Coronary angioplasty is reported to be feasible and safe in patients with coronary spasm and fixed stenosis. However, the long-term results are not positive. We compared the results of coronary angioplasty in 20 patients with variant angina versus 17 patients with non-variant angina among 231 consecutive patients with vasospastic angina. Coronary angioplasty was performed successfully in all 37 patients without any complications. Stenting for coronary dissection or recoil was performed in 8 patients, directional coronary atherectomy was selected for ostial lesion of left anterior descending coronary artery stenosis in 2 patients, and standard balloon angioplasty was performed in 27 patients. There were no clinical differences between the two groups. The restensois rate in patients with variant angina was similar to that in patients with non-variant angina (30% vs 29%, ns). There was no relationship between the provoked spasm and restenosis. During the follow-up period, no major complications were observed in patients with variant angina or those with non-variant angina. In conclusion, full medication with calcium channel antagonists and isosorbide dinitrate, and treatment by coronary angioplasty including the use of new devices, were useful treatments for patients with coronary vasospasm and significant organic stenosis. There was no difference concerning the results of coronary intervention between the patients with variant angina and those with non-variant angina.

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There is evidence for gender differences in the treatment and outcome of acute myocardial infarction (AMI). However, little data exist about these differences in patients from the Arab Middle East. Therefore, we studied the influence of patient gender on the presentation, the use of thrombolytic therapy, and in-hospital mortality after AMI in Kuwaiti nationals. This is a retrospective study of all consecutive Kuwaiti patients admitted to the coronary care unit of a university hospital with the diagnosis of AMI between June 1994 and May 1997. A total of 89 women and 267 men were included. Women were older than men and had significantly higher rates of diabetes (72% vs 46%), hypertension (58% vs 33%) and hypercholesterolemia (80% vs 53%). Women were less likely to receive thrombolytic therapy (40% vs 62%, p=0.001). Fewer women were eligible for thrombolytic therapy (50% vs 66%, p<0.05). Of those who were eligible for thrombolysis there was no sex difference in receiving such treatment. The in-hospital mortality among women younger than 70 years was 2.5 times higher than among men in the same age group; while there was no difference in mortality between women and men aged 70 years and older. We conclude that women and men with AMI have different clinical characteristics and outcomes following AMI. There was no gender bias for the use of thrombolytic therapy. The higher in-hospital mortality in younger women, i.e. less than 70 years, compared to younger men, indicates that younger women with AMI should be considered as a high-risk group.

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The possible involvement of oxidative damage in the progression of atherosclerosis has been suggested. There is some evidence that antioxidant therapy may be beneficial for the prevention of coronary heart disease. In this study, we investigated the relationship between coronary artery disease (CAD) and serum antioxidative status by measuring the total antioxidant status (TAS). Other relevant antioxidants, such as retinol, α, γ-tocopherol, ascorbic acid, α, β-carotenoids, erythrocyte glutathione peroxidase (GSH-Px) and oxidative products, were also determined in 31 male CAD patients with angiographically defined CAD and 66 male controls, aged 40-70 years, in a case-control study. The TAS levels, ratio and the concentrations of retinol, albumin, total protein and HDL cholesterol were significantly lower in the CAD patients than in the controls (p<0.01), and α-tocopherol andα/γ-tocopherol were significantly higher in the CAD patients than in the controls. The TAS level correlated positively withγ-GTP, GPT, GOT and uric acid (p<0.01). A multiple regression analysis in the CAD patients revealed that the TAS levels correlated most negatively with the number of diseased vessels. The concentrations of carotenoids and GSH-Px, as well as the α/γ-tocopherol ratio were also significantly associated. Although conditional logistic regression analysis suggested low levels of HDL-cholesterol to be a significant coronary risk factor (OR=5.1, 95% CI=1.09-24.3), the TAS level showed no significant independent contribution to CAD. This study demonstrated an association of antioxidant parameters with the atherosclerosis progression, however, it did not confirm antioxidants as an independent risk factor for CAD event.

