Safety of exercise-based cardiac rehabilitation and exercise testing for cardiac patients in Japan: a nationwide survey.

BACKGROUND: The safety of exercise-based cardiac rehabilitation (CR) has not been investigated in Japan, so a nationwide survey was conducted to investigate the incidence of adverse events (AEs) associated with CR and exercise testing. METHODS AND RESULTS: In total, 136 hospitals reported operating recovery-phase CR programs, amounting to 383,096 patient-hours of exercise training. The incidence rates of all AEs and life-threatening AEs (LAE: death, cardiac arrest, acute myocardial infarction, cardiac rupture) during exercise sessions were 12 and 1 event/383,096 patient-hours (3.13 and 0.26 events/100,000patient-hours), respectively. When CR programs were categorized as "Formal" in which an exercise prescription based on exercise testing was issued to individual patients or "Non-formal" without exercise prescription, the incidence of AEs during and within the 24 h after an exercise session was significantly lower in the Formal than the Non-formal CR programs (P<0.001), despite similar hospital size and coronary intervention volumes between the 2 category hospitals. Moreover, LAEs did not occur in 277,721 patient-hours in Formal CR, whereas 2 LAEs occurred in 105,375 patient-hours in Non-formal CR (P<0.05). During 469,215 exercise testing sessions, 3 LAEs (0.64 event/100,000tests) and 31 non-LAEs (6.61 events/100,000tests) occurred. CONCLUSIONS: This first nationwide survey in Japan revealed that both exercise-based CR and exercise testing are generally safe, and that Formal CR, in which an individual exercise prescription is determined by exercise testing, is particularly safe.

Refined balloon pulmonary angioplasty for inoperable patients with chronic thromboembolic pulmonary hypertension.

BACKGROUND: Although balloon pulmonary angioplasty (BPA) for inoperable patients with chronic thromboembolic pulmonary hypertension was first reported over a decade ago, its clinical application has been restricted because of limited efficacy and complications. We have refined the procedure of BPA to maximize its clinical efficacy. METHODS AND RESULTS: Sixty-eight consecutive patients with inoperable chronic thromboembolic pulmonary hypertension underwent BPA. We evaluated pulmonary artery diameters and determined the appropriate balloon size by using intravascular ultrasound. We performed BPA in a staged fashion over multiple, separate procedures to maximize efficacy and reduce the risk of reperfusion pulmonary injury. A total of 4 (2-8) sessions were performed in each patient, and the number of vessels dilated per session was 3 (1-14). The World Health Organization functional class improved from 3 to 2 (P<0.01), and mean pulmonary arterial pressure was decreased from 45.4 ± 9.6 to 24.0 ± 6.4 mm Hg (P<0.01). One patient died because of right heart failure 28 days after BPA. During follow-up for 2.2 ± 1.4 years after the final BPA, another patient died of pneumonia, and the remaining 66 patients are alive. In 57 patients who underwent right heart catheterization at follow-up, improvement of mean pulmonary arterial pressure was maintained (24.0 ± 5.8 mm Hg at 1.0 ± 0.9 years). Forty-one patients (60%) developed reperfusion pulmonary injury after BPA, but mechanical ventilation was required in only 4 patients. CONCLUSIONS: Our refined BPA procedure improves clinical status and hemodynamics of inoperable patients with chronic thromboembolic pulmonary hypertension, with a low mortality. A refined BPA procedure could be considered as a therapeutic approach for patients with inoperable chronic thromboembolic pulmonary hypertension.

Morphologically unique feature of recurrent ampulla (takotsubo) cardiomyopathy.

Two similar rare cases of recurrent ampulla (takotsubo) cardiomyopathy, which was induced by physical stress of recurrent rhabdomyolysis in case 1 and aggravation of respiratory disease in case 2, are presented. At the initial admission, both patients had typical ampulla cardiomyopathy, which was indicated by transient left ventricular (LV) apical ballooning, but at the second admission, they both had atypical ampulla cardiomyopathy, as diagnosed by transient basal midventricular ballooning. Electrocardiograms at each admission showed a specific T-wave inversion, which might indicate the region of LV asynergy, and prolongation of the QT interval. In both cases, the plasma level of endogenous catecholamines was high. It is possible that excessive sympathetic stimulation induced by physical stress was the cause of this cardiomyopathy, but the cause of the differences in wall motion abnormalities between the first and second admissions was not identified. Appropriate management and treatment of the underlying disease and determining the mechanisms of recurrent ampulla cardiomyopathy might prevent its recurrence.

