尾崎 行男

Computed tomography angiography (CTA) is commonly employed for exclusion of coronary artery disease and demonstration of the extent of coronary vascular involvement. It has been recently proposed that coronary artery plaques could be visualized noninvasively. This review article focused on the high risk plaque detected by CTA. Plaque characteristics of acute coronary syndrome (ACS) was compared to sable angina pectoris (SAP). The presence of positive remodeling (ACS 87 %, SAP 12 %, p &lt 0. 0001), low attenuation plaque (LAP) (ACS 79 %, SAP 9 %, p &lt 0. 0001), and spotty calcification (ACS 63 %, SAP 21 %, p = 0. 0005) were significantly more frequent in the culprit ACS lesions. Furthermore, in asymptomatic patients, presence of positively remodeling and LAP portends a greater risk for development of acute coronary events (hazard ratio = 22. 8, CI = 6. 9-75. 2, p &lt 0. 001). Possibility of drug intervention to high risk plaque was also reported. Serial CTA assessment allows for evaluation of interval change in morphological plaque characteristics and can be employed for assessment of efficacy of therapeutic intervention. Use of statin results in substantial reduction in LAP volume (follow-up: 4. 9 ± 7. 8 versus baseline: 1. 3 ± 2. 3 mm3, p = 0. 02) forwards stabilization of plaques. Although not recommended currently as a population-based strategy, CT angiographic examination may help identify very high risk asymptomatic subjects. © 2013 Japanese Association of Cardiovascular Intervention and Therapeutics.

Objective To study the usefulness of combined risk stratification of coronary CT angiography (CTA) and myocardial perfusion imaging (MPI) in patients with previous coronary-artery-bypass grafting (CABG). Design A retrospective, observational, single centre study. Setting and patients 204 patients (84.3% men, mean age 68.77.6) undergoing CTA and MPI. Main outcome measures CTA defined unprotected coronary territories (UCT; 0, 1, 2 or 3) by evaluating the number of significant stenoses which were defined as the left main trunk 50% diameter stenosis, other native vessel stenosis 70% or graft stenosis 70%. Using a cut-off value with receiver-operating characteristics analysis, all patients were divided into four groups: group A (UCT=0, summed stress score (SSS)<4), group B (UCT1, SSS<4), group C (UCT=0, SSS4) and group D (UCT1, SSS4). Results Cardiac events, as a composite end point including cardiac death, non-fatal myocardial infarction, unstable angina requiring revascularisation and heart-failure hospitalisation, were observed in 27 patients for a median follow-up of 27.5months. The annual event rates were 1.1%, 2%, 5.7% and 12.9% of patients in groups A, B, C and D, respectively (log rank p value <0.0001). Adding UCT or SSS to a model with significant clinical factors including left ventricular ejection fraction, time since CABG and Euro SCORE II improved the prediction of events, while adding UCT and SSS to the model improved it greatly with increasing C-index, net reclassification improvement and integrated discrimination improvement. Conclusions The combination of anatomical and functional evaluations non-invasively enhances the predictive accuracy of cardiac events in patients with CABG.

BACKGROUND: Matrix metalloproteinases (MMPs) have been implicated in development of atherosclerosis. MMPs are activated in patients with acute coronary syndrome (ACS). However, little data exist regarding the correlation between circulating levels of MMPs and plaque volume (PV) in patients with ACS. We therefore evaluated the impact of MMPs on coronary PV as a post hoc analysis from the JAPAN-ACS study. METHODS: The multicenter JAPAN-ACS trial revealed that aggressive statin therapy for patients with ACS significantly reduces coronary PV determined by intravascular ultrasound (IVUS). We studied 248 ACS patients who had serial IVUS examinations over 8-12 months in the trial. For each patient, MMP-1, 2, and 3 were measured both at baseline and at study end to evaluate the correlation between the percent change of PV and MMP levels. RESULTS: MMP-3 levels were significantly decreased during the follow-up period (100 ng/mL to 73 ng/mL, p < 0.001), in contrast, MMP-1, -2 levels were significantly increased. MMP-3 levels at follow-up correlated with coronary plaque regression (p for trend = 0.016). A multivariable linear regression model showed both MMP-2 and MMP-3 levels at follow-up were independent variables for change of coronary PV (p = 0.038 and p = 0.016, respectively). CONCLUSION: Circulating MMPs levels are associated with changes in coronary plaque volume determined by serial IVUS in patients with ACS.

Background: The Japan Assessment of Pitavastatin and Atorvastatin in Acute Coronary Syndrome (JAPAN-ACS) trial demonstrated that early aggressive statin therapy in patients with ACS significantly reduces plaque volume (PV). Advanced glycation end products (AGEs) and the receptors of AGEs (RAGE) may lead to angiopathy in diabetes mellitus (DM) and may affect on the development of coronary PV. The present sub-study of JAPAN-ACS investigates the association between AGEs and RAGE, and PV. Methods: Intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) was undertaken, followed by the initiation of statin treatment (either 4 mg/day of pitavastatin or 20 mg/day of atorvastatin), in patients with ACS. In the 208 JAPAN-ACS subjects, PV using IVUS in non-culprit segment &gt;5 mm proximal or distal to the culprit lesion and, serum levels of AGEs and soluble RAGE (sRAGE) were measured at baseline and 8-12 months after PCI. Results: At baseline, no differences in the levels of either AGEs or sRAGE were found between patients with DM and those without DM. The levels of AGEs decreased significantly with statin therapy from 8.6 +/- 2.2 to 8.0 +/- 2.1 U/ml (p &lt; 0.001), whereas the levels of sRAGE did not change. There were no significant correlations between changes in PV and the changes in levels of AGEs as well as sRAGE. However, high baseline AGEs levels were significantly associated with plaque progression (odds ratio, 1.21; 95% confidence interval, 1.01 - 1.48; p = 0.044) even after adjusting for DM in multivariate logistic regression models. Conclusions: High baseline AGEs levels were associated with plaque progression in the JAPAN-ACS trial. This relationship was independent of DM. These findings suggest AGEs may be related to long-term glucose control and other oxidative stresses in ACS.

Background: The JAPAN-ACS (Japan Assessment of Pitavastatin and Atorvastatin in Acute Coronary Syndrome) trial showed that intensive statin therapy could induce significant coronary plaque regression in acute coronary syndrome (ACS). We evaluated the impact of metabolic syndrome (MetS) and its components on coronary plaque regression in the JAPAN-ACS patients. Methods and Results: Serial intravascular ultrasound measurements over 8-12 months were performed in 242 ACS patients receiving pitavastatin or atorvastatin. Patients were divided into groups according to the presence of MetS or the number of MetS components. Although the percent change in plaque volume (%PV) was not significantly different between the MetS (n=119) and non-MetS (n=123) groups (P=0.50), it was significantly associated with an increasing number of MetS components (component 0: -24.0%, n=7; components 1: -20.8%, n=31; components 2: -16.1%, n=69; components 3: -18.7%, n=83; components 4: -13.5%, n=52; P=0.037 for trend). The percent change in body mass index (%BMI) significantly correlated with %PV (r=0.15, P=0.021), especially in the MetS components 4 group (r=0.35, P=0.017). In addition, %BMI was an independent predictor of plaque regression after adjustment for the changes of low- and high-density lipoprotein cholesterol, triglycerides and HbA1c. Conclusions: The clustering of MetS components, but not the presence of MetS itself, could attenuate coronary plaque regression during intensive statin therapy in ACS patients. Therefore, to achieve a greater degree of plaque regression, it is necessary to treat to each MetS component and use lifestyle modification. (Circ J 2012; 76: 2840-2847)

