Diagnostic accuracy and clinical usefulness of erythrocyte creatine content to predict the improvement of anaemia in patients receiving maintenance haemodialysis.

BACKGROUND: The improvement of anaemia over time by erythropoiesis stimulating agent (ESA) is associated with better survival in haemodialysis patients. We previously reported that erythrocyte creatine content, a marker of erythropoietic capacity, was a reliable marker to estimate the effectiveness of ESA. The aim of this study was to examine the accuracy and clinical usefulness of erythrocyte creatine content to predict the improvement of anaemia in haemodialysis patients. METHODS: ESA dose was fixed 3 months prior to the enrollment and was maintained throughout the study period. Erythrocyte creatine content and haematologic indices were measured at baseline in 92 patients receiving maintenance haemodialysis. Haemoglobin was also measured 3 months after. Improvement of anaemia was defined as ≥ 0.8 g/dL change in haemoglobin from baseline to 3 months. RESULTS: Erythrocyte creatine content was significantly higher in 32 patients with improvement of anaemia compared to 60 patients with no improvement of anaemia (2.47 ± 0.74 vs. 1.57 ± 0.49 µmol/gHb, P = 0.0001). When 9 variables (erythrocyte creatine content, ESA dose, reticulocyte, haptoglobin, haemoglobin at baseline, serum calcium, intact parathyroid hormone, transferrin saturation and serum ferritin) were used in the multivariate logistic regression analysis, erythrocyte creatine emerged as the most important variable associated with the improvement of anaemia (P = 0.0001). The optimal cut-off point of erythrocyte creatine content to detect the improvement of anaemia was 1.78 µmol/gHb (Area under the curve: 0.86). Sensitivity and specificity of erythrocyte creatine content to detect the improvement of anaemia were 90.6% and 83.3%. CONCLUSION: Erythrocyte creatine content is a reliable marker to predict the improvement of anaemia 3 months ahead in patients receiving maintenance haemodialysis.

Type A aortic dissection with left coronary malperfusion.

Left coronary artery malperfusion is a fatal complication of acute type A aortic dissection. However, effective treatment strategies have not yet been established. Herein, we report two cases of left coronary artery malperfusion successfully treated with different preoperative catheter interventions, followed by a central aortic repair. Preoperative coronary intervention ensuring the blood flow to the left coronary artery might be essential if a coronary angiogram was performed prior to the diagnosis and treatment.

Evaluation of recombinant human erythropoietin responsiveness by measuring erythrocyte creatine content in haemodialysis patients.

BACKGROUND: One of the main causes of anaemia in patients with end-stage renal disease is relative deficiency in erythropoietin production. Eythropoiesis stimulating agent (ESA), a potent haematopoietic growth factor, is used to treat anaemia in haemodialysis patients. The effect of ESA is usually assessed by haematological indices such as red blood cell count, haemoglobin concentration and haematocrit, but erythrocyte indices do not provide information of the rapid change in erythropoietic activity. As erythrocyte creatine directly assess erythropoiesis, the aim of this study was to evaluate the effect of ESA in haemodialysis patients by measuring the erythrocyte creatine content. METHODS: ESA dose was fixed 3 months prior to the enrollment and was maintained throughout the entire study period. Erythrocyte creatine was measured with haematologic indices in 83 haemodialysis patients. Haemoglobin was also measured 3 months after. RESULTS: ESA dose (152.4 ± 62.9 vs. 82.2 ± 45.5 units/kg/week, P = 0.0001) and erythrocyte creatine (2.07 ± 0.73 vs. 1.60 ± 0.41 µmol/gHb, p = 0.0003) were significantly higher in 27 patients with haemoglobin <10 g/dL compared to 56 patients with haemoglobin ≥10 g/dL. There was a fair correlation between ESA dose and the concentration of creatine in the erythrocytes (r = 0.55, P < 0.0001). Increase in haemoglobin (>0.1 g/dL) was observed in 37 patients, whereas haemoglobin did not increase in 46 patients. Erythrocyte creatine levels were significantly higher in those patients with an increase in haemoglobin compared to those without (2.04 ± 0.64 vs. 1.52 ± 0.39 µmol/gHb, p < 0.0001). When 8 variables (ESA dose, erythropoietin resistance index, C-reactive protein, intact parathyroid hormone, iron supplementation, presence of anaemia, erythrocyte creatine and reticulocyte) were used in the multivariate logistic analysis, erythrocyte creatine levels emerged as the most important variable associated with increase in haemoglobin (Chi-square = 6.19, P = 0.01). CONCLUSION: Erythrocyte creatine, a useful marker of erythropoietic capacity, is a reliable marker to estimate ameliorative effectiveness of ESA in haemodialysis patients.

