Abstract Background Epicardial adipose tissue (EAT), defined as the adipose tissue between the visceral pericardium and the outer margin of the myocardium, is associated with coronary artery disease ...in the general population. However, the clinical implications of EAT in patients with ST-segment elevation myocardial infarction (STEMI) remain unclear. Methods A total of 142 patients with a first STEMI, who received reperfusion therapy within 12 h from symptom onset, were enrolled. All patients underwent cardiac magnetic resonance imaging to evaluate infarct core (Core), area at risk (AAR), and EAT volume. Myocardial salvage index (MSI) was defined as AAR minus Core divided by AAR. Patients in the lower tertile of EAT volume were classified as the low EAT group (group L) and the other two-thirds as the high EAT group (group H). Results The mean MSI was lower in group L than in group H (0.43 ± 0.13 vs 0.49 ± 0.13, p = 0.01), and the mean extent of Core was higher in group L than in group H (25 ± 10% vs 19 ± 10%, p < 0.01). Multivariate linear regression analysis including coronary risk factors and previously reported predictors of infarct size demonstrated that EAT volume was an independent predictor of MSI ( β coefficient = 0.002 per 1 mL, p = 0.002). Conclusions A lower EAT volume is associated with less myocardial salvage and larger infarct size in patients with a first STEMI.
Abstract Heparin-induced thrombocytopenia (HIT) is an adverse immune-mediated drug reaction that is associated with thromboembolic complications. We report the case of an 82-year-old man with ...unstable angina pectoris who suffered from recurrent arterial thromboembolism due to HIT. Coronary angiography (CAG) was performed while we administered unfractionated heparin bolus. CAG showed triple-vessel disease without left main coronary artery. We performed elective percutaneous coronary angioplasty (PCI) to the left anterior descending coronary artery (LAD). The sudden thrombus formation in the LAD occurred during the procedure. We suspected HIT and administered argatroban. We deployed four everolimus-eluting stents in the LAD and intra-aortic balloon pumping (IABP) support was started. The platelet counts were rapidly reduced almost 50% next day after PCI and IgG-specific anti-PF4/heparin antibodies were elevated. Multiple cerebral infarctions were detected by magnetic resonance imaging after the PCI. The patient received the continuous argatroban administration and IABP support for 4 days. Subacute stent thrombosis occurred after quitting argatroban. We performed thrombus aspiration and fibrinolytic treatment. Finally we re-inserted IABP and stabilized the hemodynamic state. Right popliteal arterial thromboembolism occurred after emergency PCI. Argatroban is essential and following oral anticoagulant therapy is necessary to prevent thromboembolic complications. < Learning objective: Heparin-induced thrombocytopenia (HIT) is an adverse immune-mediated drug reaction that is associated with thromboembolic complications. The incidence of HIT in patients who received unfractionated heparin is reported to be 0.1– 1%. We should be aware of HIT when thromboembolic complications occur during the percutaneous coronary intervention procedure. Argatroban is essential and following oral anticoagulant therapy is necessary to prevent thromboembolic complications among patients with HIT.>
Summary Background We report a rare case of acute pulmonary embolism (PE) induced by urinary retention and bladder distention with benign prostatic hyperplasia (BPH). Case report A 76-year-old male ...with BPH presented to the hospital with anuria of 24 h duration and abdominal distention. Physical examination revealed tenderness and distention of the lower abdomen and a swollen right leg. Echocardiography after urethral catheterization showed a large free-floating thrombus traversing back and forth through the tricuspid orifice. Computed tomographic angiography demonstrated filling defects at the level of the right inter lobar pulmonary artery and the segmental branches of both pulmonary arteries, indicating acute PE. The patient was treated with heparin and warfarin for three weeks to ensure the resolution of the pulmonary embolus. After the resolution of all symptoms, the patient was discharged without further complication. Conclusion This case suggested that a distended bladder is a potential risk factor for the development of deep vein thrombosis and PE.
