Kunihiko Sugimoto

The Role of Norepinephrine and Estradiol in the Pathogenesis of Cardiac Wall Motion Abnormality Associated With Subarachnoid Hemorrhage

Background and Purpose— The majority of patients with ventricular wall motion abnormality (WMA) associated with subarachnoid hemorrhage (SAH) are postmenopausal women. In addition to elevated catecholamine, the role of estrogen in the pathogenesis of WMA has recently been implicated. The objective of this study is to clarify the interrelation among catecholamine, estrogen, and WMA in patients with SAH. Methods— A retrospective analysis was performed on the medical records of 77 patients with SAH (23 men, 54 women) whose plasma levels of epinephrine, norepinephrine, and estradiol had been measured and echocardiograms had been obtained within 48 hours of SAH onset. Results— Twenty-four patients (31%) were found to sustain WMA on admission. Multivariate regression analysis revealed that decreased estradiol (P=0.018; OR, 0.902) and elevated norepinephrine levels (P=0.027; OR, 1.002) were associated with WMA. After quadrichotomization of 77 patients based on sex/WMA, plasma norepinephrine levels were markedly elevated in men with WMA, whereas estradiol levels were markedly decreased in women with WMA. Plasma norepinephrine and estradiol levels were not correlated. Fifty-four female patients with SAH were further quadrichotomized based on norepinephrine/estradiol levels with a threshold value of 1375 pg/mL for norepinephrine and 11 pg/mL for estradiol. The incidence of WMA in the high-norepinephrine/low-estradiol group was significantly higher than the low-norepinephrine/high-estradiol group. Conclusions— To our knowledge, this is the first study to evaluate the interrelation among catecholamine, estrogen, and SAH-induced WMA. Lack of estradiol in postmenopausal women may predispose them to develop WMA after poor-grade SAH. However, the precise role of multiple sex hormones in SAH-induced WMA should be evaluated in future prospective studies.

Prognostic value of left atrial volume index in patents with first acute myocardial infarction

AIMS We evaluated the usefulness of left atrial volume index (LAVI) and the degree of changes in LAVI (delta LAVI) during hospitalization for the prediction of prognosis after acute myocardial infarction (AMI). METHODS AND RESULTS We investigated 205 consecutive patients with first AMI. They underwent echocardiography on admission as well as at discharge. Delta LAVI was calculated by subtracting the value on admission from that at discharge. The primary endpoints were major cardiac events (MACE): cardiac death due to heart failure and heart failure hospitalization. During a mean follow-up of 26 months, MACE occurred in 29 patients. Patients were divided into two groups according to the optimal cut-off values of LAVI (32.0 mL/m(2)) at discharge and delta LAVI (2.5 mL/m(2)) derived from receiver operating characteristic curves, respectively; Group I: LAVI ≤ 32.0 mL/m(2), Group II: LAVI > 32.0 mL/m(2) and Group A: delta LAVI ≤ 2.5 mL/m(2), Group B: delta LAVI > 2.5 mL/m(2). In comparisons of two groups, respectively, the incidence of MACE between the groups showed significant differences [Group I (3.8%) vs. Group II (32.0%): P < 0.001, log-rank, Group A (7.4%) vs. Group B (20.0%): P = 0.0079, log-rank]. In multivariate analysis, LAVI at discharge [risk ratio (RR): 1.077, 95% CI: 1.035-1.124, P = 0.0002] and delta LAVI (RR: 1.056, 95% CI: 1.012-1.108, P = 0.0109) were significant. LAVI > 32.0 mL/m(2) at discharge (sensitivity: 93%, specificity: 69%) and delta LAVI > 2.5 mL/m(2) (sensitivity: 79%, specificity: 50%) were predictors of MACE. CONCLUSION LAVI at discharge and delta LAVI would be useful predictors for MACE after first AMI.

Questionnaire survey on the state of routine echocardiographic examinations in Japan : second report

We mailed questionnaires to 748 registered medical sonographers [RMSs (cardiology)] to gather information for a large-scale survey of RMSs in May 2000. We wanted to evaluate the current state of routine echocardiography in Japan. Altogether, 530 (70.9%) of these sonographers responded; 18 respondents employed by equipment manufacturers were excluded from the start of the study, and 20 others later found to be employed by equipment manufacturers were also excluded. Responses from all personnel at a single institution were treated as a single response; 436 institutions were thus included in the survey. Most or all examinations were carried out by sonographers at 77.3% of the responding institutions but were performed mainly by physicians at 11.1% of the institutions. At least 80% of sonographer or physician working hours were used for echocardiographic examination at 18.9% of the surveyed institutions, whereas up to half the working hours were devoted to echocardiographic examinations at 67.0% of the institutions. The most frequently reported examination time was 30–40 min [35.6% (n = 116) of the institutions], whereas 32.8% (n = 107) of the institutions indicated durations of 10–20 min per examination. Left ventricular (LV) dimensions and wall thickness were measured on M-mode images in all patients at 14.1% (n = 59) of the institutions and mainly on M-mode images but from two-dimensional echocardiography in problematic patients at 74.2% (n = 311) of the institutions. The LV ejection fraction was calculated from LV dimensions at 55.7% (n = 205) of the institutions and from the LV cross-sectional area at 44.3% (n = 163) of the institutions. The LV ejection fraction was estimated visually at 57.0% of the institutions. Only 5.5% (n = 22) of the facilities always scored the wall motion. Pulsed Doppler echocardiography was used to assess LV inflow in all patients at 65.9% of the institutions; regurgitation and shunting were always assessed quantitatively at only 2% (n = 8). Comments concerning image quality were reported in all cases or in cases of poor image quality at 98% of the institutions, and the sonographer was also involved in writing the diagnostic report at 94% of institutions. Echocardiography is less expensive than other diagnostic imaging methods, and its importance is thus likely to continue to increase. Echocardiographic examinations should be carried out by skilled RMSs and physician echocardiographers; and an accurate, readily comprehensible report of the findings should be provided promptly to the referring physician. More such surveys are required to ensure that these practices are adopted.

