Different flow patterns between left and right internal thoracic artery grafts influence the evaluation of severe graft stenosis by transthoracic Doppler echocardiography

OBJECTIVE

An increase in the diastolic to systolic flow velocity ratio (D/S) in the proximal left internal thoracic artery (ITA) after coronary artery bypass grafting (CABG) enables noninvasive assessment of graft patency by transthoracic Doppler echocardiography (TTDE). The increase in the D/S can be less pronounced at a site distant from the anastomosis. We postulated that proximal ITA flow patterns differ between the left and right ITAs and that the increase in D/S is less pronounced in the right than in the left proximal ITA.

METHODS

Proximal ITA flow was examined by TTDE in 129 consecutive patients after CABG of the left (75) or right (69) ITA to the left coronary artery. The mean D/S of the ITAs was compared with coronary angiography.

RESULTS

The D/S was lower in the group with a patent right ITA than in the group with a patent left ITA (P < .05). The D/S of both the left and right ITAs negatively correlated with angiographic stenosis (r = 0.56 or 0.67, P < .001, respectively). The regression line was significantly shifted downward in the right ITA compared with the left ITA, according to analysis of covariance (P = .01). Graft stenosis was predicted by a D/S of <0.57 and <0.28 with an accuracy of 91% and 97% in the left and right ITAs, respectively.

CONCLUSION

The patency of both left and right ITA grafts to the left coronary artery can be assessed using TTDE, but different cutoff values of D/S are required to diagnose severe ITA stenosis.

Effect of coronary endothelial function on outcomes in patients undergoing percutaneous coronary intervention

Numerous studies have documented the association between endothelial dysfunction and adverse cardiovascular events. For example, coronary artery disease is associated with functional and structural changes of the coronary arteries, resulting in ischemia or plaque rupture, and is highly associated with endothelial dysfunction. Recent data suggest that implantation of drug-eluting stents (DES) can induce coronary artery endothelial dysfunction at follow-up when compared with bare-metal stents (BMS) and that this endothelial dysfunction may be associated with late stent thrombosis. Indeed, despite the superiority of DES in preventing restenosis, the incidence of death and myocardial infarction is similar when comparing DES with BMS. Medical treatment, such as statins, angiotensin-converting enzyme inhibitors, or angiotensin receptor blockers, can improve endothelial dysfunction. Thus, administration of these drugs along with percutaneous coronary intervention (PCI) may be a low-risk strategy to provide therapeutic benefit by stabilizing unstable plaque or by suppressing new lesion formation in patients undergoing PCI.

Relationship between bilirubin concentration, coronary endothelial function, and inflammatory stress in overweight patients

AIM

Bilirubin has antioxidant properties and may protect against atherosclerosis and coronary heart disease (CHD). Further, in patients with metabolic syndrome, hyperbilirubinemia is associated with attenuation of insulin resistance. The aim of the present study was to determine the relationship between serum bilirubin concentration and coronary endothelial function in overweight patients.

METHODS

The study population consisted of 107 patients without CHD who underwent coronary flow studies. Vascular reactivity was examined by intra-coronary administration of papaverine and nitroglycerin. Coronary endothelial function was evaluated by assessing the change in coronary artery diameter to papaverine [percent change in flow-mediated dilatation (%FMD)] and nitroglycerin (%NTG). Serum total bilirubin, high-sensitivity C-reactive protein (hs-CRP), high density lipoprotein-cholesterol (HDL-C), fasting plasma glucose and immunoreactive insulin levels were also measured, and the homeostasis model assessment insulin resistance (HOMA-IR) index was calculated. Patients were divided into two groups according to body mass index (BMI): an overweight group (BMI ≥ 25; n = 36) and a normal weight group (BMI < 25; n = 71).

