Tolvaptan (TLV) is an oral selective vasopressin 2 receptor antagonist that acts on the distal nephrons, causing a loss of electrolyte-free water. To date, its early administration in very elderly ...patients after repeat hospitalizations for acute decompensated heart failure (ADHF) despite receiving optimal medical therapy has not been evaluated. Fifty-six ADHF patients who were >80 years old and had been repeatedly hospitalized were retrospectively enrolled in this study. Twenty-five patients (14 men; mean age 86.7 ± 5.3 years; control group) received standard therapy and 31 patients (15 men; mean age 85.5 ± 4.5 years; TLV group) received oral TLV within 24 h of admission. The rate of worsening renal function was significantly lower in the TLV group than in the control group (13 vs. 40%,
P
< 0.05). The duration of the return to body weight at a steady state was significantly shorter in the TLV group (5.3 ± 2.8 days) than in the control group (13.9 ± 9.2 days,
P
< 0.01). Consequently, the hospitalization period in the TLV group (13.5 ± 5.9 days) was significantly shorter than that in the control group (24.7 ± 12.3 days,
P
< 0.01). In conclusion, the early administration of TLV to very elderly patients who underwent repeat hospitalizations for ADHF resulted in immediate decongestion and thus reduced the hospitalization period with a lower incidence of worsening renal function.
Backgrounds
The relative apical sparing pattern (RASP) of left ventricular (LV) longitudinal strain (LS) is frequently associated with cardiac amyloidosis (CA). However, the visual assessment of RASP ...is inconsistent, and the quantitative assessment of RASP is time‐consuming. This study aimed to compare assessments of RASP for the identification of CA with conventional assessments and investigate their reproducibility and relevance on the assessments.
Methods
Forty patients with biopsy‐proven CA were compared with 80 hypertrophied patients matched for mean LV wall thickness. We compared the discriminative abilities of three assessments of RASP to identify CA (visual, quantitative, and semiquantitative). Nine patterns of semiquantitative RASP were investigated; finally, it was defined as “reduction of LS” (≥ −10%) in ≥5 (of 6) basal segments, relative to “preserved LS” (< −15%) in at least one apical segment.
Results
The concordance between the two observers for visual RASP was modest (κ = 0.65). On the other hand, the consistency for semiquantitative RASP was perfect (κ = 1.00). The discriminative ability of semiquantitative RASP (area under the curve AUC = 0.74) was significantly better than that of visual RASP (AUC = 0.65) and equivalent to that of binary quantitative RASP.
Conclusion
Semiquantitative RASP assessment is reproducible and accurately discriminates CA. This simple assessment may help readily refine the risk stratification of patients with diffuse LV hypertrophy.
Recently, the development of two-dimensional speckle-tracking (2DST) technology has allowed the direct measurement of the elastic parameters of the carotid arterial wall. The aims of this study were ...to determine the feasibility of measuring peak circumferential strain (CS) of the carotid arterial wall using 2DST and to compare this value with conventional arterial stiffness parameters in subjects with and without hypertension. The study included 90 healthy subjects and 40 age-and sex-matched patients with hypertension. The short-axis view of the right common carotid artery was recorded. The CS in the posterior region of the carotid artery was calculated by 2DST using special software and corrected by the following equation: ɛ(circ)=ln (systolic blood pressure/diastolic blood pressure)/CS. We simultaneously measured the stiffness index β (β) at the same location and the brachial-ankle pulse wave velocity (baPWV). Sixty randomly selected healthy subjects were used to assess the inter/intra-observer variability of ɛ(circ) and β. In healthy subjects, ɛ(circ) was significantly correlated with β, age and baPWV. These correlations were slightly better than the corresponding correlations of β with age and baPWV. The hypertensive patients had a significantly larger ɛ(circ) than the healthy subjects (0.112 ± 0.074 vs. 0.066 ± 0.029/%, P<0.001). The inter/intra-observer variability for ɛ(circ) was significantly lower than that for β. Our data suggest that the measurement of carotid ɛ(circ) using 2DST is feasible and has better reproducibility than conventional carotid arterial stiffness.
OBJECTIVE—Angiotensin II is involved in the genesis of atherosclerosis. As the role of the angiotensin II type 1a (AT) receptor in plaque rupture is poorly understood, we assessed the hypothesis that ...the ATreceptor contributes to atherosclerotic plaque rupture.
METHODS AND RESULTS—Atherosclerotic plaque rupture was induced by carotid artery ligation for 4 weeks followed by polyethylene cuff placement around the carotid in apolipoprotein E (ApoE) and ApoE AT1a mice. The incidence of plaque rupture at 4 days after cuff placement was 72% in ApoE mice compared with 24% in ApoE AT1a mice (P<0.01). Lipid accumulation, macrophage infiltration, expression of inflammatory cytokines, nicotinamide adenine dinucleotide phosphate-oxidase activity, and matrix metalloproteinase-9 activity in atherosclerotic plaque were markedly attenuated in ApoE AT1a compared with ApoE mice. Oxidized low-density lipoprotein inhibited macrophage migration in ApoE macrophages. In contrast, oxidized low-density lipoprotein-induced macrophage trapping was abolished in ApoE AT1a macrophages, and this was associated with decreased CD36 expression and focal adhesion kinase activity.
CONCLUSIONS—Conclusion—These results suggest that blocking the AT1 receptor may reduce atherosclerotic plaque rupture and that AT1a receptor-mediated macrophage trapping, inflammation, oxidative stress, and matrix metalloproteinase activation may play crucial roles in plaque vulnerability.
