Circulation Journal
Online ISSN : 1347-4820
Print ISSN : 1346-9843
ISSN-L : 1346-9843
Volume 74 , Issue 10
Showing 1-43 articles out of 43 articles from the selected issue
Reviews
  • – Epidemiologic and Clinical Evidence –
    Noelle N. Gronroos, Alvaro Alonso
    2010 Volume 74 Issue 10 Pages 2029-2038
    Published: 2010
    Released: September 24, 2010
    [Advance publication] Released: September 11, 2010
    JOURNALS FREE ACCESS
    Dietary factors might affect the risk of atrial fibrillation (AF), but available studies have provided inconsistent results. A review of published observational studies and randomized trials identified 4 dietary exposures that had been investigated regarding AF risk: alcohol, fish-derived n-3 polyunsaturated fatty acids, caffeine, and ascorbic acid. Though studies were highly heterogeneous in their design and results, they showed a consistently increased risk of AF in heavy alcohol drinkers, but no risk associated with moderate alcohol intake. High coffee intake was not clearly associated with an increased risk of AF, and a potential U-shaped association (lower AF risk in moderate drinkers) could exist. High intake of fish-derived n-3 polyunsaturated fatty acids from diet or supplements might prevent AF episodes following cardiovascular events, but no consistent evidence supports an effect in primary prevention. Additional large, well-conducted randomized experiments are necessary to address the role of diet in AF prevention. (Circ J 2010; 74: 2029-2038)
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  • – A New Electrical Disorder Associated With Sudden Cardiac Death –
    Shinsuke Miyazaki, Ashok J Shah, Michel Haïssaguerre
    2010 Volume 74 Issue 10 Pages 2039-2044
    Published: 2010
    Released: September 24, 2010
    [Advance publication] Released: September 11, 2010
    JOURNALS FREE ACCESS
    Early repolarization (ER), consisting of a J-point elevation, notching or slurring of the terminal portion of the R wave (J wave), and tall/symmetric T wave, is a common finding on the 12-lead electrocardiogram. For decades, it has been considered as benign, barring sporadic case reports and basic electrophysiology research that suggested a critical role of the J wave in the pathogenesis of idiopathic ventricular fibrillation (VF). In 2007-2008, a high prevalence of ER in patients with idiopathic VF was reported and subsequent studies reinforced the results. This review summarizes the current state of knowledge concerning ER syndrome associated with sudden cardiac death. (Circ J 2010; 74: 2039-2044)
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  • Norihito Shibata, Christopher K. Glass
    2010 Volume 74 Issue 10 Pages 2045-2051
    Published: 2010
    Released: September 24, 2010
    [Advance publication] Released: September 11, 2010
    JOURNALS FREE ACCESS
    Macrophages play central roles in immunity and homeostasis, and contribute to the pathogenesis of atherosclerosis through their accumulation of cholesterol and the production of inflammatory mediators and cytokines. Recent studies indicate that oxysterols influence diverse aspects of macrophage biology. Rather than simply being intermediates of cholesterol catabolism, oxysterols are also potent bioactive lipids that regulate lipid metabolism, immune function, and cytotoxicity. These functions are mediated by specific oxysterol sensors, including liver X receptors (LXR), Insigs, and members of the oxysterol binding protein (OSBP) and OSBP-related protein family. The mechanisms of oxysterol-induced functions and their physiological roles in macrophages are reviewed. (Circ J 2010; 74: 2045-2051)
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Editorials
Original Articles
Aortic Disease
  • – Relationship Between the Extent of Dissection and Inflammation –
    Manabu Kurabayashi, Kaoru Okishige, Koji Azegami, Daisuke Ueshima, Koj ...
    2010 Volume 74 Issue 10 Pages 2066-2073
    Published: 2010
    Released: September 24, 2010
    [Advance publication] Released: August 06, 2010
    JOURNALS FREE ACCESS
    Background: Acute aortic dissection (AAD) often accompanies acute respiratory failure. The aim of this study was to clarify the relationship between the incidence of oxygenation impairment and the extent of distal type AAD. Methods and Results: A total of 49 patients with medically treated distal type AAD were retrospectively examined. AAD% was defined as the percentage of the volume of false lumen to that of aorta in the descending aorta. AAD% was measured by computed tomography. C-reactive protein (CRP) levels, white blood cell (WBC) counts, body temperature and arterial partial pressure of oxygen/fraction of inspired oxygen (PaO2/FiO2) ratio were measured serially. Oxygenation impairment was defined as a PaO2/FiO2 ratio ≤200. This occurred in 19 patients (39%). In patients with oxygenation impairment, AAD% (50.8±10.9% vs 28.0±11.9%, P<0.001), peak CRP levels (15.2±6.5 mg/dl vs 9.6±4.6 mg/dl, P<0.001), peak WBC counts (13,600±3,700 /μl vs 10,400±2,800 /μl, P=0.001) and body temperature (38.1±0.5°C vs 37.8±0.4°C, P=0.045) were higher than those without oxygenation impairment. It was found that there were inverse correlations between the PaO2/FiO2 ratio and AAD% (r=-0.604, P<0.001), and between peak CRP levels and the PaO2/FiO2 ratio (r=-0.635, P<0.001). Multivariate analysis demonstrated that the only independent predictor of oxygenation impairment was AAD% (odds ratio, 1.323; 95% confidence interval, 1.035-1.691, P=0.026). Conclusions: Respiratory failure in AAD appears to be closely correlated with the amount of aortic injury, possibly mediated by the magnitude of the systemic inflammatory reaction to the aortic injury. (Circ J 2010; 74: 2066-2073)
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Arrhythmia/Electrophysiology
  • Yu-Feng Hu, Tsui-Lieh Hsu, Wen-Chung Yu, Sung-Hao Huang, Hsuan-Ming Ts ...