RESULTS

In the overweight group, univariate analysis revealed that log-transformed total bilirubin was positively correlated with %FMD and HDL-C (r = 0.38, p< 0.05; r = 0.30, p < 0.05, respectively) and was inversely correlated with log-transformed hs-CRP and HOMA-IR (r = -0.45, p < 0.01; r = -0.45, p< 0.05, respectively). Multivariate analysis revealed that log-transformed hs-CRP was the only independent predictor of log-transformed total bilirubin (p< 0.05).

CONCLUSIONS

These results suggest that a high bilirubin level was associated with favorable coronary endothelial function in overweight patients. Further, the anti-inflammatory effects of bilirubin may mediate this effect.

Reevaluation of quantitative flow cytometric analysis for TLR2 on monocytes using F(ab')2 fragments of monoclonal antibodies

In patients with refractory infections, reliable markers that monitor the severity and healing process are needed. The expression level of toll-like receptor 2 (TLR2) on monocytes is such candidate. In the conventional assay system, the whole IgG (wIgG) form of anti-TLR2 mAb has been used with control IgG, which blocks nonantigen-specific bindings. However, the competitive reactions against Fcγ receptors (FcγRs) between labeled anti-TLR2 mAbs and control IgG should be considered. Our goal was to precisely quantify TLR2 expression level on monocytes by flow cytometry (FCM). In this study, we prepared anti-TLR2 mAbs, D45 (IgG2a), and D29 (IgG1), as well as their fragment antigen-binding [F(ab')(2) ] fragments to avoid nonantigen-specific binding to FcγRs. And then, we determined TLR2 expression levels on monocytes by using these mAbs/fragments and our calibration system using recombinant TLR2 beads. The binding of PE-labeled D45 wIgG to monocytes was completely blocked with unlabeled D45 wIgG, but not with unlabeled D45 F(ab')(2) fragment. Although the nonantigen-specific binding of D29 wIgG to nonstimulated monocytes was negligible, it was enhanced in interleukin-10-stimulated monocytes. It proved difficult to completely block nonantigen-specific binding of D45 and D29 wIgGs by treatment with control IgG. It was demonstrated that the use of fluorescent-labeled antigen-binding region lacking the fragment crystallizable portion of anti-TLR2 mAb [such as the PE-labeled F(ab')(2) fragment] is indispensible for quantification of TLR2 levels on monocytes in flow cytometry. .

Effect of Waon therapy on oxidative stress in chronic heart failure

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.

Loss of clusterin limits atherosclerosis in apolipoprotein E-deficient mice via reduced expression of Egr-1 and TNF-α

AIM

Whether clusterin/apolipoprotein J is antiatherogenic or proatherogenic is controversial. We reported that clusterin was markedly induced in media and neointima after vascular injury and that reduced clusterin expression reduced the proliferation of vascular smooth muscle cells (VSMCs), which induced G1 arrest via p53 and p21. The purpose of this study was to investigate the physiological function of clusterin in atherosclerosis using double-knockout mice (D-KO) of apolipoprotein E-deficient mice (apoE-KO) and clusterin-deficient mice (CLU-KO).

METHODS AND RESULTS

Atherosclerotic lesions in the aortic root were quantitated at 20 weeks of age. Atherosclerotic lesions of D-KO were significantly smaller than those of apoE-KO (D-KO: 0.176±0.078 mm(2) vs. apoE-KO: 0.365±0.164 mm(2), p< 0.001). To identify underlying atherosclerotic mechanisms that were blocked by loss of clusterin, we performed immunohistochemical analysis of Egr-1. Egr-1 immunoreactivity in the nuclei of VSMCs in atherosclerotic lesions of apoE-KO was upregulated, whereas it was not in D-KO lesions. Western blotting demonstrated that the expression levels of Egr-1 and TNF-α in the D-KO were significantly lower than those in the apoE-KO. When VSMCs and macrophages were obtained from D-KO and apoE-KO, Western blotting showed that the expression levels of Egr-1 and TNF-α in VSMCs and macrophages of D-KO were significantly lower than those of apoE-KO.

