A Continuous Murmur as the Only Clinical Sign for Complex Coronary Artery Fistulas Diagnosis

An asymptomatic patient presented at our hospital exhibiting a Brugada electrocardiography pattern with coronary artery fistulas. Coronary artery fistula is a congenital or acquired rare abnormal condition with increased symptoms and complications over time. In the absence of the therapeutic consensus, we discuss the association and management for this condition. (Level of Difficulty: Advanced.).

A Strict Target for Low-Density Lipoprotein Cholesterol May not Be Necessary for Secondary Prevention of Cardiovascular Disease in All Elderly Patients With Dyslipidemia

According to the Japan Atherosclerosis Society Guidelines for the Prevention of Atherosclerotic Cardiovascular Diseases 2017, standard statin therapy for hyper-low-density lipoprotein cholesterol cholesterolemia in elderly patients may be effective for the secondary prevention of coronary artery disease, as in non-elderly adults. On the other hand, high-intensity statin therapy may not be recommended in all elderly cardiovascular disease patients with dyslipidemia, and particularly in elderly patients aged ≥ 85 years. In any case, tailor-made medical care with use of statin is required that matches the background of each patient.

Differences in lesion characteristics and patient background associated with the medium-term clinical outcomes of bare-metal and first-, second- and third-generation drug-eluting stents

We investigated the lesion characteristics and patient background factors associated with the medium-term incidence of major adverse cardiac events (MACEs) for bare-metal stents (BMS) and 1st-, 2nd- and 3rd-generation drug-eluting stents (DES) using the PCI-Registry (FU-Registry). Between January 2003 and March 2016, 2967 cases/3508 lesions for which percutaneous coronary intervention was performed at Fukuoka University Hospital and related facilities were enrolled. Patients were divided into BMS and 1st-, 2nd- and 3rd-generation drug-eluting stent (DES) groups. The incidence of MACEs in the BMS group (26.2%) was significantly higher than those in the 1st, 2nd and 3rd DES groups (18.0%, 12.5%, and 11.0%, respectively). The incidence of MACEs in the BMS group was strongly associated with insulin use, hemodialysis, low high-density lipoprotein cholesterol, stent minimum lesion diameter, stent length, severe calcification and a small vessel diameter of less than 2.5 mm. Some of these factors showed no association with MACEs among the drug-elution groups, and only hemodialysis, arteriosclerosis obliterans and severe calcification showed a strong correlation in the 2nd DES group. In the 3rd DES group, none of the factors considered were associated with MACEs. In conclusion, in stent implantation, the number of factors associated with MACEs has gradually decreased as the stent generation increased.

Atherosclerotic Coronary Artery Disease in Patients With Cardiometabolic Syndrome

Major risk factors for cardiovascular disease (CVD) include aging, gender, smoking, family history and cardiometabolic syndrome. The relative residual risks for CVD after statin treatment for primary and secondary prevention have been reported by several large-scale randomized clinical trials. Statin treatment appears to prevent one-third of the onset and progression of CVD, but not the remaining two-thirds. There are three major problems regarding the residual risk of CVD: 1) Insufficient reduction of low-density lipoprotein cholesterol levels; 2) Low levels of high-density lipoprotein cholesterol and elevated triglyceride; and 3) Insufficient control of other risk factors (high blood pressure, obesity, metabolic syndrome, type 2 diabetes, etc.). Thus, a multifaceted preventive approach should be needed to prevent CVD after statin treatment.