    2010 Volume 74 Issue 10 Pages 2074-2078
    Published: 2010
    Released: September 24, 2010
    [Advance publication] Released: July 27, 2010
    JOURNALS FREE ACCESS
    Background: The presence of diastolic dysfunction increases the risk of atrial fibrillation (AF), and might be associated with the left atrial (LA) substrate. The aim of the present study was to investigate the relationships between the diastolic dysfunction, atrial substrate and outcome of the catheter ablation. Methods and Results: Eighty-three patients with paroxysmal AF were enrolled. Diastolic dysfunction was defined as a left ventricular ejection fraction (LVEF) of ≥50%, and one of the following criteria: (1) a mitral inflow early filling velocity to atrial filling velocity ratio (E/A) of ≤0.75; or (2) an E/A ratio of >0.75 and a ratio of the mitral inflow early filling velocity to the velocity of the early medial mitral annular ascent of >10. Patients with diastolic dysfunction were older than those with normal cardiac function. There were no differences in the other baseline characteristics, LA diameter, or LVEF. A decreased LA voltage, and higher recurrence rate were noted in patients with diastolic dysfunction. In the univariate analysis, the patients with recurrence had a lower LA voltage and greater diastolic dysfunction. The multivariate analysis also indicated diastolic dysfunction and LA voltage as independent predictors of recurrence. Conclusions: The patients with diastolic dysfunction developed a different atrial substrate and had a worse outcome of catheter ablation for atrial fibrillation. (Circ J 2010; 74: 2074-2078)
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  • Hong Zhang, Boyoung Joung, Tetsuji Shinohara, Xi Mei, Peng-Sheng Chen, ...
    2010 Volume 74 Issue 10 Pages 2079-2088
    Published: 2010
    Released: September 24, 2010
    [Advance publication] Released: July 29, 2010
    JOURNALS FREE ACCESS
    Background: The mechanism of sinoatrial node (SAN) automaticity is traditionally attributed to membrane ion currents. Recent evidence indicates spontaneous sarcoplasmic reticulum (SR) Ca2+ cycling also plays an important role. Methods and Results: A computer simulation on SAN cell and 1D tissue model was performed. In the SAN cells, SR Ca2+ cycling broadly modulated the sinus rate from 1.74 Hz to 3.87 Hz. Shortening of the junctional SR refilling time and increase of SR Ca2+ release were responsible for sinus rate acceleration. However, under the fast SR Ca2+ cycling, decreased L-type Ca2+ current (ICaL) resulted in irregular firing. When Ca2+ cycling was suppressed, If and ICaT both acted to stabilize the pacemaker rhythm, but ICaT had less effect than If. At the 1D level, the electrical coupling between neighboring cells had little effect on the earliest pacemaker location. The leading pacemaking site always colocalized with the site with the highest SR Ca2+ cycling rate, but shifted to the site with less inhibited ICaL. Conclusions: The rate of SR Ca2+ cycling can effectively and broadly modulate the sinus rate. If, ICaL and ICaT play integral roles to guarantee SAN cell rhythmic firing. The leading pacemaker site is determined by intracellular Ca2+ dynamics and membrane currents, indicating the synergistic dual automaticity not only exists in single SAN cells, but also at the tissue level. (Circ J 2010; 74: 2079-2088)
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Cardiovascular Intervention
  • Amane Kozuki, Junya Shite, Toshiro Shinke, Naoki Miyoshi, Takahiro Saw ...
    2010 Volume 74 Issue 10 Pages 2089-2096
    Published: 2010
    Released: September 24, 2010
    [Advance publication] Released: August 07, 2010
    JOURNALS FREE ACCESS
    Background: Durable polymers used for first-generation drug-eluting stents (DES) potentially contribute to persistent inflammation and late DES thrombosis. The vascular response to the StelliumTM stent, which is coated with an absorbable polymer for slow release of low-dose paclitaxel, was evaluated in the present study. Methods and Results: The 37 patients with stable angina were implanted with 47 StelliumTM stents. Quantitative coronary angiography (QCA) was performed at baseline, and QCA and optical coherence tomography (OCT) were performed at 6 months post-implant. The primary endpoint was major adverse cardiac events (MACE). At 6 months, 1 case of MACE occurred because of total occlusion of a protected left main artery. In-stent and segment binary restenosis rates were both 0%. In-stent late loss was 0.19±0.54 mm. Altogether, 5,564 struts were visualized by OCT and mean neointimal thickness was 150.03±146.36 μm. The number of well-apposed struts with and without neointima overlay was 5,135 (92.29%) and 396 (7.12%), respectively. Peri-strut low intensity was observed in 518 struts (9.31%). Conclusions: This first-in-man study of the StelliumTM stent shows the promising possibility of bioabsorbable polymeric surface coating paclitaxel-eluting stents out to 6 months. The low rate of peri-strut low intensity suggests low cellular toxicity of the StelliumTM stent compared with the first-generation DES. (Circ J 2010; 74: 2089-2096)
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  • – Results From the RESOLUTE Trial –
    Katsuhisa Waseda, Junya Ako, Masao Yamasaki, Tomomi Koizumi, John Ormi ...
