Efficacy and safety of zuranolone in Japanese adults with major depressive disorder: A double-blind, randomized, placebo-controlled, phase 2 clinical trial

AIM

To evaluate the efficacy and safety of an oral, once-daily, 14-day treatment course of zuranolone in Japanese patients with major depressive disorder (MDD).

METHODS

This multicenter, randomized, double-blind, placebo-controlled study randomized eligible patients (1:1:1) to receive oral zuranolone 20 mg, zuranolone 30 mg, or placebo once daily for 14 days (treatment-period), followed by two 6-week follow-up periods. The primary endpoint was change from baseline in the 17-item Hamilton Depression Rating Scale (HAMD-17) total score on Day 15.

RESULTS

Overall, 250 patients (enrolled: 07/07/2020-05/26/2021) were randomized to receive placebo (n = 83), zuranolone 20 mg (n = 85), or zuranolone 30 mg (n = 82). The demographic and baseline characteristics were balanced between groups. The adjusted mean (standard error) change from baseline in the HAMD-17 total score on Day 15 was -6.22 (0.62), -8.14 (0.62), and - 8.31 (0.63) in the placebo, zuranolone 20-mg, and zuranolone 30-mg groups, respectively. Significant differences in the adjusted mean (95% confidence interval [CI]) for zuranolone 20 mg versus placebo (-1.92; [-3.65, -0.19]; P = 0.0296) and zuranolone 30 mg versus placebo (-2.09; [-3.83, -0.35]; P = 0.0190) groups were observed on Day 15, and also as early as Day 3. A nonsignificant yet distinct drug-placebo separation was observed during follow-up. Somnolence (placebo [3.7%], zuranolone 20 mg [10.6%], and zuranolone 30 mg [20.7%]) and dizziness (3.7%, 9.4%, and 9.8%, respectively) were more common with zuranolone.

CONCLUSION

Oral zuranolone was safe and demonstrated significant improvements in depressive symptoms, as assessed by HAMD-17 total score change from baseline over 14 days in Japanese patients with MDD.

Pharmacokinetics, safety, and tolerability of single and multiple doses of zuranolone in Japanese and White healthy subjects: A phase 1 clinical trial

AIM

This phase 1 study assessed the pharmacokinetics, safety, and tolerability of zuranolone in Japanese and White healthy adults, and Japanese healthy elderly subjects.

METHODS

This single-center study consisted of three parts. In Part A (randomized, double-blind), the safety, tolerability, and pharmacokinetics of single dose and 7-day consecutive multiple doses of zuranolone 10, 20, and 30 mg and placebo were assessed in 36 Japanese adults, 24 White adults, and 12 Japanese elderly (aged 65-75 years) subjects. In Part B (randomized, open-label, crossover), the effect of food intake on the pharmacokinetics and safety of single-dose zuranolone 30 mg was evaluated in 12 Japanese adults. In Part C (randomized, double-blind, crossover), the effects of single-dose zuranolone 10 and 30 mg and placebo on electroencephalography parameters were evaluated in eight Japanese adults.

RESULTS

Single and multiple doses of zuranolone were safe and well tolerated in all subjects. Linear pharmacokinetics were observed in the studied dose range. Time to steady-state plasma concentration was within 72 h for Japanese and White adults. Pharmacokinetic profiles were comparable between Japanese and White adults and between Japanese adults and Japanese elderly subjects. Plasma exposures of zuranolone were greater in the fed versus fasted state. Single-dose zuranolone 30 mg increased low-beta electroencephalography power.

CONCLUSION

In healthy Japanese subjects, zuranolone was well tolerated; pharmacokinetic profile was unaffected by ethnicity or age; plasma exposures were greater in the fed state. The increased low-beta electroencephalography power with the 30-mg dose is consistent with γ-aminobutyric acid receptor type A activation by zuranolone.

Lusutrombopag for the Treatment of Thrombocytopenia in Patients With Chronic Liver Disease Undergoing Invasive Procedures (L-PLUS 2)

Thrombocytopenia may be associated with increased bleeding risk impacting timing and outcome of invasive procedures in patients with chronic liver disease (CLD). Lusutrombopag, a small-molecule, thrombopoietin (TPO) receptor agonist, was evaluated as a treatment to raise platelet counts (PCs) in patients with thrombocytopenia and CLD undergoing invasive procedures. L-PLUS 2 was a global, phase 3, randomized, double-blind, placebo-controlled study. Adults with CLD and baseline PCs < 50 × 10⁹ /L were randomized to receive once-daily lusutrombopag 3 mg or placebo ≤ 7 days before an invasive procedure scheduled 2-7 days after the last dose. The primary endpoint was avoidance of preprocedure platelet transfusion and avoidance of rescue therapy for bleeding. A key secondary endpoint was number of days PCs were ≥ 50 × 10⁹ /L throughout the study. Safety analysis was performed on patients who received at least one dose of study drug. This study occurred between June 15, 2015, and April 19, 2017, with a total of 215 randomized patients (lusutrombopag, 108; placebo, 107); 64.8% (70/108) of patients in the lusutrombopag group versus 29.0% (31/107) in the placebo group met the primary endpoint (P < 0.0001; difference of proportion 95% confidence interval [CI], 36.7 [24.9, 48.5]). The median duration of PCs ≥ 50 × 10⁹ /L was 19.2 days with lusutrombopag (without platelet transfusion) compared with 0.0 in the placebo group (with platelet transfusion) (P = 0.0001). Most adverse events were mild or moderate in severity, and rates were similar in the lusutrombopag and placebo groups (47.7% and 48.6%, respectively). Conclusion: Lusutrombopag was superior to placebo for reducing the need for platelet transfusions and achieved durable PC response in patients with thrombocytopenia and CLD undergoing invasive procedures, with a safety profile similar to placebo.

