The relationship between the initial pH and neurological outcome in patients with out-of-hospital cardiac arrest is affected by the status of recovery of spontaneous circulation on hospital arrival.

The early prediction of neurological outcomes is useful for out-of-hospital cardiac arrest (OHCA). The initial pH was associated with neurological outcomes, but the values varied among the studies. Patients admitted to our division with OHCA of cardiac origin between January 2015 and December 2022 were retrospectively examined (N = 199). A good neurological outcome was defined as a Glasgow-Pittsburgh cerebral performance category (CPC) of 1-2 at discharge. Patients were divided according to the achievement of recovery of spontaneous circulation (ROSC) on hospital arrival, and the efficacy of pH in predicting good neurological outcomes was compared. In patients with ROSC on hospital arrival (N = 100), the initial pH values for good and poor neurological outcomes were 7.26 ± 0.14 and 7.09 ± 0.18, respectively (p < 0.001). In patients without ROSC on hospital arrival (N = 99), the initial pH values for good and poor neurological outcomes were 7.06 ± 0.23 and 6.92 ± 0.15, respectively (p = 0.007). The pH associated with good neurological outcome was much lower in patients without ROSC than in those with ROSC on hospital arrival (P = 0.003). A higher initial pH is associated with good neurological outcomes in patients with OHCA. However, the pH for a good or poor neurological outcome depends on the ROSC status on hospital arrival.

A case of cardiac calcified amorphous tumor complicated with acute myocardial infarction.

An 80-year-old woman with a history of eosinophilic granulomatosis with polyangiitis, cardiac hypertrophy, and diabetes called for an ambulance after developing chest pain. She was diagnosed with acute myocardial infarction (AMI), and coronary angiography revealed occlusion of the right coronary artery. Coronary aspiration was performed, and coronary aspirate was white with calcified factor. After percutaneous coronary intervention, transthoracic echocardiography performed on day 25 revealed a hyperechoic mobile mass originating from the anterior mitral leaflet. As a mobile or rapidly increasing mass carries a high risk of embolism, we decided to perform surgical resection. Preoperative cerebral magnetic resonance imaging showed asymptomatic cerebral infarction, suggesting embolism by the cardiac mass. Resection of the cardiac mass was performed by cardiac surgeons. Microscopic pathology of cardiac mass revealed nodules of calcification and fibroblasts, leading to diagnosis of calcified amorphous tumor (CAT). Furthermore, the microscopic pathology of the coronary aspirate showed calcification, fibrin, and vascular endothelial cells. The pathological similarity of the cardiac mass and coronary aspirate indicated that the AMI has been caused by CAT. CAT causes systemic embolization; however, only 1 case of MI caused by CAT has been reported. We therefore experienced a rare case in which CAT caused AMI. .

Cancer and malnutrition were independently associated with a poor prognosis in patients with heart failure.

BACKGROUND: Recent advances in treatment have improved the survival of cancer patients. Such survivors may go on to develop heart failure (HF) later in life. HF and cancer are wasting diseases, and malnutrition is associated with a poor prognosis in patients with HF or cancer. METHODS AND RESULTS: Patients admitted to our hospital with HF from April 2012 to March 2020 were retrospectively reviewed. They were divided into 2 groups: cancer patients (N = 185) and patients without cancer (N = 930). Patients discharged alive and followed by our outpatient clinic were also examined (N = 857, median follow-up period: 794 days). RESULTS: In cancer patients, the geriatric nutritional risk index and prognostic nutritional index were lower and the controlling nutritional status score was higher than in HF patients without cancer; nutrition was disturbed in HF patients with cancer. The in-hospital mortality rates of the two groups were not markedly different; however, cancer patients showed higher long-term mortality in comparison to HF patients without cancer. A multivariate analysis revealed that cancer and malnutrition were independently associated with all-cause death. CONCLUSIONS: The long-term mortality of HF patients with cancer was higher than that of HF patients without cancer. Malnutrition was associated with long-term mortality, independently of the presence of cancer. Multidisciplinary treatment is needed when treating HF patients with cancer.