    2010 Volume 74 Issue 10 Pages 2097-2102
    Published: 2010
    Released: September 24, 2010
    [Advance publication] Released: August 03, 2010
    JOURNALS FREE ACCESS
    Background: The Resolute stent is a newly developed system with a bio-histocompatible polymer that allows programmed drug delivery up to 180 days. The aim of this intravascular ultrasound (IVUS) analysis was to evaluate the short- (4 months) and mid-term (9 months) efficacy using the Resolute stent. Methods and Results: Data were derived from the RESOLUTE trial, a prospective, multicenter, non-randomized, single-arm study to treat de novo native coronary artery lesions. This trial included 2 cohorts with different follow-up periods, and all enrollment patients in this trial received IVUS study. Follow-up IVUS was available in 24 patients (4-month group) and 88 patients (9-month group). Neointimal obstruction (%) was defined as neointimal volume divided by stent volume. Cross-sectional narrowing (CSN, %) was defined as neointimal area divided by stent area. No significant differences in vessel, lumen and stent volume at post-procedure were observed within stented segments between the 4- and 9-month follow-up groups. Although neointimal volume and % neointimal obstruction showed no significant difference between the 2 groups (% neointimal obstruction: 2.2±2.5 vs 3.7±4.0%, P=0.09), maximum CSN was significantly larger in the 9-month group. There were 7 cases of late incomplete stent apposition. Conclusions: These IVUS results showed minimum growth of neointimal proliferation by the Resolute stent throughout the stented segment up to 9 months follow up. (Circ J 2010; 74: 2097-2102)
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Cardiovascular Surgery
  • Toshihiro Fukui, Shuichiro Takanashi
    2010 Volume 74 Issue 10 Pages 2103-2108
    Published: 2010
    Released: September 24, 2010
    [Advance publication] Released: August 03, 2010
    JOURNALS FREE ACCESS
    Background: The impact of gender on outcome after coronary artery bypass grafting (CABG) is controversial. The aim of this study was to compare the differences of clinical and angiographic outcomes between female and male patients after CABG. Methods and Results: The records of 954 patients who underwent isolated CABG between 2004 and 2009 were reviewed. There were 188 female and 766 male patients. Female patients were smaller (P<0.0001) and had a more unstable status (P=0.0024) preoperatively compared with the male patients. Left internal thoracic artery (ITA) use was identical in both genders. However, the right ITA (P=0.006) and radial artery (P<0.0001) use were less frequent in females compared with that in males. Consequently, the use of saphenous vein grafts (SVGs) was more frequent in females than in males (P<0.0001). Mortality was similar between the genders (1.0% vs 1.1%). Although the rate of major complications was not significantly different between the genders (12.2% vs 9.5%), the cerebrovascular event rate was higher in females compared with that in males (4.3% vs 1.6%; P=0.0432). Patency rates of arterial grafts were not significantly different between the genders; however, those of SVGs were lower in females than those in males (88.6% vs 96.1%; P=0.0003). Conclusions: The clinical outcomes of females after CABG were comparable with those of males. (Circ J 2010; 74: 2103-2108)
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  • – A Velocity Vector Imaging-Based Study –
    Yelda Tayyareci, Ozlem Yildirimtürk, Vedat Aytekin, Kadriye Memic ...
    2010 Volume 74 Issue 10 Pages 2109-2117
    Published: 2010
    Released: September 24, 2010
    [Advance publication] Released: August 31, 2010
    JOURNALS FREE ACCESS
    Background: The aim of the present study was to evaluate pre-existent subclinical mechanical atrial dysfunction in patients with postoperative atrial fibrillation (POAF) by using novel echocardiographic techniques. Methods and Results: Ninety-six patients with sinus rhythm, undergoing coronary artery bypass graft (CABG) operation were prospectively enrolled. Preoperative left atrial (LA) reservoir, conduit and booster functions were evaluated by 3 different methods: conventional echocardiography, tissue Doppler imaging (TDI), and 2-dimensional strain imaging based-velocity vector imaging (VVI). POAF occurred in 25 out of 96 patients (26%). LA volume index (LAVI) was the only conventional parameter associated with POAF. TDI-derived LA velocities were similar in study groups. In VVI analysis, LA systolic strain, strain rate (SRs) and early diastolic strain rate (ESRd) were impaired in patients who developed POAF after CABG (P=0.0001). Age, LAVI, LA peak systolic strain, SRs and ESRd were found to be the independent predictors of POAF. The optimal cut-off point of 44.0% (88.7% sensitivity, 96% specificity) for LA strain, 1.7 s-1 (88% sensitivity, 86.2% specificity) for SRs and 1.95 s-1 (sensitivity 72%, 70.4% specificity) for ESRd predicted POAF in this study. Conclusions: VVI-derived strain imaging could be used as an adjunctive non-invasive method for evaluating subclinical atrial mechanical dysfunction in patients undergoing CABG. This might help us to identify patients with high risk of POAF in clinical practice. (Circ J 2010; 74: 2109-2117)
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Heart Failure
  • Takashi Koyama, Hiroyuki Watanabe, Yusuke Kobukai, Shin Makabe, Yoshik ...
    2010 Volume 74 Issue 10 Pages 2118-2124
    Published: 2010
    Released: September 24, 2010
    [Advance publication] Released: July 29, 2010
    JOURNALS FREE ACCESS
    Background: Sleep-disordered breathing (SDB) is thought to be a state of inflammation caused by hypoxic stress. Whether adaptive servo ventilation (ASV) attenuates the inflammatory response and improves the cardiac function of patients with congestive heart failure (CHF) accompanied by SDB was not been investigated. Methods and Results: Seventeen inpatients with New York Heart Association (NYHA) II or III underwent polysomnography. There was a positive correlation between the apnea hypopnea index and high-sensitivity C-reactive protein (hs-CRP) level (r=0.753, P=0.016). The patients were divided into ASV (n=10) and non-ASV groups (n=7), and CHF-parameters were measured before and after ASV treatment. Improvement was noted for the NYHA class in the ASV group but not in the non-ASV group. In contrast to the non-ASV group, the level of brain natriuretic peptide (BNP), ejection fraction, and hs-CRP levels in the ASV group significantly improved (BNP, 212.1±181.2 to 77.3±54.0 pg/ml [P<0.05]; ejection fraction, 43.5±6.4 to 53.3±6.1% [P=0.002]; hs-CRP, 0.85±0.58 to 0.21±0.19 mg/dl, [P=0.008]). The increase in ejection fraction was correlated with a decrease in the hs-CRP level (r=-0.753, P=0.001). Conclusions: Anti-inflammatory effects of ASV are important contributors for improving cardiac function in patients with CHF accompanied by SDB. (Circ J 2010; 74: 2118-2124)
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Hypertension and Circulatory Control
  • Kentaro Toiyama, Kenji Hamaoka, Tatsujiro Oka, Naho Kobayashi, Kanae N ...
