Implications of prodromal angina pectoris in anterior wall acute myocardial infarction: acute angiographic findings and long-term prognosis

OBJECTIVES

This study was undertaken to assess how prodromal angina affects long-term prognosis after acute myocardial infarction.

BACKGROUND

Although it has been reported that prodromal angina occurring shortly before the onset of acute myocardial infarction has protective effects against ischemia, its implication for long-term prognosis remains unclear.

METHODS

We studied consecutive 350 patients with anterior myocardial infarction who underwent coronary angiography within 24 h after the onset of chest pain. Follow-up was achieved for 340 patients (97%).

RESULTS

Eighty-nine patients had one or more episodes of angina within 24 h before infarction. On initial angiography, patients with prodromal angina in the 24 h before infarction had a patent infarct-related artery more frequently than did those without prodromal angina (34% vs. 22%, p = 0.03). Among 213 patients who underwent thrombolytic therapy for an occluded infarct-related artery, reperfusion was more frequently achieved in patients with prodromal angina in the 24 h before infarction (76% vs. 56%, p = 0.01). Prodromal angina in the 24 h before infarction was associated with a lower in-hospital mortality rate (6% vs. 14%, p = 0.02) and better 5-year survival (p = 0.009). There was no significant difference in survival between patients with previous angina at any time (n = 202) and those without. Multivariate analysis showed that prodromal angina in the 24 h before infarction was an independent factor related to 5-year survival after acute myocardial infarction (odds ratio 0.49, p = 0.04).

CONCLUSIONS

Prodromal angina occurring shortly before the onset of infarction, but not previous angina itself, has a beneficial effect on long-term prognosis after infarction, suggesting a relation to ischemic preconditioning.

Directional coronary atherectomy for the treatment of acute myocardial infarction

Directional coronary atherectomy (DCA) was performed after intracoronary thrombolysis in 32 patients with a first acute myocardial infarction. DCA was successful in 31 (97%) of 32 patients. Abrupt closure of the treated segment occurred in one patient but was managed successfully by conventional balloon angioplasty. Repeat angiography was performed in 32 patients before discharge (2.7 +/- 0.7 weeks later) and in 29 patients during the follow-up (4.5 +/- 1.5 months later). No restenosis (stenosis > 50%) occurred before discharge; however restenosis occurred in 12 (41%) of 29 patients during follow-up. The restenosis rate in patients with subintimal resection was significantly higher than in those with intimal resection (78% vs 25%, p < 0.01). These data suggest that DCA in patients with acute myocardial infarction is feasible for persistent early patency of the infarct-related coronary artery, but late restenosis continues to limit success and subintimal resection may increase the restenosis rate during the follow-up.

Effects of various doses of intracoronary verapamil on coronary resistance vessels in humans

To investigate the vasodilatory effect of various doses of intracoronary verapamil on coronary resistance vessels, we studied 13 patients with normal angiograms. A coronary Doppler guide wire was inserted into the left anterior descending coronary artery, and coronary blood flow velocity (CBFV) was measured. Verapamil was injected into the left coronary artery at doses of 0.1 mg, 0.5 mg, 1.0 mg, and 2.0 mg at 10-min intervals. Nitroglycerin was also injected into the same artery to avoid changes in cross-sectional area. As a measure of coronary vascular resistance, coronary vascular resistance index (CVRI) was calculated as the quotient of mean aortic pressure/CBFV. An injection of verapamil produced a dose-dependent increase in CBFV: 79 +/- 38% with 0.1 mg, 131 +/- 56% with 0.5 mg, 143 +/- 46% with 1.0 mg, and 128 +/- 47% with 2.0 mg of verapamil. The percent peak decreases in CVRI were dose dependent: -42 +/- 13% with 0.1 mg, -50 +/- 17% with 0.5 mg, -62 +/- 14% with 1.0 mg, and -60 +/- 9% with 2.0 mg of verapamil. Thus, intracoronary verapamil produces a dose-dependent dilation of coronary resistance vessels, and the optimal effect is produced with an injection of verapamil at a dose of 1.0 mg into the left coronary artery. At this dose, verapamil did not affect atrioventricular conduction.