Poor implementation of cardiac rehabilitation despite broad dissemination of coronary interventions for acute myocardial infarction in Japan: a nationwide survey.

BACKGROUND: The implementation of cardiac rehabilitation (CR) after acute myocardial infarction (AMI) has not been fully investigated in Japan, so a nationwide survey of hospitals was conducted. METHODS AND RESULTS: Questionnaires were sent in 2004 to a total of 1,875 hospitals in Japan, including all the 859 Japanese Circulation Society (JCS)-authorized cardiology-training hospitals (THs), 311 JCS-associated hospitals (AH), and 705 randomly sampled non-THs (NTHs). The response rate was 59% (1,106/1,875). The percentages of hospitals treating hospitalized AMI patients were 97% in 526 TH, 85% in 194 AH, and 20% in 339 NTH. Although the rates of implementation of emergency percutaneous coronary intervention were very high (92%, 56%, and 4%, respectively), the rates of implementation of recovery phase CR were low (20%, 8%, and 2%, respectively). In addition, patient education programs (23%, 13% and 2%) and formulated exercise prescriptions based on exercise testing (16%, 7% and 1%) were poorly implemented. More importantly, only 9%, 2% and 0% of these hospitals had outpatient CR programs. From these data, the nationwide participation rate in outpatient CR after AMI in Japan was estimated to be only 3.8-7.6%. CONCLUSION: This first nationwide survey demonstrated that, in contrast to the broad dissemination of acute phase invasive treatment for AMI, the implementation of recovery phase CR, especially outpatient CR, is extremely poor in Japan. In addition, patient education programs and exercise prescription based on exercise testing are only poorly implemented.

Relationships between depolarization abnormality and repolarization abnormality in patients with Brugada syndrome: using body surface signal-averaged electrocardiography and body surface maps.

INTRODUCTION: Repolarization and depolarization abnormalities have been reported to be related to Brugada syndrome. METHODS AND RESULTS: We evaluated the relationships between repolarization abnormality and depolarization abnormality using 48-lead unipolar signal-averaged electrocardiograms and 87-lead unipolar body surface maps in 15 patients with Brugada-type ECGs. Data were compared with those from healthy control subjects (n = 5) and within subgroups of Brugada syndrome with (n = 8) and without (n = 7) ventricular arrhythmias (VA) induced by programmed electrical stimulation (PES). Eighty-seven-lead body surface maps were recorded, and potential maps were constructed to evaluate elevation of the ST segment 20 ms after the J point. Forty-eight-lead signal-averaged ECGs were recorded, and isochronal maps of duration of the delayed potential (dDP) were constructed to evaluate the dDP in each lead. Potential maps showed that patients with Brugada-type ECG, especially those with VA induced by programmed electrical stimulation, had greater elevation of the ST segment in the right ventricular outflow tract, especially at E5. Isochronal maps of dDP in the Brugada-type ECG group showed that maximum dDP was located at E5 and that the area with long dDP was larger than that in the control subjects. The dDPs at E7, E5, F7, and F5 in the VA-inducible group were significantly longer than those in the VA-noninducible group. These results showed that the location of greater elevation in the ST segment coincided with the location of longer dDP. CONCLUSION: Repolarization abnormality and depolarization abnormality in the walls of both ventricles, especially in the right ventricular outflow tract, are related to the VA of Brugada syndrome.

Nicotine dependence and smoking cessation after hospital discharge among inpatients with coronary heart attacks.

This study focuses on the predictability of two alternative questionnaires for nicotine dependence, i.e., the Fagerstrom Tolerance Questionnaire (FTQ) and the Tobacco Dependence Screener (TDS), each of which represents a different aspect of dependence, among patients with coronary heart disease (CHD). Twenty-nine male inpatients that had been newly diagnosed as CHD were followed up for 30 weeks after hospital discharge. The baseline information included age, number of cigarettes per day, years of smoking, disease type (angina pectoris [AP] or acute myocardial infarction [AMI), whether they had received a briefing on smoking cessation, the FTQ, and the TDS. At 30 weeks after hospital discharge, 19 (66%) were abstainers. The group with a high TDS score (of 6 or greater) was significantly less likely to quit smoking than the group with a low TDS score (p=0.046). The FTQ score was not significantly different between the abstainers and non-abstainers. The subjects with AP were significantly less likely to quit smoking than those with AMI (p=0.021). Multiple logistic regression analysis showed that belonging to the high-TDS group and being diagnosed as AP were significantly associated with failure in smoking cessation (p<0.05). The present study suggests that the TDS may have higher predictability than the FTQ concerning smoking cessation among CHD inpatients.