Out-of-Hospital Cardiac Arrest Does Not Affect Post-Discharge Survival in Patients With Acute Myocardial Infarction.

Background: Acute myocardial infarction (AMI) patients complicated by out-of-hospital cardiac arrest (OHCA) show poor in-hospital outcomes. However, the post-discharge outcomes of survivors of OHCA have not been well studied. Methods and Results: Data for patients admitted to The Jikei University Kashiwa Hospital with AMI between April 2012 and March 2020 were examined retrospectively. The Jikei University Kashiwa Hospital is a tertiary emergency medical facility, so the frequency of OHCA in this hospital is higher than in an ordinary AMI population. Of 803 patients, 92 (11.5%) were complicated by OHCA. Of the 92 OHCA patients, 37 died in hospital, compared with 45 of 711 non-OHCA patients who died in hospital (P<0.001). OHCA was more frequent in men than in women. The estimated glomerular filtration rate was lower in those with than without OHCA. Long-term mortality was evaluated in patients discharged alive and followed-up at an outpatient clinic (n=635; median follow-up period 607 days). The long-term post-discharge mortality was comparable between AMI patients with and without OHCA. Conclusions: The post-discharge mortality of AMI patients with OHCA was comparable that of patients without OHCA.

Therapeutic hypothermia after cardiac arrest increases the plasma level of B-type natriuretic peptide.

Natriuretic peptides (NPs) regulate blood pressure and fluid homeostasis and exert various effects on the cardiovascular system. Recently, the relationship between NPs and the energy metabolism has been reported, and using a cell culture experiment system, we previously showed that NP activated brown cells in a low temperature environment while also suppressing a decrease in the cell temperature. However, few reports have described the secretion of NPs in cold environments, and there have been almost no studies of B-type natriuretic peptide (BNP) in humans. We investigated how NPs respond to cold environments in 21 patients who underwent therapeutic hypothermia (TH) after cardiac arrest. The plasma BNP levels were significantly increased (more than fivefold) during TH (logarithmically from 1.98 ± 0.79 to 2.63 ± 0.59, P < 0.01). During TH, diastolic pulmonary artery pressure (PAP) significantly decreased, and there were no significant changes in the stroke volume index (SVI). This increase of BNP was not associated with any hemodynamic changes. In contrast to our findings for BNP, the change in A-type NP (ANP) was quite small. We detected a significant increase in the plasma BNP levels during TH, unrelated to hemodynamics. This elevation of BNP levels seems to be potential influenced by hypothermia.

123I-BMIPP/201Tl dual myocardial SPECT proves the efficacy of surgical treatment for an adult with Bland-White-Garland syndrome.

Bland-White-Garland (BWG) syndrome is a rare congenital heart disease in which the left coronary artery originates from the pulmonary artery (PA). Surgical treatment to rebuild a dual coronary system is recommended at the time of the diagnosis. However, no effective operative procedure has been established for adult-type BWG patients because of the paucity of such cases. We herein report a case of adult-type BWG that was successfully treated by patch closure of the orifice of the left main tract from the main PA and coronary artery bypass grafting. 123I-15-(p-iodophenyl)-3-(R,S)-methylpentadecanoic acid (BMIPP) and 201thallium (Tl) dual myocardial single-photon emission computed tomography (SPECT) were performed before surgery, early after surgery, and at three months after surgery. Before surgery, dual SPECT showed myocardial perfusion defects in the anterior and septal wall, which corresponded to the cardiovascular magnetic resonance imaging findings. Early after surgery, only 201Tl images demonstrated an improvement in the defect area. At three months after surgery, both the 201Tl and 123I-BMIPP imaging findings demonstrated an improvement in the defect area, which was correlated with the recovery of the left ventricular function. These results showed the effectiveness of this surgical approach for BWG syndrome. .

Midterm angiographic outcomes with sirolimus- and everolimus-eluting stents for small vessels in diabetic patients: propensity-score-matched comparisons in three different vessel diameters.

