Yasuharu Nakama

Assessment of outcomes and differences between in- and out-of-hospital cardiac arrest patients treated with cardiopulmonary resuscitation using extracorporeal life support☆

AIM Cardiopulmonary resuscitation (CPR) using extracorporeal life support (ECLS) for in-hospital cardiac arrest (IHCA) patients has been assigned a low-grade recommendation in current resuscitation guidelines. This study compared the outcomes of IHCA and out-of-hospital cardiac arrest (OHCA) patients treated with ECLS. METHODS A total of 77 patients were treated with ECLS. Baselines characteristics and outcomes were compared for 38 IHCA and 39 OCHA patients. RESULTS The time interval between collapse and starting ECLS was significantly shorter after IHCA than after OHCA (25 (21-43)min versus 59 (45-65)min, p<0.001). The weaning rate from ECLS (61% versus 36%, p=0.03) and 30-day survival (34% versus 13%, p=0.03) were higher for IHCA compared with OHCA patients. IHCA patients had a higher rate of favourable neurological outcome compared to OHCA patients, but the difference was not statistically significant (26% versus 10%, p=0.07). Kaplan-Meier analysis showed improved 30-day and 1-year survival for IHCA patients treated with ECLS compared to OHCA patients who had ECLS. However, multivariate stepwise Cox regression model analysis indicated no difference in 30-day (odds ratio 0.94 (95% confidence interval 0.68-1.27), p=0.67) and 1-year survival (0.99 (0.73-1.33), p=0.95). CONCLUSION CPR with ECLS led to more favourable patient outcomes after IHCA compared with OHCA in our patient group. The difference in outcomes for ECLS after IHCA and OHCA disappeared after adjusting for patient factors and the time delay in starting ECLS.

Prevalence of incidental coronary artery disease in tako-tsubo cardiomyopathy.

ObjectiveEarlier studies have often required the absence of obstructive coronary artery disease (CAD) as the criteria. However, it is probable that patients with tako-tsubo cardiomyopathy have an incidental CAD because most patients are elderly. We assessed the prevalence of incidental CAD. MethodsWe reviewed coronary angiograms of 97 Japanese patients with tako-tsubo cardiomyopathy. A wrapped left anterior descending artery (LAD) was defined as a LAD that perfused at least one-quarter of the inferior wall of the left ventricle in the 30° right anterior oblique projection. ResultsTen patients (10%) had definitively incidental CAD defined as greater than 75% reduction in the luminal diameter of the major epicardial coronary artery. All patients had ST-segment elevation, and five patients had T-wave inversion on admission. Nine patients had single vessel disease, and one patient had double vessel disease. Six patients had CAD in the nonwrapped LAD, and they were judged to be definitively incidental. Three patients had CAD in the left circumflex artery, and two patients had CAD in the right coronary artery. ConclusionThis study showed that incidental CAD was found in 10% of Japanese patients with tako-tsubo cardiomyopathy. In patients with CAD in the LAD, it should be carefully judged whether the CAD causes left ventricular apical ballooning to avoid performing coronary revascularization unnecessarily.

Incidence and treatment of left ventricular apical thrombosis in Tako-tsubo cardiomyopathy

Among 95 patients with Tako-tsubo cardiomyopathy, left ventricular (LV) apical thrombus was documented in 5 (5.3%) patients. The thrombus was mural in 2 (40%), and protruding in 3 (60%) patients. In 4 patients, LV apical thrombus disappeared after anticoagulant therapy. In one patient with protruding thrombus, brain infarction occurred. LV dysfunction was resolved during follow-up in all patients.

Presentation of Tako-tsubo Cardiomyopathy in Men and Women

Recent studies have demonstrated that stress‐induced Tako‐tsubo cardiomyopathy is likely to occur in elderly female patients.

Torsade de pointes associated with bradycardia and takotsubo cardiomyopathy

Two cases of torsade de pointes associated with bradycardia and takotsubo cardiomyopathy are reported. In both cases, atrioventricular block preceded the occurrence of takotsubo cardiomyopathy. Bradycardia-induced QT interval prolongation seemed to be amplified by the occurrence of takotsubo cardiomyopathy, resulting in torsade de pointes. Temporary ventricular pacing at a high rate decreased the QT interval and prevented the recurrence of torsade de pointes. Because atrioventricular block recurred or persisted even after the resolution of takotsubo cardiomyopathy, the patients received permanent pacemakers.

