Circulation Journal
Online ISSN : 1347-4820
Print ISSN : 1346-9843
ISSN-L : 1346-9843
Volume 75, Issue 2
Displaying 1-41 of 41 articles from this issue
Massage From the Editor-in-Chief
Reviews
  • – Not a Simple Relationship –
    Gerd Heusch
    2011 Volume 75 Issue 2 Pages 229-236
    Published: 2011
    Released on J-STAGE: January 25, 2011
    Advance online publication: October 28, 2010
    JOURNAL FREE ACCESS
    Resting heart rate (HR) is increased in patients with heart failure (HF). Sustained tachycardia can cause HF. The magnitude of HR reduction in treatment trials of patients with HF is associated with a reduction in mortality. Yet, the mechanistic and causal role of HR in HF is unclear, and recent trials with selective HR reduction have not consistently achieved benefit: the BEAUTIFUL trial in patients with coronary artery disease and left ventricular dysfunction did not achieve a significant benefit in the primary endpoint, and only the coronary outcome, not the HF outcome, was improved; in the SHIFT trial, however, patients with symptomatic heart failure had a significant benefit in the primary endpoint of cardiovascular mortality and hospitalization for worsening HF. The present review addresses the pathophysiology of tachycardia-induced HF, the force-frequency relationship, and the clinical potential of HR reduction in HF. (Circ J 2011; 75: 229-236)
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  • Alvaro Yogi, Glaucia E. Callera, Tayze T. Antunes, Rita C. Tostes, Rhi ...
    2011 Volume 75 Issue 2 Pages 237-245
    Published: 2011
    Released on J-STAGE: January 25, 2011
    Advance online publication: December 07, 2010
    JOURNAL FREE ACCESS
    Decreased Mg2+ concentration has been implicated in altered vascular reactivity, endothelial dysfunction and structural remodeling, processes important in vascular changes and target organ damage associated with hypertension. Unlike our knowledge of other major cations, mechanisms regulating cellular Mg2+ handling are poorly understood. Until recently little was known about protein transporters controlling transmembrane Mg2+ influx. However, new research has uncovered a number of genes and proteins identified as transmembrane Mg2+ transporters, particularly transient receptor potential melastatin (TRPM) cation channels, TRPM6 and TRPM7. Whereas TRPM6 is found primarily in epithelial cells, TRPM7 is ubiquitously expressed. Vascular TRPM7 has been implicated as a signaling kinase involved in vascular smooth muscle cell growth, apoptosis, adhesion, contraction, cytoskeletal organization and migration, and is modulated by vasoactive agents, pressure, stretch and osmotic changes. Emerging evidence suggests that vascular TRPM7 function might be altered in hypertension. The present review discusses the importance of Mg2+ in vascular biology in hypertension and focuses on transport systems, mainly TRPM7, that might play a role in the control of vascular Mg2+ homeostasis. Elucidation of the relationship between the complex systems responsible for regulation of Mg2+ homeostasis, the role of TRPM7 in vascular signaling, and the cardiovascular impact will be important for understanding the clinical implications of hypomagnesemia in cardiovascular disease. (Circ J 2011; 75: 237-245)
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  • Hyuk-Jae Chang, Namsik Chung
    2011 Volume 75 Issue 2 Pages 246-252
    Published: 2011
    Released on J-STAGE: January 25, 2011
    Advance online publication: January 19, 2011
    JOURNAL FREE ACCESS
    Since a 4-detector row coronary computed tomographic angiography (CCTA) was launched in 1998, CCTA has experienced rapid improvement of imaging qualities with the ongoing evolution of computed tomography (CT) technology. The diagnostic accuracy of CCTA to detect coronary artery stenosis is well established, whereas improvements are still needed to reduce the overestimation of coronary artery disease (CAD) and assess plaque composition. CCTA has been used to evaluate CAD in various clinical settings. For example, CCTA could be an efficient initial triage tool at emergency departments for patients with acute chest pain with low-to-intermediate risk because of its high negative predictive value. In patients with suspected CAD, CCTA could be a cost-effective alternative to myocardial perfusion imaging and exercise electrocardiogram for the initial coronary evaluation of patients with intermediate pre-test likelihood suspected CAD. However, in asymptomatic populations, there is a lack of studies that show an improved prognostic power of CCTA over other modalities. Therefore, the clinical use of CCTA to detect CAD for purposes of risk stratification in asymptomatic individuals should be discouraged. As CT technology evolves, CCTA will provide better quality coronary imaging and non-coronary information with lower radiation exposure. Future studies should cover these ongoing technical improvements and evaluate the prognostic power of CCTA in various clinical settings of CAD in large, well-designed, randomized trials. (Circ J 2011; 75: 246-252)
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  • Kohei Yamamizu, Jun K. Yamashita
    2011 Volume 75 Issue 2 Pages 253-260
    Published: 2011
    Released on J-STAGE: January 25, 2011
    Advance online publication: December 20, 2010
    JOURNAL FREE ACCESS
    Cyclic adenosine monophosphate (cAMP) is an important second messenger mediating physiological functions, including metabolism, gene expression, cell growth and differentiation. Recently, we demonstrated novel roles of cAMP pathway in endothelial cell (EC) differentiation and arterial-venous specification using an embryonic stem cell differentiation system. These studies offered a concept that vascular formation is accomplished by a 2-layered mechanism: (1) a basal mechanism for common EC differentiation, whereby vascular endothelial growth factor (VEGF) signaling plays a central role in the basal mechanism, and (2) a vascular diversification mechanism working on the basis of common EC differentiation. Vascular diversification, such as artery and vein formation, can be only achieved by enacting specific machineries in the presence of the basal EC machinery. cAMP/protein kinase A signaling contributes to common EC differentiation through upregulation of the VEGF-A receptors, Flk1 and neuropilin1. On the other hand, cAMP can activate phosphatidylinositol-3 kinase, which induces an arterial fate in vascular progenitors via dual activation of Notch and β-catenin signaling as an arterial-specific machinery. cAMP signaling thus plays a pivotal role in both the basal and diversification machinery during vascular development. (Circ J 2011; 75: 253-260)
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Editorials
Original Articles
Arrhythmia/Electrophysiology
  • Akira Fujiki, Masao Sakabe
    2011 Volume 75 Issue 2 Pages 274-279
    Published: 2011
    Released on J-STAGE: January 25, 2011
    Advance online publication: December 17, 2010
    JOURNAL FREE ACCESS
    Background: The aim of this study was to compare QT/RR relation based on a 15-s averaged beat ECG with a single beat ECG during atrial fibrillation (AF) and to determine which was better to estimate the QT interval after sinus restoration. Methods and Results: QT and RR intervals were measured using an automatic QT analyzing system in 33 patients who had both AF and sinus rhythm on the same 24-h Holter ECG recording. In 14 patients, antiarrhythmic drugs (AAD) were administered. QT/RR relations were analyzed from ECG waves obtained by the summation of consecutive QRS-T complexes during each 15-s period (QT/RR-average) and a single beat QRS-T (QT/RR-single). During sinus rhythm, the slope of QT/RR-average did not differ from that of QT/RR-single in patients with and without AAD. On the other hand, during AF, the slope of QT/RR-average was significantly greater than that of QT/RR-single (without AAD: 0.12±0.06 vs. 0.06±0.03, P<0.001; with AAD: 0.15±0.05 vs. 0.08±0.04, P<0.001). During AF, the QT interval at an RR interval of 1.2-s (QT-1.2) determined from QT/RR-average was significantly greater than QT-1.2 from QT/RR-single in patients with and without AAD. QT-1.2 in QT/RR-single during AF was significantly smaller than that during sinus rhythm but QT-1.2 in QT/RR-average during AF was not. Conclusions: The QT interval after sinus restoration could be estimated better using QT/RR-average than using QT/RR-single during AF. (Circ J 2011; 75: 274-279)
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Cardiovascular Intervention
  • – Insights From a Meta-Analysis of 7,090 Patients –
    Alessandro Lupi, Eliano Pio Navarese, Maurizio Lazzero, Mara Sansa, St ...
