Objectives
The currently available Japanese normal database (NDB) in stress myocardial perfusion scintigraphy recommended by the Japanese Society of Nuclear Medicine (JSNM-NDB) is created based on ...the data from exercise tests. The newly developed adenosine normal database (ADS-NDB) remains to be validated for patients undergoing adenosine stress test. We tested whether the diagnostic accuracy of adenosine stress test is improved by the use of ADS-NDB (Kanazawa University).
Methods
Of 233 consecutive patients undergoing
99m
Tc-MIBI adenosine stress test, 112 patients were tested. The stress/rest myocardial
99m
Tc-MIBI single-photon emission computed tomography (SPECT) images were analyzed by AutoQUANT 7.2 with both ADS-NDB and JSNM-NDB. The summed stress score (SSS) and summed difference score (SDS) were calculated. The agreements of the post-stress defect severity between ADS-NDB and JSNM-NDB were assessed using a weighted kappa statistic.
Results
In all patients, mean SSSs of all, right coronary artery (RCA), left anterior descending (LAD), and left circumflex (LCx) territories were significantly lower with ADS-NDB than those with JSNM-NDB. Mean SDSs in all, RCA, and LAD territories were significantly lower with ADS-NDB than those with JSNM-NDB. In 28 patients with significant coronary stenosis, the mean SSS in the RCA territory was significantly lower with ADS-NDB than that with JSNM-NDB. In 84 patients without ischemia, both mean SSSs and SDSs in all, RCA, LAD, and LCx territories were significantly lower with ADS-NDB than those with JSNM-NDB. Weighted kappa values of all patients, patients with significant stenosis, and patients without ischemia were 0.89, 0.83, and 0.92, respectively.
Conclusions
Differences were observed between results from ADS-NDB and JSNM-NDB. The diagnostic accuracy of adenosine stress myocardial perfusion scintigraphy may be improved by reducing false-positive results.
Coronary plaques can be reduced by some medications. The aim of this study was to compare the effects of 2 angiotensin II receptor blockers (olmesartan at 20 mg/day or valsartan at 80 mg/day) on ...coronary plaque by coronary intravascular ultrasound. One hundred hypertensive patients with stable angina pectoris who underwent elective percutaneous coronary intervention were randomly selected to receive 1 of the 2 angiotensin II receptor blockers after coronary intervention. Nontarget coronary lesions with mild to moderate stenosis were measured by volumetric intravascular ultrasound at baseline and after 6 months. After 6 months, both the olmesartan and the valsartan groups showed significant reduction of the examined coronary plaque volume (46.2 ± 24.1 mm3 at baseline vs 41.6 ± 21.1 mm3 at 6 months: 4.7% decrease, p = 0.0002; and 47.2 ± 32.7 mm3 at baseline vs 42.5 ± 30.2 mm3 at 6 months: 4.8% decrease, p = 0.002, respectively). There was no statistically significant difference of plaque regression between the 2 groups (p = 0.96). In conclusion, there was a significant decrease from baseline in the coronary plaque volume in patients with stable angina pectoris who received olmesartan or valsartan for 6 months. In addition, there was no significant difference in the reduction of plaque volume achieved by these 2 medications.
Abstract Background In myocardial ischemia–reperfusion injuries, the involvement of the Na+ /H+ exchanger (NHE) is considered to be one of the pathogenic mechanisms following reperfusion. TY-51924 is ...a novel hydrophilic NHE inhibitor with a lower risk of central neurotoxicity than previous NHE inhibitors. This open-label, dose-escalating study was undertaken to investigate the safety, efficacy, and pharmacokinetics of TY-51924 in patients with ST-elevation myocardial infarction (STEMI). Methods Consent was obtained from a total of 30 patients with first anterior STEMI. After 12 patients were determined to be ineligible, the remaining 18 patients, each of whom was undergoing primary percutaneous coronary intervention (pPCI), received TY-51924 intravenously up to 10, 20, or 30 mg/kg as the low-, medium-, or high-dose groups, respectively ( n = 6 in each group). The primary endpoints were safety (up to 7 days) and plasma drug concentration. The myocardial salvage index (MSI) was measured by201 Tl/123 I-beta-methyl- p -iodophenyl pentadecanoic acid single photon emission computed tomography (SPECT) 3–5 days after pPCI. Results No side effects were observed. Plasma drug concentrations increased dose-dependently, and were subsequently eliminated rapidly. MSIs were 0.118, 0.335, and 0.192 in the low-, medium-, and high-dose groups, respectively. In additional analysis, the combined MSIs in the medium- and high-dose groups were significantly higher than those in the low-dose group, in patients with a longer time from symptom onset to reperfusion ( p = 0.0247). Conclusions No side effects were observed even at the highest dose with this novel hydrophilic NHE inhibitor. Therefore, TY-51924 is thought to be safe in patients with STEMI, even at the highest dose. Potential cardioprotective effects of intravenous TY-51924 might be expected based on the results obtained for the MSIs using SPECT at 20–30 mg/kg. However, further large-scale, double-blind, placebo-controlled clinical studies are required to confirm the efficacy and safety implied in the current study.
