Nighttime blood pressure and glucose control impacts on left ventricular hypertrophy: The Japan Morning Surge Home Blood Pressure (J-HOP) Study

Several studies investigated the association between nighttime blood pressure (BP) and left ventricular hypertrophy (LVH) in diabetes, but since most of these studies were conducted in diabetes populations only, they did not compare differences in the impact of nighttime BP on LVH in subjects without diabetes. Moreover, data about the impact of glucose control in diabetes on the relationship between nighttime BP and LVH are sparse. We classified 1277 adults (age 64.7 ± 11.8 years) performing ambulatory BP monitoring while enrolled as part of the Japan Morning Surge Home Blood Pressure (J-HOP) study into groups according to the control status of daytime BP (systolic BP [SBP] < 135 mmHg or ≥135 mmHg), nighttime BP (SBP < 120 mmHg or ≥120 mmHg), and diabetes (HbA1c < 7.0% or ≥7.0%). LVH was assessed by echocardiography. LVH according to echocardiographic criteria was identified in 33.7% of the participants. The group with poorly controlled diabetes plus uncontrolled nighttime BP (n = 90) had a 2.1-fold higher risk of LVH compared to the group with controlled nighttime BP and non-diabetes (n = 505) (odds ratio [OR] 2.10, 95% confidence interval [CI]: 1.29-3.44). No association was observed between uncontrolled daytime BP and diabetes for LVH. In the participants with poorly controlled diabetes (n = 146), uncontrolled nighttime BP posed a 3.1-fold higher risk of LVH compared to controlled nighttime BP (OR 3.12, 95%CI: 1.47-6.62). This association was not found in controlled diabetes. Uncontrolled nighttime BP was associated with a risk of LVH, especially among individuals with poorly controlled diabetes.

Leadless Pacemaker Implantation for a Super-elderly Woman with a Mediastinal Tumor

A 95-year-old woman with no cardiac history presented with symptomatic complete atrioventricular block. She underwent temporary cardiac pacing via the cervical vein, but a pacing lead could not be introduced via the usual route because of a mediastinal tumor. A leadless pacemaker (Micra™; Medtronic, Minneapolis, USA) was implanted at the right ventricular septum via the right femoral vein. The procedure time was 40 minutes, with no complications noted. Over the two-year follow-up period, the threshold and impedance remained stable. The implantation of a leadless pacemaker was useful for improving the symptoms of a super-elderly woman with a mediastinal tumor.

Different age-related impacts of lean and obesity on cardiovascular prognosis in Japanese patients with cardiovascular risks: The J-HOP (Japan Morning Surge-Home Blood Pressure) Study

The relationship between lean and cardiovascular events has been shown to vary with age, but the relationship between age‐related lean and cardiovascular events in Asia has not been established. We divided patients enrolled in the J‐HOP (Japan Morning Surge‐Home Blood Pressure) study with one or more cardiovascular disease risks into three groups based on their body mass index (BMI): lean (BMI < 21), normal‐weight (21 ≤ BMI <27), and obese (BMI ≥ 27). We stratified the risk of cardiovascular events of lean and obesity compared to normal weight into the patients < 65 years old and those aged ≥ 65 years. A total of 286 cardiovascular disease events were observed during the follow‐up period (73 ± 46 months). Regarding the relationship between BMI and cardiovascular disease risk, both lean and obesity were independent prognostic factors: lean: hazard ratio (HR) 1.43, 95% confidence interval (CI): 1.02‐2.01, p = .040; obesity: HR 1.55, 95%CI: 1.13‐2.12, p = .006. In patients < 65 years old, the risk of cardiovascular disease of the lean patients was lower than that of the normal‐weight patients (HR 0.39, 95%CI: 0.12‐1.29, p = .124) and the risk of obesity patients was significantly higher (HR 1.77, 95%CI: 1.08‐2.92, p = .024). In the patients aged ≥ 65 years, lean was a significant independent factor of cardiovascular events compared to normal‐weight (lean: HR 1.70, 95%CI: 1.18‐2.47, p = .005). In conclusion, lean was an independent predictor of cardiovascular events in patients aged ≥ 65 years.

Evaluation of stent length on the outcome of ST-segment elevation myocardial infarction receiving primary percutaneous coronary intervention

BACKGROUND

A longer stent length is known to be a predictor of adverse events after a percutaneous coronary intervention (PCI). However, the evaluation of the stent length on the outcome of ST-segment elevation myocardial infarction (STEMI) patients is not enough.