    2011 Volume 75 Issue 2 Pages 280-289
    Published: 2011
    Released on J-STAGE: January 25, 2011
    Advance online publication: December 14, 2010
    JOURNAL FREE ACCESS
    Background: Evidence supporting the use of drug-eluting stents (DES) in saphenous vein graft (SVG) disease is uncertain. Previous studies have suggested that DES might reduce the re-intervention rate in SVG disease, with conflicting data on mortality. Thus, a meta-analysis was performed to compare outcomes of DES vs. bare metal stent (BMS) in SVG disease. Methods and Results: Medline and Web databases were searched for studies comparing DES and BMS for SVG disease, reporting rates of overall mortality, target vessel revascularization (TVR) and myocardial infarction (MI) with a follow-up of ≥6 months. The meta-analysis included 23 studies (7,090 patients). Compared with BMS, DES-treated patients had lower rates of TVR (odds ratio (OR), 0.53; confidence interval (CI), 0.39-0.72; P<0.0001) and overall mortality (OR, 0.63; CI, 0.40-0.99; P=0.05), but similar rates of MI (OR, 0.92; CI, 0.64-1.33; P=0.7). Subgroup analysis highlighted differences between non-randomized studies, in which DES improved mortality rates, and randomized trials, in which benefit from DES was not evident. Meta-regression analysis showed that DES were more effective in the presence of older grafts and type 2 diabetes. Conclusions: The present meta-analysis showed that, in SVG disease, DES significantly reduced TVR, but did not provide clear benefits on mortality and MI, with an opposite direction of results in mortality observed from randomized and observational data (clinicaltrials.gov identifier: NCT01036048). (Circ J 2011; 75: 280-289)
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  • – A Propensity Score-Matched Cohort Study –
    Shu-Kai Hsueh, Chiung-Jen Wu, Hsiu-Yu Fang, Yuan-Kai Hsieh, Chih-Yuan ...
    2011 Volume 75 Issue 2 Pages 290-298
    Published: 2011
    Released on J-STAGE: January 25, 2011
    Advance online publication: December 10, 2010
    JOURNAL FREE ACCESS
    Background: Percutaneous coronary intervention (PCI) with stent implantation is now considered a safe and feasible treatment for stenosis of the unprotected left main coronary artery (ULMCA). Because few studies have focused on de novo distal ULMCA lesions, a propensity score-matched cohort study was conducted to compare bare metal stents (BMS) with drug-eluting stents (DES) for long-term outcomes following PCI. Methods and Results: This study reviewed the outcomes of patients undergoing PCI with DES (n=127) or BMS (n=51) for distal de novo ULMCA stenosis. The baseline demographic, angiographic and procedural characteristics differed between the 2 groups, indicating potential selection bias. The propensity score-matched cohort showed that the DES group had significantly less target lesion revascularization (TLR) and major adverse cardiovascular events (MACE) following PCI than the BMS group. Furthermore, heart failure (HF) of New York heart Association functional class III/IV was associated with an increased risk of TLR and MACE, whereas implantation of DES in patients with significant HF led to more favorable outcomes. Conclusions: Lower rates of TLR and MACE occurred in patients following PCI with DES implantation than with BMS implantation for distal ULMCA stenosis. Implantation of DES in patients with significant HF may improve the unfavorable outcome. When PCI is chosen to manage distal ULMCA stenosis, DES is the preferred stent type. (Circ J 2011; 75: 290-298)
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  • – Review of Current Classifications –
    Shams Y-Hassan, Magnus C Lindroos, Christer Sylvén
    2011 Volume 75 Issue 2 Pages 299-305
    Published: 2011
    Released on J-STAGE: January 25, 2011
    Advance online publication: December 24, 2010
    JOURNAL FREE ACCESS
    Background: Several classification systems for coronary artery bifurcation lesions (CABL) have been described in the literature, but despite the commendable effort to simplify a difficult subject in interventional cardiology, all of them have certain limitations and shortcomings. Methods and Results: The proposed Descriptive, INtelligible and Ordered (DINO) is a new descriptive and clinically oriented system of classifying CABLs. This classification system takes into consideration more details of the side branch angulation relative to the main branch. It uses self-explanatory terms and mnemonic characters (acronyms related to the branches of the bifurcation and the shape of side branch angulation). The DINO classification describes the extent of CABL distribution and designates its localization at the bifurcation region. Moreover, systematized simple and easy to remember terms may form a relevant classification basis for multicenter and meta-analysis investigations. Conclusions: The DINO is the first verbally anchored, all-inclusive classification system of CABLs. It describes precisely side branch angulation, using self-explanatory and instructive terms that describe both the extent of the lesion's distribution and its localization. The current coronary bifurcation lesion classifications are reviewed. (Circ J 2011; 75: 299-305)
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  • – The J-PMS Study –
    Ken Kozuma, Yoshimi Ota, Yoshiyuki Nagai, Yousuke Katsuta, Eiji Nozaki ...