    2010 Volume 74 Issue 10 Pages 2125-2131
    Published: 2010
    Released: September 24, 2010
    [Advance publication] Released: August 21, 2010
    JOURNALS FREE ACCESS
    Background: Hypoxic gas ventilation therapy has recently been performed to prevent post-birth increased pulmonary blood flow in cases of congenital heart diseases with increased pulmonary blood flow. However, how the oxygen supply to the tissues changes during breathing a hypoxic gas mixture, remains unknown. The changes in cerebral oxygen saturation and blood supply during hypoxic gas ventilation therapy using a nitrogen gas mixture were studied. Methods and Results: Cerebral regional oxygen saturation (cerebral rSO2) was measured by near-infrared spectroscopy, and changes in middle cerebral artery (MCA) blood flow and an index of vascular resistance (RI) were assessed in 8 consecutive patients having congenital heart diseases with increased pulmonary blood flow. In all patients, urinary volume increased significantly, and the respiratory rate showed a clear decrease. Percutaneous oxygen saturation showed no significant change. The average of cerebral rSO2 was 67.3% before hypoxic gas ventilation, but increased to 69.4%, 69.1%, and 70.7% within 1, 12, and 24 h after initiation of treatment, respectively. MCA blood flow significantly increased in the diastolic phase, and RI significantly improved from 0.80 to 0.68 within 12 h after initiation of therapy. Conclusions: These results indicate that hypoxic gas ventilation therapy does not decrease cerebral oxygen saturation, but safely improves the cerebral blood supply in cases of congenital heart diseases with increased pulmonary blood flow. (Circ J 2010; 74: 2125-2131)
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  • – A Subanalysis of the CASE-J Trial –
    Kenji Ueshima, Shinji Yasuno, Koji Oba, Akira Fujimoto, Masashi Mukoya ...
    2010 Volume 74 Issue 10 Pages 2132-2138
    Published: 2010
    Released: September 24, 2010
    [Advance publication] Released: August 21, 2010
    JOURNALS FREE ACCESS
    Background: In this subanalysis of the CASE-J, which was conducted to compare the effects of candesartan and amlodipine in Japanese high-risk hypertensive patients, the association of left ventricular hypertrophy (LVH) with renal function is clarified. Methods and Results: Patients were divided into 2 groups: 1,082 patients with LVH and 2,119 patients without LVH. The primary endpoint was the change in the estimated glomerular filtration rate (eGFR). The eGFRs were increased from 63.6 to 65.1 ml · min-1 · 1.73 m-2 in patients with LVH and from 63.6 to 68.5 ml · min-1 · 1.73 m-2 in those without LVH. The improvement in the eGFR was greater in patients without LVH than in those with LVH (P=0.004). In patients with chronic kidney disease (CKD) patients, the eGFR increased from 52.7 to 60.5 ml · min-1 · 1.73 m-2 in patients without LVH, but from 53.1 to 57.2 ml · min-1 · 1.73 m-2 in those with LVH (P<0.001, patients without LVH vs patients with LVH). Furthermore, because the eGFR changed from 76.5 to 75.4 ml · min-1 · 1.73 m-2 in patients without CKD but with LVH, and from 76.5 to 77.5 ml · min-1 · 1.73 m-2 in those without either CKD or LVH, the final eGFR was higher in patients without LVH than in those with LVH (P=0.048). Conclusions: LVH related to the time-course of renal function in Japanese hypertensive patients. (Circ J 2010; 74: 2132-2138)
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  • Lars Mense, Manja Reimann, Heinz Rüdiger, Georg Gahn, Heinz Reich ...
    2010 Volume 74 Issue 10 Pages 2139-2145
    Published: 2010
    Released: September 24, 2010
    [Advance publication] Released: August 03, 2010
    JOURNALS FREE ACCESS
    Background: Carotid endarterectomy (CEA) is the first-line treatment in severe carotid stenosis to prevent stroke. Because of methodological limitations, the acute impact of CEA on baroreflex function and cerebral autoregulation is not well defined and was therefore investigated by applying a novel algorithm. Methods and Results: Systemic arterial blood pressure, ECG and respiration during metronomic breathing and Valsalva maneuver were continuously recorded in 18 patients with carotid stenosis before and after CEA, and in 10 healthy controls. Baroreflex sensitivity, frequency spectra of RR intervals and indices for cerebral autoregulation were evaluated by trigonometric regressive spectral analysis. Compared with the controls, patients had impaired baroreflex sensitivity. Baroreflex sensitivity and frequency spectra were not changed by CEA. Cerebral autoregulation of patients with carotid stenosis as calculated by phase shift was reduced compared with controls but it improved significantly after CEA. Improvement of cerebral autoregulation was independent of changes in cerebral blood flow velocity. Conclusions: Baroreflex sensitivity and cerebral autoregulation are impaired in patients with carotid stenosis, conferring a high stroke risk. CEA improves cerebral autoregulation, but does not affect baroreflex sensitivity. For further risk reduction, interventional approaches targeting baroreflex function need to be considered. (Circ J 2010; 74: 2139-2145)
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Imaging
  • Kosuke Arai, Hideki Ishii, Tetsuya Amano, Tadayuki Uetani, Michio Nank ...
