Naohisa Hamashige

EFFECT OF AGE ON CHRONOLOGICAL VARIATION OF ACUTE MYOCARDIAL INFARCTION ONSET: STUDY IN JAPAN

To evaluate the effect of age on circadian and seasonal variation in the onset of acute myocardial infarction (AMI) in Japan, we studied 725 patients whose onset date and time of the symptom were determined. In the analysis of all AMI patients, the occurrence showed significant circadian variation (P < 0.01); 30% of episodes occurred between 0600 and 1200 h which formed a dominant morning peak. In the analysis of separate age-groups, a significant difference in the occurrence among four 6-hour periods of day was observed only in the early-elderly group (65–74 years), in which a significant (P < 0.01) morning peak comprising 33% of episodes was observed between 0600 and 1200 h. The monthly variation of AMI onset in total subjects tended to show two peaks; April and August. The seasonal variation tended to show a trough in autumn when analyzed in all patients, but the variation was significant only in middle-aged group (<65 years). In conclusion, the incidence of AMI in Japanese population showed dominant morning peak, and tended to show autumn trough. These circadian and seasonal variations were affected by age.

Patients' Characteristics and Clinical Course of Hypertrophic Cardiomyopathy in a Regional Japanese Cohort ― Results From Kochi RYOMA Study ―

BACKGROUND There have been few studies on the clinical course of hypertrophic cardiomyopathy (HCM) in a community-based patient cohort in Japan.Methods and Results:In 2004, we established a cardiomyopathy registration network in Kochi Prefecture (the Kochi RYOMA study) that consisted of 9 hospitals, and finally, 293 patients with HCM were followed. The ages at registration and at diagnosis were 63±14 and 56±16 years, respectively, and 197 patients (67%) were male. HCM-related deaths occurred in 23 patients during a mean follow-up period of 6.1±3.2 years. The HCM-related 5-year survival rate was 94%. In addition, a total of 77 cardiovascular events that were clinically severe occurred in 70 patients, and the HCM-related 5-year event-free rate was 80%. Multivariate Cox proportional hazards model analysis showed that the presence of NYHA class III at registration was a significant predictor of HCM-related deaths and that the presence of atrial fibrillation, lower fractional shortening and presence of left ventricular outflow tract obstruction in addition to NYHA class III were significant predictors of cardiovascular events. CONCLUSIONS In our unselected registry in an aged Japanese community, HCM mortality was favorable, but one-fifth of the patients commonly suffered from HCM-related adverse cardiovascular events during the 5-year follow-up period. Careful management of HCM patients is needed, particularly for those with the above-mentioned clinical determinants.

Comprehensive arrhythmic surgery for sustained ventricular tachycardia revisited

A 68-year-old woman with a history of old inferior myocardial infarction was admitted because of sustained ventricular tachycardia. Double vessel coronary disease was found with subtotal obstruction of the right coronary artery (#1) and severe stenosis of the left circumflex coronary artery (#13). Dilated left ventricle with a large ventricular aneurysm at the inferior wall and severely reduced systolic function were also present. A comprehensive surgical ablation using subendocardial resection and cryoablation was performed in combination with aneurysmectomy, left ventricular reconstruction, and coronary bypass grafting to the circumflex coronary artery. An implantable cardioverter-defibrillator was also implanted. She has remained well without recurrence of sustained ventricular tachycardia for one year. Although radiofrequency catheter ablation is nowadays considered a first-line therapy for patients with sustained ventricular tachycardia, surgical ablation remains a valuable option for selected patients, particularly for those requiring left ventricular aneurysmectomy and coronary artery bypass grafting, in order to gain a better long-term prognosis through total cure of ventricular tachycardia. <Learning objective: Although radiofrequency catheter ablation is nowadays considered a first-line therapy for patients with sustained ventricular tachycardia, surgical ablation remains a valuable option for selected patients, particularly for those requiring left ventricular aneurysmectomy and coronary artery bypass grafting, in order to gain a better long-term prognosis through total cure of ventricular tachycardia.>.

