Miction-induced Hypertension Disclosed by Home Blood Pressure Measurement in a Patient with Small Paraganglioma.

A 46-year-old woman complained of a 10-year history of headache, nausea, a precordial oppressive feeling and shortness of breath on miction. She had noted a marked elevation in her blood pressure after miction using home blood pressure measurement. Her catecholamine levels were less than twice the value of the normal upper limit. Several imaging modalities detected a urinary bladder tumor, and 123I-metaiodobenzylguanidine scintigraphy showed positive accumulation. The diagnosis of urinary bladder paraganglioma was confirmed by partial cystectomy. We must keep in mind that paroxysms and hypertension associated with miction are important diagnostic clues of pheochromocytoma/paraganglioma. Home blood pressure measurement was very useful for detecting hypertension in this case.

Detection of restenosis after percutaneous coronary intervention in three major coronary arteries by transthoracic Doppler echocardiography.

BACKGROUND: The aim of this study was to evaluate the diagnostic potential of coronary flow velocity reserve (CFR) measurement by transthoracic Doppler echocardiography (TTDE) to detect restenosis in the 3 major coronary arteries: the left anterior descending coronary artery, right coronary artery, and left circumflex coronary artery. METHODS: The lesions of 175 patients who were scheduled for follow-up coronary angiography and TTDE 6 months after undergoing stents implantation were studied. CFR was assessed by TTDE in the targeted arteries into which stents had been implanted. RESULTS: Coronary stents were implanted in a total of 238 angiographic lesions in 175 patients. Doppler recordings of coronary flow in the 3 major arterial lesions were obtained in 211 of the 238 angiographic lesions (89% feasibility). CFR was significantly lower in lesions with restenosis than those without restenosis (1.70 +/- 0.32 vs 2.65 +/- 0.66, P < .01). A CFR value < 2.0 was 89% sensitive and 91% specific for detecting restenosis in the 3 major coronary arteries. Sensitivity and specificity were 86% and 91%, respectively, in the left anterior descending coronary artery (95% feasibility); 92% and 92%, respectively, in the right coronary artery (85% feasibility); and 91% and 92%, respectively, in the left circumflex coronary artery (81% feasibility). CONCLUSION: CFR assessment by TTDE is an accurate method for monitoring restenosis, not only in the left anterior descending but also in the right and left circumflex coronary arteries in patients previously subjected to percutaneous coronary intervention.

Análise comparativa do grau de liberdade rotacional e da integridade física das conexões protéticas de diferentes implantes com hexágono interno / Comparative rotational freedom and physical integrity analyses of internal hexagonal connections from different implant systems

Este estudo avalia e quantifica o grau de liberdade rotacional na interface implantes/componentes protéticos usinados, em implantes com hexágono interno de diferentes sistemas, com aplicação de torque controlado. Foram utilizados 75 conjuntos de amostras (implantes de hexágono interno, pilares protéticos preparáveis com altura gengival de 2 mm, com seu respectivo parafuso de retenção) de cinco marcas comerciais (Frialit, 3i, Conexão, SIN e Neodent). As dimensões das amostras de implantes variaram entre 4,0 mm a 4,5 mm de diâmetro externo por 13 mm de comprimento. Utilizou-se um dispositivo para avaliação da liberdade rotacional e um microscópio eletrônico de varredura (MEV) para verificação da integridade física das paredes internas dos hexágonos envolvidos, antes e após aplicação de torque controlado. Com as médias obtidas aplicamos os testes estatísticos com Anova e Tukey (p<0,05). Na análise ao MEV obteve-se registro de deformações tanto na parede interna do hexágono (deformações tipo arranhões), como também nos ângulos externos dos pilares protéticos (deformações tipo amassamento dos ângulos). Todos os grupos apresentaram média de desajuste rotacional inferior a 5º, indicando adequada estabilidade das conexões estudadas. Os valores médios individuais antes do torque foram: 3i (1,45º), Frialit (1,77º), Neodent (3,88º), SIN (3,95º), Conexão (4,23º), e após o torque obtivemos os seguintes valores: 3i (1,70º), Frialit (1,98º), SIN (4,20º), Neodent (4,28º), Conexão (4,52º). Não houve diferença estatisticamente significante na média de desajuste entre Frialit e 3i, tampouco entre Conexão, SIN e Neodent. Houve diferença na média, estatisticamente significante (p<0,05), na liberdade rotacional dos componentes Frialit e 3i quando comparada aos componentes Conexão, SIN e Neodent.