Combined analysis of multislice computed tomography coronary angiography and stress-rest myocardial perfusion imaging in detecting patients with significant proximal coronary artery stenosis.

OBJECTIVE: Multislice computed tomography (MSCT) coronary angiography (CAG) is limited in detecting significant coronary artery stenosis because of its low specificity and positive predictive value. Stress-rest myocardial perfusion imaging (MPI) can detect myocardial ischemia. The aim of this study was to evaluate the diagnostic accuracy of detecting patients with proximal coronary artery disease for coronary intervention by combined analysis of MSCT-CAG and MPI. METHODS: MSCT-CAG, MPI, and CAG were performed in 125 patients with chest pain suggestive of coronary artery disease. A significant proximal coronary artery stenosis was defined as > or = 75% stenosis by MSCT and CAG. Myocardial ischemia was defined as reversible defect by MPI. Patients were defined as having coronary artery disease with a significant coronary stenosis by CAG. RESULTS: Seventy-four patients had a significant proximal coronary artery stenosis by MSCT. Of the 74 patients with a coronary artery stenosis by MSCT, 50 (67.6%) patients had a significant proximal coronary artery stenosis by CAG. In contrast, 50 (98.0%) of 51 patients without coronary artery stenosis by MSCT did not have coronary artery disease. In detecting patients with proximal coronary artery disease, combined analysis of MSCT and MPI showed a considerable improvement in specificity (94.6 vs. 67.6%, P = 0.0001) and positive predictive value (92.3 vs. 67.6%, P = 0.01) without significant changes in sensitivity (94.1 vs. 98.0%) and negative predictive value (95.9 vs. 98.0%) compared with MSCT alone. CONCLUSION: Combined analysis of MSCT-CAG and MPI can accurately detect patients with proximal coronary artery disease.

Factors associated with myocardial salvage immediately after emergent percutaneous coronary intervention in patients with ST-elevation acute myocardial infarction.

OBJECTIVE: The amount of myocardial salvage after percutaneous coronary intervention (PCI) is reported to be a major determinant of functional recovery in patients with ST-elevation acute myocardial infarction (MI). However, factors related to the amount of myocardial salvage remain unknown. The goal of this study was to investigate the factors related to the amount of myocardial salvage after emergent PCI in patients with ST-elevation acute MI by incorporating pre- and post-treatment indices and adjunctive treatments. METHODS: Technetium-99m myocardial imaging was performed before, immediately after, and one month after emergent PCI in 161 patients with ST-elevation acute MI, and the defect score was serially evaluated. A good myocardial salvage was defined as >/=4 change (before minus immediately after PCI) of the defect score. RESULTS: Good myocardial salvage was observed in 89 patients. Based on nine clinical variables, logistic regression analysis was performed to determine the important variables related to myocardial salvage. Multivariate analysis revealed that earlier time from onset to PCI (chi (2) = 6.55, P = 0.01, odds ratio = 2.78), larger defect score before PCI (chi (2) = 7.29, P = 0.01, odds ratio = 1.13) and administration of nicorandil before PCI (chi (2) = 9.88, P = 0.008, odds ratio = 4.42) were independently associated with good myocardial salvage. Thrombolysis In Myocardial Infarction (TIMI) flow grade <2 before PCI (chi (2) = 4.91, P = 0.03, odds ratio = 0.36) and TIMI flow grade

Preservation of myocardial viability within the risk area by intravenous nicorandil before primary coronary intervention in patients with acute myocardial infarction.

OBJECTIVE: To investigate the cardioprotective effect of intravenous nicorandil before primary percutaneous coronary intervention (PCI) on preservation of myocardial viability, we studied 199 consecutive patients with acute myocardial infarction. METHODS: Nicorandil was given intravenously on admission (before primary PCI). Echocardiography and technetium-99m tetrofosmin perfusion imaging were performed before and 1 month after primary PCI. Echocardiographic asynergic score before primary PCI was used to define the size of risk area, whereas the sum of scintigraphic defect grade before primary PCI was used to estimate myocardial viability within the area at risk. The change (before primary PCI and 1 month after primary PCI) in asynergic score and scintigraphic salvage index were calculated. RESULTS: Patients were divided into nicorandil (n=101) and control (n=98) groups. Although asynergic score before primary PCI was not different between the two groups (nicorandil=3.5+/-2.1 and control=3.9+/-1.5), myocardial viability was preserved in nicorandil group (defect score=11.0+/-4.0) than that in control group (defect score=14.0+/-4.7, P<0.0001). Multivariate analysis revealed that the presence of antegrade flow (P=0.015) and nicorandil (P<0.0001) were independently associated with preserved myocardial viability before primary PCI. Moreover, the greater reduction in asynergic score (66+/-41 vs. 49+/-23%, P=0.0006) and larger salvage index (65+/-25 vs. 53+/-26%, P=0.0015) were observed in nicorandil group compared with the control group. CONCLUSION: Intravenous administration of nicorandil before primary PCI preserved myocardial viability within the risk area, which leads to greater myocardial salvage and better functional recovery after primary PCI.