Abstract Background It remains unknown whether the time course of the antiplatelet effects of clopidogrel differs according to cytochrome P450 (CYP) 2C19 phenotype in Japanese patients with acute ...coronary syndromes (ACS). Methods and results Platelet reactivity was serially assessed by VerifyNow-P2Y12 assay (Accumetrics, San Diego, CA, USA). Results were expressed as P2Y12-reaction-units (PRU) in 177 patients with ACS who underwent stent implantation and received aspirin plus a 300-mg loading dose of clopidogrel followed by 75 mg/day. High on-clopidogrel treatment platelet reactivity (HTPR) was defined as PRU > 235. On the basis of the CYP2C19*2 and *3 alleles, 46 patients (26.0%) were classified as extensive metabolizers (EM), 103 (58.2%) as intermediate metabolizers (IM), and 28 (15.8%) as poor metabolizers (PM). At <7 days, the PRU level (232 ± 102 vs. 279 ± 70, 308 ± 67, p < 0.001) and the incidence of HTPR (49% vs. 74%, 86%, p = 0.001) was lower in EM than in IM and PM. At 14–28 days the effects of CYP2C19 polymorphisms on PRU levels increased in a stepwise fashion (168 ± 99 vs. 213 ± 77 vs. 278 ± 69, p < 0.001), and EM and IM had lower percentages of HTPR than PM (28%, 37% vs. 73%, p < 0.001). There was no significant difference in the cumulative frequency of 12-month adverse cardiovascular events among 3 phenotypes (16.5%, 14.1%, 9.2%; p = 0.67). Conclusion About three quarters of Japanese patients with ACS carried CYP2C19 variant alleles. The majority of IM and PM had increased platelet reactivity during the early phase of ACS. Although HTPR was frequently observed even 14–28 days after standard maintenance doses of clopidogrel in PM, the incidence of adverse outcomes did not differ, irrespective of CYP2C19 genotype.
Abstract Background Heart failure (HF) is associated with adverse metabolic influences and provokes fat loss as well as bone and muscle loss at the terminal stages. Pericardial fat is an ectopic fat ...depot that can potentially affect the myocardium, but the role of pericardial fat in HF is unclear. We sought to characterize pericardial fat in HF, particularly in association with bone tissue using cardiac computed tomography (CT). Methods In 61 consecutive hospitalized HF patients with left ventricular ejection fraction ≤50%, pericardial fat volume (PFV), CT density in the thoracic vertebrae, and ectopic calcification in the aortic valve were assessed simultaneously using electrocardiogram-gated non-contrast-enhanced CT. Results The mean PFV was 93.5 ± 50.6 cm3 , which might reflect the total body fat measured with dual energy X-ray absorptiometry (Pearson's r = 0.48, p = 0.01). The PFV index, defined as the PFV/body surface area, was significantly higher among older patients (>65 years; 63.5 ± 30.6 cm3 /m2 vs. 42.7 ± 17.1 cm3 /m2 , p < 0.01) and among patients with atrial fibrillation (AF; 70.9 ± 36.4 cm3 /m2 vs. 48.8 ± 21.2 cm3 /m2 , p < 0.01) and hypertension (60.7 ± 29.3 cm3 /m2 vs. 41.5 ± 18.2 cm3 /m2 , p < 0.01) compared to patients without these conditions. The PFV indices were comparable between the patients with and without ischemic etiology, diabetes, and renal dysfunction. Patients with increased PFV indices (above the median) exhibited lower CT density in the thoracic vertebrae (134 ± 41 Hounsfield units vs. 161 ± 57 Hounsfield units, p = 0.04), and were more likely to have aortic valve calcification (48% vs. 18%, p = 0.02) and N-telopeptide (bone resorption marker; 20.7 ± 5.2 nmol BCE/mmol Cr vs. 25.5 ± 5.9 nmol BCE/mmol Cr, p = 0.03) levels than those without increased PFV indices. Conclusions We simultaneously assessed the pericardial fat and bone tissue of HF patients with CT and successfully characterized AF, hypertension, and advanced age as factors that are associated with increased PFV. PFV was correlated with bone tissues and alterations in bone turnover.