Screening of fungal beta-xylanases for production of acidic xylooligosaccharides using in situ reduced 4-O-methylglucuronoxylan as substrate

Fungal beta xylanases were screened for production of acidic xylooligomers from 4-O-methylglucuronoxylan. In situ reduced hardwood xylan was used as substrate because the products of neutral- and acidic-branched xylooligomers help define substrate specificity of the enzymes. Borohydride reduction in situ transformed 30% of 4-O-methyl-alpha-D-glucopyranosyluronic acid residues into 4-O-methyl-alpha-D-glucopyranosyl residues and reduced C-1 end groups in the xylan backbones. A total of ten beta-xylanase fractions from four fungi were partially purified by chromatography by anion exchange and molecular sieving, and graded qualitatively for enzymatic hydrolysis of the substrate. The yield of acidic xylooligomers was highly affected by whether alpha-glucuronidases were present in the beta-xylanase fractions. Some fractions gave free 4-O-methyl-alpha-D-glucopyranosyluronic acid, but none of the enzyme fractions could release free 4-O-methyl-alpha-D-glucose. Among the beta-xylanase fractions studied, xylanase II of Trichoderma viride was the best producer of aldotetraouronic acid [2-O-(4-O-methyl-alpha-D-glucopyranosyluronic acid)-D-xylotriose]. The results obtained suggested that there was a difference in the steric hindrance of the branch point on fungal beta-xylanases between 4-O-methyl-alpha-D-glucopyranosyl and 4-O-alpha-D-glucopyranosyluronic acid residues.

Effect of Luminance Contrast on the Motion Aftereffect

The effects of luminance contrast and spatial frequency in the transient channel were investigated by making use of the motion aftereffect (MAE) caused by adaptation to a drifting sinusoidal grating. Two experiments were performed. The PSE of the velocity was measured as an index of the MAE. The adapting grating was made to drift at a velocity of 2.28 deg s−1 and its spatial frequency was 0.8, 1.6, or 3.2 cycles deg−1. In the first experiment, the MAE caused by a luminance contrast grating or an equiluminous chromatic grating was measured. In the second experiment, luminance contrast gratings were used to measure the effect of the contrast differences between adapting and test gratings. The largest MAE was observed when a low-luminance-contrast grating or an equiluminous chromatic grating was presented as test stimulus after adaptation to a high-luminance-contrast grating in the low-spatial-frequency condition. Generally, the MAE increased with increasing adapting contrast and with decreasing test contrast or spatial frequency. Little MAE was observed at high test contrasts. The results may be explained by assuming that activity in the sustained channel (or parvocellular pathway) inhibits activity in the transient channel (or magnocellular pathway) owing to the domination of sustained channel activity when the test is a static high-luminance-contrast grating providing much information about position and form.

[Cooperative multicentre study on posttraumatic epilepsy]

A multicentre cooperative prospective study have been conducted to investigate the factors influencing posttraumatic epilepsy (PTE) and to evaluate the prophylactic effect of anticonvulsants. Since April 1994, patients with head injury have been observed following our protocol as follows; anticonvulsants are administered only to the patients with brain parenchymal injury for one month just after head trauma and no anticonvulsants are administered after one month after trauma to any patients except those with posttraumatic epilepsy (PTE). Brain parenchymal injury included traumatic subarachnoid hemorrhage, acute subdural hematoma, contusion, intracerebral hematoma, and diffuse axonal injury. To April 1996, 635 patients with head injury have been registered and analyzed. During the follow-up period, 14 patients (2.2%) developed PTEs, which had only been observed in patients with brain parenchymal injury. Multiple regression analysis revealed that two factors, early epilepsy and brain parenchymal injury, could contribute to the prediction of PTE. The frequency of PTE in this study was compared with that in our previous retrospective study (Nakamura, 1995), in which anticonvulsants were administered to the patients with head injury. There was no significant difference in the percentage of patients having PTE between the group treated without anticonvulsants in this study and the untreated group in previous retrospective study. Anticonvulsants treatment after head injury was not likely to have a prophylactic effect against the development of PTE.