CONCLUSION

Loss of clusterin strongly suppressed apoE-KO-induced atherosclerotic lesions at a step prior to the expression of Egr-1 and TNF-α, suggesting that clusterin is a candidate for an antiatherogenic target.

Waon therapy mobilizes CD34+ cells and improves peripheral arterial disease

BACKGROUND

We previously reported that Waon therapy upregulates endothelial nitric oxide synthase protein, and augments ischemia-induced angiogenesis in mice with hindlimb ischemia, and it improves limb ischemia in patients with peripheral arterial disease (PAD). The aim of this study was to investigate the underlying mechanism of Waon therapy for the treatment of patients with PAD, and to determine whether Waon therapy can mobilize blood-derived progenitor cells.

METHODS

21 consecutive PAD patients received standard medications, and were randomly divided into control (n=10) and Waon therapy groups (n=11). The Waon therapy group received Waon therapy daily for 6 weeks. The control group continued conventional therapy for 6 weeks. Leg pain was scored using a visual analogue scale. The ankle-brachial pressure index (ABPI) and the 6-min walking distance were measured at baseline and 6 weeks after therapy. Frequency of circulating CD34+ progenitor cell numbers was measured by quantitative real-time polymerase chain reaction, and the serum nitrate and nitrite levels were also measured at baseline and 6 weeks after therapy.

RESULTS

The leg pain score, ABPI and the 6-min walking distance improved significantly after 6 weeks in the Waon therapy group, but not in the control group. Frequency of circulating CD34+ cells increased after 6 weeks of Waon therapy [2.0 ± 1.2 (×10(-4)) at baseline to 3.9 ± 1.9 (×10(-4)), p=0.015], while it remained unchanged in the control group [1.8 ± 1.8 (×10(-4)) at baseline to 1.2 ± 0.9 (×10(-4))]. Serum nitrate and nitrite levels increased significantly after Waon therapy (29.6 ± 17.6 to 36.0 ± 17.7 μmol/ml, p<0.05), but not in the control group (34.4 ± 9.4 to 38.3 ± 8.8 μmol/ml).

CONCLUSION

Waon therapy mobilized circulating endothelial progenitor cells and improved limb ischemia in patients with PAD. Waon therapy is a highly promising therapy for patients with PAD.

Preliminary clinical experience with waon therapy in Korea: safety and effect

BACKGROUND

Waon therapy has beneficial effects on chronic heart failure (CHF), peripheral arterial disease, and other various diseases. This was to assess the safety and effect of Waon therapy by echocardiography for the first time in Korea.

METHODS

Ten patients with CHF were enrolled. The patients with a light gown were placed in a sitting-position in an evenly maintained 60 dry sauna system for 15 minutes, and then after leaving the sauna, they underwent bed rest with a blanket to keep them warm for an additional 30 minutes. Waon therapy was performed once a day, 5 days a week.

RESULTS

Four of the 5 patients who had been treated for more than 2 weeks as protocol noted improvement of heart failure (HF) symptoms and decrease in left ventricular (LV) volume. There were trends in improvement of LV ejection fraction and parameters of diastolic function after the therapy although statistical significance was lack. No one complained of worsening of HF symptoms. In each session, body weight (61.8+/-10.2 kg vs. 61.6+/-10.3 kg, p=0.008) and blood pressure (systolic, 119+/-28 vs. 111+/-27 mmHg, p=0.005; diastolic, 69+/-12 mmHg vs. 63+/-10 mmHg, p=0.005) were significantly decreased, oral temperature (35.9+/-0.4 vs. 37.0+/-0.9, p=0.017) was increased by 1.0 at the end of sauna bathing, but the heart rate (71+/-10/min vs. 72+/-8/min, p=0.8) was not changed.

CONCLUSION

We have experienced Waon therapy which was safe and well tolerated and some beneficial effects for patients with CHF. Large scale randomized study is needed to apply Waon therapy as a promising therapy in Korean HF patients.

