Independent predictors of restenosis after percutaneous coronary revascularization in haemodialysis patients.

BACKGROUND: Percutaneous balloon angioplasty has become a well-established and routine procedure for coronary revascularization of haemodialysis patients with coronary artery disease. However, the incidence of restenosis after balloon angioplasty is significantly higher in haemodialysis patients than in the general population. We performed a retrospective study comparing balloon angioplasty with coronary stenting in haemodialysis patients. We evaluated the long-term clinical and angiographic outcome after successful percutaneous coronary revascularization in haemodialysis patients. METHODS: A total of 103 consecutive haemodialysis patients (123 lesions) underwent procedurally and clinically successful percutaneous revascularization. Patients were treated with three different strategies: (i) balloon angioplasty in 55 patients (69 lesions); (ii) coronary stenting with balloon angioplasty in 23 patients (25 lesions); and (iii) coronary stenting with rotational atherectomy in 25 patients (29 lesions) who had severely calcified stenotic coronaries. RESULTS: The rates of in-hospital mortality were similar in the three groups. The 1-year incidence of overall events and major adverse cardiac events (MACE) were significantly higher in the balloon group than in the stent with/without rotational atherectomy groups (75% vs 36 and 28%, P<0.01; 71% vs 32 and 28%, P<0.01). Use of coronary stenting (relative risk=0.006, P<0.001) and the presence of calcified coronary lesion (relative risk=68.2, P<0.001) were independent predictors of the 1-year MACE-free survival after percutaneous revascularization. The 3-year MACE-free survival rate was significantly lower in the balloon group than in the stent with/without rotational atherectomy groups (11% vs 33 and 47%, P<0.005 and P<0.001). CONCLUSIONS: This study shows that coronary stenting reduces the incidence of MACE in haemodialysis patients with/without calcified coronary lesions. Moreover, coronary stenting reduces the restenosis rate of both complex and restenotic lesions, and rotational atherectomy prior to coronary stenting reduces the restenosis rate of the severely calcified coronary lesions. These results suggest that coronary stenting with/without rotational atherectomy has led to an improved long-term outcome in the haemodialysis patients with coronary artery disease.

Coronary artery disease as a definitive risk factor of short-term outcome after starting hemodialysis in diabetic renal failure patients.

Cardiovascular disease is a major cause of morbidity and mortality in patients with diabetes who are receiving dialysis. It is known that cardiac mortality is high in the first year of hemodialysis (HD). The purpose of this study was to clarify the prevalence of coronary artery disease (CAD) in patients with diabetes at the initiation of HD, and to investigate the relationship between short-term outcomes after starting hemodialysis and CAD. We performed coronary angiography (CAG), whether or not patient had angina, within one month of initiation of maintenance HD in 17 of 34 consecutive unselected diabetic patients. We studied the two-year survival rate of those with CAD. Eleven patients (65%) were classified CAD-positive. Nine (82%) of these 11 had multivessel disease. Clinical and hematologic factors did not differ significantly between the groups with and without CAD. During the two-year follow-up period, 28 (82%) of 34 patients survived. In patients with CAD the two-year survival rate was 60%. None of the patients without CAD died within 2 years after starting HD. These results suggest that the presence of CAD at the initiation of HD may play a critical role in short-term outcomes after starting HD. We believe that an evaluation of CAD should be performed at the initiation of HD.

Evaluation of autonomic nervous function in patients with essential hypertension complicated with peptic ulcer.

BACKGROUND AND AIMS: The relationship between peptic ulcer, autonomic activity and the incidence of Helicobacter pylori infection in untreated hypertensive patients complicated with peptic ulcer were evaluated. METHODS: Ten hypertensive patients with peptic ulcer (HT-PU group), 15 untreated essential hypertensive patients without peptic ulcer (HT group) and 10 normal subjects (N group) were enrolled, and a power spectral analysis was performed in each subject. A biopsy urease test was used to detect infection by H. pylori. RESULTS: No significant differences were observed in the values of mean low-frequency (LF) power between the three groups. However, the mean high-frequency (HF) power in the HT-PU group was significantly greater than those of the HT and N groups (P<0.01). The mean LF/HF ratios in the HT-PU and HT groups were significantly greater than that of the N group (P<0.01). With respect to H. pylori infection, no significant differences between the three groups were observed. Sympathetic activity (LF power) was increased in the HT and HT-PU groups. Furthermore, parasympathetic activity (HF power) was increased in the HT-PU group. CONCLUSIONS: These findings suggest the participation of increased parasympathetic activity in peptic ulcer patients. Therefore, it is suggested that new techniques, such as spectral analysis of heart rate variability, as used in this study, will clarify the relationship between peptic ulcer and autonomic nervous function.