Electrocadiographic Scoring Helps Predict Left Ventricular Wall Motion Abnormality Commonly Observed after Subarachnoid Hemorrhage

BACKGROUND Cardiac wall motion abnormality (WMA) is a common complication in patients with subarachnoid hemorrhage (SAH) and is one determinant of their prognosis. The aim of this study was to examine whether the electrocardiography (ECG) findings at admission could predict WMA commonly observed after SAH. MATERIALS AND METHODS We studied 161 SAH patients with SAH who were hospitalized in our institution between April 2007 and November 2010. We performed bedside 2-dimensional transthoracic echocardiography and 12-lead surface ECG within 24hours of SAH onset. Each of the following ECG changes was scored as having 1 point: ST elevation, ST depression and T wave inversion. We summed up the points in every patient and compared with WMA evaluated by echocardiography. RESULTS The study subjects were classified into 2 groups based on the presence of WMA. Multivariate analysis revealed that ST elevation, ST depression and T wave inversion were strong independent predictors of WMA. Receiver operating characteristic curve determined that the threshold value to predict WMA was 4 points (sensitivity 86.5%, specificity 83.1%, AUC 0.94, P < .0001). CONCLUSIONS In conclusion, a novel ECG score may well predict WMA after SAH which may associate with an increased risk of mortality.

Clinical implication of LAVI over A′ ratio in patients with acute coronary syndrome

Purpose The ratio of the left atrial volume index (LAVI) and late diastolic mitral annular velocity (A′) is a useful echocardiographic index for identifying advanced left ventricular (LV) diastolic dysfunction in patients with dyspnoea. We investigated the clinical implications and prognostic value of the aforementioned ratio (LAVI/A′) in patients with ST elevation (STE) or non-STE (NSTE) acute coronary syndrome (ACS). Methods We studied 212 patients with ACS. All patients underwent electrocardiography, echocardiography and measurement of plasma B-type natriuretic peptide (BNP) level on admission. The study endpoints were hospitalisation and mortality because of heart failure (HF). Results There was a significant, moderate positive correlation between LAVI/A′ and natural logarithm (Ln) BNP level among the participants (r=0.48, p<0.0001). During a mean follow-up of 17 months, eight patients died and nine patients were hospitalised because of HF. The receiver operating characteristics curve indicated that LAVI/A′≥3.0 predicted these events (log-rank, p=0.0021). A significant and moderate positive correlation existed between LAVI/A′ and Ln BNP level in the NSTE-ACS group (n=128; r=0.58, p<0.0001). However, the correlation between LAVI/A′ and Ln BNP level was weaker in the STE-ACS group (n=84; r=0.33, p=0.0017). Conclusion LAVI/A′ was related to plasma BNP levels in patients with ACS, particularly in those with NSTE-ACS. This index was useful for predicting cardiac events in patients with ACS.

P-115 Diastolic Stunning Following Acute Myocardial Infraction: Role of Conventional Echocardiography

Some studies have shown that predischarge stress perfusion imaging after AMI gives incremental prognostic information. On the other hand, I-123-BMIPP at rest has been actively applied to patients with AMI. However, no data are available in comparison between long-term prognosis assessment with early rest I-123-BMIPP and predischarge stress perfusion imaging. The aim of this study was to investigate incremental prognostic values of early rest I-123-BMIPP imaging after AMI compared to predischarge stress perfusion imaging established. Data from 107 consecutive patients with AMI who had undergone both early rest I-123-BMIPP and predischarge stress perfusion imaging were analysed. Tracer uptake was graded using a 17-segment model and the total defect score (TDS) was calculated. Patients were followed up for 60 months with primary end points (cardiac death, nonfatal AMI) as hard events and with secondary end points (late revascularization, recurrent angina and heart failure) as soft events. For overall cardiac events (11 hard and 29 soft events), Kaplan-Meier analysis revealed significantly lower event rates in subgroups with I-123-BMIPP and perfusion tracer with TDS of <18, or absence of diabetes mellitus when compared to each counterpart. For the prediction of primary hard events, the stepwise elimination with I-123BMIPP TDS forced in the first step was performed. In conclusion, impaired I-123-BMIPP uptake are related to high probability of cardiac events, suggesting prognostic value to differentiate “vulnerable patients” on impaired fatty acid metabolism following AMI.