Abstract 3607: The effect of gefitinib on the expression of c-MYC and TSP-1 in cancer cells

Gefitinib is a selective inhibitor of epidermal growth factor receptor tyrosine kinase, and is known to suppress tumor angiogenesis. We previously reported that gefitinib suppressed E2F-1 expression and telomerase activity in A431 and A549 cells. The expression of hTERT was increased by c-MYC, whereas we found that 5-FU decreased the expression of c-MYC and increased Thrombospondin-1 (TSP-1) expression. In the present study, we examined the effects of gefitinib on the expression of c-MYC and TSP-1 in human epidermmoid carcinoma A431 and lung adenocarcinoma A549 cells. Gefitinib suppressed the expression of c-MYC in both of two cell lines within 12 hours after gefitinib exposure, however, the expression of c-MYC mRNA was reduced only in A431 cells. A549 cells are known to have K-RAS mutation but A431 cells do not. We suppose that post-transcriptional inhibition or degradation of c-MYC had been induced by the treatment with gefitinib. MG132, a proteasome inhibitor, could inhibit the suppression of c-MYC expression by gefitinib exposure in both of these cells. Thus, the promotion of c-MYC degradation may be one of the mechanisms of the suppression of c-MYC expression by gefitinib exposure on these cells.

On the other hand, in A549 cells, 5-20μM of gefitinib suppressed the expression of c-MYC after incubation for 96 hours too, while TSP-1 expression was increased by gefitinib. In A431 cells, 0.12-1.0μM of gefitinib affected the expression of c-MYC and TSP-1. As in A549 cells, TSP-1 expression was up-regulated but the expression of c-MYC was attenuated by gefitinib. Our findings suggest that the anti-angiogenic effects of gefitinib might be, at least in part, due to TSP-1 expression augmented by gefitinib.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 3607.

Alpha-galactosidase A-Tat fusion enhances storage reduction in hearts and kidneys of Fabry mice

The protein transduction domain from human immunodeficiency virus (HIV) Tat allows proteins to penetrate the cell membrane. Enhanced cellular uptake of therapeutic proteins could benefit a number of disorders. This is especially true for lysosomal storage disorders (LSDs) where enzyme replacement therapy (ERT) and gene therapy have been developed. We developed a novel recombinant lentiviral vector (LV) that engineers expression of alpha-galactosidase A (alpha-gal A)-Tat fusion protein for correction of Fabry disease, the second-most prevalent LSD with manifestations in the brain, kidney and heart. In vitro experiments confirmed mannose-6-phosphate independent uptake of the fusion factor. Next, concentrated therapeutic LV was injected into neonatal Fabry mice. Analysis of tissues at 26 wks demonstrated similar alpha-gal A enzyme activities but enhanced globotriaosylceramide (Gb3) reduction in hearts and kidneys compared with the alpha-gal A LV control. This strategy might advance not only gene therapy for Fabry disease and other LSDs, but also ERT, especially for cardiac Fabry disease.

Sequencing and characterization of the porcine α-galactosidase A gene: towards the generation of a porcine model for Fabry disease

Fabry disease is an inherited lysosomal disorder caused by a deficiency of alpha-galactosidase A (α-gal A). The systemic accumulation of substrate, mainly globotriaosylceramide (Gb3), results in organ failure. Although Gb3 accumulation has been observed in an α-gal A-deficient mouse model, important clinical manifestations were not seen. The pursuit of effective treatment for Fabry disease through gene therapy, for example, has been hampered by the lack of a relevant large animal model to assess the efficacy and safety of novel therapies. Towards assembling the tools to generate an alternative animal model, we have sequenced and characterized the porcine ortholog of the α-gal A gene. When compared to the human α-gal A, the porcine α-gal A showed a high level of homology in the coding regions and located at chromosome Xq22. Cell lysate and supernatants from Fabry patient-derived fibroblasts transduced with a lentiviral vector (LV) carrying the porcine α-gal A cDNA (LV/porcine α-gal A), showed high levels of α-gal A activity and its enzymological stability was similar to that of human α-gal A. Uptake of secreted porcine α-gal A was observed into non-transduced cells and was partially inhibited by soluble mannose-6-phosphate. Furthermore, Gb3 accumulation was reduced in Fabry patient-derived fibroblasts transduced with the LV/porcine α-gal A. In conclusion, we elucidated and characterized the porcine α-gal A gene and enzyme. Similarity in enzymatic profile and chromosomal location between α-gal A of porcine and human origins may be of great advantage for the development of a large animal model for Fabry disease.