Impact of von Willebrand factor on coronary plaque burden in coronary artery disease patients treated with statins

High von Willebrand factor (VWF) levels have been reported to be associated with an increased risk of cardiovascular events. However, the relationship between VWF levels and coronary atherosclerosis in patients with coronary artery disease (CAD) who have already received stain treatment is still unclear. We examined the association between VWF levels and coronary plaque as assessed by intravascular ultrasound (IVUS) in CAD patients treated with statins. Ninety-one CAD patients who underwent percutaneous coronary intervention under IVUS guidance, and who were already receiving statin treatment based on Japanese guidelines, were included. An IVUS examination was performed for the culprit lesion, and plasma VWF antigen levels were measured using enzyme-linked immuno sorbent assay. In all of the patients, the low-density lipoprotein cholesterol levels just before the IVUS examination were low (86 ± 26 mg/dL). The VWF levels were positively correlated with the plaque burden expressed as percent atheroma volume (PAV) (r = 0.39, P = .001), while there was no significant association between VWF and plaque composition. Multivariate stepwise regression analysis showed that higher VWF levels were independently associated with increased PAV (β=0.26, P = .01). In CAD patients who had already been treated with statins, higher VWF levels were associated with a higher coronary plaque burden, suggesting that a high VWF level may be a marker of the residual cardiovascular risk after statin treatment.

Correction to: Association between discordance of LDL-C and non-HDL-C and clinical outcomes in patients with stent implantation: from the FU-Registry

Unfortunately, the Fig. 1 was published incorrectly in the original publication of the article. The correct figure is as below.

Associations between microalbuminuria and parameters of flow-mediated vasodilatation obtained by continuous measurement approaches

The associations between microalbuminuria and various parameters of flow-mediated vasodilatation (FMD) are not completely understood. We retrospectively analyzed 265 consecutive patients who underwent coronary angiography and in whom we could measure FMD and the urine albumin-creatinine ratio (UACR). Using 15 continuous measurement approaches, we measured FMD as the magnitude of the percentage change in the brachial artery diameter from baseline to peak (bFMD), the maximum FMD rate calculated as the maximal slope of dilation (FMD-MDR), and the integrated FMD response calculated as the area under the dilation curve during the 60- and 120-s dilation periods (FMD-AUC60 and FMD-AUC120). We divided the patients into two groups according to UACR: normoalbuminuria (NOR, n = 211) and microalbuminuria (MIC, n = 54). The MIC group showed a significantly higher percentage of coronary artery disease than the NOR group. FMD-AUC60 and FMD-AUC120, but not FMD-MDR, in the MIC group were significantly lower than those in the NOR group. On the other hand, bFMD in the MIC group tended to be lower than that in the NOR group, but this difference was not significant. A multiple regression analysis indicated that FMD-AUC120 and diabetes mellitus were predictors of MIC. Finally, we defined the cut-off value of FMD-AUC₁₂₀ for the presence of MIC in all patients as 8.4 mm x second (sensitivity 0.640, specificity 0.588) by a receiver-operating characteristic curve analysis. In conclusion, this study provides more definitive evidence for the association of microalbuminuria with endothelial dysfunction. FMD-AUC120 may be a superior marker for MIC.

Sex difference between target levels of cholesterol-related parameters and post-PCI long-term clinical outcomes: From the FU-Registry

BACKGROUND

Since single lipid parameters are too weak to predict the risk of coronary artery disease, we examined whether the allocation of patients into four groups based on achievement of the target levels set by the Japan Atherosclerosis Guidelines at the time of percutaneous coronary intervention (PCI) would reveal different long-term (5 years) clinical outcomes in males and females.

METHODS

The results of a 5-year follow-up study are summarized as FU-Registry, Long-Term Clinical Outcome Results. The subjects consisted of 1158 patients who underwent elective PCI. The male and female patients were separately allocated into four groups: (1) high-density lipoprotein cholesterol (HDL-C≥40mg/dl as well as low-density lipoprotein-cholesterol (LDL-C)≥100mg/dl); (2) HDL-C≥40mg/dl as well as LDL-C<100mg/dl; (3) HDL-C<40mg/dl as well as LDL-C≥100mg/dl; (4) HDL-C<40mg/dl as well as LDL-C<100mg/dl, for a comparison of both patient as well as lesion characteristics and the endpoint of major adverse cardiac events (MACEs).

