Prevalence and clinical implication of metabolic syndrome in chronic heart failure.

BACKGROUND: Metabolic syndrome (MetS) is a pathological condition with a clustering of metabolic components and is a well-known risk and prognostic factor for ischemic heart disease (IHD). However, the prevalence and clinical significance of MetS remain to be fully elucidated in chronic heart failure (CHF), an important clinical syndrome caused by various cardiac abnormalities. METHODS AND RESULTS: The present nationwide, large-scale clinical study enrolled 3,603 patients with stage C/D CHF from 6 institutes in Japan. First, the prevalence of MetS in CHF patients was demonstrated to be 45% in males and 19% in females, which is more than double compared with the general population in Japan. The CHF patients with MetS were characterized by younger age, higher prevalence of current smoking and drinking, IHD, and hypertensive heart disease, whereas the prevalence of HF with preserved ejection fraction and MetS was higher in elderly female patients. Next, the contribution of the metabolic components (waist circumference, hypertension, glucose intolerance/diabetes mellitus and dyslipidemia) was found to be comparable between the ischemic and the non-ischemic CHF patients. CONCLUSIONS: The prevalence of MetS in CHF patients is more than double compared with the general population in Japan and suggest that the metabolic components may have a substantial effect on the development of both ischemic and non-ischemic CHF.

Elevated serum C-reactive protein levels as a predictive indicator for subsequent renal impairment in patients with acute heart failure.

Renal impairment is often observed in acute heart failure (HF), which is an independent prognostic factor. It is important to identify high-risk patients, who need close follow-up and intensive care for renal protection. This study was conducted to identify the factors associated with the subsequent occurrence of HF-related renal dysfunction in patients, who were admitted to the hospitals due to acute HF symptoms. We evaluated 254 consecutive patients with acute HF. HF-related renal dysfunction was defined when highest serum creatinine level was greater than 1.2 mg/dl and the serum creatinine level increased by more than 50% compared with the baseline value during the admission. Forty patients with acute HF (16%) had subsequent renal dysfunction after admission. Elevated serum C-reactive protein (CRP) levels (> or = 5 mg/dl, odds ratio 2.51, p = 0.008 by univariate analysis, odds ratio 2.43, p = 0.019 by multivariate analysis) during the first week after admission and over-reduction of body weight (> or = 4.5 kg, odds ratio 2.68, p = 0.005 by univariate analysis, odds ratio 2.53, p = 0.010 by multivariate analysis) by acute HF treatment were significantly associated with this phenomenon. Patients with high CRP levels (> or = 5 mg/dl) during the first week after admission showed a significantly greater elevation of serum creatinine levels as compared to the levels before admission than those with low CRP levels (< 5 mg/dl). In conclsion, higher serum levels of CRP could predict the subsequent renal impairment in patients admitted with the worsening of HF symptoms.

Statin therapy may prevent restenosis after successful coronary intervention, independent of lipid-lowering effect and CRP level.

BACKGROUND: As statins have the anti-atherosclerotic pleiotropic effects, we retrospectively examined the effects of statins on restenosis after percutaneous coronary intervention (PCI). METHODS: We reviewed consecutive 341 patients who underwent successful PCI and follow-up angiography six months after the procedure between January 2002 and December 2004. Statins were initiated in 207 patients (statin group), but not in the other 134 (control group). We compared the angiographic findings, low-density lipoprotein cholesterol (LDL-C) and C-reactive protein (CRP) between the two groups. RESULTS: LDL-C level in statin group was significantly higher than those in control group at baseline (116.0 +/- 35.8 vs 103.1 +/- 24.5 mg/dL, p < 0.01); however, the values were inverted between the two groups at follow-up (99.9 +/- 29.5 vs 107.6 +/- 26.0 mg/dL, p = 0.015). CRP levels were comparable between these two groups. Statin group showed significantly lower angiographic restenosis (defined as > or = 50% stenosis at the target site) rate (35.3 vs 46.3%, p = 0.042) and target lesion revascularization (TLR) rate (14.5 vs 23.9%, p = 0.018) than control group. Multivariate analysis indicated that the prescription of statin, but not LDL-C level at follow-up and % reduction of LDL-C during the follow-up period, predict the restenosis prevention. CONCLUSIONS: Statins can decrease restenosis and TLR rate after PCI, independent of lipid-lowering effect and CRP level in this study.

Fatal case of amiodarone-induced acute respiratory distress syndrome in a patient with severe left ventricular dysfunction due to extensive anterior acute myocardial infarction.

We here report a case of 71-year-old man with acute extensive anterior myocardial infarction, who was complicated with ventricular tachycardia (VT) even after successful percutaneous coronary intervention. As intravenous administration of nifekalant terminated VT, we started oral administration of amiodarone (day 1). We gave 400 mg of amiodarone a day for the first week and 200 mg a day from the second week. The patient was stable with normoxia by day 20, in spite of pulmonary congestion-like infiltrates on chest X-ray. On day 21, he was complicated with acute respiratory distress syndrome. Immediate discontinuance of amiodarone and high-dose pulse glucocorticoid therapy with intubation slightly improved the infiltrations on chest X-ray. However, glucocorticoid therapy induced hyperglycemia with an increase in plasma osmolality, complicated with hypoalbuminemia, and gastrointestinal bleeding. Despite treatment with a large amount of saline, high-doses of catecholamines, and blood transfusion, the patient died on day 28. It is sometimes difficult to diagnose congestive heart failure or amiodarone-induced pulmonary infiltrates in patients with severe left ventricular dysfunction.