Concordant and discordant adrenocorticotropin (ACTH) responses induced by growth hormone-releasing peptide-2 (GHRP-2), corticotropin-releasing hormone (CRH) and insulin-induced hypoglycemia in patients with hypothalamopituitary disorders: evidence for direct ACTH releasing activity of GHRP-2

The insulin-induced hypoglycemia test (insulin tolerance test: ITT) and corticotropin-releasing hormone (CRH) test are used to examine the activities of the hypothalamo-pituitary-adrenal (HPA) axis. Growth hormone-releasing peptide-2 (GHRP-2), a potent GH secretagogue, also stimulates adrenocorticotropin (ACTH) secretion. To evaluate the role of GHRP-2 in assessing the HPA axis, we examined 6 patients with various hypothalamo-pituitary disorders, and measured ACTH and cortisol responses during provocative tests (ITT, CRH, and GHRP-2 test). None of the 6 patients showed any significant ACTH or cortisol responses to ITT, but significant ACTH release was observed during CRH and GHRP-2 tests. These findings suggest GHRP-2 may directly stimulate ACTH secretion in patients with hypothalamo-pituitary disorders.

Deficiency of clusterin inhibits neointimal hyperplasia after vascular injury

AIM

Increased clusterin mRNA and protein levels have been detected in various tissues undergoing stress, and we previously reported that clusterin is markedly induced in media and neointima following vascular injury. The present study therefore investigated the impact of clusterin on neointimal hyperplasia following vascular injury.

METHODS AND RESULTS

As compared with wild-type mice, clusterin knockout mice (clusterin-KO) demonstrated a significant decrease of the intima/media ratio 4 weeks after cuff placement. Immunohistochemical analysis of injured femoral arteries in clusterin-KO demonstrated the accumulation of p53 in nuclei of neointimal vascular smooth muscle cells (VSMCs). Moreover, VSMCs from either clusterin-KO or rat VSMCs treated with clusterin-short-interfering (si) RNA subjected to static stretch exhibited significantly increased p53 and p21, and increased G1 cell cycle arrest as indicated by flow cytometry compared with VSMCs from wild-type mice.

CONCLUSION

Reduced clusterin expression reduced the proliferation of VSMCs and induced G1 arrest via p53 and p21. Clusterin therefore represents a promising molecular target to limit restenosis after coronary intervention.

Association between arterial stiffness and estimated glomerular filtration rate in the Japanese general population

AIM

Chronic kidney disease (CKD) is associated with an increased risk of cardiovascular disease, although it has yet to be established whether CKD is an independent risk factor for arterial stiffness in community residents. The purpose of this study was to determine the correlation between the cardio-ankle vascular index (CAVI) and estimated glomerular filtration rate (eGFR) in the general population.

METHODS

We studied 881 consecutively enrolled subjects undergoing health checkups. CAVI was calculated automatically from the pulse volume record, blood pressure and the vascular length from the heart to the ankle. CKD was evaluated by the eGFR.

RESULTS

The distribution of eGFR was as follows: 241 with eGFR (mL/min/1.73m(2)) > or =90; 572 with eGFR 60-89; 65 with eGFR 30-59; 3 with eGFR 15-29; 0 with eGFR <15. Linear regression analysis showed that CAVI was negatively correlated significantly with eGFR, while multiple regression analysis using CAVI as an objective variable, adjusted for conventional atherosclerotic risk factors and eGFR as explanatory variables, demonstrated that CAVI was an independent determinant of eGFR. We also showed that stepwise increments of CAVI occurred with progressive deterioration of CKD.

