Tetsushiro Takeuchi

Combination of Urinary Sodium/Creatinine Ratio and Plasma Brain Natriuretic Peptide Level Predicts Successful Tolvaptan Therapy in Patients With Heart Failure and Volume Overload

To evaluate the short-term clinical and hemodynamic effects of tolvaptan therapy and to identify predictors of the therapeutic outcomes, we retrospectively recruited 60 consecutive hospitalized heart failure (HF) patients (70 ± 11 years) with volume overload. The subjects were divided into two groups on the basis of the changes in HF symptom scores and hemodynamic status assessed by right heart catheterization after tolvaptan therapy (median: 7 days). The majority of patients were successfully treated (group 1). However, 22% of patients (group 2) were unsuccessfully treated, in whom 1) the HF symptom score worsened or 2) there was a stationary HF symptom score ≥ 6 points, and mean PCWP > 18 mmHg and mean RAP > 10 mmHg, after tolvaptan therapy. HF symptom scores, hemodynamic parameters, and plasma brain natriuretic peptide (BNP) level improved in group 1, but all of these parameters remained unchanged in group 2. Lower urine sodium/creatinine ratio (UNa/UCr) and higher BNP level at baseline were independently associated with unsuccessful tolvaptan therapy, and UNa/UCr best predicts unsuccessful tolvaptan therapy with a cut-off value of 46.5 mEq/g·Cr (AUC 0.847, 95% CI: 0.718-0.976, sensitivity 77%, specificity 81%, P < 0.01). Double-positive results of UNa/UCr < 46.5 mEq/g·Cr and plasma BNP level > 778 pg/mL predicted unsuccessful tolvaptan therapy with high diagnostic accuracy (sensitivity 54%, specificity 100%, positive predictive value 100%, negative predictive value 89%, and accuracy 90%). In summary, short-term tolvaptan therapy ameliorated HF symptoms and provided hemodynamic improvement in the majority of patients, and UNa/UCr and BNP level strongly predicted the therapeutic outcomes.

Calcified amorphous tumor of the heart in a hemodialysis patient

We report a case of calcified amorphous tumor (CAT) of the heart in a 60‐year‐old Japanese man on hemodialysis. Because the masses in the mitral annulus developed during two‐year echocardiographic follow‐up, he underwent surgical resection with mitral valve replacement. Histological examination showed that the tumor contained multiple calcified nodules, which confirmed the diagnosis of CAT. This case report reinforces the need to deeply and periodically investigate for cardiac involvement of CAT in all patients on hemodialysis.

A case of aortic thrombosis and embolism preceding the progression of early esophageal cancer

Aortic thrombosis is rare, especially in non-atherosclerotic aortae. A 51-year-old woman presented with intermittent claudication in the right lower extremity. She was diagnosed as having peripheral artery disease on ultrasound. A computed tomography scan showed a large, sessile, aortic mural thrombus from the infrarenal abdominal aorta to the right common iliac artery. An arteriogram showed an abrupt occlusion of the right superficial femoral artery with collateral arteries. She had no risk factors for atherosclerosis. Interestingly, this occurred before early esophageal cancer progressed. Heparin was administered intravenously and later changed to warfarin. In the follow-up period, the thrombus disappeared, and her symptoms improved. A careful investigation for malignant disease is needed when aortic thrombus occurs in patients with no atherosclerosis risk factors. <Learning objective: Aortic thrombosis is rare, especially in non-atherosclerotic aortae. A patient who presented with descending aortic thrombosis and peripheral embolism complicating early esophageal carcinoma is presented. Interestingly, this occurred before the cancer progressed. A careful investigation for malignant disease is needed when aortic thrombus occurs in patients with no atherosclerosis risk factors.>.

Effect of Sitagliptin on Coronary Flow Reserve Assessed by Magnetic Resonance Imaging in Type 2 Diabetic Patients With Coronary Artery Disease

BACKGROUND The present study was conducted to assess the cardiovascular effects of dipeptidyl peptidase-4 inhibitors (DPP4i) on coronary flow reserve (CFR), left ventricular (LV) function and endothelial function of the peripheral artery by comparison with those of α-glucosidase inhibitors (αGI) in patients with type 2 diabetes mellitus (T2DM) and coronary artery disease (CAD).Methods and Results:We randomly assigned 30 patients with T2DM and CAD to receive either sitagliptin or voglibose, and 28 patients (age 69±9 years, 75% male, hemoglobin A1c [HbA1c] 6.62±0.48%) completed the study (14 in each group). CFR and LV function, assessed by cardiac magnetic resonance imaging, and endothelial function, assessed by reactive hyperemia peripheral arterial tonometry (RH-PAT), were measured at baseline and 24 weeks after treatment. Clinical and laboratory parameters, including HbA1c level, plasma active glucagon-like peptide-1 concentrations, and biomarkers of inflammation, were unchanged in both groups after 24 weeks of treatment. CFR were unchanged in both the αGI group (3.01±0.98 at baseline and 3.06±0.8 after treatment, P=NS) and the DPP4i group (4.29±2.04 at baseline and 3.63±1.31 after treatment, P=NS), with no interaction effect. LV functional parameters and the reactive hyperemia index also remained unchanged after the 24-week treatment. CONCLUSIONS DPP4i did not improve CFR, LV function or endothelial function of the peripheral artery in patients with relatively well-controlled T2DM and CAD.

PS 17-29 CLINICAL CHARACTERISTICS ASSOCIATED WITH A GREATER BLOOD PRESSURE INCREASE DURING AEROBIC EXERCISE IN PATIENTS WITH CARDIOVASCULAR DISEASES

Objective: Patients with a hypertensive response to exercise may have left ventricular (LV) diastolic dysfunction. However, clinical characteristics of patients who have a greater systolic blood pressure increase (SBP) during aerobic exercise have been still unclear. Design and method: Eighty-seven cardiovascular patients who underwent echocardiography and maximal cardiopulmonary exercise test (CPX) were enrolled. CPX was performed to determine anaerobic threshold and peak oxygen uptake (peak VO2) with simultaneous measurements of cardiac output (CO) using an impedance cardiograph device. The increase in SBP per work load during aerobic exercise and that during anaerobic exercise were determined. Patients were stratified into either greater SBP increase during aerobic exercise than anaerobic exercise (AE) or during anaerobic exercise (AN). Hemodynamics during exercise were compared. Clinical characteristics associated with AE were assessed. Results: Forty-nine patients (66 ± 13 yrs, 61% male) were in AE and 38 (57 ± 15 yrs, 79% male) in AN. AE were older and tended to be more diabetic. No differences were observed in LV dimension and ejection fraction, E wave velocity or estimated LV end-diastolic pressure among the two groups. At rest, heart rate, SBP (125 ± 27 vs. 125 ± 21 mmHg), CO, and aortic elastance were similar in two groups. At anaerobic threshold, SBP (162 ± 34 vs. 144 ± 24 mmHg) and aortic elastance were significantly higher in AE than AN, while heart rate and CO were similar in two groups. Peak SBP, CO, and SV were similar in AE and AN, while peak VO2 was lower in AE. Multivariate analyses showed that female, age, diabetes mellitus, and higher brain natriuretic peptide (BNP) were independent determinants of AE. Conclusions: Patients in AE tended to be older female with diabetes mellitus and higher BNP. They could have greater cumulative afterload in their daily life. Thus, strict BP monitoring using ambulatory BP monitoring may be necessary to prevent diseases such as heart failure with preserved ejection.