CD8+ T lymphocyte counts as an adjunctive predictor of cytomegalovirus retinitis in patients with acquired immunodeficiency syndrome

We encountered a case of cytomegalovirus (CMV) retinitis with spontaneous regression in association with an increased number of CD8+ but not CD4+ T lymphocytes in a patient with acquired immunodeficiency syndrome (AIDS). Thus, we examined the number of CD4 and CD8 counts at the diagnosis of CMV retinitis and compared with those of Pneumocystis carinii pneumonia (PCP). All 21 patients with a confirmed diagnosis of PCP (22 episodes) and 14 CMV retinitis patients were included in this study. Although PCP occurred after depletion of CD4 count to below 200/microl, CD8 count at that time varied widely and remained normal in some patients (median: 276.5/microl, range: 133-900/microl). In contrast, as CMV retinitis occurred after further depletion of CD4 count to below 50/microl, CD8 count decreased to below 500/microl (median: 238/microl, range: 43-448/microl) (p<0.05; PCP vs CMV retinitis). The values of the sensitivity and specificity for CMV retinitis obtained at the cutoff point of either 400/microl in CD8 count and 50/microl in CD4 count were similar. When these two cutoff points were combined, the positive predictive value was 46%. Monitoring of CD8 count may prove valuable as an additional predictor of CMV retinitis in patients with AIDS after CD4 depletion.

[Assessment of cerebral circulation using echo planar imaging--basic analysis in quantitating the mean transit time, cerebral blood flow, and cerebral blood volume]

The mean transit time (MTT), cerebral blood flow (CBF) and cerebral blood volume (CBV) using echo planar imaging (EPI) in 22 aged volunteers were measured based on moment analysis and gamma variate method. The first peak of signal intensity curve (p delta R2.) and the area under the curve after the first peak (AUC) were calculated according to the height over area method, as a convenient quantification. Then, MTT, CBF, and CBV were compared with AUC/p delta R2, p delta R2, and AUC, respectively. There was a good correlation between each other parameter (r = 0.67 - 0.92, every p < 0.001). The slow upward slope and the low peak height, however, caused a larger error between each other parameter.

[Assessment of regional microcirculatory changes by EPI perfusion studies in patients with multiple lacunar infarction]

The aim of this report is to assess regional cerebral microcirculatory changes by EPI perfusion study in patients with multiple lacunar infarction(MLI). Especially, we focused on the parameter(rCBV, MTT, rCBF) changes in the white matter and on the relationship between these changes in the gray and white matter. Twenty MLI patients(mean age 72 +/- 15 years) and 10 age-similar normal controls (mean age 65 +/- 12 years) were examined. As a result, the MLI patients demonstrated an insignificant rCBF reduction due to the rCBV elevation in the gray matter and a moderate rCBF reduction with less rCBV elevation in the white matter. These results show a difference in the vascular reserve between the gray and white matter, and insufficiency of the vascular reserve in MLI's white matter.

A strong association between HLA-B*5101 and Behçet's disease in Greek patients

Behçet's disease is known to be associated with HLA-B51, one of the split antigens of HLA-B5, among many different ethnic groups. In a Greek population, an increased incidence of HLA-B5 in the patient group has also been reported. Because the B51 antigen has been recently identified to comprise seven alleles, B*5101-B*5107, we performed HLA-B51 allele genotyping by the PCR-SSP method as well as serological HLA-A and -B typing among 31 Greek patients with Behçet's disease to investigate whether there is any correlation between one particular B51-associated allele and Behçet's disease. The frequency of B51 was remarkably high (80.6%) in the patient group as compared to the ethnically matched control group (26.7%). In addition, HLA-A26 was also increased in the patients (29.0%) as compared with the healthy controls (3.3%). B51 allele genotyping revealed that all these B51-positive patients carried B*5101. This study revealed a strong association of Behçet's disease in Greeks with one of the B51 subantigens, providing insight into the molecular mechanism underlying an HLA association with Behçet's disease.