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In patients with primary atrioventricular (AV) conduction disturbances, lesions are commonly believed to be limited to the conduction system. In the present study, myocardial lesions were analyzed histologically in patients with AV conduction disturbances to determine the presence of myocarditis. We studied 50 patients with second or third degree AV block in whom the cause was not clear (AVB group). Endomyocardial biopsy was performed from the right ventricle and examined by light microscopy. Tissue specimens also were obtained from 12 normal hearts at autopsy as a control group (N group). The diagnosis of myocarditis was based on the Dallas criteria. The myocyte transverse diameter was 15.4±4.1 μm in the AVB group and 11.7 ±3.1 μm in the N group (P<0.01). The fibrosis area ratio also was significantly higher in the AVB group than in the N group (10.1±6.7% vs 5.1±2.0%). The mean number of lymphocytes per 400-fold magnified field was significantly greater in the AVB group than in the N group (1.9±1.6 vs 1.3±0.4). In addition, disorganization of the cardiac myocytes was noted in 8 patients in the AVB group (16%), myocyte disarrangement in 39 patients (78%), myocytolysis in 23 patients (46%), and nuclear deformity in 21 patients (42%). Myocarditis was diagnosed in 3 of the 50 patients (6%). The present study demonstrates that myocardial lesions can be detected in a large proportion of patients with AV conduction disturbances. Furthermore, myocarditis is present in 6% of the cases.

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The effect of 450 mg/day propafenone for two weeks on premature ventricular contractions (PVCs) was studied in combination with an assessment of heart rate (HR) dependency of PVCs using Holter ECG monitoring in patients with more than 720 PVCs per day. The PVC-HR correlation was classified into positive (P), bidirectional (B), and flat and negative (FN) correlation groups. The positive group included only patients in whom PVC frequency increased with a heart rate increase, while the bidirectional group included patients with PVCs whose frequency increased at low heart rates and decreased at high heart rates. The FN group contained both flat (PVC frequency was almost fixed regardless of heart rate changes) and negative (PVC frequency decreased as heart rate increased) correlations. The effectiveness of propafenone was 70% in the positive group and 50% in the nonpositive group which included both bidirectional (67%) and FN (0%) groups, using a > 70% PVC reduction as a criterion of efficacy. From this, we concluded that propafenone is effective in patients showing either positive or bidirectional PVC-HR correlation. The coupling interval (CI) of PVCs was also prolonged by propafenone as a whole. The present study suggests that there are differences in the mechanism of PVC development in patients with flat or negative correlation and those with a positive or bidirectional correlation. Thus, this type of analysis contributes to an understanding of the action of antiarrhythmic agents, and may allow the prediction of their efficacy on PVCs.

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The second deflection of the atrial double potential (DP) recorded at the intercaval region is considered to reflect the far-field potential of the left atrium. The conduction via the upper interatrial connection was evaluated utilizing this DP and the relationship between atrial fibrillation (AF) and the conduction via the interatrial connection evaluated. In 30 consecutive patients with the DP at the intercaval region, prolongation in the left atrial activation time during the right atrial extra stimulation was measured at the intercaval region (ΔDP) and the coronary sinus (ΔCS). The difference between ΔDP and ΔCS (ΔDP-ΔCS) was used as an index of inhomogeneity in interatrial conduction. The patients were divided into AF (n=13) and non-AF (n=17) groups in accordance with the inducibility of AF in the electrophysiologic study. The max ΔDP and the max ΔCS were greater in the AF group than in the non-AF group, i.e., max ΔDP (43±19 vs 27±17 ms, P=0.021), max ΔCS (35±15 vs 21±14 ms, P=0.029). The max |ΔDP-ΔCS| was also greater in the AF group than in the non-AF group (19±12 vs 9±8 ms, P=0.019). In accordance with the indices of the interatrial conductions, the delayed or inhomogeneous conductions during the atrial extra stimulation via interatrial connections were more prominent in the AF group than in the non-AF group. Analysis of the DP at the intercaval region might provide a useful index to evaluate the inducibility of AF.

