Kazuya Takehana

Early identification of impaired myocardial reperfusion with serial assessment of ST segments after percutaneous transluminal coronary angioplasty during acute myocardial infarction

To evaluate the relation between ST-segment analysis and microvascular reperfusion in patients with acute myocardial infarction (AMI), we studied 51 patients with first AMI who were successfully treated by percutaneous transluminal coronary angioplasty (PTCA). The lead showing the greatest ST-segment elevation on the 12-lead electrocardiogram (ECG) was serially investigated until 24 hours after PTCA. Successful reperfusion was determined by technetium-99m tetrofosmin single-photon emission computed tomography. Impaired reperfusion (group 1: < 4 change in the sum of the defect score from before to immediately after PTCA) was observed in 24 patients, and successful reperfusion (group 2) was observed in 27 patients. Although ST-segment elevation was reduced significantly at 30 minutes after PTCA in group 2 (2.2 +/- 1.4 to 1.7 +/- 1.3 mm, p = 0.01), there was no significant change in group 1 (1.9 +/- 1.9 to 2.4 +/- 1.7 mm). Ten of 14 patients (71%) with persistent ST-segment elevation (DeltaST > 0 mm change in ST segment from before to 30 minutes after PTCA > 0) were in group 1, whereas 23 of 37 patients (62%) with ST-segment resolution (DeltaST < or = 0) were in group 2. The sensitivity and specificity of persistent ST-segment elevation for predicting impaired microvascular reperfusion were 42% and 85%, respectively. Thus, persistent ST-segment elevation 30 minutes after primary PTCA was a highly specific electrocardiographic marker of impaired reperfusion in patients with AMI.

An autopsy case of pseudoxanthoma elasticum: histochemical characteristics.

An autopsy case of pseudoxanthoma elasticum is reported. A Japanese female patient complained of yellow papules on the neck, precordium, and axilla, beginning at 54 years of age. When the patient was 58 years old, in response to her visual disturbance a funduscopic examination was performed, revealing angioid streaks, and skin biopsy identified a characteristic pseudoxanthoma elasticum (PXE) lesion. The patient developed congestive heart failure, and following mitral valve prolapse and regurgitation flow into the left atrium, mitral valve replacement with a prosthetic valve was performed when the patient was 65 years old. Soon afterward, the patient complained of gait disturbance, and she died of congestive heart failure at 68 years of age. Autopsy specimen revealed fragmented, granular, and calcified elastic fibers in the middle to deep dermis and in the thickened subendocardium, and small to medium-sized muscular arteries revealed fragmented, laminated, and calcified elastic lamina; vascular changes were seen in the heart, lung, kidney, gastrointestinal tract, and iliac artery. Disrupted elastic fibers were visualized using the Weigert resorcin fuchsin method and were stained positive by antielastin and antifibronectin antibodies. Calcification was confirmed by von Kossa staining. Affected areas were PAS-positive after diastase digestion, indicating the presence of glycoprotein. Affected areas were colloidal iron-positive, indicating the presence of proteoglycan matrix.

Importance of left ventricular diastolic function on maintenance of exercise capacity in patients with systolic dysfunction after anterior myocardial infarction

To investigate the role of left ventricular (LV) diastolic function in the maintenance of exercise capacity in patients with systolic dysfunction, symptom-limited cardiopulmonary exercise testing combined with radionuclide ventriculography was performed in 24 patients with an LV ejection fraction < 35% after anterior myocardial infarction. The ratio of pulmonary artery wedge pressure (PAWP) to LV end-diastolic volume (EDV), an index of global diastolic function, correlated significantly with peak oxygen consumption at peak exercise (r = -0.55; p = 0.006), whereas ejection fraction at peak exercise did not. The change in PAWP/EDV ratio from rest to peak exercise was related to the increases in stroke volume (r = -0.54; p = 0.006) and cardiac output (r = -0.51; p = 0.01) during exercise, but the change in ejection fraction was not. Resting hemodynamics did not differ between patients with preserved exercise capacity (group 1, n = 8) and those with exercise impairment (group 2, n = 16). At peak exercise, stroke volume, cardiac output, and EDV were significantly higher, and PAWP and PAWP/EDV ratio were significantly lower in group 1 than in group 2, but ejection fraction and end-systolic volume were similar in both groups. Although the incidences of hypertension, LV hypertrophy, and infarct-related coronary artery lesions did not differ between the two groups, group 2 had a significantly higher incidence of non-infarct-related coronary artery lesions than group 1 (p < 0.05). Thus in patients with LV systolic dysfunction after anterior myocardial infarction, the major cause of exercise impairment and failure to increase LV performance during exercise was diastolic dysfunction associated with the presence of non-infarct-related coronary artery lesions with the potential for exercise-induced ischemia of the noninfarcted areas.