Nucleotide sequence analysis of the HLA class I region spanning the 237-kb segment around the HLA-B and -C genes

To elucidate the detailed gene organization of the human leukocyte antigen (HLA) class I region on chromosome 6, seven contiguous cosmid genomic clones covering the 237-kb segment around the HLA-B and -C loci were subjected to DNA sequencing by the shotgun strategy to give a single contig of 236,822 bp from the MICA gene (58.2 kb centromeric of HLA-B) to 90.8 kb telomeric of HLA-C. This region was confirmed to contain four known genes, MICA, HLA-17, HLA-B, and HLA-C, from centromere to telomere. Further, a new member of the P5 multicopy genes was found to be about 1.3 kb upstream of the HLA-17 gene and designated P5.8. Five novel genes designated NOB1-5 were identified by RT-PCR and Northern blot hybridization. In addition, two pseudogenes, dihydrofolate reductase pseudogene (DHFRP) and ribosomal protein L3 homologous gene (RPL3-Hom), were also found in the vicinity of the HLA-B and -C genes, respectively. The two segments (about 40 kb) downstream of the HLA-B and HLA-C genes showed high sequence homology to each other, suggesting that segmental genome duplication including the major histocompatibility complex (MHC) class I gene must have occurred during the evolution of the MHC.

Usefulness of directional coronary atherectomy in patients with acute anterior myocardial infarction

To assess the usefulness of directional coronary atherectomy (DCA) in acute myocardial infarction (AMI), 139 consecutive patients with anterior wall AMI undergoing successful catheter intervention were studied. The reocclusion rate was significantly lower in the last 70 patients who underwent DCA as aggressively as possible compared with the first 69 patients treated with coronary balloon angioplasty (12.1% vs 3.0%, p <0.05).

DNA damage-induced apoptosis and Ice gene induction in mitogenically activated T lymphocytes require IRF-1

Lymphocytes are highly sensitive to DNA damage-induced apoptosis. In thymocytes, the tumor suppressor p53 has been shown to be required for this type of apoptosis. However an as yet unknown, p53-independent pathway(s) appears to mediate the same event in mitogenically activated mature T lymphocytes. By using mice with a null mutation in the IRF-1 gene, we revealed that DNA damage-induced apoptosis in the latter cell type is dependent on the anti-oncogenic transcription factor interferon regulatory factor-1 (IRF-1). Thus two different anti-oncogenic transcription factors, p53 and IRF-1, are required for distinct apoptotic pathways in T lymphocytes. Furthermore, we found that mitogen induction of the interleukin-1 beta-converting enzyme (Ice) gene, a mammalian homolog of the Caenorhabditis elegans cell death gene ced-3, is also IRF-1-dependent. An IRF-1 binding sequence was identified in the 5' flanking region of the Ice gene. In addition, ectopic overexpression of IRF-1 results in the activation of the endogenous Ice gene and enhances the sensitivity of cells to radiation-induced apoptosis. Thus, induction of Ice gene may be involved in IRF-1 dependent DNA damage-induced apoptosis in activated mature T lymphocytes.

[Assessment of left ventricular systolic function derived from ECG-gated myocardial SPECT with 99mTc-tetrofosmin: automatic determination of LV epi- and endocardial surface]

Non-invasive assessment of ischemic heart disease requires information of both LV function and myocardial perfusion. Recently, ECG-gated myocardial SPECT with technetium-labeled radiopharma-ceuticals can provide both of them. Gated myocardial SPECT were performed in thirty-three patients with cardiac disease using a two-headed rotating gamma camera system (ADAC; VERTEX), 30-60 minutes after resting injection of 555-740 MBq of 99mTc-Tetrofosmin. Then, the SPECT data were used to determine the LV epi- and endocardial surface, and LV volume for measurement of LVEF was calculated automatically. This entire computational process required only 210 seconds per 16 frame study. Interobserver agreement of EF values obtained from gated SPECT was excellent (r = 0.996, n = 10, p < 0.01). LVEFs obtained from gated SPECT showed good correlation to those calculated from radionuclide ventriculography (MUGA) (r = 0.91, p < 0.01). In conclusion, this automatic method using gated myocardial SPECT data was considered to be useful for assessment of LV function with reproducibility.

