The prevalence and risk factors of microalbuminuria in hypertensive patients under current medical treatment.

OBJECTIVE: A link between urinary albumin excretion and an increased incidence of cardiovascular mortality has already been demonstrated. However, the reported prevalence of microalbuminuria (MAU) in patients with hypertension is highly variable. We therefore aimed to conduct a cross-sectional multicenter study to investigate the prevalence of urinary albumin excretion in treated hypertensive patients in our current practice. METHODS: A total of 1,258 hypertensive patients were enrolled in this study. Patients with macroalbuminuria were excluded. The concentrations of urinary microalbumin and creatinine were measured. Urinary albumin excretion was expressed as the ratio of albumin to creatinine excretion. RESULTS: The mean systolic and diastolic blood pressures were 130.9±12.7 mmHg and 74.7±8.9 mmHg, respectively. The overall prevalence of MAU was 42.8%, and it was observed in 35.8% of patients treated with a single medication. Patients with polyvascular disease exhibited a higher prevalence of MAU compared with patients with monovascular disease. The factors related to the presence of MAU included the estimated glomerular filtration rate (eGFR), systolic blood pressure, and glycated hemoglobin (HbA1c) level (odds ratios [ORs] of 0.988, 1.026, and 1.371, respectively). CONCLUSION: The present study showed that the prevalence of MAU among hypertensive patients was 42.8%, even in patients whose blood pressure was relatively well controlled. Additionally, the eGFR, systolic blood pressure, and HbA1c level are risk factors for the development of MAU. These findings suggest that a substantial number of hypertensive patients have MAU and highlight the importance of strictly controlling these factors to improve patient prognosis.

Higher body mass index at the time of acute myocardial infarction is associated with a favorable long-term prognosis (8-year follow-up).

Obesity is an important public health problem, especially among patients with cardiovascular disease. However, little is known about the impact of obesity on the long-term prognoses of patients with acute myocardial infarction (AMI). Major adverse cardiac and cerebrovascular events (MACCE) consist of all causes of death, stroke, target lesion revascularization, target vessel revascularization, non-fatal myocardial infarction, and hospitalization. From January 2001 to March 2005, we analyzed 121 patients who survived >30 days after suffering their first AMI of the left anterior descending artery for MACCE. The mean follow-up period for this study was 59 ± 26 months. Seventy-five patients presented with normal weight (BMI <25 kg/m(2)) and 46 were obese (BMI >25 kg/m(2)). During the follow-up period, 56 patients presented MACCE, including 18 deaths, 11 strokes, and seven non-fatal myocardial infarctions. Normal weight was significantly associated with the occurrence of MACCE (p = 0.012). Grouping of the patients by BMI and homeostasis model assessment ratio (HOMA-R) indicated that the combination of a higher BMI (>25) and lower insulin resistance (HOMA-R < 2.0) provided the best prognosis (p = 0.0006). Kaplan-Meier curves stratified to the four groups, sorted by diabetes mellitus and BMI at admission, showed that the normal weight patients with diabetes mellitus presented the highest risk of MACCE (p < 0.0001). Patients with higher BMI and no insulin resistance or diabetes mellitus present better long-term outcomes following anterior AMI.

Stent deformation: an experimental study of coronary ostial stenting.

OBJECTIVES: To investigate stent deformation by torsional stress after implantation at the ostium of a model coronary artery. BACKGROUND: Little is known about coronary stent deformation, especially the association between stent design and deformation at the coronary ostium. Recent reports have suggested that mechanical factors are important for stent restenosis. METHODS: A coronary ostium model was constructed and three different stents (Express(2), Cypher, and Tsunami, n=5 each) were implanted at the aorto-ostial junction. Differences of stent deformation were assessed after exposure to torsional stress. Intravascular ultrasound was used to measure the luminal area along each stent. Then the extent and pattern of plastic deformation were compared between the three stent types. RESULTS: The Express(2) stents and Cypher stents both showed significant deformation (P<.0001 and P=.045, respectively) adjacent to the ostium, whereas only a minimal decrease of luminal area was observed with the Tsunami stent. In the central and distal parts of each stent, the decrease of luminal area was minimal and no differences were noted among the three types. Sudden fracture of a Cypher stent strut occurred during the experiment. CONCLUSION: Differences of structural characteristics influence permanent plastic deformation at sites where continuous stress occurs, such as the coronary ostium. A more elastic design may show better resistance to such stress.