RESULTS

Regarding lesion characteristics, significant differences (p<0.05) were detected in the usage rate of a drug-eluting stent (DES) as well as the bend, stent reference diameter, and stent minimum lumen diameter in females by ANOVA, and in severe calcification, the bend, and usage rate of DES (p<0.001) in males. In females, significant differences (p<0.05) were observed in MACEs and target lesion revascularization-PCI. In contrast, among males, the four groups had nearly equivalent outcomes. Uni- and multivariate analyses revealed that HDL-C as well as LDL-C in females were associated with MACEs [OR 3.29 (95% CI 1.05-8.57, p=0.04)], while no association was observed in male multivariate analysis.

CONCLUSION

In female patients, HDL-C<40mg/dl and LDL-C≥100mg/dl were even more strongly related to MACEs, whereas the combination of LDL-C and HDL-C was not related to MACEs in male patients.

Depressor and Anti-Inflammatory Effects of Angiotensin II Receptor Blockers in Metabolic and/or Hypertensive Patients With Coronary Artery Disease: A Randomized, Prospective Study (DIAMOND Study)

Background

We compared the efficacy and safety of azilsartan to those of olmesartan in a prospective, randomized clinical trial.

Methods

Forty-four hypertensive patients who had coronary artery disease (CAD) were enrolled. We randomly assigned patients to changeover from their prior angiotensin II receptor blockers (ARBs) to either azilsartan or olmesartan, and followed the patients for 12 weeks.

Results

Office systolic blood pressure (SBP) in the azilsartan group was significantly decreased after 12 weeks. SBP and diastolic blood pressure (DBP) after 12 weeks in the azilsartan group were significantly lower than those in the olmesartan group. The percentage of patients who reached the target BP at 12 weeks (78%) in the azilsartan group was significantly higher than that at 12 weeks (45%) in the olmesartan group. There were no significant changes in pentraxin-3, high-sensitively C-reactive protein or adiponectin in blood after 12 weeks in either group. Although serum levels of creatinine (Cr) in the azilsartan group significantly increased, these changes were within the respective normal range.

Conclusion

In conclusion, the ability of azilsartan to reduce BP may be superior to that of prior ARBs with equivalent safety in hypertensive patients with CAD.

Association of Arterial Pressure Volume Index With the Presence of Significantly Stenosed Coronary Vessels

Background

A blood pressure (BP) monitoring system (PASESA^®) can be used to easily analyze the characteristics of central and peripheral arteries during the measurement of brachial BP.

Methods

We enrolled 108 consecutive patients (M/F = 86/22, age 70 ± 10 years) who underwent coronary angiography (CAG) due to suspected coronary artery disease (CAD) in whom we could measure various parameters using PASESA^® in addition to brachial-ankle pulse wave velocity (baPWV). The patients were divided into two groups: patients who did not have significantly stenosed coronary vessel disease (n = 33, non-SVD group) and those who had at least one significantly stenosed coronary vessel (n = 75, SVD group). The characteristics of central and peripheral arteries (arterial velocity pulse index (AVI) and arterial pressure volume index (API), respectively) and baPWV were measured. Estimated central BP (eCBP) was calculated from the data obtained from PASESA^®, and CBP was also measured simultaneously by invasive catheterization.

Results

API, but not AVI and baPWV, in the SVD group was significantly higher than that in the non-SVD group. Although eCBP was significantly associated with CBP, there was no difference in eCBP between the groups. There were significant associations among API, AVI and baPWV, albeit these associations were relatively weak. A multivariate logistic regression revealed that API and β-blocker were significant independent variables that were associated with the presence of significant coronary stenosis. The cut-off level of API that gave the greatest sensitivity and specificity for the presence of SVD was 24 units (sensitivity 0.636 and specificity 0.667).

Conclusion

In conclusion, API, but not AVI or baPWV, is associated with the presence of significant coronary stenosis.

