice MRI can detect concealed CMBs.

Late Gadolinium Enhancement on Cardiac MRI Correlates with QT Dynamicity Represented by QT/RR Relationship in Patients with Ventricular Arrhythmias

The distribution of late gadolinium enhancement (LGE) on the cardiac MRI (CMR) indicates myocardial fibrosis and provides information of possible reentry substrates. QT dynamicity reflecting repolarization abnormalities has gained attention as a potential prognostic predictive factor.

Bow Hunter syndrome elicited by vertebral arterial occlusion after total arch replacement

An 83-year-old man with arch aneurysm underwent total arch replacement with frozen elephant trunk and extra-anatomical left subclavian artery bypass. One year later, he felt dizziness associated with head rotation. The hypoplastic left vertebral artery was occluded by a thrombus extending from the left subclavian artery ligation site, and the dynamic stenosis of right vertebral artery by head rotation induced dizziness. He was diagnosed with Bow Hunter syndrome. Vertebral artery hypoplasia represents a possible cause of this rare complication. To the best of our knowledge, this is the first report describing Bow Hunter syndrome after total arch replacement.

PS 05-37 MALNUTRITION, RENAL DYSFUNCTION, AND LEFT VENTRICULAR HYPERTROPHY SYNERGISTICALLY INCREASE THE LONG-TERM INCIDENCE OF CARDIOVASCULAR EVENTS

Objective: This study investigated the impact of malnutrition, low estimated glomerular filtration rate (eGFR) and left ventricular hypertrophy (LVH) on cardiovascular events in a long-term observational study. Design and Method: Among 338 patients aged 40–80 years who underwent echocardiographic evaluation between 2003 and 2005, 161 patients followed up for >7 years were recruited. Echocardiographic LVH was defined as left ventricular mass index (LVMI) ≥ 125 g/m2 for men and ≥ 110 g/m2 for women. The geriatric nutritional risk index (GNRI) was used to assess the nutritional status of the patients and was calculated using the following formula: GNRI = (14.89 × serum albumin) + [41.7 × (body weight / body weight at BMI of 22)]. Malnutrition was defined as GNRI ⩽ 96. Results: Mean age was 63.5 ± 9.2 years, mean eGFR: 72.9 ± 18.7 ml/min/1.73m2, mean GNRI: 100.4 ± 6.0 and mean LVMI: 114 ± 33 g/m2. The number of patients with eGFR <60 ml/min/1.73m2, GNRI ⩽ 96 and LVH was 40 (25%), 32 (20%) and 59 (37%), respectively. During the follow-up period (median: 95 months), cardiovascular events were recorded in 15 patients (9%), including 7 acute coronary syndromes, 4 heart failures, 2 strokes, 1 aortic dissection and 1 aortic rupture. Kaplan-Meier curves showed a significantly higher incidence in patients with eGFR < 60 mL/min/1.73m2 (log rank P = 0.007), GNRI ⩽ 96 (P = 0.003), or LVH (P = 0.010) (Figure 1). In Cox proportional hazards analysis, Age, eGFR, LVH, and GNRI were sifnificantly associated with cardiovascular events after adjusting for gender, hemoglobin level, and the prevalence of hypertension and diabetes (Table 1). Conclusions: Malnutrition, low eGFR, and LVH were independent determinants of cardiovascular events; they synergistically increased rates of these events in the long term. It is important to evaluate and manage the progression of LVH and improve nutritional status even in non-dialysis patients.

PS 14-43 CHRONOTHERAPY WITH AN ARB AND CCB COMBINATION: COMPARISON OF THE MORNING AND BEDTIME ADMINISTRATION OF OLMESARTAN AND AZELNIPINE

Objective: Recently, great attention has been focused on chronotherapy and bedtime administration for uncontrolled hypertension. The present study aimed to determine which type of chronotropic administration is better for ARB-based combination therapies. Design and Method: We conducted a prospective, cross-over trial in hypertensive outpatients not achieving target blood pressures. Ten participants (61 ± 15 years) were assigned to switch treatment to a morning ARB (olmesartan 20 mg)+bedtime CCB (azelnidipne 16 mg) (group AC), morning CCB+bedtime ARB (group CA), or morning fixed dose combination of an ARB+CCB (group FD). We measured the average BP (ABP), daytime BP (DBP) and nighttime BP (NBP) with ambulatory BP monitoring (ABPM) of the three groups, and compared those values with each home blood pressure (HBP) measurement. We also measured the heart rate (HR), central blood pressure (CBP), and augmentation index (AI). We further measured the changes in the BP, albuminuria, and laboratory values. Results: There were no significant differences among the groups regarding each of the BP parameters, HR, CBP, and AI. However, there was a decreasing tendency of the average BP and nighttime BP in group AC, and decreasing tendency of the CBP and AI in group FD. Regarding the coeffcient variant of the SBP in the ABPM, group AC had the lowest value of the three groups. There was no significant difference regarding the urine albumin/creatine ratio. Conclusions: The morning ARB+bedtime CCB administration was effective in controlling the nighttime to morning BP control, whereas a morning fixed dose combination of an ARB+CCB was effective in controlling the CBP and AI. The application of chronotherapy with ARB and CCB combinations would be useful for a better BP control.