CONCLUSION

CAVI was independently correlated with eGFR indicating that CKD is associated with arterial stiffness in the general population.

Usefulness of the adenosine triphosphate with a sufficient observation period for detecting reconduction after pulmonary vein isolation

BACKGROUND

Although reconduction after pulmonary vein (PV) isolation is considered to play a key role in the recurrence of paroxysmal atrial fibrillation (AF), there have been few reports regarding the precise time course of early reconduction. Several studies have suggested that transient PV reconduction facilitated by adenosine may predict long-term AF recurrence. This study was designed to clarify the incidence and time course of early reconduction after PVI during the procedure and to confirm whether the use of ATP after a certain observation period was useful to detect early reconduction after PVI.

METHODS

In 21 patients (18 males, 56 +/- 11 years) with drug refractory AF, radiofrequency circumferential PV antrum ablation was performed in all 4 PVs. After the completion of isolation, electrograms in each PV were repeatedly recorded (1.98 +/- 0.57 times per PV) using a circular mapping catheter for an observation period of 87 +/- 29 minutes. After isolation of all 4 PVs, 30 mg of adenosine triphosphate (ATP) was administered during isoproterenol infusion.

RESULTS

PV electrical isolation was initially achieved in all 81 PVs. During the observation period, 12 (15%) PVs in 10 (48%) of 21 patients exhibited spontaneous reconduction. Among the remaining 69 PVs, 8 (12%) additional PVs had reconduction with the use of ATP. All PV reconduction was successfully eliminated by 4.5 +/- 2.2 additional radiofrequency applications.

CONCLUSION

A sufficient observation period and the use of ATP are useful to detect early reconduction after PV isolation.

Expression of endothelia and lymphocyte adhesion molecules in bronchus-associated lymphoid tissue (BALT) in adult human lung

Background

Bronchus-associated lymphoid tissue (BALT) is the secondary lymphoid tissue in bronchial mucosa and is involved in the development of bronchopulmonary immune responses. Although migration of lymphocytes from blood vessels into secondary lymphoid tissues is critical for the development of appropriate adaptive immunity, the endothelia and lymphocyte adhesion molecules that recruit specific subsets of lymphocytes into human BALT are not known. The aim of this study was to determine which adhesion molecules are expressed on lymphocytes and high endothelial venules (HEVs) in human BALT.

Methods

We immunostained frozen sections of BALT from lobectomy specimens from 17 patients with lung carcinoma with a panel of monoclonal antibodies to endothelia and lymphocyte adhesion molecules.

Results

Sections of BALT showed B cell follicles surrounded by T cells. Most BALT CD4⁺ T cells had a CD45RO⁺ memory phenotype. Almost all BALT B cells expressed α₄ integrin and L-selectin. In contrast, 43% of BALT T cells expressed α₄ integrin and 20% of BALT T cells expressed L-selectin. Almost all BALT lymphocytes expressed LFA-1. HEVs, which support the migration of lymphocytes from the bloodstream into secondary lymphoid tissues, were prominent in BALT. All HEVs expressed peripheral node addressin, most HEVs expressed vascular cell adhesion molecule-1, and no HEVs expressed mucosal addressin cell adhesion molecule-1.

Conclusion

Human BALT expresses endothelia and lymphocyte adhesion molecules that may be important in recruiting naive and memory/effector lymphocytes to BALT during protective and pathologic bronchopulmonary immune responses.