    2011 Volume 75 Issue 2 Pages 306-314
    Published: 2011
    Released on J-STAGE: January 25, 2011
    Advance online publication: December 14, 2010
    JOURNAL FREE ACCESS
    Background: Long-term outcomes of patients with bifurcated lesions and the restenotic response of the side branches after sirolimus-eluting stent (SES) implantation, comparing 1-stent with 2-stent treatment, are still under discussion. Methods and Results: Japan Post-Marketing Surveillance Registry (J-PMS) is a prospective registry designed to evaluate the safety and efficacy of the SES in routine clinical practice. Angiograms of 1,063 patients with 1,250 lesions were analyzed at the independent core lab. Of these, 324 patients with bifurcation lesions were enrolled. Clinical endpoints were assessed at 3 years. Both main and side branches were evaluated by quantitative coronary angiography at post-procedure (n=349) and 8-month follow up (n=293). Two-stent treatment was performed in 12% of the cases. In-segment restenosis rates at 8 months were 25.6% in the side branch, but newly developed restenosis was seen in only 6.8%. Late loss at the carina of the side branch was -0.11mm in the 1-stent group. Major adverse cardiovascular events rate was 18.3% at 3 years. Target-lesion revascularization rate up to 3 years was 21.6% in the 2-stent group and 8.7% in the 1-stent group (P=0.037). Stent thrombosis occurred in 6 cases (2.0%) until 3 years. Of these, 4 cases were treated with 2-stent (10.81% vs. 0.76% in 1-stent, P=0.003, respectively). Conclusions: In a real-world setting, treatment of coronary bifurcation lesions using SES demonstrated favorable long-term outcomes as long as the side branch was not stented. (Circ J 2011; 75: 306-314)
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Cardiac Rehabilitation
  • Tsukasa Kamakura, Rika Kawakami, Michio Nakanishi, Muneaki Ibuki, Taka ...
    2011 Volume 75 Issue 2 Pages 315-321
    Published: 2011
    Released on J-STAGE: January 25, 2011
    Advance online publication: December 14, 2010
    JOURNAL FREE ACCESS
    Background: The efficacy of out-patient cardiac rehabilitation (OPCR) in patients with a low prognostic risk after acute myocardial infarction (AMI) is unclear in the recent primary intervention era. Methods and Results: A total of 637 AMI patients who participated in in-hospital cardiac rehabilitation were divided into 2 groups; low prognostic risk group (n=219; age <65 years, successful reperfusion, Killip class I, peak serum creatine kinase <6,000U/L, and left ventricular ejection fraction ≥40%) and non-low prognostic risk group (n=418). The prevalence of coronary risk factors (CRF) was compared between the 2 groups. Then, in the low-risk group, the efficacy of OPCR was compared between active OPCR participants (n=52; ≥20 sessions/3 months) and non-active participants (n=60; <6 sessions/3 months). Compared with the non-low prognostic risk group, the low prognostic risk group had a significantly higher prevalence of current smokers (72% vs. 49%, P<0.05) and patients with multiple CRF (3 or more; 49% vs. 39%, P<0.05). Among the low- risk group, active OPCR participants showed a significantly greater improvement in exercise capacity (peak VO2, P<0.05) and maintained a better CRF profile (total cholesterol, triglyceride and blood pressure, all P<0.05) than inactive participants at 3 months. Conclusions: Low prognostic risk AMI patients have a higher prevalence of multiple CRF than non-low risk patients. Even in this low risk group, active participation in OPCR is associated with improved exercise capacity and better CRF profile. (Circ J 2011; 75: 315-321)
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Cardiovascular Surgery
  • – Does Bicuspid Valve Matter? –
    Ho Young Hwang, Mi-Suk Shim, Eun-Ah Park, Hyuk Ahn
    2011 Volume 75 Issue 2 Pages 322-328
    Published: 2011
    Released on J-STAGE: January 25, 2011
    Advance online publication: December 09, 2010
    JOURNAL FREE ACCESS
    Background: The outcomes of reduction ascending aortoplasty (RAA) performed with aortic valve surgery were evaluated and the results of RAA in patients with bicuspid aortic valve (BAV) were compared with those in patients with tricuspid valve. Methods and Results: From October 1994 to April 2009, 88 patients underwent RAA. Aortic valve was bicuspid in 45 patients (BAV group) and tricuspid in 43 patients (TAV group). Total circulatory arrest was required in 45 patients. Preoperative ascending aortic diameter was 45.5±4.7mm. Early mortality rate was 1.1%. Ten-year survival rate and freedom from cardiac death were 91.1% and 96.2%, respectively. No differences in clinical outcomes were found between the 2 groups. No aorta-related complications including aortic rupture, dissection and reoperation were observed. Aortic diameter at the last follow-up (61±43 months) was 37.8±4.3mm. The interval between surgery and follow-up CTA was associated with aneurysmal recurrence (P=0.022). Average rate of dilatation was 0.42±0.49mm/year (n=37). A need for total circulatory arrest was associated with an increase of the aortic diameter (P=0.009). BAV was associated with neither aneurysmal recurrence nor increase of aortic diameter. Conclusions: RAA in patients with an ascending aortic aneurysm combined with aortic valve disease could be performed with acceptable early and long-term outcomes, even in patients with BAV. Long-term follow-up evaluation might be necessary due to the risk of redilatation especially in patients with an extended aneurysm, which required total circulatory arrest for RAA. (Circ J 2011; 75: 322-328)
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  • Dai Kawashima, Takayuki Ohno, Osamu Kinoshita, Noboru Motomura, Arihir ...
    2011 Volume 75 Issue 2 Pages 329-335
    Published: 2011
    Released on J-STAGE: January 25, 2011
    Advance online publication: December 18, 2010
    JOURNAL FREE ACCESS
    Background: In patients with diabetic retinopathy (DR), vitreous hemorrhage (VH) is a common complication that threatens visual acuity and hence, quality of life. A considerable number of DR patients at risk of VH require coronary revascularization, but little is known about the prevalence of VH after coronary revascularization.Methods and Results: This study investigated 151 patients with DR who were followed up by ophthalmologists between April 2004 and September 2008, and underwent coronary revascularization (coronary artery bypass surgery n=36 or drug-eluting stent implantation n=115). At the time of coronary revascularization 56 had non-proliferative DR (NPDR) and 95 had proliferative DR (PDR). During an average follow-up of 531 days after revascularization, VH occurred in 24 (15.9%) patients, 18 (11.9%) of whom experienced VH within 6 months of the procedure. In VH patients, PDR rather than NPDR predominated as the background to VH (21 vs. 3, respectively). The 1-year prevalence of VH was higher in patients with PDR than in those with NPDR (22.0% vs. 1.9%, P=0.0055).Conclusions: VH is not a rare complication following coronary revascularization among patients with DR, especially in those with PDR. Thus, in terms of maintaining quality of life, VH after coronary revascularization needs further attention in these patients. (Circ J 2011; 75: 329-335)
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Heart Failure
  • Yasue Fukushima, Michio Nakanishi, Hiroshi Nonogi, Yoichi Goto, Naohar ...