Case of isolated thoracic aortic aneurysm as a manifestation of undiscovered giant cell arteritis.

A 73-year-old woman was referred to our hospital to investigate dilatation of an aortic arch which had been detected by a chest roentgenogram and severe aortic valve regurgitation detected by echocardiography. On admission, a computed tomography scan of the chest showed a large fusiform ascending aortic aneurysm. She had not shown any symptoms such as headache or polymyalgia rheumatica and had no significant coronary atherosclerosis. She underwent aneurysmectomy and reconstruction of the ascending aorta using cardiopulmonary bypass without aortic valve replacement, and pathological examination of the aneurismal wall revealed giant cell arteritis (GCA). Preoperatively, she did not have any temporal pain, and no signs of inflammation were detected serologically. Postoperatively, aortic valve regurgitation improved and she did well. However, three months after the surgery, she died suddenly due to the rupture or dissection of aorta. In the Japanese population, GCA is reportedly a rare cause of aortic aneurysm. However, retrospective studies show that GCA affects the aorta and that thoracic aortic aneurysm is a possible complication of GCA. In cases of the thoracic aortic aneurysms with unknown etiology, there is a possibility that GCA is the cause of the aortic aneurysm.

Postprandial increase in plasma concentrations of remnant-like particles: an independent risk factor for restenosis after percutaneous coronary intervention.

Postprandial increase in remnant lipoprotein concentrations has been suggested as an important atherogenic factor. However, the influence of these remnants on the development of restenosis after percutaneous coronary intervention (PCI) remains to be examined. The present study was designed to address this point. In 60 consecutive patients with successful PCI, the influences of possible risk factors on the development of restenosis, including remnant-like particles (RLP) cholesterol (RLP-C) and triglyceride (RLP-TG), were examined. While mean concentrations of RLP-C and RLP-TG were normal in fasting state, postprandial change in RLP-C concentrations was a significant and independent risk factor for restenosis after PCI. The calculated cut-off index (COI) for the change was +64%. When the patients were divided into 2 groups according to this COI, minimal lumen diameter (MLD) and reference coronary diameter were comparable before and immediately after PCI between the high- (COI < 64%) and the low- (COI < 64%) responders. However, follow-up coronary angiography 3 to 6 months after PCI demonstrated that MLD, late loss, and loss index were all worse in the high responders compared with the low responders. These results indicate that post-prandial increase in RLP-C concentrations is an independent risk factor for restenosis after successful PCI, even in patients with normal fasting RLP-C levels.

Simultaneous assessment of wall motion and coronary flow velocity in the left anterior descending coronary artery during dipyridamole stress echocardiography.

OBJECTIVES: This study was designed to assess the feasibility and clinical meaning of simultaneous assessment of wall motion and coronary flow velocity (CFV) reserve in the left anterior descending coronary artery (LAD) by transthoracic approach for detecting LAD stenosis during dipyridamole stress echocardiography. BACKGROUND: Coronary flow reserve plays an important role, which can be evaluated by transthoracic Doppler echocardiography during vasodilator stress. METHODS: Dipyridamole stress test was performed in 110 patients with known or suspected coronary artery disease. CFV in the distal LAD was obtained at baseline and after dipyridamole infusion, and wall motion was also assessed up to the administration of atropine, if required. All patients underwent quantitative coronary angiography within 2 days of the stress test, and significant LAD stenosis was defined as > 50% stenosis. RESULTS: The success rate of both measurements was 92%. CFV reserve < 2 had a higher sensitivity (94% vs 72%, P <.01) and a lower specificity (65% vs 95%, P <.01) than wall-motion assessment for detecting significant LAD stenosis, and diagnostic accuracy between 2 methods was comparable (81% vs 82%). A total of 69 patients (73%) showed concordant results of the 2 methods, and diagnostic accuracy for detecting significant LAD stenosis was high (94%) in this subset of patients. CONCLUSIONS: The simultaneous assessment of CFV and wall motion was feasible in the majority of cases during dipyridamole stress echocardiography. Although diagnostic accuracy between the 2 tests was comparable, concordant results of the 2 methods provided accurate diagnosis in detecting significant LAD stenosis.

Impact of sex and its interaction with age on the management of and outcome for patients with acute myocardial infarction in 4 Japanese hospitals.

BACKGROUND: Several studies from the United States and from European countries have detected sex and age differences in clinical characteristics, management, and outcomes of acute myocardial infarction. The aim of this study was to determine how sex and age influence the management of and outcome for patients with acute myocardial infarction in Japan. METHODS: A retrospective cohort study was performed by means of patient chart review at 4 teaching hospitals in Japan. There was a total of 482 patients (136 females [28%], 346 males [72%]) admitted consecutively with a diagnosis of acute myocardial infarction between July, 1995 and June, 1996. RESULTS: Female patients were older and had more comorbid diseases than male patients. Female patients also tended to have more cardiac complications during hospitalization and a greater 30-day mortality (10% vs 4%, P <.05). After adjustment for baseline characteristics and age/sex interaction, it was found that female patients were less likely to undergo thrombolytic therapy, cardiac catheterization, or revascularization, and they had a greater 30-day mortality. These sex differences in cardiac catheterization and revascularization were more pronounced for older patients. On the other hand, the sex differences in 30-day mortality were greater for younger patients. CONCLUSIONS: Our data suggest that cardiac catheterization, revascularization and 30-day mortality may have been related to patient sex and age, but further study is needed.