Comparison of blood glucose values on admission for acute myocardial infarction in patients with versus without diabetes mellitus

Previous studies have reported that acute hyperglycemia is associated with high mortality after acute myocardial infarction (AMI). However, optimal plasma glucose level may be different between diabetic and nondiabetic patients. The purpose of this study was to assess the relation between admission glucose and in-hospital mortality after AMI in patients with and without diabetes. This study consisted of 3,750 patients who were admitted to the 35 hospitals participating to the Japanese Acute Coronary Syndrome Study (JACSS) group within 48 hours after the onset of AMI. Plasma glucose was measured at the time of hospital admission. In patients without a history of diabetes, there was a linear relation between admission glucose and in-hospital mortality. Nondiabetic patients with a glucose level <6 mmol/L had the lowest mortality (2.5%). As admission glucose increased by 1 mmol/L, mortality increased by 17% (13% to 21%, p <0.001). In patients with a history of diabetes, however, there was a U-shape relation between glucose and mortality. Diabetic patients with glucose 9 to 10 mmol/L had the lowest mortality (1.9%); not only severe hyperglycemia (glucose > or =11 mmol/L, 9.1%, p <0.001) but also euglycemia (glucose <7 mmol/L, 9.4%, p = 0.009) were associated with higher mortality compared to moderate hyperglycemia (glucose 9 to 11 mmol/L, 3.2%). Diabetic patients with admission glucose 9 to 10 mmol/L had the lowest mortality, whereas lower glucose was better in nondiabetic patients. In conclusion, optimal glucose level on admission may be different between diabetic and nondiabetic patients with AMI.

Left ventricular reconstruction with or without mitral annuloplasty

OBJECTIVES

The aim of this study was to review characteristics of patients undergoing left ventricular reconstruction (LVR) with or without mitral annuloplasty (MAP) for postinfarction ventricular remodeling.

PATIENTS AND METHODS

Forty-seven patients were divided into two groups: LVR (LVR group, n = 22) and LVR with MAP (LVRM group, n = 25). Echocardiographic parameters including left ventricular (LV) dimensions, LV end-diastolic and end-systolic volume indexes, and LV ejection fraction (LVEF) at immediate and midterm postoperative stages were evaluated. The perioperative contributing factors to all deaths and death from congestive heart failure (CHF) were analyzed in all 47 patients.

RESULTS

Patients in the LVRM group had greater preoperative LV dimension and volume, and significantly lower LVEF, with notably frequent use of intra-aortic balloon pumping. All postoperative deaths occurred within 1 year from surgery. The LV end-diastolic volume > 110 ml/m2 and creatinine > 1.2 mg/dl were significant preoperative contributing factors to all deaths, and the latter was to CHF deaths.

CONCLUSIONS

The coexistence of ischemic mitral regurgitation with LV dilatation required more aggressive surgical approaches for the patients with more impaired LV function. More intensive postoperative management is required for patients with enlarged hearts and renal dysfunctions.

Combined prognostic utility of white blood cell count, plasma glucose, and glomerular filtration rate in patients undergoing primary stent placement for acute myocardial infarction

Although high white blood cell (WBC) count and plasma glucose (PG) and low glomerular filtration rate (GFR) on admission have been associated with poor outcomes after acute myocardial infarction (AMI), the combined prognostic utility of these 3 variables was unclear. The association of WBC count, PG, and GFR on admission to in-hospital outcomes was examined in 2,633 patients who underwent primary stent placement for ST-segment elevation AMI within 48 hours after symptom onset. In-hospital mortality progressively increased as the number of the variables of high WBC count (> or =11,120/microl; upper tertile), high PG (> or =10.4 mmol/L; upper tertile), and low GFR (< or =60 ml/min/1.73 m(2); lower tertile) increased. Patients with all 3 variables had a strikingly higher in-hospital mortality rate (25.9%). After adjusting for baseline characteristics, multivariate analysis showed that compared with patients who had none of these variables, odds ratios for in-hospital mortality were 1.63 (95% confidence interval [CI] 0.88 to 3.03, p = 0.12) in patients with only 1 variable, 2.33 (95% CI 1.28 to 3.96, p = 0.047) in those with 2 variables, and 6.16 (95% CI 2.98 to 12.6, p <0.001) in those with all 3 variables. In conclusion, combined evaluation of WBC count, PG, and GFR on admission was a simple and useful method for the early prediction of risk of in-hospital death in patients undergoing primary stent placement for ST-segment elevation AMI.