    2011 Volume 75 Issue 2 Pages 336-340
    Published: 2011
    Released on J-STAGE: January 25, 2011
    Advance online publication: December 09, 2010
    JOURNAL FREE ACCESS
    Supplementary material
    Background: MicroRNAs (miRNAs) are endogenous small RNAs that are 21-25 nucleotides in length. Recently, plasma miRNAs have been reported to be sensitive and specific biomarkers of various tissue injuries and pathological conditions. The goal of this study was to assess plasma miRNA profiles and to identify plasma miRNAs that are differentially expressed in patients with heart failure. Methods and Results: A total of 33 patients with ischemic heart diseases and 17 asymptomatic controls were recruited. In 10 patients with heart failure, miRNAs were assessed at both NYHA IV and III. miRNA array analyses were found to be not appropriate for plasma miRNA profiling. The plasma concentrations of well-characterized miRNAs (miR-126, 122 and 499) were assessed by a real-time reverse transcription-polymerase chain reaction using an artificial small RNA as an internal standard. Plasma concentrations of miR-126 were negatively correlated with age and logBNP. In 10 patients with heart failure, plasma concentrations of miR-126 were up-regulated with improvement of the NYHA class from IV to III. Conclusions: The plasma concentration of miR-126 was negatively correlated with age and NYHA class, and could be a useful biomarker for heart failure. (Circ J 2011; 75: 336-340)
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  • Keizo Nishiyama, Takayoshi Tsutamoto, Masayuki Yamaji, Chiho Kawahara, ...
    2011 Volume 75 Issue 2 Pages 341-347
    Published: 2011
    Released on J-STAGE: January 25, 2011
    Advance online publication: December 17, 2010
    JOURNAL FREE ACCESS
    Background: To evaluate the biological variation and prognostic value of brain natriuretic peptide (BNP) for stable outpatients with nonischemic chronic heart failure (NICHF). Methods and Results: Biological variation in BNP was evaluated using an automated assay system in 140 outpatients with NICHF. The stable clinical condition during the 2-month study period was defined as unchanged NYHA and unchanged left ventricular ejection fraction; therefore, 7 patients were excluded during the 2 months. Thereafter, 133 patients were prospectively followed and the relationship between cardiac events and the plasma BNP concentrations (at baseline and after 2 months) were evaluated as well as the changes in BNP. The biological variation in BNP (2-month interval) was calculated as 22.3%. During a mean follow-up period of 42 months, 26 patients had cardiac events. According to stepwise multivariate analyses, plasma BNP after 2 months (P=0.0002) and % change in BNP (P=0.0067) were significant independent predictors of cardiac events. Conclusions: These findings indicated that a combination of the absolute value of BNP after 2 months and % increase in BNP (2-month interval) is useful for predicting cardiac events in stable outpatients with NICHF. (Circ J 2011; 75: 341-347)
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  • Shoji Fujita, Yoshiyuki Ikeda, Masaaki Miyata, Takuro Shinsato, Takuro ...
    2011 Volume 75 Issue 2 Pages 348-356
    Published: 2011
    Released on J-STAGE: January 25, 2011
    Advance online publication: December 14, 2010
    JOURNAL FREE ACCESS
    Background: A previous report by our team showed that Waon therapy, using a far infrared-ray dry sauna at 60°C, improves cardiac and vascular function in patients with chronic heart failure (CHF). The purpose of the present study was to clarify the effect of Waon therapy on oxidative stress in CHF patients and investigate its mechanism by animal experiments. Methods and Results: Forty patients with CHF were divided into control (n=20) and Waon therapy (n=20) groups. All patients received standard optimal medications for CHF. Waon therapy group was treated with Waon therapy daily for 4 weeks. After 4 weeks of Waon therapy, concentrations of hydroperoxide and brain natriuretic peptide (BNP) decreased significantly (hydroperoxide, 422±116 to 327±88U.CARR, P<0.001; BNP, 402±221 to 225±137pg/ml, P<0.001), and the nitric oxide metabolites increased (71.2±35.4 to 92.0±40.5mmol/L, P<0.05). In contrast, none of these variables changed over the 4-week interval in the control group. Furthermore, animal experiments were performed using TO-2 cardiomyopathic hamsters. On immunohistochemistry, cardiac expression of 4-hydroxy-2-nonenal, a marker of oxidative stress, was decreased in the 4-week Waon therapy compared to untreated hamsters. On Western blotting, cardiac expressions of heat shock protein (HSP) 27, manganese superoxide dismutase and HSP32, which reduce oxidative stress, were significantly upregulated in the 4-week Waon therapy compared to untreated hamsters. Conclusions: Waon therapy decreases oxidative stress in patients and hamsters with heart failure. (Circ J 2011; 75: 348-356)
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Hypertension and Circulatory Control
  • Sung-Ji Park, Jeong Bae Park, Dong-Ju Choi, Ho Joong Youn, Chang Gyu P ...
    2011 Volume 75 Issue 2 Pages 357-365
    Published: 2011
    Released on J-STAGE: January 25, 2011
    Advance online publication: October 30, 2010
    JOURNAL FREE ACCESS
    Background: Masked hypertension (MH) is characterized by its hidden nature and poor prognosis. However, it is not practical to routinely recommend home or ambulatory blood pressure monitoring (HBP or AMBP) to all patients with apparently well-controlled BP. The purpose of this study is to present, within the group of patients with well-controlled office BP (OBP), the clinical predictors of MH and to evaluate the gap (ie, the `mask effect' (ME)) between OBP and HBP. Methods and Results: BP was measured at the outpatient clinic and at home in 1,019 treated hypertensive patients. Candidate predictors for MH were analyzed within 511 patients with well-controlled OBP (45.6% men, 57.1±9.0 years). Among them, the prevalence of MH was 20.9% (n=107). In the multivariate-adjusted analysis, the risk of MH increased with high serum fasting blood glucose level (odds ratio (OR) 1.009, 95% confidence interval (CI): 1.001-1.018, P=0.020), higher systolic OBP (OR 1.075, 95%CI 1.045-1.106, P<0.001), higher diastolic OBP (OR 1.045, 95%CI 1.007-1.084, P=0.019) and the number of antihypertensive medications (OR 1.320, 95%CI 1.113-1.804, P=0.021). Furthermore, systolic HBP correlated well with systolic OBP (r=0.351, P<0.001) and with the degree of systolic ME (r=-0.672, P<0.001). Conclusions: To recognize MH, it is practical to investigate those patients who are taking multiple antihypertensive drugs and have a high OBP with a high FBG level. The term "ME" identifies MH more appropriately than the term "negative white-coat effect". (Circ J 2011; 75: 357-365)
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Imaging
  • Jin-Ho Choi, Young Bin Song, Joo-Yong Hahn, Seung Hyuk Choi, Hyeon-Che ...