    2010 Volume 74 Issue 10 Pages 2146-2151
    Published: 2010
    Released: September 24, 2010
    [Advance publication] Released: July 29, 2010
    JOURNALS FREE ACCESS
    Background: Metabolic syndrome (MetS) is associated with adverse cardiovascular events and mortality, where acute coronary syndrome significantly impacts on mortality and morbidity. In contrast, evidences have accumulated that the lipid-rich plaque might play a critical role in acute coronary syndrome. Methods and Results: The study population consisted of 94 patients with suspected angina pectoris who underwent multi-detector computed tomography (MDCT). Of those, we identified 41 with MetS. In MDCT analysis, low-density plaque volume (LDPV) (42±28 vs 24±18 mm3, P=0.0003), moderate-density plaque volume (105±41 vs 82±33 mm3, P=0.003), total plaque volume (164±70 vs 118±59 mm3, P=0.0008) and %LDPV (24.2±10.0 vs 18.3±7.1%, P=0.01) were significantly increased in the MetS group compared to the non-MetS group. Multivariate linear regression analysis after adjusting for confounding variables revealed that MetS was significantly correlated with an increase in %LDPV (β=0.48, P=0.0001). Multivariate logistic regression analysis for lipid-rich plaque after adjusting for confounding variables indicated that MetS was significantly associated with lipid-rich plaque (odds ratio: 5.99, 95% confidence intervals: 1.94-18.6, P=0.002). Conclusions: Patients with MetS were strongly related to having a lipid-rich composition in their coronary plaque, as detected by MDCT. (Circ J 2010; 74: 2146-2151)
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  • – Long-Term Follow-up Data –
    Chisato Izumi, Shuichi Takahashi, Makoto Miyake, Jiro Sakamoto, Koji H ...
    2010 Volume 74 Issue 10 Pages 2152-2157
    Published: 2010
    Released: September 24, 2010
    [Advance publication] Released: August 03, 2010
    JOURNALS FREE ACCESS
    Background: There are no reports about the long-term follow-up data of patients with aortic plaques among the Japanese population. The purpose of this study was to clarify the frequency of patients with severe aortic plaques and the impact of aortic plaque morphology on the prognosis. Methods and Results: We retrospectively investigated 1,570 consecutive patients who underwent transesophageal echocardiography. Survival rate and subsequent embolic event rate were compared between patients with severe aortic plaque (>5 mm in thickness) and control patients. The relationship between aortic plaque morphology and prognosis was also estimated according to the presence of ulceration, calcification, hypoechoic plaques, and mobile plaques. The mean follow-up period was 8.7 years. Among 1,570 patients, severe aortic plaque was detected in 92 patients (5.9%). These 92 patients showed a significantly low survival rate and high subsequent embolic event rate compared to control patients (5-year survival rate: 69% vs 94%; 5-year embolic event free rate: 52% vs 95%). Among patients with severe aortic plaque, only ulceration was associated with a low survival rate (hazards ratio: 2.4, 95% confidence interval (CI): 1.1-5.2) and only mobile plaque was associated with a high embolic event rate (hazards ratio: 2.2; 95%CI: 1.1-5.1). Conclusions: Aortic plaque >5 mm in thickness was a predictor of poor prognosis. In the presence of aortic plaque >5 mm, ulceration was a predictor of a low survival rate and mobile plaque was a predictor of a high embolic event rate. (Circ J 2010; 74: 2152-2157)
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  • Katsuomi Iwakura, Atsushi Okamura, Yasushi Koyama, Motoo Date, Yoshiha ...
    2010 Volume 74 Issue 10 Pages 2158-2165
    Published: 2010
    Released: September 24, 2010
    [Advance publication] Released: August 06, 2010
    JOURNALS FREE ACCESS
    Background: Low-dose dobutamine stress echocardiography (DSE) assesses myocardial viability at the early stage of acute myocardial infarction (AMI), but its assessment is subjective and variable. Automated function image (AFI) determines global longitudinal peak strain (GLPS) based on tissue tracking technique. The ability of GLPS obtained by AFI during dobutamine stress to assess myocardial viability after AMI was investigated. Methods and Results: Low-dose DSE at day 3 in 23 consecutive patients with AMI was performed using Vivid 7 (GE Healthcare). Segmental longitudinal peak strain with AFI and obtained GLPS was analyzed. Wall motion score index (WMSI) by echocardiography 1 month later was determined. In 18 patients, left ventriculography was also performed at 3.2±1.5 months later to obtain left ventricular ejection fraction (LVEF) and regional wall motion (RWM, SD/chord). GLPS was improved during dobutamine infusion at 10 μg · kg-1 · min-1 (-12.9±3.5% to -15.2±3.6%, P=0.0004). GLPS during dobutamine stress showed good correlations with follow-up WMSI (R=0.47, P=0.02), with peak CK-MB (R = 0.52, P=0.01), with RWM (R = -0.48, P=0.04), and with LVEF (R = -0.54, P=0.02), whereas GLPS at baseline showed no correlations with them. Averaged segmental peak strain at baseline and during stress were correlated with follow-up WMSI (R = 0.50 and 0.43, respectively), but not with LVEF. Conclusions: GLPS during dobutamine stress determined by AFI is a promising, objective index to assess myocardial viability on the early stage of AMI. (Circ J 2010; 74: 2158-2165)
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  • Jeonggeun Moon, In Jeong Cho, Chi Young Shim, Jong-Won Ha, Yangsoo Jan ...