Impact of the Absolute Difference in Diastolic Blood Pressure Between Arms in Patients With Coronary Artery Disease

BACKGROUND

We investigated the relationship between the severity and presence of coronary artery disease (CAD) and a difference in systolic and diastolic blood pressure (SBP and DBP) between arms or between lower limbs.

METHODS

We enrolled 277 patients who underwent coronary angiography. We calculated the absolute (|right BP (rt. BP) - left BP (lt. BP)|) and relative (rt. BP - lt. BP) differences in SBP or DBP between arms or between lower limbs, and assessed the severity of CAD in terms of the Gensini score.

RESULTS

The absolute difference in DBP between arms in the CAD group was significantly lower than that in the non-CAD group, whereas the absolute difference in DBP between lower limbs in the CAD group was significantly higher. There were no differences in the absolute or relative difference in SBP between arms or lower limbs between the groups. The absolute difference in DBP between arms decreased as the Gensini score increased. In a logistic regression analysis, the presence of CAD was independently associated with the absolute difference in DBP between arms, in addition to male, family history, dyslipidemia, diabetes mellitus and hypertension.

CONCLUSION

The absolute difference in DBP between arms in addition to traditional factors may be a critical risk factor for the presence of CAD.

Association Between Visit-to-Visit Variability in Blood Pressure and Cardiovascular Events in Hypertensive Patients After Successful Percutaneous Coronary Intervention

Background

Visit-to-visit variability (VVV) in blood pressure (BP) in addition to high BP has been shown to be a strong predictor of coronary events and stroke. Therefore, we investigated the associations between VVV in BP or BP levels and cardiovascular events after successful percutaneous coronary intervention (PCI).

Methods

We enrolled 176 hypertensive patients who had undergone successful PCI and who had four clinic visits to measure BP until follow-up coronary angiography (CAG) at 6 - 9 months after PCI. The patients were divided into those with acute coronary syndrome (ACS group; n = 50) and those with stable angina pectoris (SAP group; n = 126). We determined VVV in BP expressed as the standard deviation (SD) of average BP, average, and the maximum and minimum BP during the follow-up period. Major adverse cardiovascular events (MACEs) (myocardial infarction (MI), target lesion revascularization (TLR) and all-cause death) were also analyzed.

Results

There were no significant differences in VVV in BP, average BP or maximum or minimum BP between the patients with and without MACE in all patients, the ACS and SAP groups. Interestingly, in the ACS group, VVV in SBP and maximum SBP in patients with MI were significantly higher than those in patients without MI. The cut-off levels for VVV in BP and maximum SBP that gave the greatest sensitivity and specificity for MI in the ACS group were 15.1 and 138 mm Hg, respectively.

Conclusion

Higher VVV in SBP and maximum SBP in patients with ACS after successful PCI were associated with the onset of MI.

A relative difference in systolic blood pressure between arms by synchronal measurement and conventional cardiovascular risk factors are associated with the severity of coronary atherosclerosis

It is not known the relationships between a difference in systolic blood pressure (SBP) or diastolic BP (DBP) between arms by synchronal measurement and the presence of coronary artery disease (CAD), and between a difference in BP between arms and the severity of coronary atherosclerosis. We enrolled 425 consecutive patients (M/F = 286/139, 67 ± 13 year) who were admitted to our University Hospital and in whom we could measure the absolute (|rt. BP - lt. BP|) and relative (rt. BP - lt. BP) differences in SBP and DBP using a nico PS-501(®) (Parama-Tech). We divided all patients into those who did and did not have CAD. The relative differences in SBP between arms in patients with CAD were significantly lower than those in patients without CAD. However, the relative difference in SBP between arms was not a predictor of the presence of CAD. We also divided 267 patients who underwent coronary angiography into tertiles according to the Gensini score (low, middle, and high score groups). Interestingly, the middle + high score groups showed significantly lower relative differences in SBP between arms than the low score group. The mean Korotkoff sound graph in the middle + high Gensini score group was significantly higher than that in the low Gensini score group. Among conventional cardiovascular risk factors and nico parameters, the relative difference in SBP between arms in addition to the risk factors (age, gender, body mass index, hypertension, dyslipidemia, and diabetes mellitus) was associated with the score by a logistic regression analysis. In conclusion, the relative difference in SBP between arms as well as conventional risk factors may be associated with the severity of coronary arteriosclerosis.