This study assessed and quantified the degree of rotational freedom at implant-abutment interfaces with internal hexagonal connections from different implant systems under controlled torque procedures. Seventy-five sets of samples (internal hexagon implants, custom prosthetic abutments with 2 mm collar height, and corresponding retention screws) from five manufacturers were used: Frialit, 3i, Conexão, Sin and Neodent. The dimensions of the implants samples ranged from .0 mm to 4.5 mm- diameter and 13 mm- length. A device for assessing rotation freedom was used, and scanning electron microscope (SEM) analysis performed to verifying physical integrity of internal hexagonal , before and after controlled torque. Statistical analysis was made with Anova and Tukey´s tests (p < 0.05). Under SEM analysis, deformations at internal hexagonal walls (scratch type) and also in external angles of prosthetic abutments (angular squeezing ) were recorded. All groups showed rotational misfit values lower than 5 degrees, pointing to adequate stability of studied connections. Iindividual mean values before torque were: 3i (1.45°), Frialit (1.77°), Neodent (3.88°), SIN (3.95°), Conexão (4.23°). After torque tightening, the following values were obtained: 3i (1.70°), Frialit (1.98°), SIN (4.20°), Neodent (4.28°), Conexão (4.52°). There were no statistically significant differences on rotational misfit between Frialit and 3i, neither between Conexão, SIN and Neodent. There was a statistically significant difference (p <0.05) on, rotational freedom of Frialit and 3i components when compared to Conexão, SIN and Neodent components.

Usefulness of a combination of systolic function by left ventricular ejection fraction and diastolic function by E/E' to predict prognosis in patients with heart failure.

Left ventricular (LV) ejection fraction (EF) was known as a conventional predictor of heart failure (HF). However, early transmitral flow velocity (E)/early diastolic velocity of mitral annulus (E') correlated well with LV end-diastolic pressure, and E/E' ratio >15 was an excellent predictor of adverse outcomes in patients with HF. This study was designed to determine the prognostic value of a new combined index, E/E' ratio and LVEF, in patients with HF. One hundred twenty-six consecutive patients hospitalized with HF underwent comprehensive echocardiographic-Doppler study when ready for discharge. Patients were divided into the 4 groups of group I (LVEF >40% and E/E' ratio <15), group II (EF >40% and E/E' ratio >or=15), group III (EF or=15). The ability of this index to determine the primary end point (rehospitalization for HF or cardiac death) was assessed. Patients with significant valvular disease were excluded. Of 126 patients, 110 met the inclusion criteria. Follow-up was complete for 108 of 110 patients at 351 +/- 252 days after discharge. There were 27, 30, 21, and 30 patients in groups I, II, III, and IV, respectively. There were 52 patients with the primary end point. On univariate analysis, E/E' ratio, group IV, E', and age were significant predictors. In multivariable analysis, the most powerful independent prognostic indicator of events was group IV (hazard ratio 12.6, 95% confidence interval 2.2 to 74.2, p = 0.005). In conclusion, a new index, a combination of LVEF and E/E' ratio, allowed the identification of patients at higher risk of readmission and cardiac death in patients with HF.

Relationship between longitudinal morphology of ruptured plaques and TIMI flow grade in acute coronary syndrome: a three-dimensional intravascular ultrasound imaging study.