Abstract This report describes a case of paradoxical atrial undersensing by a dual-chamber pacemaker during paroxysmal atrial fibrillation. Undersensing of 5.6 mV atrial signals at a programmed ...sensitivity of 0.5 mV returned to normal sensing by decreasing atrial sensitivity to 1.0 mV. This uncommon phenomenon can be explained by a repeated activation of the quiet timer blanking interval. Knowledge of this phenomenon is important in the current pacemaker management to improve the accuracy of the diagnostic feature for atrial tachyarrhythmia burden and to avoid unnecessary lead revisions.
The cutoff values of fractional flow reserve (FFR) to detect physiological myocardial ischemia are still controversial. Some studies have reported that left ventricular (LV) dyssynchrony occurs in ...patients with coronary artery disease (CAD). The purpose of this study was to investigate LV dyssynchrony in patients with moderate coronary stenosis and borderline FFR, using stress electrocardiographically-gated myocardial perfusion single-photon emission computed tomography (SPECT). The study population comprised 10 patients with moderate (50-75% diameter) stenosis and an FFR in the range 0.75-0.90, who were compared to 10 control subjects. All underwent stress myocardial (99m)Tc-sestamibi (MIBI) or tetrofosmin SPECT imaging. The regional time to end systole (TES), time to peak ejection (TPE), and time to peak filling (TPF) were obtained as indexes of perfusion and function, using gated SPECT (pFAST) in combination with Cardio Gated SPECT Regional Assessment for LV Function (cardioGRAF). The dyssynchrony index (DI) was also calculated. The DI of post-stress TES was significantly greater than that of rest in patients with moderate CAD (4.8 ± 2.8 vs. 2.7 ± 1.5, P = 0.01), but there were no significant differences in the control subjects (3.0 ± 1.7 vs. 2.9 ± 1.9, P = 0.99). There were no significant differences in TPE and TPF between the groups. In conclusion, LV dyssynchrony may occur after stress in patients with coronary stenosis and borderline FFR, even without a significant reduction in perfusion.
A 34-year-old postpartum woman presented at hospital with chest pain. She had experienced an uneventful delivery of a healthy infant and had no known coronary risk factors. Electrocardiography ...demonstrated an acute myocardial infarction, which resolved on intravenous glyceryl trinitrate infusion. Coronary angiography revealed diffuse narrowing of the left anterior descending artery and tapering of the left main trunk, but there were no obvious hallmarks of intimal dissection.
Electrocardiography, coronary angiography, multidetector CT and intravascular ultrasonography.
Postpartum coronary artery dissection.
The lesion was stabilized with orally administered amlodipine, aspirin, ticlopidine and pitavastatin, along with intravenous heparin and glyceryl trinitrate. The patient was later discharged on bisoprolol, aspirin, pitavastatin and temocapril.
To explore optimal management strategies for bifurcation lesions with sirolimus-eluting stents (SES).
Among 12,824 patients enrolled in the j-Cypher Registry, we identified 2,122 patients with 2,250 ...non-left main bifurcation lesions (average age: 69 years; diabetes: 39%; acute coronary syndrome: 24%; lesion length ≥30 mm: 17%; true bifurcation: 53%) treated exclusively with SES. The majority of lesions (1,978 lesions, 88%) were treated by provisional side branch stenting approach with a 4.5% crossover rate, while the elective two-stent approach (stenting both main and side branches) was adopted in 272 lesions. The 3-year incidence of target-lesion revascularisation (TLR) was significantly higher in the elective two-stent group than in the provisional group (18.5% vs. 9.8%, p<0.0001). The incidence of definite stent thrombosis was not different between the two groups (1.3% vs. 0.61%, p=0.21). Among 1,871 lesions with main branch stenting alone, final kissing balloon dilatation (FKB) was performed in 938 lesions (50%). The incidence of TLR was not different between the two groups with or without FKB (9.9% vs. 9.2%, p=0.98).
The provisional approach provided a good long-term outcome in the majority of lesions with low crossover rate to the two-stent approach. Lesions treated with FKB had similar TLR outcome to those without FKB after main branch stenting alone.
