Yoshiaki Tsuka

Long-term Administration of Atrial Natriuretic Peptide in Patients with Acute Heart Failure

A short-term treatment of atrial natriuretic peptide (ANP), a circulating hormone of cardiac origin, is reported to improve cardiac performance in patients with chronic heart failure. However, clinical usefulness of long-term administration of ANP in patients with congestive heart failure has not been reported. We studied 36 patients with severe acute heart failure who resisted various therapy. Hemodynamic parameters were measured before and 48 h after initiating ANP infusion (n = 18) or normal saline (n = 18). Mean pulmonary capillary wedge pressure (23-->13 mm Hg), mean right atrial pressure (10-->5 mm Hg), systemic vascular resistance (2,169-->1,307 dyn x s x cm(-5)) and pulmonary vascular resistance (318-->136 dyn x s x cm(-5)) decreased significantly, whereas cardiac index (1.9-->2.6 L/min/m2) and urine volume (1,692-->2,560 ml/day) increased during long-term ANP infusion (before-->48 h). Moreover, in eight patients with long-term ANP infusion, these hemodynamic effects were maintained at 7 days after initiating ANP infusion. Vasodilating, pulmonary vasorelaxant, and diuretic activities of ANP are maintained without tolerance, and thus long-term ANP infusion is clinically useful in patients with severe acute heart failure.

The effect of verapamil on the restoration of myocardial perfusion and functional recovery in patients with angiographic no-reflow after primary percutaneous coronary intervention.

ObjectiveAngiographic thrombolysis in myocardial infarction (TIMI) flow grade≤2 after primary percutaneous coronary intervention (PCI), defined as angiographic no-reflow, predicts poor functional recovery in patients with acute myocardial infarction. We investigated the effect of verapamil on the restoration of myocardial perfusion and functional recovery in patients with angiographic no-reflow after PCI. Methods99mTc tetrofosmin single photon emission computed tomographic (SPECT) imaging was performed (before, immediately after and 1 month after PCI) in 101 consecutive patients with acute myocardial infarction. The defect score was calculated as the sum of perfusion defect in a 13-segment model (scores of 3, complete defect to 0, normal perfusion). The asynergic score, defined as the number of asynergic segments, was assessed by echocardiography before and 1 month later. Multiple logistic regression analysis was performed to elucidate the effect of verapamil administration. ResultsOf 101 patients, 32 (31%) had angiographic no-reflow and were divided into two groups: 18 patients with verapamil (group 1) and 14 patients without verapamil (group 2). Sixty-nine patients had TIMI grade 3 reflow after PCI (group 3). The change in the defect score 1 month after PCI in group 1 was significantly larger than that in group 2 (P=0.003). The asynergic score improved more at 1 month in group 1 compared to that in group 2 (P=0.007). Moreover, logistic regression analysis revealed that TIMI grade reflow ≤2 after PCI (P=0.04, OR=5.51), the defect score before PCI (P=0.03, OR=1.15), the asynergic score before PCI (P=0.01, OR=0.64) and the administration of verapamil (P=0.002, OR=22.4) were independently associated with successful myocardial reperfusion immediately after PCI. ConclusionsIntracoronary verapamil restored myocardial perfusion in patients with angiographic no-reflow after PCI and lead to better functional recovery after acute myocardial infarction.

Combined analysis of multislice computed tomography coronary angiography and stress-rest myocardial perfusion imaging in detecting patients with significant proximal coronary artery stenosis.

ObjectiveMultislice computed tomography (MSCT) coronary angiography (CAG) is limited in detecting significant coronary artery stenosis because of its low specificity and positive predictive value. Stress–rest myocardial perfusion imaging (MPI) can detect myocardial ischemia. The aim of this study was to evaluate the diagnostic accuracy of detecting patients with proximal coronary artery disease for coronary intervention by combined analysis of MSCT-CAG and MPI. MethodsMSCT-CAG, MPI, and CAG were performed in 125 patients with chest pain suggestive of coronary artery disease. A significant proximal coronary artery stenosis was defined as ≥75% stenosis by MSCT and CAG. Myocardial ischemia was defined as reversible defect by MPI. Patients were defined as having coronary artery disease with a significant coronary stenosis by CAG. ResultsSeventy-four patients had a significant proximal coronary artery stenosis by MSCT. Of the 74 patients with a coronary artery stenosis by MSCT, 50 (67.6%) patients had a significant proximal coronary artery stenosis by CAG. In contrast, 50 (98.0%) of 51 patients without coronary artery stenosis by MSCT did not have coronary artery disease. In detecting patients with proximal coronary artery disease, combined analysis of MSCT and MPI showed a considerable improvement in specificity (94.6 vs. 67.6%, P = 0.0001) and positive predictive value (92.3 vs. 67.6%, P = 0.01) without significant changes in sensitivity (94.1 vs. 98.0%) and negative predictive value (95.9 vs. 98.0%) compared with MSCT alone. ConclusionCombined analysis of MSCT-CAG and MPI can accurately detect patients with proximal coronary artery disease.

Preservation of myocardial viability within the risk area by intravenous nicorandil before primary coronary intervention in patients with acute myocardial infarction.

ObjectiveTo investigate the cardioprotective effect of intravenous nicorandil before primary percutaneous coronary intervention (PCI) on preservation of myocardial viability, we studied 199 consecutive patients with acute myocardial infarction. MethodsNicorandil was given intravenously on admission (before primary PCI). Echocardiography and technetium-99m tetrofosmin perfusion imaging were performed before and 1 month after primary PCI. Echocardiographic asynergic score before primary PCI was used to define the size of risk area, whereas the sum of scintigraphic defect grade before primary PCI was used to estimate myocardial viability within the area at risk. The change (before primary PCI and 1 month after primary PCI) in asynergic score and scintigraphic salvage index were calculated. ResultsPatients were divided into nicorandil (n=101) and control (n=98) groups. Although asynergic score before primary PCI was not different between the two groups (nicorandil=3.5±2.1 and control=3.9±1.5), myocardial viability was preserved in nicorandil group (defect score=11.0±4.0) than that in control group (defect score=14.0±4.7, P<0.0001). Multivariate analysis revealed that the presence of antegrade flow (P=0.015) and nicorandil (P<0.0001) were independently associated with preserved myocardial viability before primary PCI. Moreover, the greater reduction in asynergic score (66±41 vs. 49±23%, P=0.0006) and larger salvage index (65±25 vs. 53±26%, P=0.0015) were observed in nicorandil group compared with the control group. ConclusionIntravenous administration of nicorandil before primary PCI preserved myocardial viability within the risk area, which leads to greater myocardial salvage and better functional recovery after primary PCI.