Comparison of the efficacies of irbesartan and olmesartan after successful coronary stent implantation

OBJECTIVE

We compared the efficacies of irbesartan and olmesartan after successful stent implantation in patients with stable angina.

METHODS

Twenty-six patients were randomly divided into irbesartan and olmesartan groups and treated for approximately eight months (at follow-up coronary angiography).

RESULTS

There were no differences in blood pressure (BP) reduction or late loss between the groups. The BP levels in both groups at follow-up were significantly reduced. The equality of variance of systolic (S)BP (i.e., the intragroup standard deviation of SBP) in the irbesartan group was significantly smaller than that observed in the olmesartan group at follow-up. In addition, log[pentraxin-3] was significantly decreased in all of the patients at follow-up, with no differences between the groups. Interestingly, the levels of log[high-sensitive C-reactive protein (hs-CRP)] measured at 0 weeks were positively associated with in-stent late loss, and among independent biochemical variables in addition to age, gender, body mass index and the kind of angiotensin receptor blockers at 0 weeks, only these levels were related to in-stent late loss, as assessed by a multivariate analysis.

CONCLUSION

The ability of irbesartan to reduce BP is comparable to that of olmesartan, and irbesartan exhibits a lower variance of systolic BP after treatment. The level of log[hs-CRP] before stent implantation is a predictor of in-stent late loss.

Impact of glycemic control on the clinical outcome in diabetic patients with percutaneous coronary intervention--from the FU-registry

BACKGROUND

It is not yet clear whether glycemic control affects the clinical outcome of percutaneous coronary intervention (PCI) in diabetic patients.

METHODS AND RESULTS

This study compared the effects of glycemic control on the clinical outcome in 2 groups of patients with diabetes mellitus (DM) who underwent PCI: a poor-glycemic-control group, who showed greater than 6.9% HbA(1c) at the time of PCI (Pre-HbA(1c)) (`≥6.9 group', n=334 patients) and a good-glycemic-control group, who showed less than <6.9% at Pre-HbA(1c) (`<6.9 group', n=212 patients). The patients in the ≥6.9 group were further divided into 2 groups for further comparisons: a `DM control group' and a `Poor control group'. At follow-up (300 days), the incidence of major adverse cardiac event (MACE) was significantly (P<0.05) lower in the <6.9 group (18.4% vs. 26.2%). However, there was no difference in MACE between the DM control group and the Poor control group. In a multivariate analysis, there was no relationship between the incidence of MACE and Pre-HbA(1c), Pre-HbA(1c)≥6.9% or the HbA(1c) difference (Pre-HbA(1c)-HbA(1c) at follow-up).

CONCLUSIONS

Clinical outcomes in the <6.9 group were superior to those in the ≥6.9 group as pre-PCI glycemic control affected the baseline characteristics. The results suggested that glycemic control started at PCI was not associated with an improvement in the clinical outcome at follow-up.

Polymorphisms of the cannabinoid 1 receptor gene and cognitive impairment in multiple sclerosis

Cognitive impairment occurs in 45—65% of multiple sclerosis (MS) patients. The cannabinoid system may potentially be neuroprotective in MS. We examined the relationship between polymorphisms of the CNR1 gene and neuropsychological outcome in MS using a test and confirmatory sample of patients. One hundred and ninety-four MS patients were assessed over five key areas of neuropsychological function, which are most commonly impaired in MS. The first 97 patients formed the test sample. A further confirmatory sample of 97 patients was used to test association found in the test sample. The schedule included: Wisconsin card sorting test 64 version, Rey auditory verbal learning task immediate and delayed scores, controlled oral word association task, judgement of line orientation and symbol digit modalities task. Three single nucleotide polymorphisms (SNPs) were typed within the CNR1 gene.