    2011 Volume 75 Issue 2 Pages 366-375
    Published: 2011
    Released on J-STAGE: January 25, 2011
    Advance online publication: November 05, 2010
    JOURNAL FREE ACCESS
    Background: The purpose of the present study was to investigate whether multidetector computed tomography (MDCT) can identify the nature of chronic total occlusion (CTO) plaque, which cannot be measured quantitatively using traditional coronary angiography, and predict the success of percutaneous coronary intervention (PCI). Methods and Results: MDCT and 3-dimensional volumetric radiologic density analysis was performed for 186 consecutive CTO lesions. Plaque characteristics were determined using Hounsfield units (HU) of the image voxels. The remodeling index decreased significantly as the duration of CTO lengthened. Volumetric plaque analysis using HU showed that volumetric fraction of calcification (>324HU) did not, but low-density plaque (<49HU) did decrease significantly as the duration of CTO lengthened. The overall PCI success rate was 77.4% (144/186). In addition to the unknown or >12-month occlusion duration (odds ratio [OR]=3.0, 95% confidence interval [CI]=1.4-6.5, P=0.005), 2 MDCT parameters, that is, lesion length >18mm (OR=2.7, 95%CI=1.1-6.4, P=0.024) and segmental radiologic density >139HU (OR=2.7, 95%CI=1.2-6.4, P=0.021), were independent predictors of PCI failure on multivariate analysis. Conclusions: MDCT might be helpful for the prediction of successful CTO PCI. In addition to the occlusion duration, lesion length and high segmental radiologic density measured on MDCT were significant predictors of PCI failure in the present study. (Circ J 2011; 75: 366-375)
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  • Masahiko Kato, Naoya Matsumoto, Yoshimochi Nakano, Yasuyuki Suzuki, Sh ...
    2011 Volume 75 Issue 2 Pages 376-382
    Published: 2011
    Released on J-STAGE: January 25, 2011
    Advance online publication: December 18, 2010
    JOURNAL FREE ACCESS
    Background: The mid-term prognostic significance of ECG-gated single-photon emission computed tomography (SPECT) remains unclear in Japanese patients with type 2 diabetes mellitus (DM). In the present study rates of future cardiac events (nonfatal acute myocardial infarction (AMI), cardiac death (CD) and severe heart failure (HF) requiring hospitalization) were compared in patients with and without DM. Methods and Results: 1,810 patients (563 DM and 1,247 non-DM) we followed for a mean of 26.3±15.5 months. Summed stress score (SSS), summed difference score (SDS), poststress ejection fraction (EF) and resting end-diastolic volume (EDV) were calculated. In total, 20 cases of AMI (9 in DM (1.59%) and 11 in non-DM (0.88%)), 20 of CD (7 in DM patients (1.24%) and 13 in non-DM (1.04%)) and 54 of severe HF (31 in DM (5.5%) and 23 in non-DM (1.84%)) occurred. Univariate Cox analysis showed that, in DM patients, predictors of total cardiac events were poststress EF (Wald 60.4; P<0.001), resting EDV (Wald 53.8; P<0.001), SSS (Wald 39.6; P<0.001), SDS (Wald 26.1; P<0.001), history of prior MI (Wald 4.32; P<0.05) and hemoglobin A1c value (Wald 4.30; P<0.05). Multivariate Cox analysis showed that poststress EF (Wald 9.85; P<0.01) and SDS (Wald 6.19; P<0.01) were independent predictors of total cardiac events. Conclusions: Combined assessment of perfusion and function by ECG-gated SPECT may predict future cardiac events in type 2 DM patients. (Circ J 2011; 75: 376-382)
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  • – An Integrated Backscatter Intravascular Ultrasound Analysis of Culprit and Non-Culprit Lesions –
    Hirohiko Ando, Tetsuya Amano, Tatsuaki Matsubara, Tadayuki Uetani, Mic ...
    2011 Volume 75 Issue 2 Pages 383-390
    Published: 2011
    Released on J-STAGE: January 25, 2011
    Advance online publication: December 14, 2010
    JOURNAL FREE ACCESS
    Background: Patients with acute coronary syndrome (ACS) have multiple complex coronary plaques associated with plaque vulnerability. The present study assessed the tissue characteristics of coronary plaques between ACS and stable angina pectoris (SAP) of culprit and non-culprit lesions using integrated backscatter intravascular ultrasound (IB-IVUS). Methods and Results: IVUS was performed in 165 patients (40 patients with ACS) with 225 culprit (65 lesions in ACS) and 171 non-culprit lesions (42 lesions in ACS). The percentage of fibrous area (fibrous area/plaque area, %FIB) and the percentage of lipid area (lipid area/plaque area, %LIP) at the segment with minimal luminal area were calculated using IB-IVUS system. Culprit and non-culprit lesions with ACS showed a significant increase in %LIP (38±18 vs. 30±15%, P=0.002, and 38±21 vs. 32±17%, P=0.03, respectively) and a significant decrease in %FIB (59±15 vs. 63±12 %, P=0.04, and 57±18 vs. 62±14%, P=0.04, respectively) compared to those with SAP. On logistic regression analysis, not only culprit lesions but also non-culprit lesions with ACS patients were significantly associated with the lipid-rich plaque. Conclusions: Non-culprit coronary lesions with ACS patients are associated with the lipid-rich plaque, suggesting the extensive development of plaques instability in these patients. (Circ J 2011; 75: 383-390)
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  • – A Multidetector Computed Tomography Study –
    Radoslaw Pracon, Mariusz Kruk, Cezary Kepka, Jerzy Pregowski, Maksymil ...
