河合 秀樹

BACKGROUND Coronary computed tomography angiography (CTA)-verified positive remodeling and low attenuation plaques are considered morphological characteristics of high-risk plaque (HRP) and predict short-term risk of acute coronary syndrome (ACS). OBJECTIVES This study evaluated whether plaque characteristics by CTA predict mid-term likelihood of ACS. METHODS The presence of HRP and significant stenosis (SS) of >= 70% were evaluated in 3,158 patients undergoing CTA. Serial CTA was performed in 449 patients, and plaque progression (PP) was evaluated. Outcomes (fatal and nonfatal ACS) were recorded during follow-up (mean 3.9 +/- 2.4 years). RESULTS ACS occurred in 88 (2.8%) patients: 48 (16.3%) of 294 HRP(+) and 40 (1.4%) of 2,864 HRP(-) patients. ACS was also significantly more frequent in SS(+) (36 of 659; 5.5%) than SS(-) patients (52 of 2,499; 2.1%). HRP(+)/SS(+) (19%) and HRP(+)/SS(-) (15%) had higher rates of ACS compared with no-plaque patients (0.6%). Although ACS incidence was relatively low in HRP(-) patients, the cumulative number of patients with ACS developing from HRP(-) lesions (n = 43) was similar to ACS patients with HRP(+) lesions (n = 45). In patients with serial CTA, PP also was an independent predictor of ACS, with HRP (27%; p < 0.0001) and without HRP (10%) compared with HRP(-)/PP(-) patients (0.3%). CONCLUSIONS CTA-verified HRP was an independent predictor of ACS. However, the cumulative number of ACS patients with HRP(-) was similar to patients with HRP(+). Additionally, plaque progression detected by serial CTA was an independent predictor of ACS. (C) 2015 by the American College of Cardiology Foundation.

Two patients after Kawasaki disease (KD) developed acute myocardial infarction in their thirties, though coronary artery follow-up were deemed unnecessary because of apparently angiographic normal coronary arteries in their children more than 1-year after acute KD. Angiographic findings of apparently normal coronary arteries in the late period after acute KD are possible to mislead their prognoses. It should be recognized that coronary aneurysms can often regress in the late period. There is ongoing controversy about the therapeutic strategy in patients whose coronary aneurysms regressed within several years after acute KD. Coronary computed tomography angiography and flow-mediated dilatation might be useful for the detection of mild sequelae of KD non-invasively.

Background and purpose: Many patients with atrial fibrillation (AF) and coronary artery stent deployment are given both antiplatelet drug and warfarin. Little information is available as to the relationship between the antithrombotic therapies in the late phase after stenting and the clinical outcomes of these patients. We examined the clinical outcomes of AF patients 12 months after coronary artery stenting. Methods: We retrospectively examined 146 patients and classified them into three groups according to the antithrombotic therapies [dual antiplatelet therapy (DAPT), single antiplatelet therapy (SAPT) plus warfarin, and DAPT plus warfarin] 12 months after stenting. We defined the primary endpoint as Thrombolysis in Myocardial Infarction major bleeding and the secondary endpoint as a composite of adverse events (CAE: all-cause death, nonfatal myocardial infarction, intracranial bleeding, and cerebral infarction). Results: During a median follow-up of 37 months, major bleeding and CAE were observed in 14(9.6%) and 46 (31.5%) patients, respectively. DAPT plus warfarin was an independent risk factor for major bleeding in a multivariate Cox hazard regression model after adjustment for age, gender, and the type of AF (hazard ratio: 4.20; 95% confidence interval: 1.13-17.27; p = 0.033). No significant clinical variables were found for CAE. Conclusions: Prolonged use of DAPT with warfarin significantly increases the risk of major bleeding in AF patients after coronary artery stenting. Individualized antithrombotic treatment is required in these patients to prevent major bleeding. (C) 2014 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.