[Long-term outcome of coronary events in hemodialysis patients younger and older than 65 years of age].

BACKGROUND AND AIM: It has been reported that a coronary event is the leading cause of mortality in HD patients. The aim of this study was to examine and compare prospectively the effect of aging in relation to the in-hospital and the long-term outcome in HD patients with or without revascularization therapy who had experienced a coronary event. STUDY PATIENTS AND METHODS: Seventy consecutive HD patients with coronary events (9 AMI, 48 AP, and 13 CHF) were registered in this study and 69 patients underwent CAG. Patients were classified into elderly (> or = 65, n = 33) and younger (< 65, n = 37) groups based on their ages at the time of the events. Forty-six patients (21 vs 25) underwent initial coronary revascularization therapy. We followed 70 HD patients with coronary events for a mean period of 31 +/- 21 months (range: 1 day to 77 months). RESULTS: A level of 64% of the elderly group and 41% of the younger group experienced coronary events within the first year of HD. The diseased vessels (2.2 vs 1.9 per patient) and stenotic lesions (2.8 vs 2.5 pre patients) were not significantly different between the two groups. The 70-month survival rate was significantly lower (21% vs 65%, p = 0.0423) in the elderly group than in the younger group. The complicated rate of stroke after a major event was significantly higher (14 vs 4, p = 0.0025) in the elderly group than in the younger group. Moreover 21 elderly patients (11 cardiac death, 5 stroke, 4 cancer) and 9 younger patients (8 cardiac death, 1 stroke) died during the 70-month follow-up period. CONCLUSIONS: Coronary events were most frequent in the first year of HD. Long-term survival rate was significantly lower in elderly patients than in younger patients. Cardiac death was the most common cause of death in both groups regardless of performing coronary revascularization. Death due to stroke and cancer was also more common in elderly patients.

Assessment of autonomic nervous activity during gastrointestinal endoscopy: analysis of blood pressure variability by tonometry.

We continuously measured blood pressure by tonometry in 30 patients during endoscopy to determine the influence of upper gastrointestinal endoscopy on cardiac events. Patients were divided into two groups: one group treated with scopolamine butylbromide as premedication (SB group) and another group without premedication (C group). Time- and frequency domain analyses of beat-to-beat systolic blood pressure variability were performed for 128 consecutive beats. For time-domain analysis, we calculated the coefficient of variation of systolic blood pressure (CV(BP)). For the frequency domain analysis, we determined the low-frequency (LF(BP); 0.04-0.15 Hz) and high-frequency (HF(BP); 0.15-0.40 Hz) powers of the variation in systolic blood pressure and the ratio of LF(BP) to HF(BP) (LF(BP)/HF(BP)) during endoscopy. The CV(BP) and HF(BP), indicators of parasympathetic tone, increased in the early phase of endoscopy but decreased significantly in the middle and late phases compared with the pre-endoscopy value. The ratio of LF(BP)/HF(BP), an indicator of indirect sympathetic tone, increased throughout the endoscopic procedure. Moreover, premedication with scopolamine butylbromide prevents the excessive parasympathetic nervous reflex when an endoscope passes through the upper digestive tract and also brings both decreased parasympathetic tone and increased sympathetic tone at the late phase of endoscopic procedure. Our results indicate that gastrointestinal endoscopy induced an autonomic nervous abnormality, which may contribute to the occurrence of cardiac events during endoscopic procedures.

Autonomic nervous system activity during infusion of L-arginine in patients with liver cirrhosis.

Patients with liver cirrhosis exhibit a hyperdynamic circulatory state as evidenced by tachycardia and an increase in cardiac output accompanied by an elevation of sympathetic tone. This condition is due to the excessive release of nitric oxide (NO), an endogenous vasodilator, which is in turn related to the abnormal induction of NO synthase. The present study investigated whether the intravenous infusion of L-arginine, the precursor of NO, may cause a similar hyperdynamic circulatory state. A new method, the analysis of power spectrum heart rate variability, was used to evaluate autonomic nervous activity. Twenty patients with liver cirrhosis underwent continuous Holter monitoring of the ECG during the intravenous administration of L-arginine (10 g) (Fisher's solution) infused over 60 min. Power spectral analysis was computed from 512 beats of the Holter ECG data. Low frequency (LF; 0.04-0.15 Hz) and high frequency (HF; 0.15-0.40 Hz) spectral powers and the ratio of LF to HF (LF/HF) were calculated every 10 min before and after the infusion of L-arginine. The LF power, which reflects sympathetic tone modified by vagal tone, and the LF/HF, an indicator of sympathetic tone, were both significantly increased during the infusion (p<0.05). HF power, an indicator of parasympathetic tone, showed no significant change in the early stage of the infusion but was significantly increased in the late stage (p<0.05). The administration of L-arginine thus led to an elevation of sympathetic tone. Fisher's solution, which is administered to patients with hepatic insufficiency, contains L-arginine, and may also produce a hyperdynamic circulatory state as an adverse effect related to an elevation of the plasma level of NO by L-arginine. The monitoring of such patients is thus indicated.