    2011 Volume 75 Issue 2 Pages 391-397
    Published: 2011
    Released on J-STAGE: January 25, 2011
    Advance online publication: December 18, 2010
    JOURNAL FREE ACCESS
    Background: Preliminary research indicates that epicardial adipose tissue (EAT) may display both anti- and proatherosclerotic properties. Because the varying radiodensities of selected human tissues assessed by multidetector computed tomography (MDCT) has been shown to reflect differences in biological characteristics, the present study investigated the hypothesis that the proatherosclerotic properties of EAT may be linked to its radiodensity. Methods and Results: The study included 164 consecutive patients (82 females, mean age 58.8±11.1 years) with suspected coronary artery disease (CAD) undergoing MDCT coronary angiography. Coronary atherosclerosis was defined as: (1) CAD (ie, presence of at least 1 coronary stenosis ≥50%) and (2) coronary artery calcium (CAC) determined by Agatston score. EAT radiodensity was assessed by MDCT and averaged 81.00±4.64 HU (Hounsfield unit (HU) scale). Mean CAC score was 96.0±220.0. Patients with CAD (n=36) showed higher EAT radiodensity than patients without CAD (78.99±4.12 vs. -81.57±4.64 HU, P<0.01). In the multivariable model, only EAT radiodensity and age were independently associated with CAD (odds ratio (OR) 1.15, 95%confidence interval (CI) 1.04-1.28; OR 1.08, 95%CI 1.04-1.12; respectively). EAT radiodensity also correlated with CAC score (r=0.23, P<0.01). EAT radiodensity (P<0.001), age (P<0.001), sex (P=0.03), and past smoking (P<0.01) were independent correlates of CAC in the multivariable linear regression model. Conclusions: Increased EAT radiodensity is independently associated with coronary atherosclerosis, which may reflect the unfavorable, proatherosclerotic metabolic properties of more radiodense epicardial fat. (Circ J 2011; 75: 391-397)
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Ischemic Heart Disease
  • Young Joon Hong, Myung Ho Jeong, Daisuke Hachinohe, Khurshid Ahmed, Yu ...
    2011 Volume 75 Issue 2 Pages 398-406
    Published: 2011
    Released on J-STAGE: January 25, 2011
    Advance online publication: December 09, 2010
    JOURNAL FREE ACCESS
    Background: Serial intravascular ultrasound (IVUS) was used to compare the effects of moderate doses of rosuvastatin and atorvastatin on plaque regression in patients with intermediate coronary stenosis. Methods and Results: This was a prospective, randomized, and comparative study for lipid-lowering therapy with rosuvastatin 20mg (n=65) and atorvastatin 40mg (n=63) using serial IVUS (baseline and 11-month follow-up). Efficacy parameters included changes in total atheroma volume (TAV) and percent atheroma volume (PAV) from baseline to follow-up. Changes of TAV (-4.4±7.3 vs. -3.6±6.8mm3, P=0.5) and PAV (-0.73±2.05 vs. -0.19±2.00%, P=0.14) from baseline to follow-up were not significantly different between the 2 groups. Plaque was increased in 15% in the rosuvastatin group and in 30% in the atorvastatin group at follow-up (P=0.064). The plaque increase group had higher baseline high-sensitivity C-reactive protein (hs-CRP; 1.28±2.70mg/dl vs. 0.54±1.16mg/dl, P=0.034) and higher follow-up low-density lipoprotein cholesterol (LDL-C) (78±24mg/dl vs. 63±21mg/dl, P=0.002) compared with the plaque non-increase group. Follow-up LDL-C (odds ratio [OR]=1.038, 95% confidence interval [CI]=1.003-1.060, P=0.036) and baseline hs-CRP (OR=1.025, 95%CI=1.001-1.059, P=0.046), not the type of statin, were the independent predictors of plaque increase at follow-up. Conclusions: Moderate doses of rosuvastatin and atorvastatin could contribute to effective plaque regression. Follow-up LDL-C and baseline hs-CRP are associated with plaque progression in patients with intermediate coronary stenosis. (Circ J 2011; 75: 398-406)
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Pediatric Cardiology and Adult Congenital Heart Disease
  • Hidemi Takata, Takashi Higaki, Hisashi Sugiyama, Masataka Kitano, Eiic ...
    2011 Volume 75 Issue 2 Pages 407-412
    Published: 2011
    Released on J-STAGE: January 25, 2011
    Advance online publication: December 14, 2010
    JOURNAL FREE ACCESS
    Background: Coil occlusion has been widely indicated for the closure of patent ductus arteriosus (PDA). Although many reports have shown the efficacy and safety of coil occlusion, the long-term outcome in patients remains controversial. Here, we analyzed the long-term outcome of coil occlusion in patients with PDA in Japan. Methods and Results: We collected the longitudinal data of patients who underwent coil occlusion between 1995 and 2009. A total of 310 coil occlusions were performed in 298 patients with PDA. The median minimum duct diameter was 1.4mm. Successful coil occlusion was achieved in 286 patients (96.0%), and total adverse events were seen in only 28 cases (9.0%). The median follow-up period was 50 months. The occlusion rates at 1 month, 6 months, 1 year, 2 years and 5 years were 90.1%, 94.4%, 97.4%, 97.8% and 97.8%, respectively. Patients with a large PDA (≥4mm) showed a higher rate of residual leakage than those with a small (<2mm) or moderate (2-4mm) PDA (P=0.004). Patients who underwent this procedure in the early study period also showed a higher rate of residual leakage than those in the late study period. Conclusions: Coil occlusion is an effective procedure for patients with PDA. Our data indicate that the long-term outcome is promising without any adverse events. (Circ J 2011; 75: 407-412)
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  • Aya Miyazaki, Heima Sakaguchi, Hideo Ohuchi, Osamu Yamada, Masataka Ki ...