Background: We prospectively investigated the prognostic value of the combined use of cardiac troponin T (TnT), B-type natriuretic peptide (BNP), and high-sensitivity C-reactive protein (CRP) for long-term mortality in hemodialysis (HD) patients. Methods and Results: Baseline measurements of TnT, BNP, and CRP were performed in 516 patients on chronic HD. Patients were followed up for 10 years. Using the Cox multivariate model with these 3 biomarkers as variables categorized into tertiles for mortality, a simplified score was obtained by underscoring individual biomarkers based on the adjusted hazard ratio (HR). The multimarker score was defined as the sum of these points. TnT, BNP, and CRP levels were individually independent predictors for mortality (P<0.05). Among low-risk (multimarker score <4), intermediate-risk (multimarker score 4-7), and high-risk (multimarker score >= 7) groups, 10-year survival rates were 83.3%, 54.3%, and 27.2% (P<0.0001), respectively. After adjusting for other confounders, the multimarker score had strong predictive power for mortality (HR: 4.26; P<0.0001 for high-risk vs. low-risk group). Furthermore, adding the multimarker score to a baseline model with established risk factors improved the C-index (P<0.01), net reclassification improvement (P<0.0001), and integrated discrimination improvement (P<0.0001) greater than that of any single biomarker or baseline model alone. Conclusions: The multimarker approach (ie, simultaneous assessment of TnT, BNP, and CRP, which individually independently predict prognosis) may improve the prediction of long-term mortality in HD patients.

Recently two-dimensional (2D) speckle tracking echocardiography (STE) derived from right ventricular (RV) free wall has been shown to be a very useful tool for the estimation of RV performance. The purpose of this study was to examine whether RV basal free wall strain can detect increased mean pulmonary arterial pressure (mPAP) in patients with chronic thromboembolic pulmonary hypertension (CTEPH). We investigated a total of 126 patients with CTEPH (mean age, 56 +/- 12 years). They underwent echocardiography and right heart catheter examination. 2D STE-derived longitudinal strain was measured by placing 2 regions of interests (ROIs) on the RV basal free wall in RV-focused apical 4-chamber view. Peak strain (RV-PS) was acquired between the 2 ROIs. Conventional echocardiographic RV parameters (RV fractional area change, RV myocardial performance index, tricuspid annular plane systolic excursion, tricuspid annular peak systolic velocity, and tricuspid regurgitant pressure gradient) were evaluated as well. Right heart catheterization was performed on the day following of echocardiographic evaluation. Among RV echo parameters, RV-PS showed the best correlation with mPAP (r = 0.75, P < 0.0001). Receiver operating characteristic analysis revealed that a cut-off value of RV-PS -20.8% could detect mPAP >= 25 mmHg (sensitivity 78%, specificity 93%, area under the curve 0.90, P <0.001). RV basal free wall strain was a useful tool for the non-invasive detection of increased mPAP in patients with CTEPH.

Background: The additive value of plaque characteristics determined by computed tomography angiography (CTA) in patients undergoing invasive coronary angiography (ICA) has not been established. Methods and Results: We studied 676 patients undergoing ICA and CTA within 3 months. The luminal diameter narrowing based on ICA and the presence of high risk plaque (HAP) based on CTA were assessed in all coronary artery segments except for those after or before scheduled treatment. We followed their cardiac events including cardiac death, acute coronary syndrome (ACS), and revascularization for de novo lesions months after ICA. The incidence of coronary events was higher in the segments including >25% luminal narrowing than in those without (2.94% vs. 0.31%, P<0.0001), and higher in the segments containing HAP than in those without (12.6 vs. 0.46%, P<0.0001). Greater than 25% residual luminal narrowing and the presence of HAP were identified as independent predictors of cardiac events after risk adjustment for age, gender, and history of ACS (hazard ratio [HR], 3.22; 95% confidence interval [Cl]: 1.29-10.76; P=0.0092, HR, 2.64; 95% Cl: 1.59-4.35; P=0.0002, respectively). Adding the presence of HAP to a model including age, gender, ACS history, and >25% residual stenosis improved the prediction of cardiac events. Conclusions: Assessment of coronary plaque characteristics on CTA improves the prediction of cardiac events in patients undergoing ICA.