AIMS: In this study, we investigated the relationship between longitudinal morphology reconstructed from pre-intervention intravascular ultrasound (IVUS) images and thrombolysis in myocardial infarction (TIMI) flow grade at initial angiograms in the acute phase of acute coronary syndrome (ACS). METHODS AND RESULTS: Our patient population comprised 72 ACS patients in whom we obtained successful reconstructed longitudinal images. On the basis of the site of the maximum aperture of rupture in the longitudinally reconstructed IVUS images, patients were divided into three groups: plaques with rupture in the proximal shoulder (proximal type; n = 28), mid-portion (mid-type; n = 18), and distal shoulder (distal type; n = 26) of the plaque. There were no differences in terms of coronary risk factors or the angiographic findings. The proximal-type group more frequently showed TIMI 0 on initial angiogram (proximal type, 86%; mid-type, 50%; and distal type, 31%; P = 0.002). A multivariable logistic regression model revealed that the presence of a proximal-type rupture correlated with the presentation of ST-elevation myocardial infarction (P = 0.019; odds ratio, 8.12; 95% CI, 1.404-49.996). CONCLUSIONS: Longitudinal morphological features in a ruptured plaque may affect the formation of obstructive thrombus in ACS. Our results suggest that longitudinal morphology may be an important determinant of coronary artery occlusion.

Prevalence and clinical course of the juveniles with Brugada-type ECG in Japanese population.

BACKGROUND: Although many studies on Brugada syndrome have been done, with many reports of genetic findings and clinical features, little evidence exists to support the role of this syndrome in sudden cardiac death in a juvenile population. We sought to determine the prevalence and clinical course in children exhibiting Brugada-type ECG in a community-based population. METHODS: Our study population comprised 21,944 subjects (11,282 boys and 10,662 girls) who underwent ECG during their first-year elementary school health examinations between 1992 and 2001 in Izumi City, Osaka. Brugada-type ECG was defined as demonstrating ST-segment elevation (coved or saddle-back type, J wave amplitude > or =0.2 mV) in the right precordial leads. We also divided Brugada-type ECGs into three types according to a consensus report. Type 1: coved ST-segment elevation displaying high J wave amplitude followed by a negative T wave; Type 2: high take-off and gradually descending ST-segment elevation (remaining > or =1 mm) followed by a positive or biphasic T wave; and Type 3: ST-segment elevation of <1 mm of both types. RESULTS: Four subjects showed Brugada-type ECG (0.02%) (2 boys and 2 girls). Only one subject, a girl, met Type 1 criteria (0.005%). No history of structural heart disease was documented in these four subjects. During 6.8 +/- 1.0 years of follow-up, no episode of unexpected sudden death, syncopal attack, and fatal arrhythmia occurred. CONCLUSIONS: The prevalence of Brugada-type ECG in a juvenile population was extremely low. To investigate when the typical Brugada-type ECG might be manifested, it could be necessary to check ECGs after adolescence.

Multiple plaque rupture and C-reactive protein in acute myocardial infarction.

OBJECTIVES: This study sought to investigate the relationship between multiple plaque ruptures, C-reactive protein (CRP), and clinical prognosis in acute myocardial infarction (AMI). BACKGROUND: Several studies have demonstrated that ruptured or vulnerable plaques exist not only at the culprit lesion but also in the whole coronary artery in some acute coronary syndrome (ACS) patients. Recent studies have reported that a ruptured plaque at the culprit lesion is associated with elevated CRP, which indicates a poor prognosis in patients with ACS. METHODS: We performed intravascular ultrasound in 45 infarct-related arteries and another 84 major coronary arteries in 45 first AMI patients. RESULTS: Plaque rupture was observed in 21 patients (47%) at the culprit site. Intravascular ultrasound revealed 17 additional plaque ruptures at remote sites in 11 patients (24%). Patients with multiple risk factors were more frequently found in our multiple-plaque rupture patients compared with single-plaque rupture or nonrupture patients (82% vs. 40% vs. 29%, p = 0.01). High-sensitive CRP levels had a positive correlation with the number of plaque ruptures (p < 0.01). All culprit lesions were successfully treated by percutaneous coronary intervention. Patients with multiple plaque rupture showed significantly poor prognosis compared with others (p = 0.01). CONCLUSIONS: Multiple plaque rupture is associated with systemic inflammation, and patients with multiple plaque rupture can be expected to show a poor prognosis. Our results suggest that AMI treatment should focus not only on stabilization of the culprit site but also a systemic approach to systemic stabilization of the arteries.