We conducted propensity-score-matched comparisons of midterm angiographic follow-up outcomes of sirolimus- versus everolimus-eluting stents (SES, EES) after elective placements for de novo coronary stenosis in small vessels (SV) in patients with diabetes mellitus (DM), because the angiographic efficacy of EES over SES for those cohorts remained unclear. The study was a non-randomized, retrospective, lesion-based, multicenter study, examining lesions followed up angiographically within 550 days, extracted from the unified database of 6 institutes. The endpoint (binary restenosis) was defined as the percentage of subjects having >50% diameter stenosis at follow-up. Propensity-score-matched analyses were conducted in 3 different vessel-size cohorts, defined by a preprocedural reference diameter (RD) <2.10, <2.35, and <2.60 mm, yielding group sizes of n = 107, 183, and 312 baseline-adjusted lesions in each of the 2 stent arms. The frequency of binary restenosis decreased significantly with increasing vessel size, at 16.8, 12.6, and 12.2%, in the SES group. However, it remained almost the same across vessel-size groups in the EES group (8.0, 6.0, and 7.5%). The p values for the significance of the differences in binary restenosis between EES and SES in each vessel size increased with the decrease in vessel size [p = 0.002, 0.040, and 0.063 (the last still nearly significant)]. Thus, in patients with DM, EES showed increasingly superior efficacy over SES for SV stenosis as the vessel size became smaller, i.e., the risk for binary restenosis became greater.

Propensity-Score Matched Comparison of Midterm Angiographic Outcomes of Sirolimus- Versus Everolimus- and Biolimus-Eluting Stents for De Novo Coronary Stenosis.

We conducted propensity-score matched comparisons of midterm angiographic outcomes of sirolimus (SES) versus either everolimus- (EES) or biolimus- (BES) eluting stents after placements for coronary stenosis in a daily practice environment since previous randomized trials did not demonstrate the superiority of EES and BES over SES in terms of midterm angiographic outcomes.The present study was a non-randomized, retrospective, and lesion-based study, recruiting angiographically followed-up lesions within 550 days after successful and elective SES (n = 1793), EES (n = 1303), or BES (n = 324) placement for de novo native coronary stenosis during the period from August 2004 to January 2014 at 6 institutes. The endpoint, as an angiographic surrogate marker of clinical efficacy, was the distribution of in-stent follow-up percent diameter stenosis (%DS) which comprised the percentages of 1) follow-up %DS < 20 and 2) follow-up %DS > 50. Propensityscore matched analyses were conducted to adjust 21 baselines.In 1215 baseline adjusted lesions, the endpoints in the EES group [1) 74.1%, and 2) 4.6%] were significantly different from those in the SES group [57.9%; P < 0.001, 7.2%; P = 0.006, respectively). In 307 baseline adjusted lesions, the endpoints in the BES group [1) 80.5%, 2) 2.0%] were significantly different from those in the SES group [59.3%; P < 0.001, 2) 8.1%; P = 0.001, respectively].The present study is the first to confirm the superiority of midterm angiographic outcomes after the placement of EES and BES over SES for de novo coronary stenosis in a clinical setting.

Diabetes is a predictor of coronary artery stenosis in patients hospitalized with heart failure.

In patients with heart failure, coronary artery disease is the most common underlying heart disease, and is associated with increased mortality. However, estimating the presence or absence of coronary artery disease in patients with heart failure is sometimes difficult without coronary imaging. We reviewed 155 consecutive patients hospitalized with heart failure who underwent coronary angiography. The patients were divided into two groups: patients with (N = 59) and without (N = 96) coronary artery stenosis. The clinical characteristics and blood sampling data were compared between the two groups. The patients with coronary artery stenosis were older than those without. The prevalence of diabetes mellitus (DM), dyslipidemia and a history of revascularization was higher in the patients with coronary artery stenosis. Patients with coronary artery stenosis tended to have wall motion asynergy more frequently than those without. On the other hand, the prevalence of atrial fibrillation (AF) was lower in patients with coronary artery stenosis. The serum hemoglobin level and estimated glomerular filtration rate were lower in patients with coronary artery stenosis than in those without. In the multivariate analysis, DM (odds ratio 3.517, 95 % CI 1.601-7.727) was found to be the only the predictor of the presence of coronary artery stenosis in patients with heart failure. In conclusion, coronary imaging is strongly recommended for heart failure patients with DM to confirm the presence of coronary artery stenosis.