Stent fracture in the left brachiocephalic vein.

A 68-year-old male hemodialysis patient presented with severe congestion in his left arm. Left arm venography showed a completely occluded left brachiocephalic vein. We chose a self-expandable stent for treating this vein. However, restenosis occurred once at 8 months and again after six additional months. The cause of the restenosis was considered to be a stent fracture. On the first restenosis, we performed redilation with a balloon; on the second restenosis, we chose stent-in-stent with a balloon-expandable stent. At least 9 months after the stent-in-stent procedure, there has been no edema in his left arm. Therefore, stent-in-stent is one of the useful strategies for stent fracture in central venous obstruction.

Improvement of postprandial hyperglycemia has a positive impact on epicardial flow of entire coronary tree in acute coronary syndromes patients.

BACKGROUND: Recent studies have shown that a global flow abnormality affects the entire coronary tree in patients with acute coronary syndrome (ACS), and that it is associated with adverse outcomes. Postprandial hyperglycemia is also thought to promote coronary endothelial dysfunction, as well as the release of inflammatory and vasoconstrictive factors. This study used the corrected Thrombolysis In Myocardial Infarction frame count (CTFC) to investigate whether optimal control of postprandial hyperglycemia improves pan-coronary flow. METHODS AND RESULTS: Eighty ACS patients with postprandial hyperglycemia who had successful coronary intervention and who had undergone a 75-g oral glucose tolerance test (OGTT) were included. A second OGTT and angiogram were performed 8 months after procedures. The patients were divided according to postprandial glycemia after the second 75-g OGTT; optimal postprandial hyperglycemia was defined as a 2-h blood glucose concentration <7.8 mmol/L. Changes in the CTFC of culprit/non-culprit arteries, glucose response, and other clinical variables were compared. Forty patients improved to an optimal control at 8 months. In the culprit artery, the 8-month angiogram revealed a significantly improved CTFC among those with optimal control compared with the initial angiogram (30+/-9 vs 24+/-12, p<0.05). In contrast, the CTFC was not evidently improved among patients with suboptimal control. The CTFC at 8 months had thus obviously improved more in patients with optimal, than with suboptimal control (24+/-12 vs 30+/-11, p<0.05). CONCLUSION: Optimal control of postprandial hyperglycemia improves epicardial blood flow in both arteries and this beneficial effect might be from improved coronary endothelial function.

Insulin resistance and acute coronary syndrome in the young Japanese population have a strong association.

There are few data regarding acute coronary syndrome (ACS) in young Japanese patients. We examined the risk factors for ACS in young Japanese patients, especially impaired glucose metabolism. From a database of 789 consecutive patients admitted to our hospital with ACS between 2000 and 2005, we compared risk factors of patients divided into two age categories: < or =45 years (group Y, n = 41) and > or =46 years (group O, n = 748). All patients in group Y were male. Overt diabetes, hypertension, and a family history of ischemic heart disease were not so important to group Y. Higher triglyceride (160.5 +/- 86.0 vs 133.9 +/- 75.2 mg/dl, P = 0.0296) and lower high-density lipoprotein cholesterol (43.9 +/- 12.1 vs 48.7 +/- 13.5 mg/dl, P = 0.027) concentrations were present in group Y. We obtained data concerning insulin resistance in 326 of 789 patients. Although the incidence of impaired glucose tolerance was similar between the groups (31% vs 31%, not significant), a higher homeostasis model assessment insulin resistance index (2.26 +/- 2.03), indicating insulin resistance, was present in group Y. Insulin resistance might be correlated with the development of ACS in the young adult Japanese population.

Impact of statin therapy on coronary intervention for non-ST elevation acute coronary syndrome with decreased low-density lipoprotein cholesterol.