    2010 Volume 74 Issue 10 Pages 2166-2172
    Published: 2010
    Released: September 24, 2010
    [Advance publication] Released: August 31, 2010
    JOURNALS FREE ACCESS
    Supplementary material
    Background: Myocardial ischemia and dysfunction can occur in hypertrophic cardiomyopathy (HCM) because of the high muscle-to-blood ratio, even without significant coronary artery disease. Microbubbles reside only in the intravascular space and myocardial video-intensity during systole results mostly from microbubbles within capillaries. The hypothesis explored in the present study was that an abnormal capillary density in apical HCM (ApHCM) can be demonstrated using myocardial contrast echocardiography (MCE). Methods and Results: The 56 patients were investigated (31 males, age 58±9 years; 33 ApHCM, 9 hypertensive left ventricular hypertrophy [LVH], 14 controls). MCE was performed with low-mechanical-index power modulation imaging. Tissue Doppler imaging to assess myocardial contractile function was obtained at the mitral annulus (S'), and 99 mTc-MIBI SPECT was also performed. All ApHCM patients exhibited perfusion defects at the hypertrophied segments in the systolic phase during MCE, whereas SPECT showed normal or rather increased perfusion at those sites. The cyclic variation of video-intensity was exaggerated in ApHCM when compared with the LVH or control group (% of [systolic video-intensity]/[diastolic video-intensity]: 33.0±12.3%, 88.3±19.2% and 79.4±13.9%, respectively [P<0.05]). Concurrently, MCE cyclic variation and perfusion defect size were related to decreased S' (P<0.05 for all). Conclusions: A perfusion defect at the hypertrophied segment, representing abnormal myocardial capillary density, was observed in ApHCM patients during MCE. The extent of MCE cyclic variation and the perfusion defect size both correlate with decreased myocardial contractile property in ApHCM. (Circ J 2010; 74: 2166-2172)
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  • – Insights From Acute Inferior Myocardial Infarction After Primary Coronary Intervention –
    Shih-Hung Hsiao, Kuan-Rau Chiou, Wei-Chun Huang, Chin-Chang Cheng, Fen ...
    2010 Volume 74 Issue 10 Pages 2173-2180
    Published: 2010
    Released: September 24, 2010
    [Advance publication] Released: August 31, 2010
    JOURNALS FREE ACCESS
    Background: Tissue Doppler imaging (TDI) data for acute inferior myocardial infarction (MI) patients who have received primary percutaneous coronary intervention (PCI) are sparse. Methods and Results: One hundred and sixty-five patients received primary PCI for acute inferior MI were enrolled. Right ventricular infarction (RVI) was defined as a culprit lesion proximal to the right ventricular branch of right coronary artery (RCA). Echocardiograms and TDI were obtained within 6 h after primary PCI. The prevalence of multi-vessel disease in the RCA-P culprit group (50%) was higher than that in other groups (39% of RCA-D culprit, 43% of left circumflex artery (LCX) culprit). The myocardial performance index (MPI) of the lateral tricuspid annulus provides discriminatory power for identifying RVI, whereas systolic velocity (Sm) of the lateral tricuspid annulus does not. Lateral mitral annular MPI divided by the lateral tricuspid annular MPI is a reliable index for identifying a culprit lesion (>1.06 predicts culprit over LCX; <0.96 predicts culprit over RCA-P and RVI). Kaplan-Meier survival curves revealed that late cardiovascular events were more likely in RVI patients. However, multivariate Cox proportional hazards analysis revealed that the most important factor in hard events and all cardiovascular events was multivessel disease. Conclusions: TDI is useful for identifying RVI and culprit lesions in inferior MI patients received primary PCI. RVI itself isn't associated with 1-year hard events and all cardiovascular events. (Circ J 2010; 74: 2173-2180)
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  • Yasumi Uchida, Yasuto Uchida, Noriaki Kameda
    2010 Volume 74 Issue 10 Pages 2181-2186
    Published: 2010
    Released: September 24, 2010
    [Advance publication] Released: August 21, 2010
    JOURNALS FREE ACCESS
    Background: If oxidized low-density lipoprotein (oxLDL), LDL, lysophosphatidylcholine (LPC) and apolipoprotein B (apoB) can be visualized simultaneously, their roles in the initiation, progression and destabilization of atherosclerotic plaques can be objectively evaluated. Methods and Results: (1) The fluorescence characteristic of each atherogenic substance was investigated by microscopy using a band-pass filter (470 nm) and a band-absorption filter (520 nm) with homidium bromide (Ho) and trypan blue (TB) as indicators. (2) 50 excised human coronary plaques were classified by their autofluorescence into green, greenish-yellow and yellow, and the localization of oxLDL, LDL, LPC and apoB were investigated by color fluorescence angioscopy (CFA). The plaque colors were white, yellow and glistening yellow by conventional angioscopy. (1) OxLDL and LDL exhibited golden fluorescence, whereas LPC and apoB exhibited red fluorescence. (2) By CFA, 16 of 19 greenish-yellow and 1 of 8 yellow plaques exhibited red and golden fluorescence in a mosaic pattern, indicating co-deposition of oxLDL/LDL and LPC/apoB; 3 greenish-yellow and 7 yellow plaques exhibited red fluorescence, indicating solitary deposition of apoB; 23 green plaques infrequently exhibited these fluorescence colors. Conclusions: OxLDL/LDL and LPC/apoB were successfully visualized as co-deposited in greenish-yellow autofluorescence plaques, but only LPC/apoB in yellow autofluorescence plaques. (Circ J 2010; 74: 2181-2186)
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Ischemic Heart Disease
  • Suksiri Siriswangvat, Nakarin Sansanayudh, Surakit Nathisuwan, Duangch ...
    2010 Volume 74 Issue 10 Pages 2187-2192
    Published: 2010
    Released: September 24, 2010
    [Advance publication] Released: August 21, 2010
    JOURNALS FREE ACCESS
    Background: Emerging data suggests that several proton pump inhibitors (PPIs), including omeprazole, might interfere with the antiplatelet action of clopidogrel. However, there is a lack of data for rabeprazole. This study aimed to investigate and compare the impact of omeprazole and rabeprazole on the antiplatelet action of clopidogrel among patients with coronary artery disease (CAD). Methods and Results: A prospective, randomized, open-labeled study was conducted among 87 CAD patients receiving clopidogrel and aspirin. Forty three and 44 patients were randomized to receive omeprazole 20 mg and rabeprazole 20 mg once daily, respectively, for at least 2 weeks. Adenosine 5-diphosphate 20 μmol/L-induced platelet aggregation was performed before and after PPIs treatment. Mean maximal platelet aggregation (MPA) before and after PPIs treatment of both groups were compared. At baseline, there were no significant differences in the mean MPA between the omeprazole and rabeprazole groups (40.68±18.82% vs 36.42±21.39%; P=0.326). After a 2-week treatment with PPIs, the mean MPA in both groups significantly increased from baseline and there were no differences between the omeprazole and rabeprazole groups (55.73±19.66% vs 48.46±18.80%; P=0.141). Conclusions: Both omeprazole and rabeprazole decreased the antiplatelet effect of clopidogrel. Use of these agents resulted in a similar degree of interference on clopidogrel's action, as measured by ADP-induced platelet aggregation. (Circ J 2010; 74: 2187-2192)
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Myocardial Disease
  • Akira Ukimura, Tohru Izumi, Akira Matsumori, Clinical Research Commit ...