The Optimal Cut-off Value of Plasma BNP to Differentiate Heart Failure in the Emergency Department in Japanese Patients with Dyspnea.

OBJECTIVE: In the emergency department, it is sometimes difficult to differentiate heart failure (HF) from other diseases (e.g., respiratory diseases) in patients who develop dyspnea. The plasma B-type natriuretic peptide (BNP) levels increase in patients with HF, and various levels are associated with specific New York Heart Association classes. Although the diagnosis of HF should not be made based only on the plasma BNP levels, the identification of a cut-off value for BNP to diagnose HF would be helpful. METHODS: Patients admitted to the emergency department of our hospital with dyspnea between January 2010 and December 2011 were retrospectively reviewed. The patients whose estimated glomerular filtration rate was less than 30 mL/min/1.73 m(2) were excluded. Patients were divided into two groups: those with HF (n=131) and those without HF (n=138). The cut-off value for BNP was determined by the receiver-operating characteristic curve. RESULTS: The area under the curve of this curve was 0.934. The optimal cut-off point for detection of HF was 234 pg/mL. The sensitivity and specificity were 87.0% and 85.5%, respectively. The fifth and 95th percentiles of the HF group were 132.2 and 2,420.8 pg/mL, respectively. Those of the non-HF group were 9.7 and 430.2 pg/mL, respectively. CONCLUSION: Our study suggests that a plasma BNP level cut-off value of 234 pg/mL can be used to detect HF in the emergency department.

Retrospective comparison of the clinical and angiographic outcomes of the sirolimus-eluting stent and the bare-metal stent in 2031 nonrandomized consecutive de novo native coronary lesions.

OBJECTIVE: To evaluate the mid-term outcomes of sirolimus-eluting stents (SES; Cypher Bx Velocity) for de novo coronary stenosis in a Japanese clinical setting, and to compare these with the outcomes using bare-metal stents (BMS). METHODS: This study was a nonrandomized, lesion-based, and single-center study, retrospectively investigated in October 2010. We enrolled 2031 consecutive cases with de novo coronary lesions treated with BMS (n=587) or SES (n=1,444) from January 2003 to May 2007. SES use ratio during the available interval was 95.5%. The primary endpoint was the incidence of target vessel failure (TVF: comprising cardiac death, nonfatal recurrent MI, definite stent thrombosis (ST), and severe restenosis [% diameter stenosis (%DS) at secondary angiography ≥70%]. The secondary endpoint was the incidence of binary in-stent restenosis (%DS >50%). RESULTS: The TVF ratio after SES placement (6.6%) was significantly lower than that after BMS placement (11.8%, p<0.001), despite many disadvantageous variables in the SES group. SES related to the risk of TVF (mean follow-up for SES, 1,411 ± 539 days; BMS, 1,818 ± 825 days) (hazard ratio of 0.428 at 95% CI, 0.292-0.627, p<0.001). The ratio of binary in-stent restenosis after SES placement (13.4%) was significantly lower than that after BMS placement (25.1%; p<0.001). SES was significantly related to binary in-stent restenosis (odds ratio of 0.267 at 95% CI, 0.195-0.366, p<0.001). CONCLUSION: SES has a more favorable mid-term clinical and angiographic outcome than BMS for de novo coronary stenosis in clinical settings in Japan.

Retrospective comparison of clinical and angiographic outcomes after sirolimus-eluting and bare-metal stent implantation in 312 consecutive, nonrandomized severely calcified lesions using a rotablator.