Pericardial effusion after primary percutaneous transluminal coronary angioplasty in first Q-wave acute myocardial infarction

To evaluate the incidence and clinical significance of infarction-associated pericardial effusion in patients with successful primary percutaneous transluminal coronary angioplasty, we studied 214 consecutive patients with a first Q-wave acute myocardial infarction. Based on 9 clinical variables, multivariate analysis was performed to determine the important variables related to the occurrence of pericardial effusion. Pericardial effusion was detected by echocardiography in 45 patients (21%); pericardial rub (p <0.001), number of advanced asynergic segments (p <0.001), ventricular aneurysmal motion (p = 0.03), and pulmonary capillary wedge pressure (p = 0.04) were found to be the important variables related to pericardial effusion. Among 45 patients with pericardial effusion, 29 patients with no pericardial rub had significantly higher pulmonary capillary wedge pressure than those with pericardial rub, whereas 16 patients with pericardial rub had a higher incidence of angiographic no reflow and ventricular aneurysmal motion than those without pericardial rub. Patients with pericardial effusion and a pericardial rub had a higher mortality rate than those without pericardial effusion (19% vs 3%; p = 0.02). Thus, pericardial effusion is still a relatively common clinical finding after primary percutaneous transluminal coronary angioplasty, and those with pericardial effusion and a pericardial rub were associated with more severe transmural myocardial damage and higher in-hospital mortality.

PQ Segment Depression in Acute Q Wave Inferior Wall Myocardial Infarction

BACKGROUND PQ segment deviation is almost as characteristic as the classic ST segment deviation and is detected in most patients with pericarditis. However, as infarction-associated pericarditis remains over the infarct zone, PQ segment depression is observed much less often in patients with acute myocardial infarction. METHODS AND RESULTS We designed this study to examine the clinical significance of PQ segment depression in acute Q wave inferior myocardial infarction. We examined 171 consecutive patients with acute Q wave inferior myocardial infarction by means of auscultation, ECG, and two-dimensional echocardiography. The diagnosis of pericarditis was made on the basis of pericardial rub detected by more than two observers during the first 3 days after admission. At least 0.5 mm of PQ segment depression from the TP segment lasting more than 24 hours in both limb and precordial leads was considered diagnostic of PQ segment depression. CONCLUSIONS PQ segment depression was present in 14 patients and absent in 157 patients. Eleven patients with and 55 patients without PQ segment depression had advanced asynergy (akinesis or dyskinesis) in the posterior segments, whereas 9 patients with and 20 patients without PQ segment depression had pericardial rub. When multivariate analysis was performed to determine the important variables related to the occurrence of PQ segment depression, pericardial rub was selected with advanced asynergy of the posterior segment as significant factors related to PQ segment depression. Major complications (ventricular fibrillation, sustained ventricular tachycardia, cardiogenic shock, need for pacing) were present in 63 patients; 9 with (64%) and 54 without (34%) PQ segment depression. PQ segment depression was one of the clinical signs of more extensive damage extending to the posterior segments and increased incidence of major complications.

'Takotsubo' cardiomyopathy in a maintenance hemodialysis patient.