    2010 Volume 74 Issue 10 Pages 2193-2199
    Published: 2010
    Released: September 24, 2010
    [Advance publication] Released: August 06, 2010
    JOURNALS FREE ACCESS
    Background: An influenza pandemic occurred in 2009 and myocarditis associated with the 2009 influenza A (H1N1) pandemic was reported among hospitalized patients from August 2009. Methods and Results: The Japanese Circulation Society organized the Clinical Research Committee on Myocarditis Associated with Influenza Pandemic A (H1N1) 2009 and called for a case report on myocarditis for a national survey. The diagnosis of myocarditis was performed using the Guidelines for the Diagnosis and Treatment of Myocarditis (JCS 2009). Fifteen patients were reported to the committee. Fulminant myocarditis developed in 10 patients. Mechanical circulatory support (intra-aortic balloon pumping (IABP) and/or percutaneous cardiopulmonary support (PCPS)) was used on all 10 patients, 8 of whom were rescued. Abnormalities on echocardiography and elevated cardiac enzymes were seen in most of the patients. Myocarditis was found by endomyocardial biopsy in 6 patients. Three patients had complications with pneumonia. Conclusions: In reality, myocarditis associated with pandemic influenza A (H1N1) seemed to be more common in hospitalized patients, compared with previous seasonal influenza virus outbreaks. To avoid misdiagnosis of acute myocarditis associated with influenza pandemic A (H1N1) 2009, it is essential to determine the characteristic symptoms, signs, and laboratory findings of acute myocarditis during influenza pandemics. Mechanical circulatory support (IABP and/or PCPS) was required to rescue patients with fulminant myocarditis. (Circ J 2010; 74: 2193-2199)
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Pulmonary Circulation
  • Satoshi Akagi, Kazufumi Nakamura, Katsumasa Miyaji, Aiko Ogawa, Kengo ...
    2010 Volume 74 Issue 10 Pages 2200-2205
    Published: 2010
    Released: September 24, 2010
    [Advance publication] Released: August 06, 2010
    JOURNALS FREE ACCESS
    Background: The appropriate dose range of epoprostenol is thought to be 25-40 ng · kg-1 · min-1 based on the results of previous studies showing that epoprostenol therapy reduced mean pulmonary artery pressure (mPAP) by 12-22% and pulmonary vascular resistance (PVR) by 32-53% compared with baseline values in patients with idiopathic pulmonary arterial hypertension (IPAH). However, the efficacy of treatment of IPAH patients with epoprostenol >40 ng · kg-1 · min-1 has not been determined and this was the aim of the present study. Methods and Results: The study group comprised 16 consecutive patients, none of whom died; 2 dropped out because they could not be titrated up as needed to the highest effective epoprostenol dose. Hemodynamics were evaluated in 14 IPAH patients who received high-dose epoprostenol monotherapy. The mean epoprostenol dosage was 107±40 ng · kg-1 · min-1 (range, 54-190 ng · kg-1 · min-1) and the mean duration of high-dose epoprostenol therapy was 1,355±627 days (range, 582-2,410 days). Significant decreases from baseline values were seen in mPAP (from 66±16 to 47±12 mmHg, P<0.001) and PVR (from 21.6±8.3 to 6.9±2.9 Wood units, P<0.001). Compared with the baseline state, high-dose epoprostenol therapy reduced mPAP by 30% and PVR by 68%. Conclusions: The present study suggests high-dose epoprostenol therapy is a new treatment strategy for IPAH. (Circ J 2010; 74: 2200-2205)
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Renal Disease
  • Szu-Chia Chen, Jer-Ming Chang, Jer-Chia Tsai, Tsung-Hsien Lin, Po-Chao ...
    2010 Volume 74 Issue 10 Pages 2206-2210
    Published: 2010
    Released: September 24, 2010
    [Advance publication] Released: August 21, 2010
    JOURNALS FREE ACCESS
    Background: Patients with chronic kidney disease (CKD) are associated with an increased risk of cardiovascular (CV) events. An increase in the ratio of the pre-ejection period (PEP) to ejection time (ET) is correlated with a decrease of left ventricular systolic function. Brachial PEP (bPEP) and brachial ET (bET) can be automatically determined from an ankle-brachial index (ABI)-form device. The aim of this study is to investigate whether bPEP/bET is a useful predictor for CV events in patients with CKD. Methods and Results: We consecutively enrolled 242 CKD patients from our outpatient department of internal medicine. The bPEP and bET were measured using an ABI-form device. CV events were defined as cardiac death, stroke, myocardial infarction, and hospitalization for congestive heart failure. The study subjects were followed until the first episode of CV events occurred. The relative CV event risk was analyzed by Cox-regression methods. In the multivariate analysis, the presence of diabetes (hazard ratio (HR), 3.531; P=0.014), increased bPEP/bET (HR, 1.054; P=0.026), and decreased serum albumin level (HR, 0.525; P=0.005) were independent predictors for CV events. Conclusions: The study findings show that bPEP/bET is a useful predictor of CV events in CKD patients. Screening CKD patients by means of bPEP/bET might help to identify patients at high risk of increased CV events. (Circ J 2010; 74: 2206-2210)
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Vascular Medicine
  • – 24-Month Follow-up Study –
    Sanghoon Shin, Sang-Hak Lee, Sungha Park, Seok-Min Kang, Namsik Chung, ...