Peripartum cardiomyopathy in a patient with Graves' disease

Peripartum cardiomyopathy (PPCM) is a rare life-threatening cardiomyopathy of unknown etiology that occurs during the peripartum period in previously healthy women. Autoimmune and viral factors have been suggested to be involved in PPCM. Here we describe a patient with Graves' disease, which is one of the organ-specific autoimmune diseases, who developed acute heart failure due to PPCM at 2 weeks after her first delivery. The patient recovered completely with conservative treatment for heart failure. An association between PPCM and Graves' disease has not been reported before. PPCM may be an organ-specific autoimmune disease, so the coexistence of other autoimmune diseases should be considered in PPCM patients.

Waon therapy improves the prognosis of patients with chronic heart failure

BACKGROUND

We developed a Waon therapy (soothing warm therapy) and have previously reported that repeated Waon therapy improves hemodynamics, peripheral vascular function, arrhythmias, and clinical symptoms in patients with chronic heart failure (CHF). The aim of this study was to investigate the effect of Waon therapy on the prognosis of CHF patients.

PATIENTS AND METHODS

We studied 129 patients with CHF in NYHA functional class III or IV who were admitted to our hospital between January 1999 and March 2001. In the Waon therapy group, 64 patients were treated with a far infrared-ray dry sauna at 60 degrees C for 15 min and then kept on bed rest with a blanket for 30 min. The patients were treated daily for 5 days during admission, and then at least twice a week after discharge. In the control group, 65 patients, matched for age, gender, and NYHA functional class, were treated with traditional CHF therapy. The follow-up time was scheduled for 5 years.

RESULTS

Recent, complete follow-up data on each patient were obtained. The overall survival rate was 84.5% (Kaplan-Meier estimate). Twelve patients died in the control group and 8 patients died in the Waon therapy group at 60 months of follow-up. Cardiac events due to heart failure or cardiac death occurred in 68.7% of the control group but only 31.3% of the Waon therapy group (P<0.01) at 60 months of follow-up.

CONCLUSION

Waon therapy reduced cardiac events in patients with CHF. This therapy is a promising non-pharmacological treatment for CHF.

Relationship between hyperglycemia and coronary vascular resistance in non-diabetic patients

BACKGROUND

Hyperglycemia upon hospital admission in patients with acute myocardial infarction is associated with the no-reflow phenomenon after successful reperfusion, and increased mortality. However, the mechanism underlying this phenomenon remains unclear. Therefore, the aim of this study was to characterize coronary hemodynamics in a homogenous group of non-diabetic patients without coronary artery disease.

METHODS AND RESULTS

A total of 104 consecutive non-diabetic patients (mean age, 62+/-14 years) without coronary artery disease underwent Doppler flow study of the left anterior descending coronary artery. Vascular reactivity was examined by intra-coronary administration of papaverine, acetylcholine (Ach), and nitroglycerin using a Doppler guidewire. Coronary vascular resistance (CVR) was calculated as the mean arterial pressure divided by coronary blood flow (CBF). Baseline CVR was shown as CVR at control and minimal CVR was shown as CVR with papaverine administration. Fasting plasma glucose (FPG) level had a significant, positive correlation with baseline CVR and minimal CVR (r=0.24, p<0.02 and r=0.21, p<0.05, respectively). Hemoglobin A1c (HbA1c) also had a significant, positive correlation with baseline CVR and minimal CVR (r=0.31, p<0.01 and r=0.32, p<0.01, respectively). The percent change in CBF induced by Ach was inversely correlated with HbA1c but not with FPG (r=0.22, p<0.05 and r=0.06, p=0.57, respectively). By contrast, neither FPG nor HbA1c had significant correlation with coronary flow reserve to papaverine.

CONCLUSION

These data demonstrate that elevated glucose levels are associated with increases in baseline and minimal coronary vascular resistance. These changes may contribute to unfavorable coronary hemodynamics in non-diabetic patients without coronary heart disease.