[The usefulness and the problems of attenuation correction using simultaneous transmission and emission data acquisition method: studies on normal volunteers and phantom]

Attenuation correction using simultaneous transmission data (TCT) and emission data (ECT) acquisition method was applied to 201Tl myocardial SPECT with ten normal adults and the phantom in order to validate the efficacy of attenuation correction using this method. Normal adults study demonstrated improved 201Tl accumulation to the septal wall and the posterior wall of the left ventricle and relative decreased activities in the lateral wall with attenuation correction (p < 0.05: paired t-test). The counts of the posterior wall were however, significantly higher than those of the anterior wall and the lateral wall (p < 0.05: unpaired t-test). Moreover, relative low uptake of the apex was enhanced using attenuation correction. Static phantom studies revealed the self scatter from high 201Tl uptake organs such as the liver and the stomach pushed up the activities in the septal wall and the posterior wall. Cardiac dynamic phantom studies showed partial volume effect due to cardiac motion contributed to under-correction of the apex, which might be overcome using gated SPECT. Although simultaneous TCT and ECT acquisition was conceived of the advantageous method for attenuation correction, miss-correction of the special myocardial segments should be taken into account in assessment of attenuation correction compensated images.

[Histological findings of specimens obtained by directional coronary atherectomy from patients with acute myocardial infarction]

The histological characteristics of acute myocardial infarction were examined in specimens obtained from infarct-related coronary artery lesions (20 left anterior descending artery, 2 left circumflex artery, 8 right coronary artery) in 30 patients with initial acute myocardial infarction who underwent directional coronary atherectomy following intracoronary thrombolysis within 6 hours after the onset of chest pain. Resected tissues were fixed in 10% buffered formalin and embedded in paraffin, and the 4 microns-thick paraffin sections were stained with hematoxylin-eosin and examined by light microscopy. Thrombus and/ or intramural hemorrhage were present in all samples. There were high incidences of cholesterol cleft in 19 (63%), foam cell in 21 (70%), calcium deposit in 19 (63%) and intimal proliferation in 16 (53%). These data suggest that thrombus and/or intramural hemorrhage are important in the onset of acute myocardial infarction.

[Practical localization of the central sulcus using a video display during surgery by cortical somatosensory evoked potentials and how to discern precentral P20 and central P25]

In patients with lesions around the central sulcus, cortical surface somatosensory evoked potentials (SEPs) have been applied for the purpose of localization of the central sulcus based on the polarity inversion of postcentral N20 to precentral P20 across the central sulcus. We have intraoperatively monitored SEPs to infer the location of the central sulcus in 16 cases since December 1988. Intraoperative localization of the central sulcus has been most useful in patients with frontal lobe gliomas in which the localization of the central sulcus enables the surgeon to extensively resect tumor without postoperative motor weakness. The localization of the central sulcus, however, might be misjudged by using the polarity inversion criterion alone, because central P25 following N20 and P20 complicates SEP waveforms. It is significant that P25, which is recorded also posterior to the central sulcus, is discerned from the precentral P20. In order to solve this matter, we regarded only the positivity in SEP waveforms having the identical peak latency to that of N20 as the precentral P20. Positive potentials having a later peak latency than that of N20 are the superposition of P20 and P25, and might also be recorded posterior to the central sulcus. For the observation of the polarity inversion of N20 to P20 across the central sulcus, a multi-channel SEP should be recorded using a sheet of silicone rubber embedded in a 16-electrode array consisting of a 4 by 4 grid. We projected the exposed cortical surface on the video display through the microscope apparatus and marked the locations of the recording electrodes on the video display. This enabled the location of the recording electrodes to correspond easily and precisely to the cortical surface. Our reliable and simple method of intraoperative localization of the central sulcus by cortical SEPs monitoring is presented in a practical case.

Clinical features of patients with chronic liver disease associated with hepatitis C virus genotype 1a/I in Okinawa, Japan

The clinical characteristics of chronic hepatitis C virus (HCV) carriers with HCV genotype 1a/I infection were investigated and compared with those of chronic HCV carriers infected with 1b/II, 2a/III, 2b/IV and the mixed type of infection. We found that 16 of 408 (3.9%) carriers had HCV genotype 1a infection, comprising four of 67 (6.0%) blood donors, 11 of 263 (4.2%) patients with chronic hepatitis and one of 39 (2.6%) patients with liver cirrhosis. Three of 408 subjects had a mixed infection of genotypes 1a/I and 1b/II. All carriers with genotype 1a (including those with the mixed infection) were of Japanese origin and all, except one who was born in Brazil, were born in Okinawa Prefecture. Nine of 14 patients infected with genotype 1a for whom medical records were obtained had a history suggestive of infection through blood exposure; six had had blood transfusions, one had tattoos, one is a nurse and one had a history of drug addiction. There were no haemophiliacs or other multitransfused patients in the genotype 1a group. Of 10 patients infected with genotype 1a who received interferon (IFN) therapy, four (40%) showed a complete response. Although the small number of patients infected with genotype 1a in the present study precluded statistical analysis of the response to IFN, the response in patients with genotype 1a was better than the response in those infected with genotype 1b and poorer than the response in those patients infected with genotype 2a/III or 2b/IV.