Neurogenic pulmonary edema (NPE) occurs frequently after aneurysmal subarachnoid hemorrhage (SAH), and excessive release of catecholamines (epinephrine/norepinephrine) has been suggested as its principal cause. The objective of this retrospective study is to evaluate the relative contribution of each catecholamine in the pathogenesis of NPE associated with SAH. Records of 63 SAH patients (20 men/43 women) whose plasma catecholamine levels were measured within 48 h of SAH onset were reviewed, and the clinical characteristics and laboratory data of those who developed early-onset NPE were analyzed thoroughly. Seven patients (11 %) were diagnosed with NPE on admission. Demographic comparison revealed that the NPE+ group sustained more severe SAH than the NPE- group. Cardiac dysfunction was also significantly more profound in the former, and the great majority of the NPE+ group sustained concomitant cardiac wall motion abnormality. There was no significant difference in the plasma epinephrine levels between NPE+ and NPE- group (324.6 +/- 172.8 vs 163.1 +/- 257.2 pg/ml, p = 0.11). By contrast, plasma norepinephrine levels were significantly higher in the NPE+ group (2977.6 +/- 2034.5 vs 847.9 +/- 535.6 pg/ml, p &lt; 0.001). Multivariate regression analysis revealed that increased norepinephrine levels were associated with NPE (OR, 1.003; 95 % CI, 1.002-1.007). Plasma epinephrine and norepinephrine levels were positively correlated (R = 0.48, p &lt; 0.001). According to receiver operating characteristic curve analysis, the threshold value for plasma norepinephrine predictive of NPE was 2,000 pg/ml, with an area under the curve value of 0.85. Elevated plasma norepinephrine may have more active role in the pathogenesis of SAH-induced NPE compared with epinephrine, although both catecholamines may be involved via multiple signaling pathways.

Objectives: The clinical benefit of ezetimibe, an intestinal cholesterol transporter inhibitor, for treatment of postprandial hyperlipidemia was assessed in subjects who ingested a high-fat and high-glucose test meal to mimic westernized diet. Methods: We enrolled 20 male volunteers who had at least one of the following: waist circumference &gt;= 85 cm, body mass index &gt;= 25 kg/m(2), or triglycerides (TG) from 150 to 400 mg/dL. After 4 weeks of treatment with ezetimibe (10 mg/day), the subjects ingested a high-fat and high-glucose meal. Then changes in serum lipid and glucose levels were monitored after 0, 2, 4, and 6 h, and the area under the curve (AUC) was calculated for the change in each parameter. Results and conclusion: At 4 and 6 h postprandially, TG levels were decreased (p &lt; 0.01) after 4 weeks of ezetimibe treatment, and the AUC for TG was also decreased (p &lt; 0.01). Apolipoprotein B48 (apo-B48) levels at 4 and 611 postprandially were significantly decreased after ezetimibe treatment (p &lt; 0.01 and p &lt; 0.001, respectively), and the AUC for apo-B48 was also significantly decreased (p &lt; 0.01). Blood glucose and insulin levels at 2 h postprandially were significantly decreased by ezetimibe (p &lt; 0.01). The AUCs for blood glucose and insulin were also significantly decreased (p &lt; 0.05 and p &lt; 0.01, respectively). Since ezetimibe improved postprandial lipid and glucose metabolism, this drug is likely to be beneficial for dyslipidemia in patients with postprandial metabolic abnormalities. (C) 2012 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.

The Annual Congress of the European Society of Cardiology (ESC) was held in Munich from the 26th to 29th of August 2012. The daily attendance ranged from 26,600 to 27,407 up to the 28th and several important issues were presented and discussed, including antiplatelet therapy for acute coronary syndrome (TRILOGY ACS), transcatheter aortic valve implantation, renal denervation, novel oral anticoagulants for atrial fibrillation (AFib), AFib ablation, the impact of the Great East Japan Earthquake on cardiovascular disease, management of vasospastic angina, plaque rupture and erosion (ESC-JCS [Japanese Circulation Society] joint session), heart failure, and FFR-guided percutaneous coronary intervention outcome. Three ESC "GOLD MEDALS" were awarded, including one to Professor Ryozo Nagai, the first Asian to receive this award. The ESC meeting has become one of the most important for updating not only general cardiologists' education but also specialists' expertise. Japan topped the number of abstracts submitted to ESC 2012 (&gt;1,200 abstracts), while the ESC would like to establish a strong collaboration with the Japanese Cardiology Society. Relations between ESC and JCS will become closer and more favorable year by year. (Circ J 2012; 76: 2530-2535)

Background: The incidence, risk factors, and outcome of contrast-induced acute kidney injury (CI-AKI) in 730 patients with acute coronary syndrome (ACS) undergoing emergency percutaneous coronary intervention (PCI), whose contrast volume was below maximum allowable contrast dose (MACD) was prospectively investigated. Methods and Results: MACD was defined as (5 mlxbody weight [kW/baseline creatinine [mg/dl]). CI-AKI was defined as a greater than 25% increase in creatinine from the baseline or an absolute increase of &gt;= 0.5 mg/dl within 48 h after the procedure. CI-AKI occurred in 212 (29%) patients. Patients with CI-AKI had a higher risk for in-hospital mortality (9.4% vs. 1.5%, P&lt;0.001) and a longer stay in the coronary care unit (median, 4.0 vs. 3.0 days, P&lt;0.001) compared with those without CI-AKI. In a multivariate logistic analysis including 20 clinical variables, elevated glucose levels as variables categorized into quartiles were independently (P&lt;0.001) associated with the development of CI-AKI. In addition, this relationship was seen in both the subgroup of patients with known diabetes and that of those without known diabetes. Conclusions: CI-AKI might occur commonly and could be be associated with a more complicated clinical course in ACS patients undergoing emergency PCI whose contrast volume does not exceed MACD. Elevated pre-procedural glucose might be a powerful and independent risk factor for the development of CI-AKI in this population. (Circ J 2012; 76: 1848-1855)

Background: Atrial fibrillation (AF) and heart failure (HF) are associated with significant mortality and morbidity. We sometimes encounter patients who have AF upon admission to the hospital, but it spontaneously converts to sinus rhythm within several days (i.e. converter). Purpose: We examined the association between the outcome and types of strategy for AF treatment in converters. Methods: From January 2000 to December 2005, we identified 95 converters (age 69 +/- 12 years) presenting with worsening HF and AF upon admission, in which sinus rhythm was restored within 7 days without either electrical or pharmacological cardioversion. The patients were classified into three groups according to the antiarrhythmic drug (AAD) therapy used: class I AAD, class III AAD, and rate-control drug. The patients were followed for 36 +/- 23 months. Results: The left ventricular ejection fraction (LVEF) significantly improved with conversion to sinus rhythm (38 +/- 14% vs. 47 +/- 13%, p &lt; 0.05). Those receiving class I AAD had a trend toward a well-preserved LVEF (50 +/- 13%, n = 35) as compared to those receiving class III AAD (43 +/- 12%, n = 24) or rate-control drug (47 +/- 14%, n = 36). In the patients receiving class I AAD, the rate of all-cause death increased 1.9-fold (p = 0.009) compared to those receiving class III AAD, and 1.7-fold (p = 0.010) compared to those taking rate-control drug. A hospitalization for HF was observed in 49 (52%) patients, however there was no significant difference in the rate of hospitalization among the three groups (p = 0.890). Those receiving rate-control drugs had a 50% lower rate of the development of persistent AF than those taking class III AAD (p = 0.019). Conclusions: A rate-control strategy should be the primary approach for converters to reduce mortality and development of persistent AF. (c) 2012 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.