Circadian variation of plaque rupture in acute myocardial infarction.

Studies have reported a circadian variation in the onset of acute myocardial infarction (AMI). Pathologic studies have revealed that plaque rupture is 1 of the major causes of AMI, but none of these has looked specifically at the circadian variation of plaque rupture. The aim of this study was to use intravascular ultrasound (IVUS) to investigate the circadian variation of plaque rupture in AMI. This study included 174 consecutive patients with AMI who underwent preinterventional IVUS. All patients were assigned to either a rupture group or a nonrupture group according to the preinterventional IVUS. In the 81 patients (47%) in the rupture group, the frequency of the onset of AMI increased significantly in the period from 6 A.M. to 12 P.M. compared with all other time periods (p <0.05). The clinical features of AMI in the rupture group were characterized as occurring significantly more at rest (67% vs 31%, p <0.01) and after significantly less preinfarction angina (22% vs 57%, p <0.01) compared with the nonrupture group. A different circadian variation was identified in the nonrupture group, characterized as a significant nocturnal nadir (12 to 6 A.M. compared with all other periods, p <0.05). The circadian variation of AMI is the result of a morning increase in incidence of plaque rupture.

In-stent restenosis and lesion morphology in patients with acute myocardial infarction.

We investigated the correlation between lesion morphology with preintervention intravascular ultrasound and in-stent restenosis in 72 patients with acute myocardial infarction (AMI). Multivariate logistic regression analysis showed that the presence of ruptured plaque was the only predictive factor of in-stent restenosis after primary stenting for AMI.

C-reactive protein and lesion morphology in patients with acute myocardial infarction.

BACKGROUND: Elevated serum C-reactive protein (CRP) is of clinical significance in the management of acute coronary syndromes, but there have been few in vivo studies detailing the relation between lesion morphology and elevated CRP in the setting of acute myocardial infarction (AMI). In this study, we investigated the relation between lesion morphology as seen under preintervention intravascular ultrasound (IVUS) and CRP in the acute phase of AMI. METHODS AND RESULTS: Our patient population comprised 90 consecutive patients with AMI who underwent preintervention IVUS within 6 hours of the onset of symptoms. Patients were divided into an elevated CRP group (> or =3 mg/L) or a normal CRP group on the basis of serum CRP levels. There were no differences in patient characteristics or angiographic findings. We observed significantly more plaque rupture in the elevated CRP group than in the normal CRP group (70% versus 43%, P=0.01). A multivariate logistic regression model revealed that the presence of ruptured plaque alone correlated with elevation of serum CRP (P=0.02; odds ratio, 3.35; 95% CI, 1.22 to 9.18). CONCLUSIONS: Elevated CRP may be related to the presence of ruptured plaque. Our results suggest that in the setting of AMI, elevated CRP levels may reflect the inflammatory activity of a ruptured plaque.

Predicting angiographic distal embolization following percutaneous coronary intervention in patients with acute myocardial infarction.

