Background: Cardiac autonomic dysfunction and anxiety-depression is prognostic factors after acute myocardial infarction (AMI). Cardiac rehabilitation (CR) is an effective treatment for cardiac autonomic dysfunction and anxiety-depression. Also β-blocker can be expected to have the effect of improving the prognosis of heart disease. Purpose: This study aim is to verify that effect of the phase 1 cardiac rehabilitation and β-blocker for cardiac autonomic function and anxiety-depression. Methods: Subjects were AMI patients that discharged after carrying out CR. I have evaluated the heart rate variability (HRV) and HADS at the time of start of CR and discharge. We compared the parameters at the time of start of CR and discharge, and a comparison was made with and without β-blocker. Results: Subjects were 40 patients (23 patients with β-blocker and 17 patients without β-blocker). Recognizing the improvement in HRV at discharge, also anxiety was reduced. Parasympathetic function was significantly higher in with β-blocker. Conclusion: This study showed a trend toward improvement in autonomic function and anxiety by Phase 1 CR, and it is showed parasympathetic function improved and anxiety reduction by β-blocker. This study suggests the efficacy of combination therapy by CR and β-blocker.

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We report a case of severe coronary spasm following the implantation of a biodegradable polymer Biolimus-eluting stent (BES). A 70-year-old-man with effort angina pectoris presented a significant stenosis in his left anterior descending artery. He was treated with percutaneous coronary intervention (PCI) using a biodegradable polymer BES. On the second day after the PCI, he was referred to our emergent department complaining of persistent chest pain. Upon administration of nitrate, his chest pain immediately disappeared. A coronary angiogram confirmed that there were no abnormalities of the heart. An acetylcholine (ACh) provocation test performed at a later date using only 5 μg of ACh in the patient’s left coronary artery induced severe spasms at both end of implanted stent. On the basis of these findings, the patient was diagnosed with coronary artery spasm.

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A 63-year-old man who had ST elevation myocardial infarction (STEMI) was admitted to our hospital. His coronary risk factors are hypertension and current smoking. An emergency coronary angiography (CAG) revealed total occlusion with thrombus formation in the proximal portion of left anterior descending artery (LAD) and the proximal portion of left circumflex artery (LCX). A good collateral from right coronary artery to the posterolateral branch (PL) was observed. Primary percutaneous coronary intervention (PCI) was performed with an intra-aortic balloon pump (IABP) support. Firstly, 3.5×15 mm everolimus-eluting stent (EES) implantation for LAD was performed and TIMI 3 flow was obtained. Continuously, 4.0×23 mm bare metal stent (BMS) implantation for LCX was performed and TIMI 3 flow was obtained. Dual antiplatelet therapy was started after procedure. He had no major complication after primary stenting and withdrew from IABP 4 days after initial PCI. Nine days after initial PCI, he had severe chest pain with ECG change. A emergency CAG revealed total occlusion within BMS which was implanted in LCX and no stenosis within EES in LAD. Continuously, thrombectomy and balloon angioplasty were performed for LCX and TIMI 3 flow was obtained. We report a case that both EES and BMS were implanted in the patient with STEMI and subacute stent thrombosis occurred not in the EES but in the BMS 8 days after stent implantation.

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The case was a 50-years old man with insulin-treated type 2 diabetes mellitus. Bare metal stent (BMS) implantation for segment 6 (#6) was performed due to acute myocardial infarction (AMI) in 2004. Eight months follow-up coronary angiography (CAG) revealed no in-stent restenosis (ISR). He had inferior AMI in 2009. CAG revealed total occlusion at #3 and 90% stenosis at #14, and BMS implantation for #3 was performed. Staged drug-eluting stent (DES) implantation for #14 was performed. One year follow-up CAG revealed no ISR at #3 and #14, but revealed new lesions at #1, 6, 11. Fractional flow reserve (FFR) revealed functional double vessel disease (right coronary artery (RCA); 0.68, left anterior descending artery (LAD); 0.74, left circumflex artery (LCX); 0.85). Therefore, DES implantaion for #6 and BMS implantaion for #1 were performed. One year follow-up CAG revealed no ISR at #1, but revealed ISR at #7 and the progression of stenosis at #4 postero descending and #11. Because FFR revealed functional triple vessel disease (RCA; 0.72, LAD; 0.73, LCX; 0.74), coronary artery bypass graft (CABG) was performed. It was difficult to decide the timing of CABG in this patient with multi- vessel disease.

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A 65-year-old man on dialysis was performed Zotarolimus-eluting stent implantation in right coronary artery a month before and his symptom disappeared after stent implantation. He was readmitted for coronary intervention for a residual coronary lesion in left circumflex artery. Coronary angiography showed a significant stenosis within the Zotarolimus-eluting stent in right coronary artery. Intravascular ultrasound and optical coherence tomography showed a protruding material within the stented segment. We tried to use a thrombus suction catheter and material was successfully removed. Pathological examination demonstrated a block of thrombus formation within the stent.

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