Background and Purpose-The majority of patients with ventricular wall motion abnormality (WMA) associated with subarachnoid hemorrhage (SAH) are postmenopausal women. In addition to elevated catecholamine, the role of estrogen in the pathogenesis of WMA has recently been implicated. The objective of this study is to clarify the interrelation among catecholamine, estrogen, and WMA in patients with SAH. Methods-A retrospective analysis was performed on the medical records of 77 patients with SAH (23 men, 54 women) whose plasma levels of epinephrine, norepinephrine, and estradiol had been measured and echocardiograms had been obtained within 48 hours of SAH onset. Results-Twenty-four patients (31%) were found to sustain WMA on admission. Multivariate regression analysis revealed that decreased estradiol (P=0.018; OR, 0.902) and elevated norepinephrine levels (P=0.027; OR, 1.002) were associated with WMA. After quadrichotomization of 77 patients based on sex/WMA, plasma norepinephrine levels were markedly elevated in men with WMA, whereas estradiol levels were markedly decreased in women with WMA. Plasma norepinephrine and estradiol levels were not correlated. Fifty-four female patients with SAH were further quadrichotomized based on norepinephrine/estradiol levels with a threshold value of 1375 pg/mL for norepinephrine and 11 pg/mL for estradiol. The incidence of WMA in the high-norepinephrine/low-estradiol group was significantly higher than the low-norepinephrine/high-estradiol group. Conclusions-To our knowledge, this is the first study to evaluate the interrelation among catecholamine, estrogen, and SAH-induced WMA. Lack of estradiol in postmenopausal women may predispose them to develop WMA after poor-grade SAH. However, the precise role of multiple sex hormones in SAH-induced WMA should be evaluated in future prospective studies. (Stroke. 2012;43:1897-1903.)

Background: While the utilization of integrated backscatter intravascular ultrasound (IB-IVUS) for the quantitative in vivo assessment of coronary plaque continues to grow, the validity of IB-IVUS images obtained from newly developed and conventional systems remains uncertain. Methods and Results: To assess the accuracy and reliability of a newly developed IB-IVUS system (VISIWAVE) as compared to the conventional system (Clearview), we compared quantitative IB-IVUS plaque characteristics in the 2 systems using 125 post-mortem specimens from 26 coronary arteries in 11 cadavers, as well as using 200 clinical plaques in 32 patients undergoing coronary intervention. The overall agreement between the histological and IB-IVUS diagnoses using VISIWAVE (Cohen's kappa=0.82, 95%CI: 0.73-0.90) was similar to that using Clearview (Cohen's kappa=0.80, 95%Cl: 0.71-0.89). The 2 systems also demonstrated comparably high sensitivity and specificity. In the direct comparison, the overall agreement between IB-IVUS diagnoses using VISIWAVE and Clearview was also excellent (Cohen's kappa=0.87, 95%Cl: 0.78-0.95). In the clinical comparison, measured plaque dimensions were similar (VISIWAVE: 8.27 +/- 3.46 mm(2) vs. Clearview; 8.31 +/- 3.46 mm(2), P=0.44) and there was strong concordance between both greyscale and IB-IVUS parameters. Conclusions: There was close agreement of analyzed results in both systems when compared with the gold standard of histology. Both systems are able to reliably and accurately characterize coronary plaque and thereby make a valuable contribution to our understanding of atherosclerosis. (Circ J 2012; 76: 1678-1686)

INTRODUCTION Myocardial scintigraphy with I-123-15-(p-iodophenyl)-3-methyl pentadecanoic acid (I-123-BMIPP) is used to evaluate impaired fatty acid metabolism. B-type natriuretic peptide (BNP), which is secreted by the ventricular myocardium on stretching and/or pressure overload, is a useful cardiac biomarker. This study aimed to evaluate the usefulness of I-123-BMIPP imaging and serum BNP levels in patients with heart failure (HF). METHODS 113 patients with HF were enrolled. There were 68 patients with ischaemic heart disease (IHD) and 22 with overt HF. Cardiac scintigraphy was performed 7 +/- 3 days after admission, and heart-to-mediastinum (H/M) count ratios on early and delayed images and washout rates (WR) of I-123-BMIPP were recorded. Serum BNP levels were recorded on the day of I-123-BMIPP imaging. The ejection fraction (EF) was calculated just before cardiac scintigraphy using conventional echocardiography. RESULTS The mean BNP level and EF were 282 pg/mL and 47%, respectively, with significant correlation between them. The mean H/M count ratios on early and delayed images were 2.29 and 1.93, respectively, showing significant positive correlations with EF (r = 0.31, p = 0.0006). The WR was significantly correlated with EF (r = -0.36, p &lt; 0.0001) and BNP levels (r = 0.33, p = 0.003), and mean WR was significantly higher in patients with overt HF compared to those without (p &lt; 0.001). Patients with IHD had significantly higher EFs than those with non-IHD (p = 0.03). CONCLUSION The evaluation of impaired myocardial metabolism using I-123-BMIPP scintigraphy and serum BNP levels appears to be useful for the evaluation of severity of HF.

Background: The differences in the coronary plaque characteristics between patients with mild chronic kidney disease (CKD) (estimated glomerular filtration rate [eGFR] 30-59 ml . min(-1) . 1.73 m(-2)) and those without CKD (eGFR &gt;= 60) by 320-row area detector computed tomography (CT) have not been studied. Methods and Results: We enrolled 487 patients undergoing coronary CT angiography with suspected stable coronary artery disease (mean age: 66.6 +/- 10.8 years, 131 with mild CKD) and analyzed 6,352 segments. All coronary plaques were characterized for the presence of vessel remodeling, plaque consistency and the disposition of coronary calcification, and a plaque with positive vessel remodeling and/or low-attenuation was defined as high risk. The number of diseased segments per patient was higher in mild CKD patients than in those without CKD (4.61 +/- 3.83 vs. 2.95 +/- 3.11, P&lt;0.0001). The prevalence of severe stenosis (&gt;= 70% luminal diameter) was significantly higher in cases of mild CKD than in no CKD (35.1% vs. 19.4%, P=0.0003), but there was no significant difference in the prevalence of high-risk plaque (13.0% vs. 9.8%, P=0.3189). Conclusions: The severity of coronary artery stenosis was higher in the patients with mild CKD, though there was no significant difference in the prevalence of high-risk plaque. We suggest that the high risk of coronary events in patients with CKD is related to the severity of stenosis rather than to the characteristics of plaque. (Circ J 2012; 76: 1436-1441)

INTRODUCTION Myocardial scintigraphy with I-123-15-(p-iodophenyl)-3-methyl pentadecanoic acid (I-123-BMIPP) is used to evaluate impaired fatty acid metabolism. B-type natriuretic peptide (BNP), which is secreted by the ventricular myocardium on stretching and/or pressure overload, is a useful cardiac biomarker. This study aimed to evaluate the usefulness of I-123-BMIPP imaging and serum BNP levels in patients with heart failure (HF). METHODS 113 patients with HF were enrolled. There were 68 patients with ischaemic heart disease (IHD) and 22 with overt HF. Cardiac scintigraphy was performed 7 +/- 3 days after admission, and heart-to-mediastinum (H/M) count ratios on early and delayed images and washout rates (WR) of I-123-BMIPP were recorded. Serum BNP levels were recorded on the day of I-123-BMIPP imaging. The ejection fraction (EF) was calculated just before cardiac scintigraphy using conventional echocardiography. RESULTS The mean BNP level and EF were 282 pg/mL and 47%, respectively, with significant correlation between them. The mean H/M count ratios on early and delayed images were 2.29 and 1.93, respectively, showing significant positive correlations with EF (r = 0.31, p = 0.0006). The WR was significantly correlated with EF (r = -0.36, p &lt; 0.0001) and BNP levels (r = 0.33, p = 0.003), and mean WR was significantly higher in patients with overt HF compared to those without (p &lt; 0.001). Patients with IHD had significantly higher EFs than those with non-IHD (p = 0.03). CONCLUSION The evaluation of impaired myocardial metabolism using I-123-BMIPP scintigraphy and serum BNP levels appears to be useful for the evaluation of severity of HF.