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Lowering of serum cholesterol levels by pharmacologic intervention with statins reduces the incidence of cardiovascular events in subjects with and without atherosclerotic manifestations. In an 8-week, randomized, double-blind study we compared the efficacy and safety of the new compound atorvastatin for reducing LDL-cholesterol (LDL-C) with placebo in an Asian patient cohort. Patients with LDL-C between 160 mg/dl and 250 mg/dl were randomly assigned to treatment with 10 mg atorvastatin or placebo once daily for 8 weeks. At the end of weeks 4 and 8 of the randomized phase, the serum concentrations of lipid parameters as well as safety parameters were determined. Fifty-four patients (32 males and 22 females) were enrolled. Twenty-six patients were assigned to the treatment group. The primary end-point, LDL-C, was reduced by 40% and 42% after 4 and 8 weeks of treatment in the atorvastatin treated patients (p<0.001). The reductions in total cholesterol and triglycerides were up to 31% and 23%, respectively. The HDL-C levels increased up to 11% (p=0.043). There were no significant adverse events. Transient increases in CPK levels (10 times) without myalgia were identified in 1 patient. Atorvastatin, 10 mg/day produced significant reductions in LDL-C, total cholesterol and triglycerides and an elevation of HDL-C levels when used as an adjunct to diet in hyperlipidemic patients. The majority of the clinical effects could be attained by week 4. The overall safety profile of atorvastatin was similar to that of placebo. Atorvastatin was considered to be well tolerated in this patient cohort.

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Screening of young hypercholesterolemics is important because they are highly susceptible to atherosclerotic diseases. However, in some cases, serum cholesterol level may be elevated temporarily due to stress or other psychological factors. This study examined the effects of mood states on 'persistent' hypercholesterolemia in comparison with 'temporary' hypercholesterolemia among students entering a university. The subjects were 114 untreated first-year students aged 18 to 20 years old. All had been screened positive for hypercholesterolemia (serum total cholesterol >220 mg/dl) upon enrolling in the university. Three months after the screening, they were divided into two groups according to the re-examined serum total cholesterol level; a persistent hypercholesterolemic group (n=41) with >220 mg/dl and a temporary hypercholesterolemic group (n=73) with <220 mg/dl. At that time, they completed the Profile of Mood States (POMS) with tension-anxiety, depression, anger-hostility, vigor, fatigue and confusion scales. The POMS depression scores and the female ratio were higher (both p<0.01) and body mass index was lower (p<0.05) in the persistent hypercholesterolemic subjects than in the temporary hypercholesterolemic subjects; the POMS depression scores were still higher (p<0.05) after controlling for the effects of gender, body mass index, and other POMS scales by multiple logistic regression analysis. Depressive mood appeared to relate to hypercholesterolemia when the university students were screened. Assessment of mood states may be important in screening young hypercholesterolemic patients.

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The precise measurement of changes in left ventricular volume is important to elucidate the mechanisms of neurally mediated syncope. This study was conducted to determine whether or not a brand-new ambulatory radionuclide monitoring system (C-VEST system) can be clinically used to easily and precisely measure left ventricular volume and function in tilt testing. To assess the repeatability of the C-VEST system, 12 healthy volunteers (mean age 24±4 years old) underwent 20 minute head-up tilt testing and we measured the temporal changes in left ventricular volume and ejection fraction twice a day (first and second studies). To investigate the changes in the C-VEST measurements and the detector position in the first and second studies, tilt testing was performed with an 80-degree passive tilt, which is the same as the standard procedure used in diagnosing neurally mediated syncope. The coefficient of repeatability for both the C-VEST and detector position was well within the clinical range (coefficient of repeatability in left ventricular volume ranged from 1.7 to 2.8; coefficient of repeatability in the detector position ranged from 2.3 to 3.1). Precise evaluation of the left ventricular volume can be achieved by an ambulatory radionuclide monitoring system in tilt testing.

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The aim of this work was to examine factors that could be involved in the occurrence of apoptosis in rat hearts subjected to coronary occlusion followed by reperfusion. To this end, we studied the expression of the pro- and anti-apoptotic factors, bax and bcl-2, respectively, in reperfused ischemic hearts and in hearts injected with bFGF or saline. In anesthetized rats the left coronary artery was occluded for 45 min, the anesthesia withdrawn and the occlusion removed to allow reperfusion; in sham-operated rats the occlusion was omitted. After 4 hours the rats were decapitated and the heart excised. Sections from the left ventricle were stained with anti-bcl-2-antibody and anti-bax-antibody using the TUNEL method which detects apoptosis. Fragmentation of DNA isolated from reperfused ventricles was examined by agarose electrophoresis. In reperfused hearts no bcl-2 staining was observed in the discrete area in which many cardiomyocyte nuclei were stained by the TUNEL method; outside this area staining for bcl-2 was more marked than in sham-operated rats. Sections from reperfused hearts were stained for bax protein over a wide area including the apoptotic region; sham-operated hearts showed little reaction. Staining for bcl-2 was demonstrable in some nuclei in hearts from saline-injected rats; the numbers were unaffected by i. v. bFGF. Ischemia/reperfusion increases the overall expression of both bcl-2 and bax proteins, but bcl-2 is lost from the reperfused area as indicated by TUNEL staining. Accordingly, the ratio of bcl-2 to bax was reduced in the reperfused area, indicating a pro-apoptotic trend. The marked increase in bcl-2 outside the reperfused area could be a mechanism with which to salvage surviving cardiomyocytes.