[Studies of experimental model of reflux esophagitis in rats by ligature on both lower portion of duodenum and most of forestomach].

It has been well established that reflux of gastroduodenal contents causes reflux esophagitis. Experimental model of reflux esophagitis in rats was devised by 24hrs ligature on both lower portion of duodenum and most of forestomach. Erosion of esophageal mucosa and thickening of esophageal wall developed in macroscopic findings. Histologically, many neutrophils were found from lamina propria to muscular layer, mainly in lamina propria. Edema and thickening of submucosal layer developed in cases with 24hrs ligature. These severe inflammatory changes in submucosal layer suggested that it caused thickening of esophageal wall. Bile reflux was found in gastric contents of this model. No mucosal lesions were found in cases with ligature on lower portion of duodenum. Findings in this experimental model of reflux esophagitis suggested significant roles of gastric juice and bile acids in the pathogenesis of reflux esophagitis. This model was thought to be useful for studies of pathophysiology of reflux esophagitis caused by reflux of gastroduodenal contents.

Hemopneumothorax secondary to multiple cavitary metastasis in angiosarcoma of the scalp.

We report a case of hemopneumothorax secondary to multiple cavitary metastasis in the angiosarcoma of the scalp in an 86-year-old woman, who died of respiratory failure. At autopsy, multiple cavities were found in both lungs. Histologic specimen of the cavitary metastasis of the lung showed that tumor cells proliferated forming several tubular spaces and these tubular spaces seemed to communicate with the central cyst. These findings suggested that imperfect vessel-like structures of the cavitary metastasis are likely to break down and finally grow up to large thin-walled cavities.

Effect of the new calcium antagonist (+/-)-(R*)-3-[(R*)-1-benzyl-3- piperidyl] methyl 1,4-dihydro-2,6-dimethyl-4-(m-nitrophenyl)-3,5- pyridinedicarboxylate hydrochloride (KW-3049) on cardiac hypertrophy in spontaneously hypertensive rats.

Using spontaneously hypertensive rats (SHR), we studied the effects of a new calcium antagonist, (+/-)-(R*)-3-[(R*)-1-benzyl-3-piperidyl] methyl 1,4-dihydro-2,6-dimethyl-4-(m-nitrophenyl)-3,5-pyridinedicarboxylate hydrochloride (KW-3049) on the development of hypertension and cardiac hypertrophy. When KW-3049 was administered orally to 5-week-old SHR, a stage before the onset of hypertension, for 12 consecutive weeks, it showed a dose-dependent and marked antihypertensive action. Administration of 3 mg/kg of KW-3049, once a day, significantly suppressed the rise in blood pressure to a similar extent to 15 mg/kg of nicardipine, twice a day. After 12 weeks of administration, the heart weight was decreased or tended to be decreased. Co-administration with propranolol markedly decreased the heart rate, but little affected the heart weight, suggesting changes in the heart rate during the long-term administration of KW-3049 did not largely affect cardiac hypertrophy. KW-3049 did not increase plasma renin activity (PRA) or plasma aldosterone concentration (PAC). There was no significant change in the myocardial DNA and RNA contents. These results suggest the clinical usefulness of KW-3049 as an antihypertensive drug.

[Clinical experience with flomoxef in the pediatric field].

Flomoxef (FMOX, 6315-S) was given intravenously to 21 children with the following acute bacterial infections; 10 cases of bronchopneumonia, 3 cases each of purulent lymphadenitis and urinary tract infection, 2 cases of staphylococcal scalded skin syndrome and 1 case each of peritonsillar abscess, pyothorax and purulent meningitis. Good clinical responses were obtained in 18 out of 21 patients, and bacteriologically, all of the 17 isolated strains were eradicated. No side effect was observed except for 1 case with soft stool and 2 cases of eosinophilia. From the above clinical results, it is apparent that FMOX is a useful antibiotic for treating pediatric patients with various bacterial infections.