OBJECTIVES: The benefits of treating patients with acute coronary syndrome (ACS) with statins are well established. This study investigated the effects of statins on patients who presented with low levels of low-density lipoprotein (LDL) cholesterol, were diagnosed with non-ST elevation ACS, and subsequently underwent percutaneous coronary interventions (PCI). METHODS: From 2000 to 2003, 87 patients(mean age 68 +/- 10 years, 69 males, 18 females) underwent PCI because of non-ST elevation ACS, and had low LDL cholesterol on presentation. These patients were divided into two groups: those who had been taking statins (S-group, n = 46), and those not taking statins, or controls (C-group, n = 41). Only patients whose LDL cholesterol was < 100 mg/dl at admission (average: 82 +/- 12 mg/dl) were included in the study. Troponin-T (TnT), creatine kinase (CK), CK-MB, and high-sense C reactive protein (hs-CRP) were measured before and 6 hr after PCI. The two groups were evaluated at 6 months clinical follow-up. RESULTS: There was no difference in these markers before PCI in both groups. TnT and CK-MB in the S-group at 6 hr post-PCI were significantly decreased compared to those of the C-group (0.45 +/- 1.34 vs 1.40 +/- 2.37 ng/ml, respectively, for TnT, p = 0.04; 17.2 +/- 45.5 vs 81.3 +/- 157.2 IU/l, respectively, for CK-MB, p = 0.02). Major adverse cardiac events (MACE) defined as death, myocardial infarction, congestive heart failure and target lesion revascularization were evaluated after 6 months. There was no difference in MACE between the two groups. CONCLUSIONS: Statin treatment before PCI in patients with non-ST elevation ACS demonstrated beneficial effects such as less myocardial damage, even though both groups presented with low LDL cholesterol levels. However, no significant effect on MACE was seen at 6 months after PCI.

Ultrasound attenuation behind coronary atheroma without calcification: mechanism revealed by autopsy.

When performing intravascular ultrasound studies, the backward echo image can show marked attenuation, although there are no calcified deposits and it may be impossible to detect the intraplaque architecture. The pathology underlying this phenomenon was investigated in autopsy specimens. We hypothesize that the mechanism responsible for the attenuation involves micro-calcification and lipid in unstable plaques causing ultrasonic wave reflection and dispersion.

An example that presented giant aneurysm of the angina pectoris after percutaneous coronary intervention.

We present the case of a 70-year-old woman who was admitted to our hospital with heart failure due to a giant left ventricular aneurysm involving the apex and severe mitral regurgitation. Three months before the hospitalization, percutaneous coronary intervention was performed for severe stenosis of the left main trunk. During the procedure, there were no abnormalities of distal coronary flow due to problems like embolization, and repeat coronary angiography, performed after stabilization of heart failure, showed no new significant stenosis. We diagnosed her condition as a subepicardial aneurysm by pathological examination of the resected specimen.

Comparison of coronary arterial finding by intravascular ultrasound in patients with "transient no-reflow" versus "reflow" during percutaneous coronary intervention in acute coronary syndrome.

Previous studies have shown that transient no-reflow during coronary intervention but with Thrombosis in Myocardial Infarction (TIMI) grade 3 flow at the completion of the procedure is associated with increased in-hospital and 6-month mortality. We hypothesized that the use of intravascular ultrasound before intervention could identify morphologic features that were predictive of transient no-reflow in patients who had acute coronary syndrome (ACS). We analyzed 220 patients with ACS who had suitable intravascular ultrasound images that were acquired before intervention. We defined "transient no-reflow" as TIMI grade 0, 1, or 2 flow during the procedure and TIMI grade 3 flow at the completion of the procedure. We defined "reflow" as good coronary flow (TIMI grade 3 flow) during and after the procedure. Patients were categorized to a transient no-reflow group (n = 20) or a reflow group (n = 200). In the transient no-reflow group, vessel area and amount of plaque burden in the culprit lesion were significantly greater than in the reflow group (vessel 20.8 +/- 5.4 vs 16.4 +/- 6.2 mm(2), p < 0.01; plaque burden 0.90 +/- 0.03 vs 0.83 +/- 0.08, p < 0.001). The presence of ruptured plaque, lipid pool-like images, and thrombus formation were significantly higher in the transient no-reflow group than in the reflow group. Multivariate analysis identified the presence of thrombus formation (odds ratio 4.53, 95% confidence interval 1.03 to 20.0, p = 0.04) and larger plaque burden (odds ratio 1.79, 95% confidence interval 1.01 to 3.23, p = 0.05) as independent predictors of transient no-reflow. In conclusion, lesion morphologies are different for transient no-reflow and reflow. These findings suggest that the presence of thrombus formation and large plaque burden increase the risk for developing transient no-reflow during coronary intervention for ACS.