For the overall neuropsychological assessment score we used a multiple linear regression model with selected covariates to show that subjects with the AA genotype of the SNP RS1049353 were more impaired (mean -2.47, SD 5.75, P = 0.008, Bonferroni corrected P = 0.024) than the other subjects (mean 0.24, SD 4.24). This was not confirmed when the association was retested in the confirmatory sample.

No associations were identified between these CNR1 variants and cognitive impairment in MS. Multiple Sclerosis 2008; 14: 177—182. http://msj.sagepub.com

Possible predictors of target lesion revascularization after drug-eluting stent implantation

BACKGROUND

A small number of patients still need target lesion revascularization (TLR) after drug-eluting stent (DES) implantation. It is important for the management of coronary artery disease to assess the predictors of TLR after DES implantation.

METHODS AND RESULTS

Two hundred ninety-seven patients (325 lesions) were treated with Cypher sirolimus-eluting and/or TAXUS paclitaxel-eluting stent implantation at four centers in Japan and Brazil. Among these centers, 20 patients (24 lesions) needed clinically driven TLR. The clinical and angiographic characteristics of TLR patients were compared to those of non-TLR patients. Hemodialysis, prior myocardial infarction (MI) and prior coronary artery bypass grafting (CABG) were more frequent in TLR patients than in non-TLR patients. An ostial stenosis was more frequent in the TLR group than in the non-TLR group (41.7% vs 19.9%, p=0.012). In addition, post-procedure in-stent percentage diameter stenosis (%DS) was higher in TLR patients (21.9% vs 13.3%, p = 0.002). Stepwise logistic regression analysis indicated that all of these variables were independent predictors of TLR after DES implantation.

CONCLUSIONS

Hemodialysis, prior MI, prior CABG, ostial lesion location and high in-stent %DS may be independent predictors of TLR after DES implantation.

Photoproduction of hydrogen from raw starch using a halophilic bacterial community

The bacterial community designated BC1, which originates from night soil treatment sludge, exhibited a strong ability to produce H2 from raw starch in the light in the presence of 3% NaC1. Three halophilic or halotolerant bacterial species, Vibrio fluvialis, Rhodobium marinum, and Proteus vulgaris, were isolated from BC1 and identified. The level of H2 production from starch by coculture of V. fluvialis and R. marinum was nearly equal to that by BC1, indicating that these two strains play roles in starch degradation and H2 production from the degraded products in BC1, respectively. Acetic acid and ethanol, which were detected as the major products of degradation of starch by V. fluvialis in pure culture, seemed to be mainly utilized for H2 production by R. marinum in BC1 and the coculture. However, R. marinum in pure culture could not produce H2 from a synthetic medium containing acetic acid and ethanol, suggesting that V. fluvialis supplied not only substrates but also some unknown factors capable of inducing H2 production from these substrates by R. marinum. A study using the starch-rich microalgae, Chlamydomonas reinhardtii and Dunaliella tertiolecta, demonstrated that the above coculture could be applied to the production of H2 at high yield from raw starch in an algal biomass.

Prostaglandin-induced eosinopenia in splenectomized rats

PGE1, PGE2, and PGF2alpha over a dose range of 1 to 50 microgram/kg decreased the number of circulating eosinophils in splenectomized rats. Pretreatment with a beta-blocking agent, propranolol, did not alter this effect, but adrenalectomy eliminated it. Anterior hypothalamic destruction also abolished eosinopenia induced by PGE1 and PGF2alpha but not that induced by PGE2.

Serum prostaglandin levels in asthmatic patients

Levels of serum prostaglandins E and F were measured by radioimmunoassay in 40 asthmatic patients and healthy subjects. Levels of both prostaglandins--E and F--were significantly higher in asthmatic patients than in normal control subjects. The prostaglandin F/prostaglandin E ratio was significantly higher in asthmatic patients than in normal control subjects.