Objective: High-mobility group box 1 (HMGB1) is a damage-associated molecular pattern molecule, which suggests a potential role of this protein in the pathophysiology of acute coronary syndrome (ACS). Circulating HMGB1 has been shown to be independently associated with cardiac mortality in ST-segment elevation myocardial infarction. However, its prognostic value remains unclear in unstable angina and non-ST-segment elevation myocardial infarction (UA/NSTEMI). Methods: HMGB1, high-sensitivity C-reactive protein (hsCRP), cardiac troponin I and B-type natriuretic peptide concentrations were measured on admission in 258 consecutive patients (mean age of 67 years) hospitalized for UA/NSTEMI within 24 h (mean, 7.4 h) of the onset of chest symptoms. Results: A total of 38 (14.7%) cardiovascular deaths, including 10 in-hospital deaths, occurred during a median follow-up period of 49 months after admission. In a stepwise Cox regression analysis including 19 well-known clinical predictors of ACS, HMGB1 [relative risk (RR) 3.24 per 10-fold increment; P = 0.0003], cardiac troponin I (RR 1.83 per 10-fold increment, P = 0.0007), Killip class &gt; 1 (RR 4.67, P = 0.0001) and age (RR 1.05 per 1-year increment, P = 0.03), but not hsCRP, were independently associated with cardiovascular mortality. In-hospital and cardiovascular mortality rates were higher in patients with increased HMGB1 (&gt;= 2.4 ng/mL of median value) than those without increased HMGB1 (6.3% vs. 1.5%, P = 0.04; and 23% vs. 6.9%, P = 0.0003). Conclusion: Circulating concentration of HMGB1 on admission may be a potential and independent predictor of cardiovascular mortality in patients hospitalized for UA/NSTEMI within 24 h of onset. (C) 2012 Elsevier Ireland Ltd. All rights reserved.

Background: The JAPAN-ACS study demonstrated that statins significantly reduced coronary plaque volume in patients with acute coronary syndrome (ACS). The clinical implications of plaque regression for clinical outcomes in ACS patients has not been established. The Extended JAPAN-ACS study was conducted to evaluate the relationship between coronary plaque regression and long-term clinical outcome, and to explore the factors associated with cardiovascular events. Methods and Results: Patients with intravascular ultrasound (IVUS) data at both enrollment and follow-up in the JAPAN-ACS study were enrolled and observed for at least 3 years. Patients were divided into lesser and greater coronary plaque regression groups. The primary endpoint was defined as a composite of the following events: cardiovascular death, nonfatal myocardial infarction, nonfatal cerebral infarction, and unstable angina. The median value of the percent change in plaque volume, -18.0%, was used as a cutoff point. There were 4 primary events (3.4%) in the lesser regression group, and 2 events (1.7%) in the greater regression group (P=0.4). Cumulative secondary cardiovascular events did not differ between the 2 groups. Multivariate analysis identified the high-density lipoprotein cholesterol (HDL-C) at baseline and the % change of the external elastic membrane volume as independent risk factors of cardiovascular events. Conclusions: Coronary plaque regression induced by an intensive statin regimen did not predict future cardiovascular events in ACS patients. Rather, the baseline HDL-C level and reverse vessel remodeling might serve as predictors for cardiovascular events. (Circ J 2012; 76: 825-832)

OBJECTIVES The purpose of this study was to evaluate the effect of statin treatment on coronary plaque composition and morphology by optical coherence tomography (OCT), grayscale and integrated backscatter (IB) intravascular ultrasound (IVUS) imaging. BACKGROUND Although previous studies have demonstrated that statins substantially improve cardiac mortality, their precise effect on the lipid content and fibrous cap thickness of atherosclerotic coronary lesions is less clear. While IVUS lacks the spatial resolution to accurately assess fibrous cap thickness, OCT lacks the penetration of IVUS. We used a combination of OCT, grayscale and IB-IVUS to comprehensively assess the impact of pitavastatin on plaque characteristics. METHODS Prospective serial OCT, grayscale and IB-IVUS of nontarget lesions was performed in 42 stable angina patients undergoing elective coronary intervention. Of these, 26 received 4 mg pitavastatin after the baseline study; 16 subjects who refused statin treatment were followed with dietary modification alone. Follow-up imaging was performed after a median interval of 9 months. RESULTS Grayscale IVUS revealed that in the statin-treated patients, percent plaque volume index was significantly reduced over time (48.5 +/- 10.4%, 42.0 +/- 11.1%; p = 0.033), whereas no change was observed in the diet-only patients (48.7 +/- 10.4%, 50.4 +/- 11.8%; p = NS). IB-IVUS identified significant reductions in the percentage lipid volume index over time (34.9 +/- 12.2%, 28.2 +/- 7.5%; p = 0.020); no change was observed in the diet-treated group (31.0 +/- 10.7%, 33.8 +/- 12.4%; p = NS). While OCT demonstrated a significant increase in fibrous cap thickness (140 +/- 42 mu m, 189 +/- 46 mu m; p = 0.001), such changes were not observed in the diet-only group (140 +/- 35 mu m, 142 +/- 36 mu m; p = NS). Differences in the changes in the percentage lipid volume index (-6.8 +/- 8.0% vs. 2.8 +/- 9.9%, p = 0.031) and fibrous cap thickness (52 +/- 32 mu m vs. 2 +/- 22 mu m, p &lt; 0.001) over time between the pitavastatin and diet groups were highly significant. CONCLUSIONS Statin treatment induces favorable plaque morphologic changes with an increase in fibrous cap thickness, and decreases in both percentage plaque and lipid volume indexes. (J Am Coll Cardiol Img 2012;5:169-77) (C) 2012 by the American College of Cardiology Foundation

Objective: Following acute myocardial infarction (AMI) the area of myocardial perfusion and metabolism mismatch is designated as dysfunctional viable myocardium. 123I-beta-methyl iodophenyl pentadecanoic acid (BMIPP) is clinically very useful for evaluating myocardial fatty acid metabolism, and 99mTc-Tetrofosmin (TF) is a widely used tracer for myocardial perfusion. This study was designed to evaluate the degree of discrepancy between BMIPP and TF at the subacute state of AMI. Methods: Fifty-two patients (aged 59 ± 10 years mean 46 years) with AMI were enrolled, and all of them underwent percutaneous coronary intervention (PCI). Patients were classified according to ST-T change and PCI timing. 123I-beta-methyl iodophenyl pentadecanoic acid and TF cardiac scintigraphy were performed on 7 ± 3.5 days of admission using a dual headed gamma camera. Perfusion and fatty acid metabolism defect were scored on a 17 segments model. Results: The mean BMIPP defect score on early and delayed images were 16.67 ± 10.19 and 16.25 ± 10.40, respectively. The mean TF defect score was 10 ± 7.69. Defect score of BMIPP was significantly higher than that of the TF (P &lt 0.0001 95% CI 4.32-7.02), and there was a strong correlation between perfusion and metabolism defect score (r = 0.89, P &lt 0.00001). Forty-seven (90%) patients showed mismatched defect (BMIPP &gt TF), and 5 (10%) patients showed matched defect (BMIPP = TF). Mismatched defect score (MMDS) was significantly higher in patients with ST-segment elevation myocardial infarction (STEMI) than that of non-ST-segment elevation myocardial infarction (NSTEMI) (P &lt 0.041 95% CI 0.11-5.19). Conclusion: At the subacute state of AMI, most of the patients showed perfusion-metabolism mismatch, which represents the dysfunctional viable myocardium, and patients with STEMI showed higher mismatch. © 2012. Cardiological Society of India. All rights reserved.

Aim: The present study examined the importance of reducing non-high-density lipoprotein cholesterol (non-HDL-C) for the primary prevention of the occurrence of coronary artery disease (CAD) in the JELIS, and the effects of EPA. Methods: The patients were distributed into 4 subgroups using the lipid management goal for LDL-C recommended by the Japan Atherosclerosis Society guideline (2007) and the goal for non-HDL-C defined as 30 mg/dL higher than LDL-C: A) achieved both goals; B) achieved the LDL-C but not non-HDL-C goal; C) achieved the non-HDL-C but not LDL-C goal; and D) did not attain either goal. The incidences of CAD in the 4 subgroups were compared, and the effects of eicosapentaenoic acid (EPA) on the risk of CAD in these subgroups were examined. Results: In the non-EPA group, the incidence of CAD in patients who did not achieve the goals for LDL-C or non-HDL-C was higher than in patients who achieved those goals. Patients in subgroups B, C, and D were at higher risk for CAD than those in subgroup A (B, HR 2.31; C, HR 1.90; D, HR 2.47). EPA reduced the risk of CAD by 38% in subgroups B, C, and D (p=0.007). Conclusion: We reconfirmed non-HDL-C as a predictor of the risk for CAD and a residual risk marker of CAD after LDL-C-lowering therapy. EPA was useful to reduce the occurrence of CAD in patients who did not achieve the goals for LDL-C and/or non-HDL-C.