We previously reported that serial coronary computed tomography angiography (CTA) had a potential to evaluate the interval change of plaque morphology of coronary arteries. The aim of this study was to evaluate variables associated with the plaque progression by serial CTA. We included 148 patients (age 66.3 +/- 9.8 years, male 81.1 %, median scan interval 12 months) with coronary artery disease undergoing serial CTA. Each coronary artery was compared visually between baseline and follow-up CTA to detect plaque progression. Baseline characteristics between progression and nonprogression patients did not demonstrate any significant differences. Logistic analysis revealed that only low-density lipoprotein cholesterol (LDL-C) a parts per thousand yen100 mg/dl at follow-up was associated with plaque progression (odds ratio 2.59, 95 % confidence interval 1.12-6.34, P = 0.0263). Cutoff value of LDL-C for plaque progression at follow-up was 103.0 mg/dl based on receiver-operator characteristic curves analyses. Of the 36 progressive lesions in 32 patients, plaque composition at baseline included 13 lesions (36.1 %) of noncalcified plaque, 1 lesion (2.8 %) of calcified plaque, 12 lesions (33.3 %) of partially calcified plaque, and the remaining 10 lesions (27.8 %) had no plaque at baseline and revealed de novo plaques at follow-up. There were 9 lesions (25 %) with high-risk plaque (HRP) characteristics at baseline and 18 lesions (50 %) with HRP at follow-up. Plaque progression of coronary arteries by serial CTA was associated with LDL-C a parts per thousand yen100 mg/dl at follow-up regardless of baseline LDL-C level. There was no specific finding to predict plaque progression on the baseline plaque characteristics.

Background: The additive value of plaque characteristics determined by computed tomography angiography (CTA) in patients undergoing invasive coronary angiography (ICA) has not been established. Methods and Results: We studied 676 patients undergoing ICA and CTA within 3 months. The luminal diameter narrowing based on ICA and the presence of high risk plaque (HAP) based on CTA were assessed in all coronary artery segments except for those after or before scheduled treatment. We followed their cardiac events including cardiac death, acute coronary syndrome (ACS), and revascularization for de novo lesions months after ICA. The incidence of coronary events was higher in the segments including >25% luminal narrowing than in those without (2.94% vs. 0.31%, P<0.0001), and higher in the segments containing HAP than in those without (12.6 vs. 0.46%, P<0.0001). Greater than 25% residual luminal narrowing and the presence of HAP were identified as independent predictors of cardiac events after risk adjustment for age, gender, and history of ACS (hazard ratio [HR], 3.22; 95% confidence interval [Cl]: 1.29-10.76; P=0.0092, HR, 2.64; 95% Cl: 1.59-4.35; P=0.0002, respectively). Adding the presence of HAP to a model including age, gender, ACS history, and >25% residual stenosis improved the prediction of cardiac events. Conclusions: Assessment of coronary plaque characteristics on CTA improves the prediction of cardiac events in patients undergoing ICA.

An 80-year-old asymptomatic man presented with ST-segment elevation in leads V1 to V5. Coronary CT angiography showed that microfistulae arising from multiple arteries may have led to myocardial infarction from intracoronary thromboembolism within the dilated left anterior descending (LAD). (C) 2013 Society of Cardiovascular Computed Tomography. All rights reserved.

A 62-year-old woman Underwent percutaneous transhepatic obliteration of a giant portal-systemic shunt. Just after inserting a coil into the shunt, it slipped through the giant shunt and migrated to the right atrium. CT showed coil migration into the coronary sinus. (C) 2013 Society of Cardiovascular Computed Tomography. All rights reserved.

Background: The role of combined evaluation of myocardial perfusion imaging (MPI; by single-photon emission computed tomography) and computed tomography angiography (CTA) for risk stratification of coronary artery disease was evaluated. For CTA, the extent of luminal stenosis, and also the features of high-risk plaques (HRP, including positive remodeling and low attenuation) were evaluated. Methods and Results: A total of 304 patients (65 +/- 11 years, male 72%, median follow-up: 24 months) who underwent CTA and MPI were enrolled in the study. Summed stress scores and summed difference scores (SDS) for MPI, stenosis, and HRP were evaluated, and event rates were compared. Cardiac events were defined as acute coronary event including cardiac death or non-fatal acute myocardial infarction, and unstable angina requiring revascularization. Of 304 patients, 51 (16.8%) underwent early revascularization. In the remaining 253 patients, an event occurred in 11 (4.3%). HRP (hazard ratio [HR], 4.75, P=0.00171) and stenosis (+) with SDS >0 (HR, 4.58, P=0.0461) were). HRP (hazard ratio [HR], 4.75, P=0.00171) and stenosis (+) with SDS >0 (HR, 4.58, P=0.0461) were significant independent predictors of cardiac event. The event rate for stenosis (+) with SDS >0 was significantly higher than others (log-rank P=0.0490). The event rates were significantly different between HRP(+) and HRP(-) (16.1% vs. 2.7%, log-rank P=0.0013). Conclusions: HRP on CTA was an independent predictor of acute coronary events, as was stenosis (+) with SDS >0, and HRP had increased prognostic value over stenosis and abnormal MPI findings. (Circ J 2013; 77: 411-417)