Abstract:  An 84‐year‐old woman undergoing maintenance hemodialysis presented with chest discomfort lasting several days and electrocardiographic abnormalities. She had stopped smoking 2 weeks earlier and was experiencing irritability. Upon admission, electrocardiography showed ST‐segment elevation in leads I, II, aVF, and V2‐6 and an abnormal Q wave in leads II, III, and aVF. Ultrasound cardiography showed left ventricular anteroapical akinesia and basal hyperkinesia. The chest discomfort disappeared without specific therapy. During hospital days 1–5, the ST‐segment elevation gradually improved. Giant negative T waves then developed. The left ventricular asynergy resolved by day 8. Radionuclide imaging with iodine‐123‐beta‐methyl‐p‐iodophenyl pentadecanoic acid, but not with technetium‐99 m‐sestamibi, showed an apical defect. Elective coronary angiography showed no stenosis. ‘Takotsubo’ cardiomyopathy was diagnosed. After discharge, the patient continued regular dialysis without cardiac symptoms. We concluded that endogenously activated sympathetic nerve action in hemodialysis patients, especially those under emotional or physical stress, might be a causative factor for Takotsubo cardiomyopathy.

Prognostic study of cardiac and renal events in Japanese patients with chronic kidney disease and cardiovascular risk using myocardial perfusion SPECT : J-ACCESS 3 study design

Cardiovascular disease is the leading cause of morbidity and mortality in patients with chronic kidney disease. Recent studies have indicated that the incidence of cardiovascular disease increases inversely with estimated glomerular filtration rate. Although coronary angiography is considered the gold standard for detecting coronary artery disease, contrast‐induced nephropathy or cholesterol microembolization remain serious problems; therefore, a method of detecting coronary artery disease without renal deterioration is desirable. From this viewpoint, stress myocardial perfusion single photon emission computed tomography (SPECT) might be useful for patients with chronic kidney disease. We recently performed the Japanese Assessment of Cardiac Events and Survival Study by Quantitative Gated SPECT (J‐ACCESS) investigating patients with suspected or extant coronary artery disease and the J‐ACCESS 2 study of patients with diabetes. The findings from these studies showed that SPECT can detect coronary artery disease and help to predict future cardiac events. Thus, we proposed a multicenter, prospective cohort study called “J‐ACCESS 3” in patients with chronic kidney disease and cardiovascular risk. The study aimed at predicting cardiovascular and renal events based on myocardial perfusion imaging and clinical backgrounds. We began enrolling patients in J‐ACCESS 3 at 74 facilities from April 2009 and will continue to do so until 31 March 2010, with the aim of having a cohort of 800 patients. These will be followed up for three years. The primary endpoints will be cardiac death and sudden death. The secondary endpoints will comprise any cardiovascular or renal events. This study will be completed in 2013. Here, we describe the design of the J‐ACCESS 3 study.

Early prediction of regional functional recovery in reperfused myocardium using single-injection resting quantitative electrocardiographic gated SPET

Abstract. By evaluating concordant or discordant perfusion and systolic wall thickening patterns, resting quantitative electrocardiographic (ECG) gated single-photon emission tomography (SPET) can identify various myocardial pathological conditions with different functional recovery after revascularisation therapy. However, no data are available on the ability of this methodology to predict regional functional recovery after primary percutaneous transluminal coronary angioplasty (PTCA). This study evaluated whether single-injection ECG gated SPET imaging performed at rest with 99mTc-tetrofosmin early after successful PTCA can predict recovery of regional wall motion. ECG gated SPET was performed 3 days and 3 weeks after successful PTCA in 26 patients. Regional functional parameters were automatically calculated with a 20-segment model on the day 3 image, and segments with perfusion/thickening mismatch were defined as showing preserved perfusion (>55% uptake on the end-diastolic image: mean–standard deviation of the normal value) without systolic wall thickening (mean–standard deviation of the normal value). On the third day, the regional wall motion score of 37 mismatched segments (3.8±2.1) was significantly lower than that of 41 matched normal segments (6.0±2.9), but was significantly higher than that of 108 matched abnormal segments (1.4±1.9, both P<0.01). At 3 weeks after acute MI, the regional wall motion score of mismatched segments (6.4±3.9) improved to the level of matched normal segments (7.1±3.0) and was significantly higher than that of matched abnormal segments (2.5±3.0, P<0.01). Absolute change in the regional wall motion score (3 days to 3 weeks) of mismatched segments (2.6±3.5) was significantly greater than that in the regional wall motion score of matched normal segments and matched abnormal segments (1.1±1.3 and 1.2±2.6, respectively, both P<0.05). Twenty-seven of 37 segments (73%) with perfusion/thickening mismatch showed significant improvement in regional wall motion, whereas improvement in regional wall motion was observed in 22 of 108 segments (20%) with matched abnormal segments and 6 of 41 segments (15%) with matched normal segments. Segments with perfusion/thickening mismatch had a significantly higher incidence of regional functional improvement than did matched abnormal or matched normal segments (χ2=42.3, P<0.01). Thus, by estimating both perfusion and wall thickening, single-injection resting ECG gated SPET imaging with 99mTc-tetrofosmin early after primary PTCA can predict recovery of regional wall motion after successful reperfusion.