The aim of this study was to investigate the relation between lesion morphology identified by intravascular ultrasound (IVUS) before intervention and angiographic distal embolization after percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI). PCI for AMI has already been established as beneficial therapy, although some complications remain unresolved. Distal embolization is 1 of the important complications of PCI. Recently, some new devices have been developed for the prevention of distal embolization. However, few studies exist that look into the relation between lesion morphology and distal embolization. IVUS was performed safely in 140 consecutive patients with AMI before coronary intervention. No patient received thrombolytic therapy. From the incidence of angiographic distal embolization, patients were divided into 2 groups--an embolization group and a nonembolization group--and clinical background, IVUS, and angiographic information were evaluated. Distal embolization was observed in 12 patients (9%). Peak creatine kinase levels (3,877 +/- 2,285 vs 2,293 +/- 1,792 IU/L, p <0.05) and the incidence of angiographic thrombus (25% vs 5%, p <0.05) and intracoronary mobile mass detected by IVUS (75% vs 16%, p <0.001) were higher for patients in the embolization group. From the multivariate logistic regression analysis, only an intracoronary mobile mass detected by IVUS emerged as a predictor of distal embolization (odds ratio 53, 95% confidence interval 2.7 to 1,040, p <0.01). Patients with an intracoronary mobile mass detected by IVUS are prone to distal embolization after PCI and larger infarction. IVUS imaging before PCI may be useful for determining which patients need a distal protection device.

No-reflow phenomenon and lesion morphology in patients with acute myocardial infarction.

BACKGROUND: The no-reflow phenomenon is associated with poor functional and clinical outcomes for patients with acute myocardial infarction (AMI). In the era of primary intervention, accurately identifying lesions at high risk of no reflow is of crucial importance. At present, no study into the relationship between lesion morphology and no reflow has been performed. The aim of this study was to investigate the relationship between preintervention intravascular ultrasound (IVUS) lesion morphology and the no-reflow phenomenon. METHODS AND RESULTS: This study comprised 100 consecutive patients with AMI who underwent preintervention IVUS and were successfully recanalized with primary balloon angioplasty or stenting. IVUS was again performed to identify and exclude any mechanical vessel obstruction in cases of thrombolysis in myocardial infarction flow grade 0, 1, or 2 after intervention in the absence of angiographic stenosis. Angiographic no reflow was seen in 13 patients (13%). Univariate analysis indicated that hypercholesterolemia, fissure and dissection, lipid pool-like image, lesion, and reference external elastic membrane cross-sectional area correlate with the no-reflow phenomenon. Multivariate logistic regression analysis showed that lipid pool-like image (P<0.05; odds ratio 118; 95% CI, 1.28 to 11 008) and lesion elastic membrane cross-sectional area (P<0.05; odds ratio 1.55; 95% CI 1.01 to 2.38) are independent predictive factors of no-reflow phenomenon after reperfusion for AMI. CONCLUSIONS: Large vessels with lipid pool-like image are at high risk for no reflow after primary intervention for AMI. Also, plaque content may play a role in damage to the microcirculation after primary intervention for AMI.

Use of preintervention intravascular ultrasound in patients with acute myocardial infarction.

This study was designed to determine whether preintervention intravascular ultrasound (IVUS) imaging can assist in predicting the likelihood of acute coronary occlusion after primary angioplasty. Primary angioplasty is in widespread use for the treatment of acute myocardial infarction (AMI), although its usefulness is sometimes compromised by postprocedural acute coronary occlusion. If preintervention IVUS could be used to predict acute coronary occlusion, the task of determining treatment strategies for AMI would be significantly eased. Preintervention IVUS was performed without complications in 46 patients with AMI using manually prepared contrast medium. Coronary angiography was performed 1 hour after successful percutaneous transluminal coronary angioplasty. Acute coronary occlusion was seen in 13 of 46 patients (28%). There were no differences in the clinical characteristics and angiographic results between the patients with and without occlusion. In patients with acute occlusion, the incidence of eccentric plaque (85% vs 36%, p <0.01) and echolucent area (92% vs 15%, p <0.01) was significantly higher than in the occlusion-free patients. Most of the echolucent areas were associated with eccentric plaques (88%). Eccentric plaques characterized by echolucent areas are prone to acute occlusion after primary balloon angioplasty for AMI. Preintervention IVUS is both a safe and a useful adjunct to primary angioplasty.