In order to compare the long-term clinical and angiographic outcomes after sirolimus-eluting stent (SES) and bare-metal stent (BMS) placement in severely calcified lesions using a rotablator under the widespread indication of SES, a nonrandomized examination of 312 consecutive lesions after successful implantation of a BMS (99 lesions in 84 patients; from January 2003) or SES (213 in 167; from September 2004) using a rotablator was conducted. The lesion-based primary endpoints (cardiac death and nonfatal recurrent myocardial infarction) and the secondary endpoint [binary restenosis (BR) (diameter stenosis > 50%) at follow-up angiography] were retrospectively determined in August 2010. The incidence of primary endpoint in the SES group (2.3%; mean follow-up period of 1289 ± 526 days) was significantly lower than that in the BMS group (7.1%; P = 0.043; 1803 ± 887 days), although the several variables related to the endpoints were present in the SES group. Cox proportional hazard model analysis revealed that SES was not significantly related to a primary endpoint [hazard ratio of 0.42 (95% CI, 0.073-2.42; P = 0.33)]. The incidence of BR in the SES group (21.3%) was not significantly different from that in the BMS group (27.1%) (P = 0.33). Multivariate logistic regression analysis revealed that SES was not a significant predictor of BR [Odds ratio of 0.78 (95% CI, 0.41-1.51; P = 0.47)]. Thus, although the results of the present retrospective nonrandomized study demonstrate the long-term safety of SES for calcified lesions using a rotablator in daily practice, SES did not show a benefit for the angiographic outcomes compared to BMS.

Retrospective comparison of clinical and angiographic outcomes after primary stenting using sirolimus-eluting and bare-metal stents in nonrandomized consecutive 568 patients with first ST-segment elevated myocardial infarctions.

BACKGROUND AND PURPOSE: The long-term safety and efficacy of primary stenting using drug-eluting stents (DES) in patients with ST-segment elevation myocardial infarction (STEMI) are not fully understood in Japan. Therefore, we retrospectively examined the midterm clinical and angiographic outcomes in STEMI patients after primary stenting using sirolimus-eluting stents (SES) in a clinical setting through a historical comparison with those of bare-metal stents (BMS). METHODS AND RESULTS: The study design was a retrospective, nonrandomized, and single-center study. The clinical outcomes for 568 consecutive patients who presented within 12 h of their first STEMI and who were treated with BMS (n = 198; 184 STEMIs from June 2003 to August 2004 and 14 STEMIs from September 2004 to May 2007) or SES (n = 370; from August 2004 to May 2007) at our medical center in Japan were retrospectively investigated in February 2010. The incidence of post-discharge events (comprising cardiac death and nonfatal recurrent MI) after SES placement (3.9%) was not significantly different from that after BMS placement (6.7%). SES was not related to the risk of post-discharge events (mean follow-up for SES, 1327 ± 415 days; BMS, 1818 ± 681 days) (hazard ratio of 0.369 at 95% CI, 0.119-1.147, p = 0.085). The incidence of definite stent thromboses after SES placement (0.54%) was not significantly higher than that after BMS placement (0%). The incidence of binary in-stent restenosis (% diameter stenosis of more than 50% at secondary angiography) after SES placement (8.3%) was significantly lower than that after BMS placement (25.7%; p < 0.001). CONCLUSIONS: From the present historical comparison of SES and BMS, we conclude that primary stenting using SES in a clinical setting has favorable clinical and angiographic outcomes in Japanese STEMI patients.

Significantly lower incidence of early definite stent thrombosis of drug-eluting stents after unrestricted use in Japan using ticlopidine compared to western countries using clopidogrel: a retrospective comparison with western mega-studies.