PATIENTS AND METHODS

A total of 686 STEMI patients who underwent primary PCI were divided into four groups according to the total stent length as follows: short (<18 mm, n=183), lower-medium (18-23 mm, n=256), upper-medium (24-31 mm, n=155), and long (≥32 mm, n=92). We compared the all-cause mortality, major adverse cardiovascular events (MACEs; composite of cardiovascular death, myocardial infarction, and stroke after discharge), target lesion revascularization, and target vessel revascularization with a median follow-up of 1213 days among these four groups.

RESULTS

There were no significant differences in MACEs (10.4% in the short, 7.0% in the lower-medium, 6.5% in the upper-medium, 7.6% in the long, P=0.633) among the different stent length groups. The all-cause mortality, target lesion revascularization, and target vessel revascularization also did not differ among the four groups. In the drug-eluting stent (n=237) and bare-metal stent subgroups (n=449), all outcomes were comparable among the groups. However, in the diabetes subgroup (n=265), the rate of MACEs was higher in the long group than in the other groups, although the difference was not significant (6.6% in the short, 9.6% in the lower-medium, 3.4% in upper-medium, 16.7% in long group, P=0.095).

CONCLUSION

A long stent length was not associated with adverse clinical outcomes in STEMI patients who underwent primary PCI.

Outcome of staged percutaneous coronary intervention within two weeks from admission in patients with ST-segment elevation myocardial infarction with multivessel disease

BACKGROUND

The optimum timing of revascularization strategy for stenoses in nonculprit vessels in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD) remains unclear. At present, there is no evidence investigating the outcome of staged percutaneous coronary intervention (PCI) within two weeks from admission among STEMI patients with MVD.

METHODS

A total of 210 STEMI patients with MVD who underwent primary PCI were analyzed. We compared the all-cause mortality and major adverse cardiovascular events (MACE) (cardiovascular death, myocardial infarction, heart failure, unstable angina, and stroke) with median follow-up of 1200 days among the patients who underwent staged PCI within two weeks from admission (staged PCI ≤2 W) (n = 75), staged PCI after two weeks from admission (staged PCI >2 W) (n = 37) and culprit-only PCI (n = 98) in patients with STEMI and MVD.

RESULTS

The staged PCI ≤2 W showed lower all-cause mortality than culprit-only PCI (4.0 vs 29.6%, log-rank P = 0.001), and lower incidence of MACE than the staged PCI >2 W group (1.3 vs 18.9%, log-rank P = 0.001) and culprit-only PCI group (1.3 vs 22.5%, log-rank P = 0.001). In the multivariable Cox regression analysis, the staged PCI ≤2 W was a predictor of lower all-cause mortality (hazard ratio [HR], 0.176; 95% confidence interval [CI], 0.049-0.630; P = 0.008) and lower incidence of MACE (HR, 0.068; 95% CI, 0.009-0.533; P = 0.011), but staged PCI >2 W was not.

CONCLUSION

In conclusion, staged PCI within two weeks after admission showed more favorable outcomes compared with staged PCI after two weeks from admission or culprit-only PCI in STEMI patients with MVD.

Isolated Cardiac Sarcoidosis Mimicking Arrhythmogenic Right Ventricular Cardiomyopathy

The diagnosis of cardiac sarcoidosis (CS) has become easier due to advances in imaging modalities, but we sometimes encounter difficult-to-diagnose patients. We herein report the case of a 60-year-old Japanese woman who was diagnosed with isolated CS, although she also met the diagnostic criteria of arrhythmogenic right ventricular cardiomyopathy (ARVC). A histological examination by an endomyocardial biopsy of the right ventricle revealed the typical findings of granulomatous change for CS. Although she did not show any characteristics of systemic sarcoidosis, oral prednisolone treatment was introduced, and she achieved a good response. This case shows that the characteristics of CS can overlap with the diagnostic criteria of ARVC, and that a histological examination is essential for the correct diagnosis of CS.