Summary Objectives Low levels of adiponectin, an adipocytokine with anti-diabetic and anti-atherogenic properties, are associated with increased risk of future myocardial infarction in men. Previous ...studies have demonstrated that cigarette smoking is involved in the development of insulin resistance, and current smokers have been shown to have reduced plasma adiponectin levels. However, the influence of smoking cessation on adiponectin levels remains unknown. We sought to assess whether smoking cessation is associated with increased plasma adiponectin levels in men. Methods The study includes 72 men (47 non-smokers and 25 current smokers at baseline) with stable angina pectoris who underwent percutaneous coronary intervention and follow-up coronary angiography 6 months later. During the 6-month follow-up period, all 47 non-smokers remained non-smokers, while 15 men of the 25 baseline current smokers successfully quit smoking. We evaluated plasma adiponectin levels at coronary intervention and 6 months later. Results Plasma adiponectin levels at coronary intervention were comparable to those after 6 months in non-smokers (4.22 3.15–6.43 vs. 4.58 3.03–6.26 μg/mL, P = 0.124) and in persistent smokers (4.77 4.25–10.53 vs. 5.16 4.11–8.10 μg/mL, P = 0.721). Meanwhile, an increase in adiponectin level was observed in patients who quit smoking for 6 months (4.24 3.30–5.70 vs. 5.50 4.03–8.00 μg/mL, P = 0.002). Univariate analysis revealed that the percent increase in adiponectin levels correlated positively with smoking cessation ( P = 0.003) and negatively with additional use of β-blockers ( P = 0.049). In addition, increases in adiponectin levels were closely associated with increase in high-density lipoprotein cholesterol ( P = 0.148), decrease in triglycerides ( P = 0.140), and additional use of renin–angiotensin system inhibitors ( P = 0.069). Multivariate analysis demonstrated that smoking cessation was an independent determinant of the increase in adiponectin ( P = 0.036). Conclusions Smoking cessation is associated with increased plasma adiponectin levels in men with stable angina, suggesting that the significance of smoking cessation may be partly explained by the increase in adiponectin level.
Summary Background ST-segment elevation of ≥1.0 mm in the right precordial chest lead V4R (ST↑V4R) has been shown to be a reliable marker of right ventricular involvement (RVI) in inferior acute ...myocardial infarction (IMI). However, the impact of left ventricular posterior wall involvement (PWI) on the relation between ST↑V4R and RVI is unknown. Methods We studied 267 patients with recanalized IMI due to the right coronary artery (RCA) occlusion within 6 h after symptom onset. A 12-lead electrocardiogram, lead V4R, and leads V7–9 were recorded on admission. RVI was defined as occlusion proximal to the first major right ventricular branch of the RCA. The perfusion territory of the RCA was assessed by angiographic distribution score, and PWI was defined as a score of ≥0.7. Patients were stratified according to the presence or absence of PWI and RVI. Results RVI was associated with higher peak creatine kinase and a higher rate of impaired myocardial reperfusion, defined as a myocardial blush grade of 0 or 1 after recanalization, in the presence or absence of PWI, especially the former. RVI was associated with a higher rate of ST↑V4R in the absence, but not in the presence, of PWI. ST↑V4R identified RVI with sensitivities of 34% and 96% ( p < 0.001), and specificities of 83% and 82% (NS) in the presence and absence of PWI, respectively. Conclusions In patients with recanalized IMI, RVI is associated with larger infarction and impaired myocardial reperfusion in the presence or absence of PWI, especially the former. However, the presence of PWI attenuates the predictive value of ST↑V4R for RVI.
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