Multifactorial etiology of heart failure in older adults

We are an aging population. Cardiovascular disease is one of the most frequent causes of death in older adults. In particular, heart failure (HF) is a major public health problem entailing high morbidity and mortality in elderly patients who constitute most of the patients suffering from HF. Elderly patients usually have complex multiple chronic conditions. Acute HF can result from one of these multiple chronic conditions or might be caused by a new pathology in addition to baseline multiple chronic conditions, showing the importance of investigating the cause of HF, particularly yet unknown occult cardiovascular pathologies. We present an elderly patient who developed HF in sequence by different etiologies on the bases of occult and asymptomatic coronary artery disease. A 74-year-old woman with a history of hypertension and type 2 diabetes was referred to us because of fatigue and shortness of breath for the past 1 month. On examination, her blood pressure was 116/63 mmHg, with pulse rate 110 b.p.m. A grade 2/6 ejection systolic murmur was audible at the right sternal border. Electrocardiogram showed sinus tachycardia and left ventricular hypertrophy without significant ST segment changes or abnormal Q waves indicative of acute myocardial ischemia or infarction. Chest radiograph showed cardiomegaly, mild pulmonary congestion and slight bilateral pleural effusion. Echocardiogram revealed a hyperdynamic left ventricle with features of mild aortic stenosis. An elevated serum level of N-terminal Pro B-type natriuretic peptide (NT-proBNP) (1789 pg/mL) was associated with markedly reduced thyroid stimulating hormone (TSH) (0 μg/mL) and elevated free T4 (2.10 ng/dL). Serum TSH receptor antibody (5.2 IU/L) and TSH receptor stimulating antibody (365 %) were both elevated, although the patient had no features of diffuse goiter or ophthalmopathy. A diagnosis of high output HF caused by Graves’ disease hyperthyroidism was made. Treatment with thiamazole, β-blockade and diuretics significantly improved her condition. However, on the third day, she suddenly developed severe dyspnea and became orthopneic. On examination, a new apical grade 3/6 pansystolic murmur was audible. Although the serum level of high-sensitivity troponin T (0.136 ng/mL) was slightly elevated, normal serum levels of creatine kinase (86 IU/L) and creatine kinase-MB (8 IU/L) associated with no electrocardiographic ST segment changes or abnormal Q waves excluded the possibility of acute myocardial infarction. Based on echocardiographic features, a diagnosis of acute HF caused by acute and severe mitral regurgitation secondary to chordal rupture of the posterior mitral valve leaflet was made. Emergency medical treatment with human atrial natriuretic peptide (hANP) and diuretics was successful, resulting in significant improvement of her acute HF. Coronary angiography showed severe triple vessel coronary artery disease. The patient underwent mitral valve repair and coronary artery bypass graft surgery. The cause of the acute chordal rupture of the mitral valve was thought to be related to mild myxomatous changes of the valve, based on the pathological findings. It is possible that hyperdynamic left ventricular wall motion associated with hyperthyroidism might also have played a part in causing rupture of the chordae. The patient’s postoperative course was uneventful, and she is at the moment asymptomatic without any evidence of HF 1 year after successful cardiac surgery. This kind of elderly patient with presentation of sequential HF caused by multifactorial etiologies has not often been reported. However, in the real world of our aging societies, such HF patients with multiple problems might possibly not be infrequent in clinical practice in geriatric population, particularly in district hospitals. This case indeed illustrates multiple problems that require attention in the management of elderly HF patients, and is also educational for all of us geriatricians and general practitioners alike. Elderly HF patients often present with complex multiple chronic conditions. Thus, the conventional approach based on clinical practice guidelines, which focus on the management of a single disease, is usually impractical. Coronary artery disease, hypertension, valvular heart disease and myocardial disease are known to be the common causes of HF in elderly patients (Table 1). Accordingly, when we see elderly HF patients, it is essential first to look for causative cardiovascular pathology. Second, it is worth knowing that several etiologies can co-exist in one particular patient. Third, it is also helpful to carefully seek occult and asymptomatic cardiovascular pathology in particular, such as coronary artery disease, as shown in our patient. These approaches to problem-solving can hopefully pave the way to early and correct diagnosis, and proper management of elderly HF patients. Finally, although the present patient was not extremely old, surgical and interventional treatment should not be denied because of

A rare case of Rotablator® driveshaft fracture and successful percutaneous retrieval of a trapped burr using a balloon and GuideLiner®

A 75-year-old man with a severe calcified atheromatous plaque of the right coronary artery underwent percutaneous coronary intervention using a Rotablator®. During the procedure, the 1.5-mm burr became entrapped, and the driveshaft fractured. While various techniques for retrieving the burr were attempted, a new technique was created. The entrapped burr was sandwiched between an inflated balloon and the GuideLiner®, and a strong back-up force was obtained. Finally, the system was pulled back safely, and the entrapped burr was retrieved without complications. This approach may be useful and safe when coronary flow is preserved despite the trapped burr.

Early management of acute myocardial infarction in the elderly

UNLABELLED The efficacy of reperfusion treatment has been established in patients with acute myocardial infarction (AMI), however, its role is still controversial in the elderly patients. Data from Kochi Acute Myocardial Infarction Registry, consisting of 1,248 cases, showed that, compared to younger patients, elderly patients had greater ratio of women, painless infarction, delayed presentation, worse Killip classes, lower reperfusion procedure and higher mortality. To clarify the early management of AMI in the elderly, we analyzed the clinical data of 1,160 cases, according to age subgroup (317 advanced elderly, aged 75-84; 438 elderly, aged 65-74; 405 middle-aged, aged 45-64) and according to the period (term I, 1990-92; term II, 1993-95; term III, 1996-98). RESULTS 1) The advanced elderly received less reperfusion treatment (37% vs. 65%) and showed higher mortality (21% vs. 8%), compared to middle-aged patients. 2) In advanced elderly patients, mortality was reduced (term I, 27%; term II, 20%; term III, 19%), according to increasing application of reperfusion treatment (term I, 22%; term II, 45%; term III, 40%). 3) Inoadvanced elderly patients with reperfusion treatment, thrombolysis resulted in a higher mortality (17% vs. 7%) compared to direct angioplasty, probably due to increased incidence of cardiac rupture and pump failure in this age group. CONCLUSIONS Reperfusion treatment improves mortality of AMI even in elderly patients. To minimize complications, direct angioplasty may be better for elderly patients.

[The prognosis of dilated cardiomyopathy--the comparison between cases with marked improvement and death].

拡張型心筋症(DCM)の経過観察中に左室径および収縮能が正常化した1群を認め,この群と心不全死した群の初診時の心筋シンチ像および心臓カテーテル所見を対比検討した.対象はDCMとの診断後1年以上経過して心エコー検査が再施行された例と経過中の心不全死例,計21例である.平均33.2±19.5カ月の経過観察中約2割(4例)が左室径および収縮能が正常化し,利尿薬なしでNYHA I度であった.一方, 12例が正常化に至らないか増悪を示し, 5例が心不全死した.正常化群については心筋シンチ像を含めても診断時には予測困難であるが,死亡群は心筋シンチ像にて著しい欠損像を呈し,血行動態指標を組み合わせることによりほぼ予測可能である.