Toshiyuki Ishimitsu

Effect of age on carotid arterial intima-media thickness in childhood.

To investigate relationships between carotid arterial intima-media thickness (IMT) and age in childhood, we performed high-resolution carotid arterial ultrasonography in 60 healthy children (27 boys, 33 girls; age range, 5–14 years) determined by screening to have no dyslipidemia or hypertension. No plaque formation was found, and irregularity of IMT (root mean square roughness of IMT) did not correlate with age. Mean IMT increased in a linear manner with age [IMT in millimeters = (0.009 × age in years) + 0.35] (r = 0.39, P = 0.002). This correlation remained significant after adjustment for gender, parental smoking, systolic and diastolic blood pressure, body mass index, and serum concentrations of low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglycerides. None of these known cardiovascular disease risk factors in adults had a significant relationship with age-adjusted IMT in children. While circumferential wall stress and diastolic blood pressure were not correlated with age, mean IMT and lumen diameter showed significant positive relationships with circulating blood volume, which was calculated as the function of height and weight. These data suggested that age-dependent physiologic thickening of arterial walls begins in childhood.

The correlation of irregularities in carotid arterial intima-media thickness with coronary artery disease

Abstract. Noninvasive ultrasonographic assessment of carotid artery intima-media thickness (IMT) can improve risk stratification for coronary artery disease (CAD) in certain patients. Several measurements have been used to evaluate carotid atherosclerosis by ultrasonography. Although it has been reported that angiographic arterial irregularities correlate with pathologic changes of atherosclerosis and the occurrence of cardiovascular events, only a few studies have assessed carotid arterial wall irregularity by ultrasonography. The purpose of this study was to evaluate the irregularity of IMT quantitatively, and its association with the presence or absence of CAD. The correlation of maximum and mean IMT values, and IMT irregularity with the presence or absence of CAD, was investigated in 90 patients who had undergone coronary angiography. IMT was measured by manual tracking of the far wall of the common carotid arteries, carotid bulbs, and internal carotid arteries. The IMT irregularity was defined as the root mean square (RMS) difference between each IMT and averaged IMT. Multiple logistic regression analysis, after adjustment for coronary risk factors, indicated that the RMS difference was a more accurate predictor of CAD than were the mean or maximum IMT values. These results indicate that the evaluation of IMT irregularity by ultrasonography is a useful predictor for the presence of coronary atherosclerosis.

The wake of a large vortex is associated with intraventricular filling delay in impaired left ventricles with a pseudonormalized transmitral flow pattern.

Although an intraventricular filling delay has been observed in patients with a psuedonormalized transmitral flow pattern, little is known about the underlying hydrodynamic nature of this phenomenon. Methods: To examine those hydrodynamics, we studied every echocardiographic frame showing ventricular inflow (80 Hz) in the apical long‐axis view and M‐mode image using contrast echocardiography in 29 patients with a psuedonormalized pattern and in 26 normal controls. The velocity of the filling flow front (Vp), the ratio of Vp to E, and the mean radius of the vortices associated with the filling flow were measured. Results: In both groups, vortices were observed at the ridge of the mitral valve during acceleration of the E‐wave. The mean radius of the vortices was greater in the pseudonormalized filling group than that in the control group (8 ± 2 vs 3 ± 1 mm, P < 0.0001). Vp was smaller in the pseudonormalized group than in the control group (36 ± 6 vs 47 ± 6 cm/sec, P = 0.0008). Vp/E was <1 and smaller in the pseudonormalized group than that in the control group (0.46 ± 0.13 vs 0.59 ± 0.07, P = 0.014) and negatively correlated with the mean radius of the vortices (r = 0.54, P < 0.0001). Conclusions: Contrast echocardiography identified uniform flow characteristics with blood in the filling flow front moving in well‐developed vortices and resulting in a left ventricular filling delay in the impaired left ventricle in spite of an increased early transmitral flow velocity.

Combined approach with Doppler echocardiography and B-type natriuretic peptide to stratify prognosis of patients with decompensated systolic heart failure

BACKGROUND Based on the importance of left ventricular (LV) diastolic function in stratification of the cardiac prognosis in patients with systolic heart failure (SHF), we attempted to identify the prognostic impact of Doppler echocardiographic examinations and plasma B-type natriuretic peptide (BNP) concentration. METHODS Of 73 patients admitted with decompensated SHF (ejection fraction <45%), 58 were included. Among these, 21 patients had ischemic heart disease and 27 non-ischemic dilated cardiomyopathy. In all patients, Doppler echocardiographic examinations and measurements of the plasma B-type natriuretic peptide concentration were simultaneously performed before discharge. Patients were followed up for 36 months after discharge. Primary end point for the follow-up was readmission for acute decompensated heart failure or cardiac death. RESULTS During the mean follow-up period of 28±12 months, 16 patients (27.6%) were readmitted with decompensated heart failure. Based on the stepwise multivariate Cox regression analysis, mitral E/A ratio (chi-square=6.5, relative risk=1.7, p=0.01) and BNP (chi-square=3.9, relative risk=1.7, p=0.04) were identified as independent predictors of primary endpoints. Based on ROC analysis, the optimal cutoff point of E/A was 1.05 (AUC=0.836, p=0.002) and that of plasma BNP concentration was ≥254.5 pg/ml (AUC=0.768, p=0.002). In high-risk patients with E/A ≥1, event-free survival rates were significantly lower in patients with BNP <254.5 pg/ml (p<0.001). CONCLUSIONS The complementary assessment of Doppler transmitral flow and plasma BNP concentration may be reliable in identifying the prognosis of patients with SHF.

Stratification of impaired relaxation filling patterns by passive leg lifting in patients with preserved left ventricular ejection fraction

We evaluated diastolic functional reserve in 108 patients with normal left ventricular ejection fraction (LVEF) ≥ 50% but abnormal relaxation (ratio of transmitral peak velocity of early and late diastolic flow (E/A)<1) using passive leg lifting. We calculated the pulmonary venous systolic to diastolic flow ratio (S/D) as a marker of left atrial reservoir function, and the time difference between the duration of pulmonary venous retrograde flow (PVAd) and the duration of the mitral A wave (PVAd‐Ad) as a marker of left ventricular end‐diastolic pressure (LVEDP).

Unexplained Fever and Aortic Regurgitation: A Rare Presentation of Takayasu's Aortitis A Case Report

Takayasus aortitis is rare in male patients. The authors describe the case of a 48-year-old man with a fever of unknown origin, progressive general fatigue, and dyspnea due to aortic regurgitation. A severely thickened aorta was noted during aortic valve replace ment. The diagnosis was based on a histologic examination of an operative specimen of the ascending aorta. Takayasus aortitis should be considered even in male patients with fever of unknown origin and progressive aortic regurgitation.

Continuous intravenous administration of a low dose of epoprostenol greatly decreased serum concentrations of endothelin-1 in primary pulmonary hypertension--a case report.

Endothelin-1 (ET-1) is known to be a principal factor in the pathogenesis of primary pulmonary hypertension (PPH). Recently intravenous administration of epoprosterol improved the survival rate in PPH. However, the effect of epoprosterol on ET-1 remains to be investigated. Therefore, we studied a patient with PPH who was treated with a low dose of epoprosterol and examined the serum concentration of ET-1 during the treatment. Epoprosterol greatly decreased the serum concentration of ET-1 in parallel with improvement of the clinical course, suggesting that ET-1 level may be a marker for treatment of PPH.