Aim: To clarify whether the effects of statin treatment on plaque regression vary according to the presence or absence of polyvascular disease (PVD) in patients with acute coronary syndrome (ACS). Methods: 307 patients with ACS who underwent percutaneous coronary intervention for the culprit lesion at 33 centers were treated with atorvastatin or pitavastatin. Noncoronary atherosclerosis was defined as coexistent, clinically recognized arterial disease other than coronary artery disease (CAD) (cerebral, aortic, or lower extremity). Intravascular ultrasound (IVUS) was performed to assess non-culprit coronary atherosclerosis at baseline and at 8-12 months follow-up. Serial IVUS examinations were obtained in 252 patients. Atheroma volume and percent change in atheroma volume of the target plaque was assessed. Results: Patients of the CAD + PVD (n = 19) were older (68 vs. 62 years, p = 0.02), had lower low-density lipoprotein cholesterol (LDL-C) levels at baseline (116 vs. 134 mg/dL, p = 0.03) than those of the CAD-only group (n = 233), whereas LDL-C levels at follow-up were similar (81 vs. 83 mg/dL). Although the baseline plaque volume was similar in the two groups (59 vs. 57 mm(3)), patients of the CAD + PVD group showed milder regression of atherosclerosis than those of the CAD-only group (-8.9% vs. -18.2%, p = 0.005). This difference remained significant even after adjustment for coronary risk factors including age and serum LDL-C (p = 0.047). Conclusions: Statin treatment results in milder regression of coronary atherosclerosis in CAD patients with polyvascular disease compared to those with CAD only. (C) 2011 Elsevier Ireland Ltd. All rights reserved.

Aims Pathological and clinical optical coherence tomography (OCT) studies have indicated that acute coronary syndrome (ACS) lesions have either ruptured fibrous caps (RFC-ACS) or intact fibrous caps (IFC-ACS). Although computed tomographic (CT) angiographic characteristics of RFC-ACS include low-attenuation plaques and positive plaque remodelling, features associated with IFC-ACS have not been previously described. The aim of this study was to assess the CT characteristics of IFC-ACS lesions. Methods and results Seventy-four patients with ACS/stable angina consented to multimodality imaging, of which 66 underwent CT angiography. Of these, 57 culprit lesions in 57 patients were evaluated with sufficient image quality from all four of OCT, angioscopy, intravascular ultrasound, and CT angiography. Intraluminal thrombus was assessed by OCT/angioscopy, and culprit lesions further classified by OCT-based demonstration of fibrous cap integrity. Of 35 culprit lesions with ACS, OCT revealed IFC with thrombus in 10 (29%) and RFC in the remaining 25 (71%); all 22 lesions with stable angina had intact fibrous caps. Fibrous caps were significantly thinner in RFC-ACS than IFC-ACS and stable angina (45 +/- 12, 131 +/- 57, and 321 +/- 146 mu m, respectively; P = 0.001). CT angiography revealed that low-attenuation plaques were more frequently observed in RFC-ACS than IFC-ACS and stable angina (88, 40, and 18%; P = 0.001) lesions. Similarly, positive remodelling was more predominantly seen in RFC-ACS than IFC-ACS and stable angina (96, 20, and 14%; P = 0.001). However, none of the specific CT angiography features clearly distinguished IFC-ACS from stable lesions. Conclusion In contrast to the situation with RFC-ACS, distinct culprit lesion characteristics associated with non-rupture-related mechanisms are not identified by CT angiography. It will therefore not be possible to differentiate plaques likely to develop IFC-ACS from stable plaques.

Aims Increased temporal repolarization lability, assessed by beat-to-beat variability of T-wave amplitude (TAV), has been shown to be associated with ventricular tachyarrhythmia in patients with a variety of clinical conditions. The aim of this study was to test the ability of TAV to identify patients presenting with malignant ventricular arrhythmia and to predict subsequent occurrences. Methods and results We studied 20 consecutive patients (age 42 +/- 15 years, mean +/- standard deviation) presenting with ventricular tachyarrhythmia who did not have substantial underlying heart disease and compared them with 40 age-and sex-matched control subjects. The TAV was determined by Holter recording (Ela Medical). Patients with ventricular tachyarrhythmia had a higher maximum value of TAV (max TAV: 38 +/- 18 vs. 22 +/- 15 mu V, P &lt; 0.001) than did the controls. The sensitivity and specificity of max TAV &gt; 22.4 mu V for detecting the occurrence of ventricular tachyarrhythmia were 77 and 90%, respectively. During a mean follow-up period of 23 months, three patients had relapses of ventricular tachyarrhythmia. Patients with a recurrence of ventricular tachyarrhythmia had a trend towards a higher wmax TAV as compared with those who had ventricular tachyarrhythmia but did not relapse (56 +/- 23 vs. 36 +/- 16 mu V, P = 0.061). Conclusion Our results suggest that Holter-derived TAV might be associated with the occurrence and recurrence of ventricular tachyarrhythmia in patients without structural heart disease. Prospective validation will be necessary to assess the potential diagnostic value of the TAV in a large general population.

Background: n-3 polyunsaturated fatty acids, primarily eicosapentaenoic acid (EPA), has been reported to have antiarrhythmic and antiinflammatory effects. The aim of the present study was to examine whether the combination of antiarrhythmic drugs and EPA reduced the frequency of atrial fibrillation (AF) in patients with paroxysmal AF. Methods: We studied 50 patients with paroxysmal AF (age, 54 +/- 9 years) after excluding the clinical conditions associated with an increased risk of AF. Patients were initially treated with antiarrhythmic drugs for 6 months (the observation period), and thereafter, EPA was added at a dose of 1.8 g/day for 6 months (the intervention period). During a one-year period, patients obtained an ECG recording using a portable device each morning and when arrhythmia-related symptom occurred. The end point was the difference of the AF burden (defined by the days of AF per month) between observation period and intervention period. Plasma EPA and C-reactive protein (CRP) levels were also determined. Results: There was no significant difference in the AF burden before and after intervention (2.6 +/- 2.2 days/months vs. 2.5 +/- 2.2 days/months, P = 0.45). Although EPA level was significantly increased (42 +/- 15 mu g/mL to 120 +/- 47 mu g/mL, P &lt; 0.001), CRP level was unchanged (1.04 +/- 0.69 mg/L to 0.96 +/- 0.56 mg/L, P = 0.24) following EPA treatment. Conclusions: Treatment of EPA in combination with antiarrhythmic drugs did not reduce the AF burden or the CRP levels in paroxysmal AF patients who had no evidence of substantial structural heart disease. Ann Noninvasive Electrocardiol 2011; 16(4): 373-378

Background-Although stent fracture (SF) after sirolimus-eluting stent (SES) implantation has been recognized as one of the predisposing factors of in-stent restenosis, it remains uncertain whether SF can increase the risk of major adverse cardiac events (MACE), especially beyond 1 year after SES implantation. The aim of this study was to assess the impact of SF relative to non-SF on 4-year clinical outcomes after treatment with SES of comparable unselected lesions. Methods and Results-A total of 874 lesions in 793 patients undergoing SES implantation and subsequent angiography 6 to 9 months after index procedure were analyzed. At 6- to 9-month angiographic follow-up, SF was identified in 70 of 874 lesions (8.0%). In-stent late loss was significantly higher in SF lesions versus non-SF lesions (0.42 +/- 0.59 mm versus 0.13 +/- 0.49 mm, P &lt; 0.001), resulting in a significantly higher in-stent restenosis rate (21.4% versus 4.1%, P &lt; 0.001). At 4 years, SF versus non-SF was associated with a significantly higher MACE rate (23.2% versus 12.6%, P = 0.014), mainly driven by significantly higher target-lesion revascularization (18.8% versus 10.2%, P = 0.029) rate. Adverse effects of SF on clinical outcomes occurred mostly within the first year (17.4% versus 6.6%, P = 0.001), with similar MACE rate between 1 and 4 years (5.8% versus 5.9%, P = 0.611). No significant differences between SF versus non-SF patients were observed in the cumulative frequency of very late stent thrombosis (2.9% versus 1.4%, P = 0.281), death (0% versus 2.1%, P = 0.252), or myocardial infarction (5.8% versus 2.9%, P = 0.165). Conclusions-SF of SES was associated with higher MACE rate up to 1 year, mainly driven by higher target-lesion revascularization, whereas no significant association was evident between years 1 and 4. (Circ Cardiovasc Interv. 2011;4:349-354.)