BACKGROUND AND OBJECTIVES: The incidence of definite stent thrombosis (ST) after use of drug-eluting stents (DES), as defined by the Academic Research Consortium, is known to be lower in Japan than in western countries. However, a statistical difference in the incidence of early definite ST (EDST) associated with the unrestricted use of DES has not yet been documented. Therefore, the incidence of EDST in our Japanese institute after unrestricted use of DES was retrospectively compared with those reported in western mega-studies. METHODS AND RESULTS: During the 40 months from August 2004 to November 2007 (before approval of clopidogrel in Japan), DES were implanted in 3605 lesions in 1885 patients in our institute; lesion- and patient-associated percentages of DES use were 95.2% and 94.7%, respectively. Mean stent length per lesion was 33.2 mm, emergent procedures and ST-elevation myocardial infarctions made up 33.7% and 16.4% of the procedures, respectively, intravascular ultrasonography was used 96.0% of the time, a distal protection device for acute coronary syndrome was used 68.7% of the time, and the mean maximum inflation pressure was 19.5 atm. EDST was observed in five lesions (0.139%) in four patients (0.212%). The incidence of patient-associated EDST at our center was significantly lower than in four western mega-studies (0.736%, 66 of 8970 patients; 0.634%, 149 of 23,500; 0.595%, 52 of 8402; 0.997%, 20 of 2006) (p<0.05, <0.01, <0.05, <0.01, respectively, using a chi(2)-test). CONCLUSION: Due to differences in procedural approaches in Japan, the incidence of EDST after unrestricted use of DES was significantly lower than in western countries.

Predictors of target lesion revascularization and documented stent thrombosis beyond 30 days after sirolimus-eluting stent implantation: retrospective analysis in consecutive 1,070 angiographic follow-up lesions.

BACKGROUND: Outcomes after sirolimus-eluting stent (SES: Cypher) implantation remained to be elucidated in Japan. METHODS AND RESULTS: Among 1,070 consecutive angiographic follow-up lesions, 99 lesions underwent target lesion revascularization (TLR) with in-stent restenosis (ISR). Retrospective estimation by multivariate analysis including 50 variables showed that the ostiums of right coronary and left circumflex arteries, hemodialysis, calcification, non-direct stenting, ISR of SES, and non-eccentric lesion were the predictors of TLR. There was no documented late stent thrombosis (LST) among 2,166 lesions and very LST (VLST) among 1,423 lesions. CONCLUSION: Further revises are needed to implant SES to these predictive lesions. LST and VLST were very rare.

[Initial and mid-term effects of > or = 30 mm long sirolimus-eluting stents in patients with diffuse long coronary lesions: comparison with bare metal stents].

OBJECTIVES AND METHODS: Sirolimus-eluting stents (SES) can reduce restenosis and reintervention compared with bare metal stents (BMS). However, the safety and efficacy of SES for diffuse long lesions remain unknown. This study compared the efficacy of SES and BMS using the initial and mid-term outcomes of 124 patients with 130 long coronary lesions (SES lengths > or = 30 mm) compared to 141 patients with 146 lesions treated with BMS. RESULTS: Quantitative coronary arteriography parameters and initial success rate were not significantly different between the two groups. Occurrence of stent thrombosis was not different between the groups (1 case, 0.7% in group SES vs 0 case, 0% in group BMS). Restenosis and major adverse cardiac event rates at 6 months were lower in the SES group than in the BMS group (3.1% vs 34.2%, p < 0.0001, 3.8% vs 31.5%, p < 0.0001). CONCLUSIONS: Initial effects of sirolimus-eluting stents for diffuse long lesions are as useful and as safe as BMS. The mid-term outcomes for SES are superior due to the lower rates of both restenosis and major adverse cardiac event.

[Survivor of cardiogenic shock following acute myocardial infarction with Churg-Strauss syndrome: first angiographic documention of coronary recanalization of infarct-related arteries: a case report].

A 42-year-old man was treated under a diagnosis of Churg-Strauss syndrome with predonisolone pulse therapy. Three days later, he developed cardiogenic shock following acute myocardial infarction. Coronary angiography showed total occlusions in three peripheral coronary vessels. Intraaortic balloon pumping was used to maintain hemodynamics and predonisolone pulse therapy was repeated. However, he developed cardiogenic shock again after the second pulse therapy and needed percutaneous cardiopulmonary support and intraaortic balloon pumping. Accordingly, combination therapy of predonisolone and cyclophosphamide was given. He then recovered. Follow-up angiography showed recanalization of the infarct-related arteries.