Clinical Presentation, Management and Outcome of Japanese Patients With Acute Myocardial Infarction in the Troponin Era – Japanese Registry of Acute Myocardial Infarction Diagnosed by Universal Definition (J-MINUET) –

BACKGROUND New criteria for diagnosis of acute myocardial infarction (AMI) were proposed in 2000 as a universal definition, in which cardiac troponin (cTn) was the preferred biomarker. A large number of patients formerly classified by creatine kinase (CK) as unstable angina are now ruled-in by cTn as non-ST-elevation myocardial infarction (NSTEMI). METHODS AND RESULTS The Japanese registry of acute Myocardial INfarction diagnosed by Universal dEfiniTion (J-MINUET) is a prospective and multicenter registry conducted in 28 institutions. We enrolled 3,283 consecutive patients with AMI diagnosed by cTn-based criteria who were admitted to participating institutions within 48 h of symptom onset. There were 2,262 patients (68.9%) with STEMI and 1,021 (31.1%) with NSTEMI. CK was not elevated more than twice the upper limit of normal in 458 patients (44.9%) with NSTEMI (NSTEMI-CK). Although there was no significant difference in the in-hospital mortality of STEMI and NSTEMI with CK elevation (NSTEMI+CK) patients (7.1% vs. 7.8%, P=0.57), it was significantly lower in patients with NSTEMI-CK than in those with STEMI or NSTEMI+CK (1.7%, P<0.001 for each). CONCLUSIONS J-MINUET revealed the clinical presentation, management and outcomes of Japanese patients with AMI in the current cTn era. We should be aware of the difference between AMI diagnosed by CK-based criteria and AMI diagnosed by cTn-based criteria when using universal definitions for the diagnosis of AMI.

Who benefits most from mild therapeutic hypothermia in coronary intervention era? A retrospective and propensity-matched study

IntroductionThe aim of the present study was to investigate the impact of the time interval from collapse to return of spontaneous circulation (CPA-ROSC) in cardiac arrest patients and the types of patients who will benefit from therapeutic hypothermia.MethodsFour hundred witnessed adult comatose survivors of out-of-hospital cardiac arrest of cardiac etiology were enrolled in the study. The favorable neurological outcome was defined as category 1 or 2 on the five-point Pittsburgh cerebral performance scale at the time of hospital discharge. A matching process based on the propensity score was performed to equalize potential prognostic factors in the hypothermia and normothermia groups, and to formulate a balanced 1:1 matched cohort study.ResultsThe rate of favorable neurological outcome was higher (P < 0.05) in the hypothermia group (n = 110) than in the normothermia group in patients with CPA-ROSC of 15 to 20 minutes (64% vs. 17%), 20 to 25 minutes (70% vs. 8%), 25 to 30 minutes (50% vs. 7%), 35 to 40 minutes (27% vs. 0%) and 40 to 45 minutes (29% vs. 2%). A similar association was observed in a propensity-matched cohort, but the differences were not significant. There was no significant difference in the rate of favorable neurological outcome between the hypothermia-matched group and the normothermia-matched group. In the patients whose CPA-ROSC was greater than 15 minutes, however, the rate of favorable neurological outcome was higher in the hypothermia-matched group than in the normothermia-matched group (27% vs. 4%, P < 0.001). In multivariate analysis, the CPA-ROSC was an independent predictor of favorable neurological outcome (every 1 minute: odds ratio = 0.89, 95% confidence interval = 0.85 to 0.92, P < 0.001).ConclusionsThe CPA-ROSC is an independent predictor of neurological outcome. Therapeutic hypothermia is more beneficial in comatose survivors of cardiac arrest with CPA-ROSC greater than 15 minutes.