Coronary computed tomography angiography (CTA) can assess plaque characteristics and plaque size noninvasively. The purpose of this study was to investigate whether coronary CTA before percutaneous coronary intervention (PCI) can predict the no-reflow phenomenon during PCI. Seventy-eight patients [acute coronary syndrome (ACS) = 43, stable angina pectoris (SAP) = 35, male/female = 72/6, age: 65 +/- A 10 years] who underwent 16- or 64-slice CTA in the 4 weeks before PCI were enrolled. The low attenuation plaque size on CTA was compared between patients with (NR+) and without the no-reflow phenomenon (NR-). No-reflow phenomenon was observed in 11 patients, including 10 patients with ACS and 1 patient with SAP. Low attenuation plaque was detected in 9 (82%) NR(+) lesions and 35 (52%) NR(-) lesions. The length of low attenuation plaque was significantly longer in NR(+) than in NR(-) patients (9.0 +/- A 6.5 vs. 1.6 +/- A 2.7 mm, p &lt; 0.0001). On step-wise regression analysis, ACS (p = 0.036, 95% CI = 0.009-0.258) and the presence of low attenuation plaque with a length &gt; 4.7 mm (p &lt; 0.001, 95% CI = 0.447-0.778) were significant independent predictors of NR(-) no-reflow phenomenon. Low attenuation plaque with lesion length of &gt; 4.7 mm on coronary CTA and ACS were the significant predictors for the no-reflow phenomenon during PCI. Coronary CTA assessment before PCI would be useful to predict coronary events during PCI in advance.

Background: Prolonged duration of the QRS complex is a prognostic marker in patients with heart failure (HF), whereas electrocadiographic markers in HF with narrow QRS complex remain unclear. We evaluated the prognostic value of the T-wave amplitude in lead aVR in HF patients with narrow QRS complexes. Methods: We examined 331 patients who were admitted to our hospital for worsening HF (68 +/- 15 years, mean +/- standard deviation) from January 2000 to October 2004 who had sinus rhythm and QRS complex &lt;120 ms. The patients were categorized into three groups according to the peak T-wave amplitude from baseline in lead aVR: negative (&lt;-0.1 mV; n = 209, 63%), flat (-0.1-0.1 mV; n = 64, 19%), and positive (&gt; 0.1 mV; n = 58, 18%). Results: During a mean follow-up of 33 months, 113 (34%) patients had all-cause death, the primary end point. After adjusting for clinical covariates, flat T wave (hazard ratio [HR] 1.86, 95% confidence interval [CI] 1.42-2.46), and positive T wave (HR 6.76, 95% CI 3.92-11.8) were independent predictors of mortality, when negative T wave was considered a reference. Conclusions: As the peak T-wave amplitude in lead aVR becomes less negative, there was a progressive increase in mortality. The T wave in lead aVR provides prognostic information for risk stratification in HF patients with narrow QRS complexes. Ann Noninvasive Electrocardiol 2011; 16(3): 250-257

Aims We evaluated the usefulness of left atrial volume index (LAVI) and the degree of changes in LAVI (delta LAVI) during hospitalization for the prediction of prognosis after acute myocardial infarction (AMI). Methods and results We investigated 205 consecutive patients with first AMI. They underwent echocardiography on admission as well as at discharge. Delta LAVI was calculated by subtracting the value on admission from that at discharge. The primary endpoints were major cardiac events (MACE): cardiac death due to heart failure and heart failure hospitalization. During a mean follow-up of 26 months, MACE occurred in 29 patients. Patients were divided into two groups according to the optimal cut-off values of LAVI (32.0 mL/m(2)) at discharge and delta LAVI (2.5 mL/m(2)) derived from receiver operating characteristic curves, respectively; Group I: LAVI &lt;= 32.0 mL/m(2), Group II: LAVI &gt; 32.0 mL/m(2) and Group A: delta LAVI &lt;= 2.5 mL/m(2), Group B: delta LAVI &gt; 2.5 mL/m(2). In comparisons of two groups, respectively, the incidence of MACE between the groups showed significant differences [ Group I (3.8%) vs. Group II (32.0%): P &lt; 0.001, log-rank, Group A (7.4%) vs. Group B (20.0%): P = 0.0079, log-rank]. In multivariate analysis, LAVI at discharge [risk ratio (RR): 1.077, 95% CI: 1.035-1.124, P = 0.0002] and delta LAVI (RR: 1.056, 95% CI: 1.012-1.108, P = 0.0109) were significant. LAVI &gt; 32.0 mL/m(2) at discharge (sensitivity: 93%, specificity: 69%) and delta LAVI &gt; 2.5 mL/m(2) (sensitivity: 79%, specificity: 50%) were predictors of MACE. Conclusion LAVI at discharge and delta LAVI would be useful predictors for MACE after first AMI.

心室内伝導障害を伴う左心機能低下例では，両室ペーシングによる心臓再同期療法（CRT）を行うと予後が改善する．しかし，心房細動（AF）では労作や心不全の悪化などにより心室応答が速くなると心室ペーシング率が低くなるため，洞調律に比べて効果が低い可能性がある．本研究ではCRT施行例を洞調律およびAFの2群に分けて，心エコー図指標の変化と予後を比較した．対象は両室ペースメーカ植込み基準を満たした38例（年齢61±11歳，洞調律24例，AF14例）である．両室ペーシング率は2群とも95％以上であり有意差はなかった（p=0.84）．AFで房室結節アブレーションを必要とした症例はなかった．CRT施行前に比べて施行6ヵ月後の左室収縮末期容積は両群とも有意に減少し（洞調律 −16±39ml，AF−26±38ml），その減少量は両室ペーシング率と有意な相関を認めた（r =−0.42, p<0.01, n=38）．心不全による入院と心臓死をエンドポイントとし，平均25ヵ月の観察を行ったが，2群間でエンドポイント発生率に差はなかった（洞調律10例，AF7例, log-rank検定p=0.87）．心不全に合併したAFではレートコントロール薬によって心室応答を調整し，高い心室ペーシング率を維持することで洞調律と同様のCRT臨床効果が得られる可能性が示唆された．

中間径線維のひとつであるLamin A/Cは，核膜内膜を裏打ちして核膜構造を維持するとともに，遺伝子転写調節や遺伝子発現制御などの機能を有する．Lamin A/C遺伝子（LMNA）は，関節拘縮，骨格筋異常，および刺激伝導障害に伴う拡張型心筋症を3主徴とするEmery-Dreifuss型筋ジストロフィーの責任遺伝子として報告された．その後，関節拘縮や骨格筋異常を有さないものの，拡張型心筋症に刺激伝導障害を合併した症例にLMNA変異を認めることが報告され，Lamin関連心筋症とよばれる．本疾患は心不全に加え，心室性頻脈性不整脈による突然死が多いのを特徴とする．今回，われわれは，徐脈性不整脈の治療目的にペースメーカを植込まれた3同胞（ペースメーカ植込み時平均年齢49.6歳，男性：女性＝1例：2例）に遺伝子検索を行い，新たなLMNA変異（Q258X）を認めたため，文献的な考察を加えて報告する．