    2011 Volume 75 Issue 2 Pages 413-420
    Published: 2011
    Released on J-STAGE: January 25, 2011
    Advance online publication: December 09, 2010
    JOURNAL FREE ACCESS
    Background: The extra-cardiac conduit Fontan (EC) has a lower incidence of tachyarrhythmias than other types of Fontan. However, some intrinsic arrhythmogenic conditions, such as atrial isomerism, have been associated with a high incidence of arrhythmias. Methods and Results: We retrospectively reviewed the clinical course of the supraventricular tachyarrhythmias (SVTs) in 212 patients after an EC, compared the results according to the atrial situs and investigated the substrate of the SVTs. The atrial situs was a solitus or inversus (SS/SI) in 152 patients, right isomerism (RI) in 45 and left isomerism (LI) in 15. Twenty-four SVTs occurred in 22 (11%) patients ≥3 months after the EC. The freedom from SVT after the EC was 95%, 76% and 77% in the SS/SI, RI and LI patients at 5 years, respectively (P<0.0001). Among the 16 SVTs associated with atrial isomerism, 10 were not related to the atrioventricular (AV) node. For the atrial isomerism, the predictors of SVT ≥3 months after the EC were a history of an AV valve repair (risk ratio (RR) 1.9; P=0.02) and complications associated with sinus node dysfunction (RR 1.9; P=0.03). Death related to SVT occurred in 3 patients. Conclusions: Postoperative SVTs after the EC with an atrial isomerism were not uncommon, mostly did not involve the AV node and possibly were caused by atrial tissue damage. A comprehensive therapeutic strategy should be considered. (Circ J 2011; 75: 413-420)
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Peripheral Vascular Disease
  • – 5 Years' Experience –
    Osamu Iida, Yoshimitsu Soga, Keisuke Hirano, Shin Okamoto, Tomoharu Do ...
    2011 Volume 75 Issue 2 Pages 421-427
    Published: 2011
    Released on J-STAGE: January 25, 2011
    Advance online publication: January 06, 2011
    JOURNAL FREE ACCESS
    Background: The nitinol stent has proven superior primary patency than balloon angioplasty in superficial femoral artery (SFA) lesions, but a systematic comparison of the patency of 2 different nitinol stents (S.M.A.R.T. and Luminexx) in patients with SFA lesions has not been done. Methods and Results: A multicenter, prospective database that included 511 consecutive patients who had undergone endovascular therapy with nitinol stenting for 638 limbs (S.M.A.R.T.: n=503; Luminexx: n=135) was retrospectively analyzed. Patency was assessed by duplex ultrasound. Outcomes were compared between the groups by the Kaplan-Meier and log-rank methods. To minimize the differences between each group, propensity-matched analysis was also performed. Stent fracture occurred in 11% (57/503) of the S.M.A.R.T. and 23% (31/135) of the Luminexx stents (P=0.0005). Despite a higher prevalence of chronic total occlusion (55% vs. 40%, P=0.002) and longer lesions (154±93mm vs. 135±71mm, P=0.03) in the S.M.A.R.T. group, there was no significant difference in patency for up to 5 years (P=0.50). When 119 lesions per group were assessed after propensity-matched analysis, the 5-year patency rate was 74% for the S.M.A.R.T. and 65% for the Luninexx stent (P=0.10). Conclusions: Despite a different stent fracture rate, there was no significant difference in terms of patency between the S.M.A.R.T. and Luninexx stents for up to 5 years. (Circ J 2011; 75: 421-427)
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Pulmonary Circulation
  • – Comparison With Cardiac Biomarkers –
    Hyun Ju Seon, Kye Hun Kim, Woo Seok Lee, Song Choi, Hyun Ju Yoon, Youn ...
    2011 Volume 75 Issue 2 Pages 428-436
    Published: 2011
    Released on J-STAGE: January 25, 2011
    Advance online publication: December 14, 2010
    JOURNAL FREE ACCESS
    Background: To evaluate the usefulness of computed tomographic pulmonary angiographic (CTPA) variables in the risk stratification of acute pulmonary thromboembolism (APE) and compare these variables with cardiac biomarkers. Methods and Results: Eighty consecutive patients with APE were divided into patients with right ventricular (RV) dysfunction (n=49, 62.1±15.1 years, 31 females) vs. patients without RV dysfunction (n=31, 67.7±13.7 years, 18 females). CTPA variables were analyzed and compared with cardiac biomarkers. The ratio of right to left ventricular dimension (RVD/LVD), CT index of PA clot load, contrast reflux to the inferior vena cava (IVC), and ventricular septal bowing (VSB) were significantly different CTPA variables between the groups. These variables were also significantly associated with cardiac biomarkers. By receiver operation characteristic curve analysis, the area under the curve to predict RV dysfunction was 0.863 for RVD/LVD, 0.841 for PA clot load, 0.744 for contrast reflux to IVC, and 0.635 for VSB. The optimal cut-off value to predict RV dysfunction was 1.12 for RVD/LVD (sensitivity: 89.8%, specificity: 77.4%) and 19.5 for PA clot load (sensitivity: 81.6%, specificity: 77.4%). Conclusions: RVD/LVD, PA clot load, contrast reflux to IVC, and VSB on CTPA were significantly associated with RV dysfunction and cardiac biomarkers in APE. The present study demonstrated that CTPA is useful not only in the diagnosis, but also in the risk stratification of APE. (Circ J 2011; 75: 428-436)
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Renal Disease
  • Kazuko Tajiri, Hidekazu Maruyama, Akira Sato, Nobutake Shimojo, Takumi ...
    2011 Volume 75 Issue 2 Pages 437-442
    Published: 2011
    Released on J-STAGE: January 25, 2011
    Advance online publication: November 16, 2010
    JOURNAL FREE ACCESS
    Background: Oxidative stress caused by contrast medium is thought to be one of the main mechanisms of contrast-induced acute kidney injury. A prospective study was conducted to evaluate the relationship between oxidative stress caused by contrast agent administration and long-term renal function. Methods and Results: Thirty-six consecutive patients who underwent coronary angiography were enrolled. Urinary F2-isoprostane, a marker of oxidative stress, was measured at baseline and 24h after angiography, and serum creatinine was measured at baseline, 24h and 1 year after the procedure. The change in estimated glomerular filtration rate (eGFR) at 1 year after angiography correlated significantly with the change in eGFR at 24h after angiography (r=0.729, P<0.001). We also found a significant correlation between the increase in urinary F2-isoprostane at 24h and the decrease in eGFR at 1 year (r=0.439, P=0.022). In multivariate analysis, the decrease in eGFR at 1 year after coronary angiography correlated with the increase in F2-isoprostane at 24h after angiography as well as the decrease in eGFR at 24h after angiography (P=0.039 and P<0.001, respectively). Conclusions: Contrast-induced nephrotoxicity might be transient; however, an early decrease in eGFR and increase in oxidative stress are associated with chronic renal insufficiency. Careful long-term follow-up and adequate medical intervention are necessary for these patients. (Circ J 2011; 75: 437-442)
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Vascular Medicine
  • Pei-Hu Liao, Li-Man Hung, Yi-Hung Chen, Yu-Hsiang Kuan, Friedrich Bo-Y ...