The effect of verapamil on the restoration of myocardial perfusion and functional recovery in patients with angiographic no-reflow after primary percutaneous coronary intervention.

OBJECTIVE: Angiographic thrombolysis in myocardial infarction (TIMI) flow grade < or = 2 after primary percutaneous coronary intervention (PCI), defined as angiographic no-reflow, predicts poor functional recovery in patients with acute myocardial infarction. We investigated the effect of verapamil on the restoration of myocardial perfusion and functional recovery in patients with angiographic no-reflow after PCI. METHODS: 99mTc tetrofosmin single photon emission computed tomographic (SPECT) imaging was performed (before, immediately after and 1 month after PCI) in 101 consecutive patients with acute myocardial infarction. The defect score was calculated as the sum of perfusion defect in a 13-segment model (scores of 3, complete defect to 0, normal perfusion). The asynergic score, defined as the number of asynergic segments, was assessed by echocardiography before and 1 month later. Multiple logistic regression analysis was performed to elucidate the effect of verapamil administration. RESULTS: Of 101 patients, 32 (31%) had angiographic no-reflow and were divided into two groups: 18 patients with verapamil (group 1) and 14 patients without verapamil (group 2). Sixty-nine patients had TIMI grade 3 reflow after PCI (group 3). The change in the defect score 1 month after PCI in group 1 was significantly larger than that in group 2 (P = 0.003). The asynergic score improved more at 1 month in group 1 compared to that in group 2 (P = 0.007). Moreover, logistic regression analysis revealed that TIMI grade reflow < or = 2 after PCI (P = 0.04, OR = 5.51), the defect score before PCI (P = 0.03, OR = 1.15), the asynergic score before PCI (P = 0.01, OR = 0.64) and the administration of verapamil (P = 0.002, OR = 22.4) were independently associated with successful myocardial reperfusion immediately after PCI. CONCLUSIONS: Intracoronary verapamil restored myocardial perfusion in patients with angiographic no-reflow after PCI and lead to better functional recovery after acute myocardial infarction.

Assessment of coronary artery disease in hemodialysis patients with delayed systolic blood pressure response after exercise testing.

BACKGROUND: We evaluated usefulness of the postexercise systolic blood pressure (SBP) response for detecting coronary artery disease (CAD) in hemodialysis patients. METHODS: A treadmill exercise testing was done, and the SBP response was measured in 44 hemodialysis patients (30 men, 14 women; age 41 to 81 years). The postexercise SBP response was defined as the ratio of SBP after 3 minutes of recovery to SBP at peak exercise. RESULTS: The SBP ratio of the 25 subjects with coronary artery stenosis (1.01+/- 0.13) was significantly greater (p<0.01) than 19 subjects without coronary artery stenosis (0.83+/- 0.10). An SBP ratio greater than 0.92 identified CAD with higher sensitivity, specificity, and accuracy than did the conventional ST-segment depression criterion (76 vs. 56%, 90 vs. 53%, and 82 vs. 55%, respectively). CONCLUSION: Determination of the SBP ratio is a clinically useful, noninvasive method for accurately detecting CAD in hemodialysis patients.

[Acute myocardial infarction due to late stent thrombosis seventeen months after stent implantation: a case report].

A 59-year-old man with acute myocardial infarction underwent successful stent implantation for proximal left anterior descending coronary artery occlusion. Antiplatelet therapy with 100 mg aspirin/day and 200 mg cilostazol/day was started after stenting and continued for 4 weeks. There was no cardiac event during the 1 year follow-up period. Follow-up coronary angiography at 12 months after stenting revealed no in-stent restenosis. The patient was admitted 17 months later due to sudden onset of severe chest pain. Electrocardiography revealed ST segment elevation in leads V1-V4. Emergency coronary angiography disclosed obstruction of the proximal left anterior descending coronary artery with thrombus. Intracoronary aspiration thrombectomy was successful. We describe a patient with acute myocardial infarction who had late stent thrombosis 17 months after stent implantation.

Quantitative estimation of myocardial salvage after primary percutaneous transluminal coronary angioplasty in patients with angiographic no reflow.

Angiographic Thrombolysis in Myocardial Infarction (TIMI) flow grade