Successful hybrid treatment with endovascular aorto-iliac revascularization and coronary bypass surgery in a patient with an advanced complex polyvascular disease

A 72-year-old Japanese man was admitted to our hospital for effort chest pain and bilateral claudication. He was diagnosed as having severe ischemic heart disease and chronic bilateral aorto-iliac occlusions (Leriche syndrome) by a diagnostic angiography. Manifest collaterals via bilateral internal thoracic arteries (ITA) supplied sufficient blood flow for his lower limbs. We planned a two-stage operation for both the severe coronary artery disease and peripheral artery occlusive disease. He first underwent endovascular therapy (EVT) for bilateral aorto-iliac occlusion. One month later he underwent coronary artery bypass grafting (CABG) that was carried out for three coronary arteries with bilateral ITAs, also known as the internal thoracic artery, and the gastroepiploic artery. His chest symptoms and claudication were completely relieved and he was discharged uneventfully. We hereby suggest that EVT can be a safe, effective, and minimally invasive treatment to enable the patient to undergo CABG with all arterial grafts. <Learning objective: Patients with polyvascular disease are at a high risk for major vascular events. The priority among the revascularizations should be considered based on the less-invasiveness and better long-term patency. Hybrid treatment of EVT and CABG could be one of the choices among such patients.>.

Acute respiratory distress syndrome caused by Mycoplasma pneumoniae without elevated pulmonary vascular permeability: a case report

Sporadic patients with acute respiratory distress syndrome (ARDS) caused by Mycoplasma pneumoniae have been reported. However, knowledge about the pathophysiology and pharmacological treatment of this condition is insufficient. Moreover, the pulmonary vascular permeability in ARDS related to M. pneumoniae infection has not been reported. We report a case of ARDS caused by Mycoplasma pneumoniae without elevated pulmonary vascular permeability, which was successfully treated using low-dose short-term hydrocortisone, suggesting that pulmonary infiltration in ARDS caused by Mycoplasma pneumoniae does not match the criteria of permeability edema observed in typical ARDS.

[Comparative study of sublingual midazolam with oral midazolam for premedication in pediatric anesthesia]

BACKGROUND

We studied the efficacy of sublingual midazolam compared with oral midazolam for predmedication in children.

METHODS

Forty-two children (9 months-11 years of age) for minor elective surgery were divided into 2 groups; one group treated with sublingual midazolam at 30 minutes before the entrance into operating room, and the other group receiving oral midazolam at 30 minutes before entering operating room. The group treated with sublingual midazolam at 30 minutes received sublingual midazolam 0.2 mg x kg(-1), while the other group received oral midazolam 0.5 mg x kg(-1) with syrup. We evaluated the taste acceptability, the effect of sedation, the anxiolysis and the cooperation for mask acceptance by using scales.

RESULTS

Twenty children accepted sublingual midazolam, and twenty-one accepted oral midazolam. It was effective and satisfactory in taste acceptability, sedation, anxiolysis and cooperation in both groups. There was no difference between the two groups. Any respiratory depression and delayed recovery were not observed.

CONCLUSIONS

Sublingual midazolam 0.2 mg x kg(-1) is useful for premedication in pediatric anesthesia, and it equals with oral midazolam 0.5 mg x kg(-1) in efficacy.

[Gastric fluid volume and pH in scheduled surgical patients following unrestricted oral fluid intake until two hours before surgery]

BACKGROUND

In scheduled surgery, drinking is generally restricted for 6-8 hours before operation to avoid aspiration pneumonia induced by aspiration of residual gastric contents. However, the restriction is hard for patients and also there is no evidence of reduction of such a risk. We examined the correlation between water intake and residual gastric content.

METHODS

We studied 60 patients scheduled for gynecological operations (ASA 1 or 2). They were allowed to drink clear water freely until two hours before operation, and timing and volume of their drinking were recorded. In addition, volume and pH of the residual gastric content were measured at induction of anesthesia.

RESULTS

The mean volumes of fluids they had are 157 ml (range 0-750 ml) in the morning, and 486 ml (range 80-1300 ml) in the afternoon. The patients took more water as the scheduled time of operation became nearer. There was no correlation between the volume of preoperative drinking with the volume and pH of gastric content.

CONCLUSIONS

Intake of clear water until two hours before surgery has been shown to be safe and contribute to patients' satisfaction.

[Incidence of nausea and vomiting after cholecystectomy performed via laparotomy or laparoscopy]

Postoperative nausea and vomiting (PONV) are commonly observed adverse effects of general anesthesia. In a retrospective study of laparoscopy group (101 patient) and laparotomy group (101 patient), we evaluated the incidence of PONV after laparoscopic cholecystectomy. Most factors which could influence the incidence of PONV were not significantly different between the groups. The overall incidence of PONV during the first 17h postoperatively was 25.7% in laparoscopy group and 18.8% for laparotomy group respectively, but the risk was 3.2 times greater in laparoscopy group (15.8%) than in laparotomy group (5.0%) (P < 0.05) during the first postoperative hour. The risk of PONV was greater in laparoscopy group in female patients (23.4% versus 9.3% in laparotomy group, P < 0.05) and in obese patients (25.0% versus 0% in laparotomy group, P < 0.01) during the first postoperative hour. We conclude that laparoscopic cholecystectomy increases the incidence of PONV in early postoperative period probably by the effect of residual stretching and irritation of the peritoneum, and the risk is increased in female and obese patients.