    2011 Volume 75 Issue 2 Pages 443-450
    Published: 2011
    Released on J-STAGE: January 25, 2011
    Advance online publication: December 18, 2010
    JOURNAL FREE ACCESS
    Background: Antioxidants effectively reduce ischemia-reperfusion (IR) injury. The cardioprotective effects of luteolin, a flavonoid that exhibits antioxidant properties and is widely available in many fruits and vegetables, were examined in rats subjected to myocardial IR injury. Methods and Results: Rats were subjected to myocardial ischemia or reperfusion injury to evaluate the antiarrhythmic effects of luteolin. Myocardial infarct size was determined histochemically with triphenyltetrazolium chloride staining of the left ventricle. Luteolin was administered intravenously 15min before occlusion of the coronary artery. The incidence and duration of ventricular tachycardia and ventricular fibrillation and mortality during myocardial ischemia were significantly reduced by luteolin (10μg/kg). Similarly, luteolin (1μg/kg) reduced ventricular arrhythmias and mortality during the reperfusion phase. Pretreatment with luteolin decreased plasma lactate dehydrogenase and nitric oxide (NO) levels. Luteolin (10μg/kg) significantly reduced the myocardial infarct size, as well as malondialdehyde production in tissue samples of myocardial IR injury. Luteolin also downregulated inducible NO synthase protein and mRNA expression, but did not significantly alter neuronal NO synthase or endothelial NO synthase expression. Conclusions: Luteolin is capable of protecting the myocardium against IR injury. The actions of luteolin are at least partly mediated through downregulation of NO production and its own antioxidant properties. (Circ J 2011; 75: 443-450)
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  • Beom Joon Kim, Seung-Hoon Lee, Chi Kyung Kim, Wi-Sun Ryu, Hyung-Min Kw ...
    2011 Volume 75 Issue 2 Pages 451-456
    Published: 2011
    Released on J-STAGE: January 25, 2011
    Advance online publication: December 10, 2010
    JOURNAL FREE ACCESS
    Background: Coronary artery calcification (CAC) scores are widely accepted to predict risk of coronary heart diseases and are associated with atherosclerosis in other vasculatures. Cerebral small vessel diseases (SVDs), including white matter lesions (WML), silent lacunar infarction (SLI) and cerebral microbleeds (CMB), are considered to develop in conjunction with pro-atherogenic conditions, measured by CAC scores. Methods and Results: Of 672 individuals aged ≥65 years that underwent health screening, 312 subjects with brain magnetic resonance imagings (MRIs) were enrolled in this study. The distribution of baseline characteristics among individuals with or without MRIs was not different. Clinical and laboratory information was collected and CAC scores were measured using multi-detector computed tomography. Cerebral SVD were independently assessed by 2 raters who were unaware of the CAC scores. The prevalence of CAC (CAC>0) was 71.7% in men and 50.0% in women. The associations between moderate-to-extensive CAC (CAC score ≥100) and WML (adjusted odds ratio and 95% confidence interval, 4.99 and 1.33-18.73), SLI (5.04 and 1.86-13.63) and CMB (6.07 and 1.54-23.94) remained significant after adjusting for relevant confounders. Conclusions: This study documents significant associations between CAC and cerebral SVDs. The findings suggest that SVDs in the brain and CAC in the heart may develop under similar systemic pathogenic processes. (Circ J 2011; 75: 451-456)
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Controversies in Cardiovascular Medicine
  • – Is Assessment of Mechanical Dyssynchrony Necessary in Determining CRT Indication? (Pro) –
    Hideaki Kanzaki
    2011 Volume 75 Issue 2 Pages 457-464
    Published: 2011
    Released on J-STAGE: January 25, 2011
    Advance online publication: January 08, 2011
    JOURNAL FREE ACCESS
    Cardiac resynchronization therapy (CRT) improves heart failure symptoms, cardiac function and long-term prognosis. As a result, it has been established as a treatment for refractory heart failure by using a specialized pacemaker to restore coordinated ventricular contractions with pacing. Despite being an invasive treatment, however, the above effects are not observed in 30-45% of patients selected based on the standard criteria that includes New York Heart Association class III or IV heart failure, left ventricular ejection fraction ≤35%, and QRS duration ≥120 or 130ms. From the fact that quantifiable resynchronization was associated with hemodynamic and clinical improvements, it should follow that mechanical dyssynchrony is a critical substrate for the benefits from CRT. The PROSPECT study unexpectedly demonstrated limitations of echocardiographic parameters using M-mode, pulsed-wave Doppler, and tissue Doppler imaging for accurately and reproducibly predicting response to CRT. However, advances in speckle tracking strain and real-time 3-D echocardiography have furthered the development of more sophisticated indices of dyssynchrony. Stress echocardiography might be useful for the detection of latent mechanical dyssynchrony in failing hearts. Because the substrate for CRT efficacy is multifactorial, a discriminant score that includes various clinical parameters and echocardiographic indices of mechanical dyssynchrony is needed to improve patient selection for CRT. (Circ J 2011; 75: 457-464)
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  • – Is Assessment of Mechanical Dyssynchrony Necessary in Determining CRT Indication? (Con) –
    Toshiyuki Ishikawa
    2011 Volume 75 Issue 2 Pages 465-471
    Published: 2011
    Released on J-STAGE: January 25, 2011
    Advance online publication: January 08, 2011
    JOURNAL FREE ACCESS
    Contraction delay of the lateral left ventricular free wall can be improved by biventricular pacing. Cardiac resynchronization therapy (CRT) is based on the principle of resynchronizing un-uniformed contraction of the ventricle. Prolongation of the QRS duration on an electrocardiogram served as an indirect marker to identify mechanical dyssynchrony. One of the greatest problems is approximately 30% of the patients who met the criteria do not respond for CRT. One possible explanation for the lack of response for CRT could be the absence of sufficient dyssynchrony to allow the therapy to have any impact. Direct assessments of mechanical dyssynchrony might better select responder patients for CRT. However, RethinQ study demonstrated that patients with heart failure and narrow QRS intervals might not benefit from CRT, even with dyssynchrony. Moreover, the results of the PROSPECT study suggest given the modest sensitivity and specificity in the multicenter setting, despite training and central analysis, no single echocardiographic measurement of dyssynchrony could be recommended to improve patient selection for CRT beyond current guidelines. At present, assessment of mechanical dyssynchrony is not necessary in determining CRT indication. Current indication including QRS width is recommended as selection criteria to identify patients suitable for CRT. (Circ J 2011; 75: 465-471)
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