Fate of unprotected side branches as related to embolic complications during stent implantation for acute coronary syndromes using a distal protection procedure.

Coronary lesion stenting with aspiration and distal balloon occlusion is more often associated with embolic occlusion of interposed side branches when the branch arises at an angle of

Chronic stent recoil plays an important role in restenosis of the right coronary ostium.

OBJECTIVE: The efficacy of coronary stenting of aorto-ostial atherosclerotic lesions is still unclear. We investigated the frequency and mechanism of stent restenosis at this particular lesion. METHODS: Fifty-five consecutive patients with 64 native aorto-ostial lesions in the right coronary artery (RCA, n = 38) and the left main trunk (LM, n = 26) were treated by conventional stenting. Determinants of angiographic restenosis were established. The mechanism of stent restenosis was evaluated using post-stenting and follow-up intravascular ultrasound (IVUS) findings. RESULTS: Restenosis was more frequent in the RCA than in the LM (50% compared with 19%, P < 0.03) and determinants included diabetes mellitus (63% compared with 21%, P < 0.03), calcium deposition (58% compared with 5%, P < 0.003), smaller stent cross-sectional area (SA) (as demonstrated by post-stenting IVUS studies, 8.1 +/- 1.4 mm compared with 10.2 +/- 2.2 mm, P < 0.01), larger plaque burden (64 +/- 6% compared with 57 +/- 8%, P < 0.03) and less circular expansion at the aorto-coronary junction. Serial IVUS examination was performed in 11 patients with restenosis of the right coronary ostium. The mean reduction in the SA was 21% at the aorto-coronary junction (6.4 +/- 1.9 mm, P < 0.003), whereas the SA at the distal edge was unchanged. Thirty-three per cent of late luminal loss was due to chronic stent recoil. CONCLUSION: These findings suggest that stenosis of the right coronary ostium is a high-risk lesion for stent restenosis. In addition to excessive intimal growth, chronic stent recoil might be an important etiologic factor at this particular location.

Insulin resistance in nondiabetic patients is associated with expansive remodeling in coronary arterial lesions.

OBJECTIVE: Insulin resistance has been implicated as an important initiating factor in coronary atherosclerosis. However, associations between insulin resistance and specific morphologic features of atherosclerotic coronary arteries remain unclear. We ultrasonographically evaluated the morphologic features of atherosclerotic coronary arteries in nondiabetic patients with insulin resistance. METHODS: Before intervention, 90 patients with 105 culprit lesions underwent intravascular ultrasound examination through which vessel area, lumen area and plaque area were evaluated. Expansive remodeling (lesion vessel area more than 5% greater than at the proximal reference segment) and constrictive remodeling (lesion vessel area more than 5% less than at the distal reference segment) were also evaluated. Insulin resistance was determined by homeostasis model assessment and defined as values above the 75th percentile (that is, 1.71). RESULTS: Insulin-resistant patients numbered 23, while nonresistant patients numbered 67. Culprit lesions in the insulin-resistant group showed larger vessel area (18.16 +/- 6.94 compared with 13.64 +/- 4.28 mm, P = 0.0001) and plaque area (16.64 +/- 6.78 compared with 12.05 +/- 4.12 mm, P = 0.0001) and more frequently showed expansive remodeling (56% compared with 14%, P < 0.0001) and calcific plaque (33% compared with 12%, P = 0.01). Multivariable logistic regression analysis identified only insulin resistance (odds ratio, 4.9, P = 0.008) as an independent predictor of expansive remodeling. CONCLUSIONS: Insulin resistance independently predicted expansive remodeling, underscoring the importance of insulin resistance in coronary atheroscrelosis.

A case of acute myocardial infarction treated with a new thrombectomy system.

Thrombotic occlusion in the culprit lesion of acute myocardial infarction was successfully recanalized using a 4.5 Fr thrombectomy catheter (RESCUE), which was also used to normalize the coronary blood flow. The retrieved specimens were white thrombi containing red thrombi and cholesterol crystals, indicating plaque rupture.