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: 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 >= 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<0.0001). The prevalence of severe stenosis (>= 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)

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 < 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

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.

症例は73歳男性．発熱と腹部膨満を主訴に受診．入院時腹部CTで腹水貯留とびまん性の腹膜肥厚を認めた．胸部CTでは肺野や縦隔の病変を認めず．血清ACE値は正常，リゾチーム値は高値，ツベルクリン反応・QFTはともに陰性であった．FDG-PETでは，ほぼ全ての腹膜に沿って著しい集積を認め，Gaシンチでも同様の所見であった．腹水は滲出性でリンパ球優位，ADA値は15.2 IU/L．気管支肺胞洗浄液ではリンパ球の増加とCD4/8比高値を認めた．開腹下腹膜生検で壊死を伴わない類上皮細胞肉芽腫を認め，腹膜サルコイドーシスの組織診断群と診断．腹水貯留は約40日で，発熱は約50日で自然に軽快．第64病日に肺野に新しく陰影が出現．気管支洗浄液にて結核菌塗抹・培養陽性であり肺結核の合併と診断．腹膜サルコイドーシスは非常に稀であり，FDG-PET所見も報告がなく，続発して肺結核を発症した事も興味深く，報告する．

症例は68歳, 男性. 2008年8月ころより下腿浮腫, 2009年4月に入り浮腫増強, 発熱, 労作時息切れを認め, 同月下旬, 当院内科初診. 著明な心嚢水および両側胸水を認め, 同日精査加療目的で入院. 入院後, 胸腔・心嚢穿刺そのほか, 各種精査行うも原因不明. 採血にて抗核抗体1,280倍, 抗DNA抗体300倍など, 膠原病を示唆する所見を認めたが, 臨床的には非典型的であった. 診断的治療目的で抗生物質, 次いで, 抗結核薬を投与するも奏効せず, 感染性漿膜炎は否定的と考えた. 各種検査結果と臨床経過より, 稀な疾患ではあるが高齢発症ループスの可能性が高いと考え, ステロイド投与を開始したところ, 徐々に症状改善し, 心嚢水, 胸水とも減少を認めた. 各種精査を行っても原因のはっきりしない漿膜炎にたびたび遭遇するが, その中に本疾患が潜在している可能性があると考えられる.

症例は37歳の元来健康な女性.2005年1月健診にて心電図異常(左房負荷)を指摘され,当院内科外来を受診した.外来での経胸壁心臓超音波検査にて両心房内に巨大な腫瘍を認め,同年2月15日精査入院とともにワルファリン内服を開始した.精査の結果,両心房内粘液腫と診断し,3月3日腫瘍摘出術を施行した.両心房内粘液腫は,心臓粘液腫のうち2.5-5.0%と大変稀な疾患であるうえに,本症例の場合は胸部MRI上,右房内から右室内にかけて70×50mm,左房内に55×30mmと非常に巨大な腫瘍であった.一般的に心臓粘液腫は,倦怠感,易疲労感,発熱など非特異的な症状を呈することが多く,一般内科を受診された後,診断に苦慮するケースが少なくない.また塞栓症状を発症した後に受診するケースも多いとされている.われわれは,軽微な心電図異常をきっかけに両心房内巨大粘液腫と診断し,塞栓症を発症する前に摘出術を施行,良好な術後経過をたどった症例を経験したのでここに報告する.