Masaki Matsunaga

Post-challenge hyperinsulinaemia rather than hyperglycaemia is associated with the severity of coronary artery disease in patients without a previous diagnosis of diabetes mellitus

Objective: To ascertain the prevalence of abnormal glucose metabolism in patients with coronary artery disease (CAD) but no previous diagnosis of diabetes mellitus (DM) and to examine the relation between the severity of CAD and responses of glucose and insulin to the glucose tolerance test. Methods and results: Abnormalities of glucose metabolism and insulin response were analysed in 144 patients with CAD without a previous diagnosis of DM who underwent both coronary arteriography and 75 g oral glucose tolerance test. The proportions of impaired and diabetic glucose tolerance were very high (39% for impaired and 21% for diabetic glucose tolerance); only 40% had normal glucose tolerance. The parameters of glucose metabolism were not associated with the number of diseased coronary arteries or the presence of previous myocardial infarction (MI). However, the insulin concentration at 60 minutes or 120 minutes after glucose challenge, insulin area, and the ratio of insulin to glucose area were significantly higher in patients with significant coronary stenosis and with previous MI. Fasting glucose concentration and most conventional risk factors did not predict post-challenge hyperinsulinaemia. Conclusion: Patients with CAD without a previous diagnosis of DM had a high prevalence of abnormal glucose tolerance. Post-challenge hyperinsulinaemia was associated with the number of diseased coronary arteries and the presence of previous MI. The insulin response to the glucose challenge test requires further investigation as a potential risk factor for CAD and a potential target for intervention.

Unusual Serial Electrocardiographic Changes which Progressed to Arrhythmogenic Right Ventricular Cardiomyopathy

Left ventricular (LV) involvement in the advanced stage of arrhythmogenic right ventricular cardiomyopathy (ARVC) is a well recognized phenomenon. T wave inversion in the lateral leads has been reported to be an electrocardiographic marker of LV involvement. Variants of ARVC that preferentially affect the left ventricle (left-dominant subtype of arrhythmogenic cardiomyopathy) have recently been recognized. We herein report a case in which an initial electrocardiogram that was similar to the left-dominant subtype of arrhythmogenic cardiomyopathy progressed to definitive ARVC over a period of 7 years. This case supports the hypothesis that LV involvement in ARVC may precede the evident onset of significant RV dysfunction.

A case of primary cardiac lymphoma: in vivo imaging and pathologic correlation

An 86-year-old woman was admitted because of heart failure. Transthoracic echocardiography demonstrated a pericardial effusion and masses occupying the right atrium. Axial non-contrast computed tomography (CT) image showed isoattenuating masses relative to the myocardium in the right atrium ( Panel A1 ). Contrast-enhanced CT revealed mildly enhancing right atrial masses with relatively homogeneous enhancement ( Panel A2 : axial …

Subtraction coronary CT angiography clarifies in-stent restenosis of a three-layer stent segment

Received 24 February 2016; revision accepted for publication 11 April 2016. A 78-year-old man with chest pain receiving haemodialysis was referred for coronary computed tomography angiography (CCTA). Ten years previously, a bare metal stent (BMS) (Duraflex 3.0 × 14 mm) had been placed in his left anterior descending coronary artery (LAD). Subsequently, 3.0 × 23 mm and 3.0 × 23 mm sirolimus-eluting stents (SESs) were implanted in the LAD and second diagonal branch (D2), respectively, with a culotte stenting technique to treat in-stent restenosis (ISR) of the BMS (figure C). We performed subtraction CCTA using a 320-detector-row CT scanner (Aquilion ONE Vision Edition, Toshiba Medical Systems, Japan), whereby two CCTA datasets (with and without contrast injection) are acquired in a single breath-hold. Afterwards, the non-contrast image dataset (figure A, middle) is subtracted from the contrastenhanced CCTA study (figure A, left), thereby removing high-density materials including an implanted stent Subtraction coronary CT angiography clarifies in-stent restenosis of a three-layer stent segment

Serial electrocardiographic changes in isolated cardiac sarcoidosis

An asymptomatic 51-year-old woman was referred to our hospital because of progressive electrocardiographic abnormalities observed during annual health check-ups. A 12-lead electrocardiogram (ECG) at the first visit showed a complete right bundle branch block with ST elevation in leads V1 through V5 (Figure 1(A)). A 12-lead ECG performed 4 years previously had been normal. Serial ECGs showed gradual prolongation of QRS duration, attenuation of R wave amplitude and extension of T wave inversion in right precordial leads (Figure 1(B)). Ophthalmological and dermatological evaluation did not detect abnormal findings. Serum angiotensin-converting enzyme, lysozyme, soluble interleukin-2 receptor and troponin I levels were normal. Chest computed tomography revealed no hilar and mediastinal lymphadenopathy. Cardiac MRI showed regional dyskinesia (Figure 1(C)) and late gadolinium enhancement (Figure 1(D)) of the interventricular septum (white arrow) and right ventricular (RV) free wall (white arrowhead). Gallium-67 citrate SPECT/CT fusion imaging showed abnormal uptake in the basal interventricular septum (Figure 1(E), black arrowhead). However, gallium-67 citrate scintigraphy did not show abnormal uptake in other organs (Figure 1(F)). Selective coronary angiography showed normal coronary arteries. Endomyocardial biopsy from the RV side of the interventricular septum demonstrated noncaseating epithelioid cell granulomas (Figure 1(G), dotted diagram). A diagnosis of isolated cardiac sarcoidosis (CS) was confirmed, and she was treated with prednisolone. This case indicates non-specific ECG changes are observed earlier in the time course of disease progression of isolated CS, and slight changes in serial ECGs can be important initial diagnostic clues for an advanced CS workup.