Objective: Ventricular extrasystoles (VEs) originating from the right ventricular outflow tract (RVOT) are considered benign, but sometimes lead to sudden cardiac death due to polymorphic ventricular tachycardia or ventricular fibrillation (PVT/VF). Previous case reports suggested that patients with a malignant form of RVOT-VE exhibited a left bundle-branch block morphology and positive deflection in lead I. We assessed the hypothesis that patients with a malignant form of RVOT-VE may have ventricular repolarization instability. Methods and Results: We studied 3 patients with a malignant form of RVOT-VE (age, 34 ± 17 years, 2 males) and compared them to 40 control subjects without structural heart disease. All patients underwent high-resolution digital Holter recording (ela medical) and we determined the maximum value of the beat-to-beat T-wave variability (TAV). The patients with a malignant form of RVOT-VE had a higher maximum value of the TAV than the controls (max TAV: 69 ± 9 μV vs. 20 ± 7 μV, p&lt 0.001). During the follow-up, two males experienced shock deliveries for VF by an implantable cardioverter-defibrillator (ICD). The remaining one female had survived after a radiofrequency Catheter ablation and no ICD was implanted. Conclusions: Our results suggest that patients with a malignant form of RVOT-VE may have a ventricular repolarization instability. © 2011, Japanese Heart Rhythm Society. All rights reserved.

Background: Thromboprophylaxis with oral anticoagulation is most effective in reducing stroke but is associated with similar rates of major bleeding in atrial fibrillation (AF) patients. Recently, the European Society of Cardiology provided a novel bleeding risk score named HAS-BLED. This purpose of this study was to validate the predictive value of HAS-BLED and degree of the activities-of-daily-life (ADL) in patients with AF. Methods and Results: From January 2009 to October 2009, 173 consecutive patients with documented AF by ECG at presentation to the emergency department were enrolled. The ADL were dichotomized (preserved or impaired) by the use of a Katz' ADL scale (1963). During a mean follow-up period of 12 months, 41 (24%) patients experienced bleeding from any cause. There were no significant differences in the age, sex, prevalence of warfarin or antiplatelet use, or target therapeutic range of warfarin (60%) between the patients with and those without bleeding. The patients with bleeding had higher HAS-BLED scores (4.9±1.5 vs. 3.1±1.4, p=0.01) and more impaired ADL (63% vs. 37%, p=0.02) than those without bleeding. A logistic regression analysis revealed that prediction of bleeding events was improved when impaired ADL was considered with the HAS-BLED score (C-statistic:0.752 vs. 0.786). Conclusion: Impaired ADL, in addition to the HAS-BLED score, was significantly predictive of bleeding in AF patients. © 2011, Japanese Heart Rhythm Society. All rights reserved.

Objectives: Multiple studies have shown that simplified Selvester QRS scoring system (SSS) can estimate the myocardial infarct size, left ventricular function and is predictive of mortality. We then examined the relation of the SSS for the estimation of mortality in non-ischemic heart failure. Methods: We studied 136 consecutive patients (age, 72.1 ± 13.7 years, 73 males, left ventricular ejection fraction 38.6 ± 16.1%) who were admitted to our hospital for the treatment of worsening heart failure between January 2008 and January 2009. The absence of coronary artery disease was confirmed by radionuclide scintigraphy, computed tomography, or coronary angiography. The Selverster QRS score was determined using the 12-lead ECG at discharge by two cardiologists who were blinded to the clinical outcome. The primary endpoint was a composite of all-cause death or hospitalization for heart failure. Results: During a mean follow-up period of 11 months, 73 (54%) patients met the primary endpoint. Higher QRS scores were associated with lower survival rates. The multivariate Cox proportional-hazard regression analysis revealed that QRS score provide independent information on the mortality (hazard ratio 1.07, 95% confidence interval 1.07 to 1.12: p = 0.009). Conclusions: The SSS can be a useful clinical tool for risk stratification in heart failure patients with non-ischemic origin. © 2011, Japanese Heart Rhythm Society. All rights reserved.

目的:左房容積係数(left atrial volume index:LAVI)は,左室拡張能の低下に伴う左室充満圧上昇により増大することに加えて,急性心筋梗塞患者の予後評価に有効であることが報告されている.また,組織ドプラエコー法を用いた僧帽弁輪部心房収縮速度波(A')が,心房機能を反映することが報告されている.今回A'により,心事故発生を層別化出来るか否かを,左房拡大の有無を踏まえて検討を行った.対象と方法:対象は,当院CCUに入院した急性冠症候群(acute coronary syndrome:ACS)患者のうち,心房細動,心房粗動及び中等度以上の僧帽弁疾患を除外した連続212例(平均年齢64歳,男性166例).心臓死及び心不全による再入院を心事故と定義して,平均508日間の経過観察を行った.対象を左房拡大(LAVI?32ml/m2)62例と非拡大150例の2群に分類し,検討した.結果:経過観察期間中に17例(死亡8例,心不全による再入院9例)の心事故が発生した.ROC曲線からA'のカットオフ値を10.7cm/secに設定した.全例及び左房拡大例においては,A'?10.7cm/secの群で心事故回避率が有意に高値であった.結論:左房拡大を伴うACS患者において,A'は心事故予測に有用である.(著者抄録)

Objective : The Japan assessment of pitavastatin and atorvastatin in acute coronary syndrome (JAPAN-ACS) study demonstrated that aggressive lipid-lowering therapy with a statin resulted in a significant regression of coronary atherosclerotic plaques in patients with ACS. Adiponectin is an adipocyte-derived protein with anti-atherogenic properties. Here, we investigated the association between adiponectin levels and the change in the plaque volume in ACS patients. Methods : Intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) was undertaken, followed by the initiation of statin treatment, in 238 patients with ACS. Follow-up IVUS was performed between 8 and 12 months after the PCI. The percent change in the plaque volume (%PV) in a non-culprit coronary artery segment was evaluated. The serum adiponectin and lipid parameters were measured both at baseline and at the follow-up. Results : At baseline, adiponectin was correlated positively with HDL-cholesterol and negatively correlated with triglyceride, but no correlation was observed with the PV. Adiponectin levels increased significantly from 7.8 +/- 4.6 mu g/mL at baseline to 10.3 +/- 6.9 mu g/mL at the 812 months follow-up. The increase in adiponectin was also associated with an increase of HDL-cholesterol and decrease of triglyceride, however, no significant correlation was observed with the %PV. A significantly higher incidence of major adverse cardiac events (MACE) was observed in patients with hypo-adiponectinemia at baseline. A multiple logistic regression analysis identified adiponectin as a significant independent predictor of MACE. Conclusion : Adiponectin levels measured after PCI could serve as a marker of MACE in patients with ACS (C) 2010 Elsevier Ireland Ltd. All rights reserved.

Objectives Stent fracture (SF) of sirolimus-eluting stents (SES) has emerged recently in the literature and shown to be associated with an increased risk of restenosis; however, little is known regarding SF after bare-metal stent implantation. We sought to assess whether the use of SES was associated with an increased risk of SF compared with its bare-metal platform, the Bx-velocity stent (BX-BMS). Methods A total of 478 lesions in 416 patients undergoing SES implantation and subsequent angiography 6-9 months after the index procedure were compared with 152 lesions in 142 consecutive patients treated with BX-BMS. Stented lesions with total stent-length greater than 40 mm were excluded. Results There were no significant differences in overall baseline clinical and anatomic features between the SES and BX-BMS groups, or in SF frequencies at 6-9 month follow-up (4.4% for SES and 1.3% for BX-BMS, P = 0.078). In-stent restenosis was observed more often in SF lesions versus non-SF lesions (34.8 vs. 7.7%, P &lt; 0.001) in association with a higher 3-year adverse events rate (27.3 vs. 13.6%, P = 0.076). The risk of SF at 6-9 months was independently associated with total stent length [odds ratio (OR), 2.13; 95% confidence interval (CI), 1.18-3.83; P = 0.012], angulated lesions (OR, 4.25; 95% CI, 1.80-10.00; P = 0.001), and right coronary artery lesions (OR, 3.55; 95% CI, 1.46-8.62; P = 0.005) but not with SES use. Conclusion Stent implantation in right coronary artery lesions, tortuous lesions, and/or longer lesions covered with longer stents, and not SES versus BX-BMS use, may be associated with increased likelihood of SF. Coron Artery Dis 21: 298-303 (C) 2010 Wolters Kluwer Health vertical bar Lippincott Williams & Wilkins.