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Dihydropyridine (DHP) Ca²⁺ channel blockers decrease L-type Ca²⁺ channel current (I_CaL) by enhancing steady-state inactivation, whereas β-adrenergic stimulation increases I_CaL with small changes in the kinetics. We studied the effects of DHP Ca²⁺ channel blockers on cardiac I_CaL augmented by β-adrenergic stimulation. We recorded I_CaL as Ba²⁺ currents (I_Ba) from guinea pig ventricular myocytes using the whole-cell patch clamp technique, and compared the effects of nitrendipine (NIT) in the absence and presence of isoproterenol (1 μM, ISO) or forskolin (10 μM, FSK). Maximal I_Ba elicited from a holding potential of -80 mV were diminished to 69.4±13.5% (mean and SE, n=5) of control by NIT (100 nM) and the diminished I_Ba were increased to 180.3±23.2% of control by ISO in the presence of NIT, which was similar to the enhancement seen in the absence of NIT. NIT shifted the V_1/2 of the I_Ba inactivation curve from -34.6±1.9 mV (n=5) to -48.7±1.2 mV, enhancing I_Ba decay with shortening T_1/2 at -10 mV from 164.6±24.2 ms (n=7) to 105.4±15.2 ms. ISO elicited a small additional shift in the V_1/2 of I_Ba inactivation in the same direction. ISO and FSK each slowed I_Ba decay in the absence of NIT, but not in its presence. Thus, β-adrenergic agonists increase and DHP Ca²⁺ channel blockers decrease the amplitude of cardiac I_CaL independently and the kinetics of I_CaL is determined mainly by the latter when these drugs coexist.

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Cardiac function is improved by bi-ventricular pacing in patients with severe reduced cardiac function. Atrioventricular (AV) delay optimization is also important in this therapy. However, the AV delay required to achieve the optimal AV synchrony varied from time to time. We have reported that the critical AV delay that induces diastolic mitral regurgitation (MR) may represent the upper limit of the optimal AV delay. The optimal AV delay can be predicted by a simple method; slightly prolonged AV delay-interval between the end of atrial kick and complete closure of the mitral valve (duration of diastolic MR) at the AV delay setting. [Case] 60 year old Japanese male with dilated cardiomyopathy. He was repeatedly admitted to our hospital due to congestive heart failure. Ejection fraction was 14%. ECG showed complete left bundle branch block and his PQ interval was 0.22 sec. He was dependent on intravenous injections of catecolamine and could not be discharged from the hospital for over one year. Optimal AV delay was predicted as 80 msec during bi-ventricular pacing by our formula. Cardiac output was 4.9, 6.0, 5.1 l/min when the AV delay was set at 50, 80, 110 msec. Cardiac function was improved from NYHA class III to IIand he has been relieved from the dependency on intravenous catecholamine injections. AV delay was optimized (70-100 msec) by our method during follow-up for one year. This case indicates that AV delay optimization is important in bi-ventricular pacing.

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Two-dimensional echocardiography can provide intracardiac images. However, the cross-sectional images require mental reconstruction to understand a three-dimensional intracardiac structure. It is sometimes hard for inexperienced echocardiographers to engage in reconstruction. Thus, three-dimensional echocardiography is potentially beneficial because these images can provide extra information without mental reconstruction. Herein we demonstrate three-dimensional reconstruction using transesophageal echocardiography in a patient with a left atrial myxoma. It contributed to clarifying the surgical considerations, including whether the tumor was adhering to the left atrium or the mitral valve.

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