Assessment of medications in patients with tako-tsubo cardiomyopathy

BACKGROUND Tako-tsubo cardiomyopathy has been gradually recognized worldwide. However, medications for the prevention remain not to be investigated in part because the precise mechanism is unclear. We sought to examine medications before the onset of tako-tsubo cardiomyopathy, and to prove the limitation of these medications for the prevention. METHODS AND RESULTS This study consisted of 21 patients with tako-tsubo cardiomyopathy who received one or more medications for hypertension or suspected angina pectoris. Each patient was assessed with history, medications, coronary angiography and left ventriculography. All patients but 1 were female, and age ranged 41 to 87 years (73+/-11 years). Twelve patients received calcium channel blockers, 7 patients received nitrates, and one patient received beta blocker. Three patients received angiotensin coverting enzyme inhibitors, and 4 patients received angiotensin II receptor blockers. One patient died of serious pneumonia, but there was no patient who died of tako-tsubo cardiomyopathy itself. During the 3 year follow-up, one patient receiving angiotensin receptor blocker had the recurrence of tako-tsubo cardiomyopathy due to recurrent epileptic seizure. CONCLUSIONS Tako-tsubo cardiomyopathy can occur despite treatment with calcium channel blockers, nitrates or beta-blockers, suggesting limitation of these medications to prevent tako-tsubo cardiomyopathy.

Longitudinal extent of lipid pool assessed by optical coherence tomography predicts microvascular no-reflow after primary percutaneous coronary intervention for ST-segment elevation myocardial infarction

BACKGROUND Distal embolization during percutaneous coronary intervention (PCI) may deteriorate microvascular reperfusion in patients with ST-elevation myocardial infarction (STEMI). Reperfusion at the coronary microvascular level is important for STEMI and culprit plaque is associated with distal embolization and microvascular reperfusion. ST-segment resolution (ST-R) in the electrocardiogram reflects microvascular reperfusion after primary PCI. Longitudinal extent of lipid pool assessed by optical coherence tomography (OCT) may predict the risk of failure of microvascular reperfusion after primary PCI. METHODS AND RESULTS This study consisted of 39 patients with STEMI who underwent primary PCI within 24h after the onset of chest pain. Immediately after thrombectomy, OCT was performed and length of lipid pool was measured. Microvascular reperfusion after primary PCI was assessed by ST-R, which was defined as >50% decrease in ST elevation at 1h after primary PCI. There were 23 patients with ST-R and 16 patients without ST-R, with no significant difference in baseline clinical and angiographical variables between the 2 groups. Final thrombolysis in myocardial infarction 3 flow was obtained in all of the patients. Peak creatine kinase was significantly higher in the ST-R (-) group than in the ST-R (+) group (p=0.01). Length of lipid pool was 10.1 ± 2.8mm in the ST-R (-) group and 7.8 ± 3.2mm in the ST-R (+) group (p=0.02). In receiver operating characteristics curve assessing the ability of length of lipid pool to predict ST-R, area under the curve was 0.74 (p=0.02). Length of lipid pool >9.0mm best predicted the absence of ST-R with sensitivity 88% and specificity 78%. CONCLUSIONS These findings suggest that length of lipid pool estimated by OCT may predict microvascular no-reflow after primary PCI.

History of diabetes mellitus as a neurologic predictor in comatose survivors of cardiac arrest of cardiac origin treated with mild hypothermia.

AIM To investigate the impact of a history of diabetes mellitus on the neurologic outcome in comatose survivors of cardiac arrest of cardiac origin treated with mild hypothermia. METHODS A prospective observational study was performed between September 2003 and July 2008. Eighty comatose survivors of cardiac arrest of cardiac origin were treated with mild hypothermia. Neurologic outcome at the time of hospital discharge, 30-day survival, and complications were assessed. RESULTS Twenty-four of the 80 patients (30%) had a history of diabetes. The rate of favorable neurologic outcome was significantly lower in diabetic (17%) than in nondiabetic patients (46%) (p=0.01). The rate of 30-day survival was lower in diabetic (33%) than in nondiabetic patients (54%), but the difference was not significant (p=0.10). Multivariate analysis suggested that a history of diabetes was an independent predictor of unfavorable neurologic outcome (odds ratio 7.00, 95% confidence interval 1.42-46.19, p=0.03), but not for 30-day survival. There was no significant difference in the prevalence of complications. CONCLUSION A history of diabetes is associated with poor neurologic outcome in comatose survivors of cardiac arrest treated with mild hypothermia.