Aims: There remains significant concern about the long-term safety of drug-eluting stents (DES). However, bare metal stents (BMS) have been used safely for over two decades. There is therefore a pressing need to explore alternative strategies for reducing restenosis with BMS. This study was designed to examine whether IVUS-guided cutting balloon angioplasty (CBA) with BMS could convey similar restenosis rates to DES. Methods and results: In the randomised REstenosis reDUction by Cutting balloon angioplasty Evaluation (REDUCE III) study, 521 patients were divided into four groups based on device and IVUS use before BMS (IVUS-CBA-BMS: 137 patients; Angio-CBA-BMS: 123; IVUS-BA-BMS: 142; and Angio-BA-BMS: 119). At follow-up, the IVUS-CBA-BMS group had a significantly lower restenosis rate (6.6%) than the other groups (p=0.016). We performed a quantitative coronary angiography (QCA) based matched comparison between an IVUS-guided CBA-BMS strategy (REDUCE III) and a DES strategy (Rapamycin-Eluting-Stent Evaluation At Rotterdam Cardiology Hospital, the RESEARCH study). We matched the presence of diabetes, vessel size, and lesion severity by QCA. Restenosis (&gt;50% diameter stenosis at follow-up) and target vessel revascularisation (TVR) were examined. QCA-matched comparison resulted in 120-paired lesions. While acute gain was significantly greater in IVUS-CBA-BMS than DES (1.65±0.41 mm vs. 1.28±0.57 mm, p=0.001), late loss was significantly less with DES than with IVUS-CBA-BMS (0.03±0.42 mm vs. 0.80±0.47 mm, p=0.001). However, no difference was found in restenosis rates (IVUS-CBA-BMS: 6.6% vs. DES: 5.0%, p=0.582) and TVR (6.6% and 6.6%, respectively). Conclusions: An IVUS-guided CBA-BMS strategy yielded restenosis rates similar to those achieved by DES and provided an effective alternative to the use of DES. © Europa Edition 2010. All rights reserved.

The purpose of this study is to investigate the effects of renal function and anemia on the outcome of chronic heart failure (CHF). We targeted 711 consecutive patients who were hospitalized at the Division of Cardiology of Fujita Health University Hospital during a 5-year period. The subjects were divided into four groups according to their estimated glomerular filtration rate (e-GFR) calculated using the Modification of Diet in Renal Disease (MDRD) formula. Intergroup comparisons were conducted for underlying heart diseases, clinical findings at the time of hospitalization, treatment, and outcome. Moreover, the patients were divided into two groups according to their serum hemoglobin concentration at the time of hospitalization, using 12.0 g/dl as the dividing point, to study the effects of anemia on the outcome. In the group with decreased renal function, the average age was higher, and ischemic heart disease and associated conditions such as hypertension and diabetes mellitus were observed in most of the patients. In addition, the rate of anemia development and the plasma B-type natriuretic peptide concentration were also high. The greater the deterioration in renal function, the poorer the outcome became (P &lt; 0.0001). Chronic heart failure complicated by anemia showed an especially poor outcome (P &lt; 0.0001). As this study showed that renal function and anemia significantly affected the outcome of CHF, it is clear that the preservation of renal function and the management of anemia are important in addition to the conventional treatments for CHF.

OBJECTIVES This study sought to assess, by serial computed tomography angiography (CTA), the effect of statin treatment on coronary plaque morphology. BACKGROUND In addition to the assessment of luminal stenosis, CTA also allows characterization of plaque morphology. Large, positively remodeled plaques with large necrotic cores have been reported as indicators of plaque instability. METHODS CTA was performed in 32 patients (26 men, ages 64.3 +/- 8.5 years). Of these, 24 received fluvastatin after the baseline study; 8 subjects who refused statin treatment were followed as the control subjects. Serial imaging was performed after a median interval of 12 months. All vessels were examined in every subject, and a 10-mm-long segment was identified for comparison before and after intervention. Total plaque volume, low attenuation plaque (LAP) volume, lumen volume, and remodeling index were calculated. RESULTS In the statin-treated patients, the total plaque volume (92.3 +/- 37.7 vs. 76.4 +/- 26.5 mm(3), p &lt; 0.01) and LAP volume (4.9 +/- 7.8 vs. 1.3 +/- 2.3 mm(3), p = 0.01) were significantly reduced over time; however, there was no change in the lumen volume (63.9 +/- 25.3 vs. 65.2 +/- 26.2 mm(3), p = 0.59). On the other hand, no change was observed in the CTA characteristics in the control subjects, including total plaque volume (94.4 +/- 21.2 vs. 98.4 +/- 28.6 mm(3), p = 0.48), LAP volume (2.1 +/- 3.0 vs. 2.3 +/- 3.6 mm(3), p = 0.91), and lumen volume (80.5 +/- 20.7 vs. 75.0 +/- 16.3 mm(3), p = 0.26). The plaque volume change (-15.9 +/- 22.2 vs. 4.0 +/- 14.0 mm(3), p +/- 0.01) and LAP volume change (-3.7 +/- 7.0 vs. 0.2 +/- 1.5 mm(3), p = 0.01) were significantly greater in the statin than the control group. The lumen volume (1.3 +/- 15.6 vs. -5.5 +/- 13.1 mm(3), p = 0.24) and remodeling index (-2.4 +/- 6.8% vs. -0.3 +/- 6.5%, p = 0.53) did not show the significant differences between the 2 groups. The decrease in the plaque volume was due to reduction in the LAP volume (R = 0.83, p &lt; 0.01), and was not related to any changes in the lumen volume (R = 0.21, p = 0.24). CONCLUSIONS This preliminary study suggests that serial CTA evaluation of coronary plaques allows for the assessment of interval change in the plaque morphology. Statin treatment results in decreases in the plaque and necrotic core volume. The features known to be associated with plaque instability. (J Am Coll Cardiol Img 2010;3:691-8) (c) 2010 by the American College of Cardiology Foundation

Background: The Japan Assessment of Pitavastatin and Atorvastatin in Acute Coronary Syndrome (JAPAN-ACS) trial has found that early aggressive statin therapy in patients with acute coronary syndrome (ACS) significantly reduces the plaque volume (PV) of non-culprit coronary lesions. The purpose of the present study was to evaluate clinical factors that have an impact on plaque regression using statin therapy. Methods and Results: Serial intravascular ultrasound observations over 8-12 months were performed in 252 ACS patients receiving pitavastatin or atorvastatin. Linear regression analysis identified the presence of diabetes mellitus (DM) and PV at baseline as inhibiting factors, and serum remnant-like particle-cholesterol level at baseline as a significant factor significantly affecting the degree of plaque regression. Significant correlation between % change of PV and low-density lipoprotein cholesterol (LDL-C) level was found in patients with DM (n=73, P&lt;0.05, r=0.4), whereas there was no significant correlation between the 2 parameters in patients without DM (n=178). Conclusions: The regression of coronary plaque induced by statin therapy after ACS was weaker in diabetic patients than their counterparts. Moreover, vigorous reduction of the LDL-C levels might induce a greater degree of plaque regression in ACS patients with DM. (Circ J 2010; 74: 1165-1174)