Importance of 2-O-sulfate groups of uronate residues in heparin for activation of FGF-1 and FGF-2

Complete drying of heparin with various concentrations of NaOH by lyophilization caused specific 2-O-desulfation to various degrees without detectable depolymerization or other chemical changes. In order to assess the importance of 2-O-sulfate groups in uronate residues to promote FGF-1 and FGF-2 activities, various 2-O-desulfated (2-O-DS-) heparins were quantitatively examined for their effects on FGF-1 and FGF-2-induced proliferation of BALB/c3T3 clone A31 (A31) cells and the chlorate-treated cells. Twenty-seven percent or less loss to the 2-O-sulfate groups had no effect on the ability to activate both FGF-1 and FGF-2, while 44% loss resulted in a significant loss of the ability. Complete loss of the ability was observed in 2-O-DS-heparins with 75% or more 2-O-desulfation. These results suggest that a high content of 2-O-sulfate groups in uronate residues of heparin is required for activation of both FGF-1 and FGF-2.

Analysis of allelic variation of the TAP2 gene in sarcoidosis

Sarcoidosis is a systemic granulomatous disease and the DRB1 gene of the DR subregion has been implicated for determining the genetic susceptibility to the disease. We evaluated the allelic variation of the TAP2 gene using the PCR-RFLP method as well as the mismatched PCR-RFLP method in 82 Japanese patients with sarcoidosis and 92 healthy controls. A new allele, TAP2*0103 and a new polymorphic variation at codon 577 in addition to TAP2*0101, TAP2*0102 and TAP2*0201 have been recognized in the Japanese subjects. No significant differences were observed in the frequencies of any TAP2 alleles or dimorphism at codon 577 between the patients and healthy controls. Polymorphic variation of the TAP2 gene does not confer the susceptibility to sarcoidosis.

Structure of fucose branches in the glycosaminoglycan from the body wall of the sea cucumber Stichopus japonicus

Fucose-branched chondroitin sulfate E was prepared from the body wall of sea cucumber Stichopus japonicus. The purified glycosaminoglycan (GAG) was chemically desulfated, followed by carboxyl reduction. Intact, desulfated, and desulfated/carboxyl-reduced GAG fractions were subjected to per-O-methylation. GC-MS analyses of the resultant partially methylated alditol acetates demonstrated that the fucose branch is formed by two fucopyranosyl residues linked glycosidically through position (1-->3), and that the fucose branch and glucuronic acid are almost equimolar. In addition, it was elucidated that about 20% of the branches stretch from O-3 position of a glucuronic acid moiety of the core chondroitin sulfate polymer, while remaining fucose branches are postulated to protrude from O-4 and/or O-6 position(s) of a N-acetylgalactosamine moiety. This fucose branch was also confirmed to be highly sulfated according to six kinds of substitution pattern in methylation analysis.

[Evaluation of three-dimensional CT angiography (3D-CTA) for the diagnosis of cerebral vasospasm]

We evaluated the usefulness of three-dimensional CT angiography (3D-CTA) for the diagnosis of cerebral vasospasm following subarachnoid hemorrhage (SAH). Eleven patients with SAH who were suspected of having cerebral vasospasm on the basis of their clinical symptoms were examined by 3D-CTA with a spiral CT scanner after an intravenous bolus administration of contrast medium. 3D-CTA revealed vasospastic changes of the cerebral vessels in eight patients. Conventional angiography was performed in six patients immediately after the 3D-CTA examination, and demonstrated the cerebral vasospasm. In eight patients, a second 3D-CTA was performed with the same technique one week after the first 3D-CTA examination. The second 3D-CTA showed the cerebral vessels without vasospastic change. In conclusion, 3D-CTA is a promising, minimally invasive strategy for the assessment of cerebral vasospasm.