Objectives This study assessed 5-year outcomes after implantation of sirolimus-eluting stents (SES) for unprotected left main coronary artery (ULMCA) disease in comparison with that for non-left main ...disease. Background More information on long-term outcomes after ULMCA stenting is needed. Methods The j-Cypher is a multicenter prospective registry of consecutive patients undergoing SES implantation in Japan. Results Among 12,812 patients enrolled in the j-Cypher registry, the unadjusted mortality rate at 5 years was significantly higher in patients with ULMCA stenting than in patients without ULMCA stenting (22.8% vs. 14.1%; p < 0.0001); however, the risk for death with ULMCA stenting was no longer significant after adjusting for confounders (hazard ratio: 1.18, 95% confidence interval: 0.95 to 1.46; p = 0.14). In the lesion-level comparison, the nonbifurcation ULMCA lesions treated exclusively with SES had a significantly lower rate of target lesion revascularization (TLR) than those in non-ULMCA nonbifurcation lesions (2.4% vs. 12.7%; p = 0.04). Among bifurcation lesions, those treated with a provisional 2-stent approach had similar rates of TLR (12.1% vs. 11.4%; p = 0.79) between the ULMCA and non-ULMCA groups. Lesions treated with an elective 2-stent approach had higher TLR rates in the ULMCA group as compared with the non-ULMCA group (33.5% vs. 19.7%; p = 0.002). Conclusions The safety of ULMCA stenting relative to non-LMCA stenting was maintained through 5 years follow-up. In terms of efficacy, SES implantation in nonbifurcation ULMCA lesions was associated with an extremely low cumulative incidence of TLR, whereas the elective 2-stent approach for ULMCA bifurcation lesions was associated with a markedly higher cumulative incidence of TLR as compared with that for non-ULMCA bifurcation lesions.
Background: Tranilast is an antiallergic drug that suppresses the release of cytokines such as platelet-derived growth factor, transforming growth factor-β1, and interleukin-1β and prevents keloid ...formation after skin injury. Treatment with this drug reduced the restenosis rate after percutaneous transluminal coronary angioplasty in a preliminary study. Methods and Results: We conducted a multicenter, randomized, double-blind, placebo-controlled trial. A total of 255 patients with 289 lesions were randomly assigned to treatment with the oral administration of 600 mg/d tranilast, 300 mg/d tranilast, or a placebo for 3 months after successful angioplasty. Angiographic follow-up was done at 3 months, and a clinical follow-up examination was performed at 12 months. Two hundred ten (72.7%) lesions of 188 (73.7%) of the patients met the criteria and were eligible for the assessment of restenosis. The restenosis rates defined as ≥50% loss of the initial gain were 14.7% in the 600 mg/d tranilast group, 35.2% in the 300 mg/d tranilast group, and 46.5% in the placebo group (P < .0001 for 600 mg/d tranilast vs placebo). The restenosis rates defined as percent diameter stenosis of ≥50% at follow-up were 17.6% in the 600 mg/d tranilast group, 38.6% in the 300 mg/d tranilast group, and 39.4% in the placebo group (P = .005 for 600 mg/d tranilast vs placebo). Conclusions: The oral administration of 600 mg/d of tranilast for 3 months markedly reduced the restenosis rate after percutaneous transluminal coronary angioplasty. (Am Heart J 1999;138:968-75.)
There is a scarcity of long-term data from large-scale drug-eluting stent registries with a large enough sample to evaluate low-frequency events such as stent thrombosis (ST).
Five-year outcomes were ...evaluated in 12 812 consecutive patients undergoing sirolimus-eluting stent (SES) implantation in the j-Cypher registry. Cumulative incidence of definite ST was low (30 day, 0.3%; 1 year, 0.6%; and 5 years, 1.6%). However, late and very late ST continued to occur without attenuation up to 5 years after sirolimus-eluting stent implantation (0.26%/y). Cumulative incidence of target lesion revascularization within the first year was low (7.3%). However, late target lesion revascularization beyond 1 year also continued to occur without attenuation up to 5 years (2.2%/y). Independent risk factors of ST were completely different according to the timing of ST onset, suggesting the presence of different pathophysiological mechanisms of ST according to the timing of ST onset: acute coronary syndrome and target of proximal left anterior descending coronary artery for early ST; side-branch stenting, diabetes mellitus, and end-stage renal disease with or without hemodialysis for late ST; and current smoking and total stent length >28 mm for very late ST. Independent risk factors of late target lesion revascularization beyond 1 year were generally similar to those risk factors identified for early target lesion revascularization.
Late adverse events such as very late ST and late target lesion revascularization are continuous hazards, lasting at least up to 5 years after implantation of the first-generation drug-eluting stents (sirolimus-eluting stents), which should be the targets for developing improved coronary stents.
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