    2010 Volume 74 Issue 10 Pages 2211-2215
    Published: 2010
    Released: September 24, 2010
    [Advance publication] Released: August 03, 2010
    JOURNALS FREE ACCESS
    Supplementary material
    Background: The relationship between fms-like tyrosine kinase-1 (sFlt-1), a soluble receptor for vascular endothelial growth factor (VEGF), and vascular disease has not been established, so this study aimed to elucidate the association between sFlt-1 and the progression of carotid intima - media thickness (IMT) in hypertensive patients. Methods and Results: The 120 hypertensive patients under medical control were enrolled and 112 completed the study (age 59±9 years, 57 females). Plasma VEGF and sFlt-1 levels were measured at enrollment. At baseline and 24-month visit, carotid IMT was measured and the association between sFlt-1 and IMT progression was assessed by linear regression. At baseline, age (r=0.186) and low level of high-density lipoprotein-cholesterol (HDL-C <40 mg/dl, r=0.214) were significantly related to carotid IMT. Over the 24 months, carotid IMT increased from 0.670±0.089 mm to 0.696±0.095 mm. There was a positive correlation between sFlt-1 tertiles and IMT change (P=0.05 by ANOVA). Upon multivariate analysis, log-transformed sFlt-1 level (β=0.137, P=0.003) and low HDL-C (β=0.048, P=0.04) were identified as predictors of IMT progression, independent of other confounding variables. Conclusions: High sFlt-1 level is predictive of carotid IMT progression in hypertensive patients. Low HDL-C level was also associated with IMT change. These observations support a high sFlt-1 level being indicative of progression of atherosclerosis. (Circ J 2010; 74: 2211-2215)
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  • Natsumi Masai, Junko Tatebe, Gen Yoshino, Toshisuke Morita
    2010 Volume 74 Issue 10 Pages 2216-2224
    Published: 2010
    Released: September 24, 2010
    [Advance publication] Released: August 31, 2010
    JOURNALS FREE ACCESS
    Background: Chronic kidney disease (CKD) is recognized as a common condition that elevates the risk of atherosclerotic cardiovascular disease (CVD). Evidence suggests that increased oxidative stress is an emerging key mechanism of atherosclerosis in CKD. One recent study reported that indoxyl sulfate (IS), a uremic toxin derived from dietary protein, could cause vascular disorder, however, little is known about the mechanism involved. The present study examined the signaling pathway that is activated by IS to induce monocyte chemoattractant protein-1 (MCP-1), which plays an important role in the development of atherosclerosis, in cultured human umbilical vein endothelial cells (HUVEC). Methods and Results: We show that IS enhanced reactive oxygen species (ROS) production, assessed by dihydroethidium staining, by HUVEC. IS also induced the expression of MCP-1, which was measured by enzyme-linked immunosorbent assay and real-time reverse transcription-polymerase chain reaction. These changes were suppressed by apocynin, a specific inhibitor of NADPH oxidase. Furthermore, IS induced the expression of NADPH oxidase 4 (Nox4) mRNA. IS-induced stimulation of ERK1/2 and p38 phosphorylation, detected by immunoblotting, was inhibited by apocynin. Finally, IS activated NF-κB, which was suppressed by inhibiting ERK1/2 and p38, resulting in reduced MCP-1 expression. These results suggest that IS increases NADPH oxidase-derived ROS, which in turn, activates the MAPK/NF-κB pathway and leads to induction of MCP-1 expression in HUVEC. Conclusions: These findings raise the possibility that IS plays an important pathophysiological role in the development of CVD in individuals with CKD. (Circ J 2010; 74: 2216-2224)
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Controversies in Cardiovascular Medicine
  • – Should Drug-Eluting Stents Be Indicated for Patients With Acute Coronary Syndrome? (Pro) –
    Yoshihisa Nakagawa
    2010 Volume 74 Issue 10 Pages 2225-2231
    Published: 2010
    Released: September 24, 2010
    [Advance publication] Released: August 31, 2010
    JOURNALS FREE ACCESS
    The effective use of drug-eluting stents (DES) in the treatment of ST-elevation myocardial infarction (STEMI), a condition representative of acute coronary syndrome, has not been clarified, particularly among Japanese patients. The indication of DES for STEMI patients is discussed by reviewing the evidence from both Western countries and Japan. Currently, in the registry studies, randomized studies, and meta-analyses comparing the use of DES and bare-metal stents (BMS) in STEMI patients, DES show a consistent trend toward decreasing the risk of repeat revascularization without increasing the incidence of death, recurrent MI or stent thrombosis when compared with BMS in the treatment for patients with STEMI. Japanese data are also consistent with this trend. However, there are no clear data indicating safety concerns. Longer-term follow-up studies are necessary to assess the effectiveness of DES in STEMI patients. (Circ J 2010; 74: 2225-2231)
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  • – Should Drug-Eluting Stents Be Indicated for Patients With Acute Coronary Syndrome? (Con) –
    Katsumi Inoue
    2010 Volume 74 Issue 10 Pages 2232-2238
    Published: 2010
    Released: September 24, 2010
    [Advance publication] Released: August 31, 2010
    JOURNALS FREE ACCESS
    Drug-eluting stents (DES) have been proven to reduce the rate of restenosis by marked inhibition of neointimal hyperplasia, but unusual vessel responses to DES, such as substantially impaired arterial healing characterized by incomplete endothelialization and persistent inflammatory response, have been recognized. The culprit sites in acute coronary syndrome (ACS), especially acute myocardial infarction, have large necrotic cores with a paucity of smooth muscle cells. In these lesions, penetration of the stent struts into the necrotic core is frequently observed after stent implantation. Pathologic observations have revealed that the lesions stented with DES frequently show greater delay in arterial healing than those treated with bare-metal stents. Thus, ACS culprit sites could be at persistent risk for thrombosis after DES implantation. (Circ J 2010; 74: 2232-2238)
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