Abstract Background Anticoagulation therapy is essential in atrial fibrillation (AF), and in Japan, less intense control is popular. Purpose To assess the efficacy and safety with a special reference ...to low intensity warfarin therapy. Subjects and methods In 488 out of 508 patients with non-valvular AF, prothrombin time-international normalized ratio (PT-INR) was kept at 1.6–2.59, and they were followed for 49.5 months: 2098 person-years. The mean age was 73.7 ± 9.9 years and 62% were male. The patients were divided by age: ≥70 years and <70 years, and by the intensity of warfarin therapy: PT-INR at 1.6–1.99 and at 2.0–2.59, respectively. The clinical data and event rates, ischemic stroke and major bleeding, were compared among the subgroups. Results Heart failure, previous stroke, and higher CHADS2 score were more often reported in patients ≥70 years while males were involved more often as younger patients. A total of 166 of 339 patients ≥70 years and 69 of 149 patients <70 years belonged to the low intensity group. Ischemic stroke and major bleeding occurred in 1.47%/year and 1.27%/year, respectively but there was no difference between the two age groups and between the two intensities of warfarin therapy. Time in therapeutic range was a predictor for ischemic stroke. A fall of PT-INR to <1.6 was found in 41.9% with ischemic stroke and a rise >2.61 in 40.0% with major bleeding at the time of the events. Blunt trauma and concomitant use of antiplatelets were risks for intracranial hemorrhage in the patients ≥70 years. Conclusions The event rates were similar between the low- (1.6–1.99) and high- (2.0–2.59) intensity warfarin therapy groups in aged patients: <70 years and ≥70 years. Time in therapeutic range and a transient fall or rise in PT-INR were risks for clinical events. Blunt head trauma and concomitant use of antiplatelets were risks for intracranial hemorrhage.
Abstract A 66-year-old man was admitted for congestive heart failure with tachycardiac atrial fibrillation (AF). Heart failure was improved by diuretics, but control of heart rate by verapamil was ...insufficient, and bisoprolol was prescribed. After taking 2.5 mg of bisoprolol, he developed a general malaise followed by sinus bradycardia and shock. In addition to catecholamines, the patient was treated with intra-aortic balloon pumping and a pacemaker. With intensive therapy, the general condition was improved, and acute elevation of liver enzymes after bisoprolol was normalized by the 17th hospital day. The blood sample taken 30 h after the intake of bisoprolol showed abnormally high levels. Although the patient was CYP2D6*10 heterozygote, the precise mechanism for excess accumulation of bisoprolol and refractory shock remains unknown. < Learning objective: Bisoprolol has been used for heart failure, but it may need caution to avoid hemodynamic deterioration. In our case, refractory shock and acute liver injury were induced by bisoprolol. The blood concentration was excessively high. The patient was CYP2D6*10 heterozygote, but the precise mechanism and shock are to be studied.>
Summary Background Peroxisome proliferator-activated receptor-gamma (PPAR-γ) agonists are used as anti-diabetic drugs, and their pleiotrophic action has been reported to improve endothelial function ...leading to cardioprotective effects. In this study we evaluated the long-term effect of pioglitazone on cardiac function in diabetic patients after percutaneous coronary intervention (PCI) by drug-eluting stent (DES). Methods and results We investigated 54 diabetic patients who received PCI using a sirolimus-eluting stent. We excluded cases of acute myocardial infarction. They were divided into two groups: Group C received only conventional therapy ( n = 26) and Group P received additionally pioglitazone 15 mg/day ( n = 28). The left ventricular ejection fraction (LVEF) was measured by left ventriculography and analyzed before and 8 months after PCI. In Group C, LVEF did not change significantly: 55.6% vs. 56.7%, before and after PCI respectively ( p = 0.58). However, pioglitazone significantly improved LVEF: 54.4% vs. 60.0% ( p = 0.014). Multiple linear regression analysis showed that ΔLVEF was significantly related to pioglitazone therapy ( p = 0.037). In particular, the combination of pioglitazone and statin improved LVEF (ΔLVEF 9.6% with vs. 2.2% without statin). Conclusions Pioglitazone improved cardiac function after PCI using SES in diabetic patients, especially in combination with a statin.
Summary The aim of this study was to elucidate endothelial dysfunction due to chronic cigarette smoking in young smokers and to determine practical markers of the functional derangement. The subjects ...were young, healthy, male non-smokers ( n = 11) and smokers ( n = 9). Endothelium-dependent and -independent vasodilation was assessed by flow-mediated vasodilation (FMD) and nitroglycerine-induced vasodilation (NID), respectively, and possible markers of endothelial function were measured. FMD in smokers was significantly lower than in control subjects (5.0 ± 2.6% and 9.5 ± 5.2%, p < 0.05). Plasminogen activator inhibitor type 1 (PAI-1) and tissue plasminogen activator levels were significantly ( p < 0.05) higher in smokers (6.7 ± 4.5 ng/ml and 4.3 ± 2.0 ng/ml) compared with control subjects (2.9 ± 1.9 ng/ml and 3.0 ± 0.6 ng/ml). Furthermore, PAI-1 levels correlated inversely with FMD ( r = −0.451, p < 0.05). No significant differences were observed for NID, or plasma NO2− , NO X , thrombomodulin, von Willebrand factor, and tissue factor pathway inhibitor levels. Chronic cigarette smoking-induced endothelial dysfunction and the PAI-1 level could be a good marker of endothelial dysfunction in young smokers.
Summary A healthy 25-year-old man suffered from loss of consciousness due to ventricular fibrillation (VF). Emergency services required multiple cardioversion to restore sinus rhythm. Repeated ...electrocardiographic (ECG) recordings after admission showed non-type 1 Brugada ST-segment elevation in V1 and V2. Intravenous pilsicainide infusion augmented the ST-segment elevation but its morphology did not represent type-1 ECG. Intravenous administration of isoproterenol normalized the ST-segment elevation, and programmed electrical stimulation induced VF. Spontaneous VF recurred 1 year after introduction of implantable cardioverter defibrillator. Non-type 1 ST-segment elevation, to which pharmacological responses are similar to Brugada syndrome, may be used as a hallmark of ventricular tachyarrhythmia.
Summary Legionella infection, although commonly seen as pneumonia, can also manifest systemic involvement. Here, we describe a case of sporadic Legionella infection coinciding with pneumonia, ...rhabdomyolysis, renal failure, and severe left ventricular dysfunction, which subsequently developed refractory septic shock. An endomyocardial biopsy revealed no findings of interstitial inflammatory infiltrates. After 3 days of intensive care, including percutaneous cardiopulmonary support, intraaortic balloon pumping, and continuous hemodialysis with endotoxin adsorption therapy, left ventricular wall motion improved spontaneously in accordance with a decrease in the concentration of inflammatory cytokines. Cardiac complications are rare but Legionella infection should be considered as a possible etiology of left ventricular dysfunction in patients with sepsis.
Summary Subarachnoid hemorrhage (SAH) often accompanies cardiac abnormalities. Sudden cardiac arrest is also known to occur after SAH. A 32-year-old woman was admitted to our hospital because of ...cardiac arrest immediately after the onset of SAH. Return of spontaneous circulation was obtained by conventional advanced cardiovascular life support. After resuscitation, her echocardiogram showed left ventricular apical ballooning, which improved within 7 days. This is the first report presenting both sudden cardiac arrest and transient left ventricular apical ballooning after SAH.
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