[Effects of hypocapnia on hemodynamics and myocardial metabolism in anesthetized dogs]

The authors previously reported that hypocapnia increased myocardial oxygen demand under droperidol-fentanyl (D-F) anesthesia. In this study, we observed myocardial oxygen tension, hemodynamics, and coronary arterial-venous blood content differences of oxygen and lactate before and after hyperventilation in dogs with and without a narrowed coronary artery under halothane anesthesia. We studied the functional and metabolic responses of the heart to hypocapnia under halothane in comparison with D-F anesthesia. In the intact heart, heart rate, LV dp/dt max and myocardial energy demand (heart rate x systolic aortic pressure x LV dp/dt max), which increased during hypocapnia under D-F anesthesia, were unchanged during hypocapnia under halothane anesthesia. Aortic pressure and coronary flow were unchanged under both types of anesthesia. Though subendocardial oxygen tension decreased significantly, myocardial lactate extraction was unchanged under both types of anesthesia. In the heart with a constricted coronary artery, subendocardial oxygen tension and lactate extraction ratio decreased significantly during hypocapnia under both types of anesthesia. Myocardial lactate production was observed in six of eleven dogs in which myocardial energy demand increased under D-F anesthesia. Myocardial lactate production was observed in one dog under halothane anesthesia. Coronary arterial-venous blood oxygen content difference increased under D-F anesthesia, but not under halothane anesthesia. In summary, hypocapnia increased myocardial oxygen demand under D-F anesthesia but not under halothane anesthesia. In the intact heart under both types of anesthesia, hypocapnia deteriorated myocardial oxygen supply-demand relations, but the evidence of myocardial anaerobic metabolism was not observed.(ABSTRACT TRUNCATED AT 250 WORDS)

[Difference in the effect of halothane on regional oxygen demand-supply relationship depending on the severity of coronary artery stenosis]

We examined the effect of halothane on myocardial oxygen balance and hemodynamics in three groups of canine heart. We measured regional subendocardial oxygen tension before and after 30 minute inhalation of 0.8% and 1.5% halothane in the mixture of nitrogen and oxygen (FIO2 not equal to 0.5). In moderate and severe stenosis group, left circumflex coronary artery flow was reduced to 66% and 31% respectively, at buprenorphine-anesthetized basal condition. In occlusion group, left circumflex coronary artery was ligated at its origin. Both concentrations of halothane decreased heart rate, aortic pressure and LV dp/dt max in all groups. Subendocardial oxygen tension increased in moderate stenosis group. But it was unchanged in severe stenosis group, and it rather decreased in occlusion group with 1.5% halothane inhalation. Halothane might improve endocardial oxygen demand-supply relation in the myocardium with mild to moderate coronary stenosis, while it will possibly deteriorate endocardial oxygen demand-supply balance in ischemic myocardium after coronary artery occlusion.

[Effect of isoproterenol on regional myocardial oxygen balance in dog hearts with coronary stenosis]

Effects of intravenous and intracoronary isoproterenol on oxygen balance in the regional myocardium as well as on coronary hemodynamics were investigated in eight dogs with coronary stenosis under droperidol-fentanyl anesthesia. From these observations, the effect of an increase in myocardial contractility per se on regional myocardial oxygen balance was deduced. After intravenous isoproterenol of 0.5 microgram.kg-1, oxygen tension at the regional subendocardium decreased (23.7--15.4 mmHg) although transmural blood flow increased (26.0--41.4 ml.min-1). Function of the whole heart improved; heart rate increased (85--161 beats.min-1); and aortic blood pressure decreased (94--60 mmHg). After intracoronary isoproterenol of 0.005 microgram.kg-1, oxygen tension at the regional subendocardium slightly but significantly increased (22.8--25.4 mmHg). Although transmural blood flow (27.6--36.6 ml.min-1) and cardiac function improved, heart rate (83--93 beats.min-1) and aortic blood pressure (106--104 mmHg) remained at the pre-isoproterenol level. The results suggest that oxygen balance at the regional subendocardium is deteriorated through tachycardia and hypotension and a vasodilatory effect is seen largely at the subepicardium after isoproterenol to the heart with coronary stenosis, and that an increase in myocardial contractility per se does not deteriorate the oxygenation at the subendocardium.