Abstract Background Adaptive servo-ventilation (ASV) at home has been used for patients with chronic heart failure. However, its effect on acute cardiogenic pulmonary edema (ACPE) is not clear. The ...aim of this study was to elucidate the effect of ASV use in the emergency room in patients with ACPE. Methods We enrolled 198 consecutive patients with ACPE. Eighty patients received standard therapies, such as oxygen inhalation and vasodilators (conventional therapy group), and 118 received ASV in addition to standard therapy (ASV therapy group). ASV was initiated in the emergency room immediately after diagnosis. The procedure was switched over from ASV to endotracheal intubation (ETI) when oxygenation was insufficient. Results The ETI rate in the ASV therapy group was significantly lower than that in the conventional therapy group (3% vs. 21%, p < 0.01). The intensive care unit and/or high care unit length of stay in the ASV therapy group was also significantly shorter than that in the conventional therapy group (1.9 ± 2.1 days vs. 5.3 ± 6.8 days, p < 0.01). Consequently, the hospitalization period in the ASV therapy group was shorter than that in the conventional therapy group (19.3 ± 11.0 days vs. 26.3 ± 16.6 days, p < 0.01). Conclusion In patients with ACPE, rapid introduction of ASV in the emergency room reduces the need for ETI and decreases the hospitalization period.
A 67-year-old man was transferred to our hospital because of anterior ST elevation myocardial infarction (STEMI). He had a history of a sirolimus-eluting stent implantation from the left main to the ...left anterior descending coronary artery (LAD) 9 years before and had undergone laparoscopic prostatectomy 8days before in the setting of discontinuation of dual antiplatelet therapy. Emergent coronary angiography showed total occlusion in the distal LAD that was successfully treated by aspiration alone. Optical coherence tomography (OCT) showed no vulnerable lesion from the occluded lesion to the proximal LAD. OCT demonstrated that the thrombus attached to floating struts at the left main bifurcation and non-apposed struts at the left coronary ostium partly protruding to aorta, while the other struts were covered and well-apposed. Based on OCT findings, this case of STEMI was thought to be caused by distal embolism of a thrombus that formed at the stent site before it evolved into total occlusion.
<Learning objective: We demonstrated how optical coherence tomography can be essential in revealing the underlying pathology. The patient showed an unusual manifestation of ST-elevation myocardial infarction caused by distal embolism of a thrombus that formed at the sirolimus-eluting stent due to dual antiplatelet therapy discontinuation during perioperative period. Optical coherence tomography revealed very late stent thrombosis at the left coronary ostium and could elucidate the underlying mechanism.>
BACKGROUND AND PURPOSE—We examined the possibility that activation of the human brain renin–angiotensin system is involved in enhancement of ischemic brain damage using chimeric transgenic mice with ...human renin (hRN) and human angiotensinogen (hANG) genes.
METHODS—Chimeric (hRN/hANG-Tg) mice were generated by mating of hRN and hANG transgenic mice. Permanent occlusion of the middle cerebral artery (MCA) by an intraluminal filament technique induced focal ischemic brain lesions.
RESULTS—hRN/hANG-Tg mice showed higher angiotensin II levels in the plasma and brain. The ischemic brain area at 24 hours after MCA occlusion was significantly enlarged in hRN/hANG-Tg mice with an enhanced neurological deficit compared to that in wild-type, hRN-Tg and hANG-Tg mice. The reduction of cerebral blood flow in the periphery region of the MCA territory after MCA occlusion was markedly exaggerated in hRN/hANG-Tg mice. Superoxide anion production in the brain and arteries was also increased significantly in hRN/hANG-Tg mice even before MCA occlusion and was further enhanced after MCA occlusion. Treatment with an AT1 receptor blocker, valsartan (3.0 mg/kg per day), for 2 weeks significantly reduced the ischemic brain area and improved the neurological deficit after MCA occlusion in hRN/hANG-Tg mice, similar to those in wild-type, hRN-Tg, and hANG-Tg mice, with restoration of cerebral blood flow in the peripheral region and decreases in superoxide anion production and blood pressure.
CONCLUSIONS—These results indicate that activation of the human renin–angiotensin system exaggerates ischemic brain damage mainly through stimulation of the AT1 receptor and marked reduction of cerebral blood flow and enhanced oxidative stress.
Background: Right ventricular (RV) pacing alters left ventricular (LV) mechanical activation, resulting in adverse impacts on LV function. This study was aimed to investigate the acute effect of RV ...apical (RVA) and septal pacing (RVS) on LV dyssynchrony and function using speckle tracking echocardiography. Methods and Results: The 103 patients (749 years) with symptomatic bradyarrhythmia and preserved LV ejection fraction, and 50 age-matched control subjects were studied. All patients received a permanent pacemaker and were randomly assigned into 2 groups (RVA: n=51, RVS: n=52). After insertion, patients underwent an echocardiographic study during RV pacing. LV dyssynchrony and global strain parameters were analyzed using speckle tracking echocardiography. The QRS width and dyssynchrony indices by longitudinal and radial strain were significantly greater in RVA than in both the control and RVS. The LV longitudinal dyssynchrony index was significantly related to global longitudinal strain (GLS) among 103 patients receiving RV pacing (R2=0.25, P<0.0001). The GLS in RVA were the lowest among the 3 groups (GLS: Control: -18.22.4%, RVA: -14.33.1%, P<0.001 vs. control, RVS: -16.82.7%, P<0.01 vs. RVA). Conclusions: RVA created heterogeneous LV contraction, which resulted in deteriorated LV longitudinal contraction. RVS could be a better pacing alternative in terms of less LV dyssynchrony and better longitudinal function compared to RVA. (Circ J 2011; 75: 1609-1615)
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