Clinical significance of PQ segment depression in acute Q wave anterior wall myocardial infarction

OBJECTIVES This study was designed to evaluate the clinical significance of PQ segment depression and to examine the frequency of PQ segment depression in infarction-associated pericarditis. BACKGROUND PQ segment deviation is almost as characteristic as the classic ST segment deviation and is detected in most patients with pericarditis. However, the incidence and clinical characteristics of PQ segment depression in acute myocardial infarction are not defined. METHODS Three hundred four consecutive patients with acute Q wave anterior wall myocardial infarction were examined carefully by auscultation, electrocardiogram, echocardiogram and chest roentgenogram. The diagnosis of pericarditis was made on the basis of pericardial rub detected by more than two observers during the 1st 3 days after hospital admission. At least 0.5 mm of PQ segment depression from the TP segment observed for > 24 h in both limb and precordial leads was considered diagnostic of PQ segment depression. RESULTS A pericardial rub was present in 65 patients (21%) and absent in 239 patients. PQ segment depression was detected in both limb and precordial leads in 30 patients (10%): 18 patients with pericardial rub and 12 patients without pericardial rub. On the basis of five clinical variables, multivariate analysis was performed to determine the important variables related to the occurrence of PQ segment depression. Pericardial rub was selected with left ventricular segments with advanced asynergy as a significant factor related to PQ segment depression. There were 31 in-hospital deaths, and a significantly higher hospital mortality rate was observed in patients with PQ segment depression (23% vs. 9%). CONCLUSIONS Although PQ segment depression was observed in a minority of patients with infarction-associated pericarditis, it was one of the clinical signs of larger infarct size and increased hospital deaths.

Late potentials during left ventricular healing of acute myocardial infarction.

BackgroundLate potentials and left ventricular remodeling are important factors in the prognosis of acute myocardial infarction. However, the relationship between late potentials and ventricular remodeling has not been fully evaluated. MethodsWe evaluated clinical characteristics, coronary angiographie findings and radionucltde angiographie measures about 1 month after an acute myocardial infarction in patients with and without late potentials. ResultsAlthough the left ventricular ejection fraction of patients with late potentials was not different from that of patients without late potentials, the left ventricular end-diastolic volume of patients with late potentials was larger than that of patients without late potentials (P<0.05). There was a significant positive correlation between the left ventricular end-diastolic volume and the filtered QRS duration (r = 0.53, P< 0.001). The root mean square of the voltage in the terminal 40ms and the low-amplitude signal duration of 7lt;40 μV in the terminal QRS sequence were also correlated with the left ventricular end-diastolic volume (r = 0.40, P<0.02, and r = 0.39, P<0.02, respectively). Patency of the infarct-related vessel in the late phase of an acute myocardial infarction was an important factor associated with the occurrence of late potentials (P<0.01). ConclusionA larger left ventricular end-diastolic volume in patients with late potentials might be associated with left ventricular remodeling during the first month after an acute myocardial infarction.