Anticarcinogenic compounds in the Uzbek medicinal plant, Helichrysum maracandicum

An ethanol extract of Helichrysum maracandicum showed antiproliferative activity against cultured cells of SENCAR mouse in an in vitro assay, and activity-guided fractionation of the extract resulted in the isolation of isosalipurposide as an active substance. Naringenin chalcone, the aglycone of isosalipurposide, also showed strong antiproliferative activity. An in vivo assay of two-stage carcinogenesis on mouse skin revealed that epidermal application of isosalipurposide resulted in delayed formation of papillomas. Western blot analysis showed that the expression of p38 mitogen-activated protein kinase was suppressed by the administration of naringenin chalcone or isosalipurposide, which might be related to the anticarcinogenic activity.

Effects of aspirin and trapidil on cardiovascular events after acute myocardial infarction. Japanese Antiplatelets Myocardial Infarction Study (JAMIS) Investigators

Aspirin therapy confers conclusive net benefits in the acute phase of evolving myocardial infarction, but no clear evidence of benefit from the long-term use of aspirin after acute myocardial infarction (AMI) has been shown in any single study. This multicenter study, the Japanese Antiplatelets Myocardial Infarction Study, was performed to find out whether aspirin or trapidil would improve clinical outcome compared with no antiplatelets in postinfarction patients. The study was a multicenter, open-label, randomized controlled trial of aspirin 81 mg/day, trapidil 300 mg/day, and no antiplatelets in patients with AMI admitted within 1 month from the onset of symptoms. Seven hundred twenty-three patients were enrolled at 70 hospitals in 18 prefectures of Japan; 250 were randomly assigned to treatment with 81 mg aspirin (aspirin group), 243 to that with trapidil (trapidil group), and 230 were not given antiplatelet agents. The mean follow-up period was 475 days. This study demonstrated that long-term use of aspirin at the dose of 81 mg/day reduced the incidence of recurrent AMI compared with the group receiving no antiplatelets after AMI (p = 0.0045) and that trapidil also reduced the occurrence of reinfarction compared with the group receiving no antiplatelets, but the difference was not significant (p = 0.0810). The incidence of cardiovascular events including cardiovascular death, reinfarction, uncontrolled unstable angina requiring admission to hospital, and nonfatal ischemic stroke was reduced in the group receiving 300 mg trapidil daily compared with the group receiving no antiplatelets (p = 0.0039). The use of aspirin 81 mg/day provided almost no benefit over no antiplatelets therapy in the incidence of cardiovascular events. In conclusion, low-dose aspirin (81 mg) effectively prevented recurrent AMI in postinfarction patients after thrombolysis or coronary angioplasty when used over a long term. Furthermore, the long-term use of trapidil resulted in a significant reduction in the incidence of cardiovascular events.

[Secondary prevention of acute coronary syndrome]

The sudden conversion of a stable atherosclerotic plaque to an unstable and life-threatening atherothrombotic lesion which is known as plaque rupture is the potential mechanism for the development of acute coronary syndrome (ACS). Accordingly, secondary prevention of ACS could be achieved with the prevention of the plaque rupture and thrombus formation. Coronary angioplasty and coronary bypass surgery have a limited value in the long-term prevention of ACS. Coronary risk factor modification is certainly the important strategy for secondary prevention. The drug treatment with lipid lowering agents, especially 3-hydroxy-3-methyl-glutaryl coenzyme A (HMG-CoA) reductase inhibitors, beta-adrenergic receptor blockers, antiplatelet agents and anticoagulants, have been proven to be effective for the secondary prevention of myocardial infarction. Estrogen for postmenopausal women has also been reported to be beneficial. However, calcium channel blockers except verapamil, nitrates and angiotensin converting enzyme (ACE) inhibitors are not recommended for the secondary prevention of ACS.

Non-dipolarity of heart potentials estimated by magnetocardiography in normal subjects

We studied non-dipolarity characteristics during ventricular excitation in normal adults and children by magnetocardiography (MCG) by recording magnetic field on the thorax. The source and currents of the electrical dipole from the onset up to 60 ms of ventricular excitation were analyzed in 16 adults and 5 children. A single equivalent current dipole (ECD) was estimated by Sarvas' formula for the sphere model at 1 ms intervals. The non-dipole value (NDV) was calculated from the magnetic field strength at each recording point and theoretically estimated by ECD, representing an index for the non-dipolarity. At 32-34 ms from the beginning of QRS, the mean NDV was a minimum in all subjects suggesting at least a non-dipole component during this period. High NDV (over 5%) were present in most subjects in both the early and late phase compared to this period. Thirteen of 16 adults had a high NDV in the early phase (9.3 +/- 3.0%, mean +/- SD) and all 16 subjects had a high NDV in the late phase (21.5 +/- 10.5%). All 5 children had high NDV in both the early (10.5 +/- 5.4%) and late phases (16.8 +/- 7.9%). A single ECD estimation by MCG showed a relatively low non dipolar component and MCG could be applied to the clinical evaluation of cardiac excitation in both normal and pathological conditions.

Significance of abnormal root mean square voltages in signal averaged electrocardiogram as a reliable predictor of sustained ventricular tachycardia

The late potential is useful to predict patients with sustained ventricular tachycardia (VT). However, because positive predictive value for sustained VT is low, the validity of late potential for screening the patients to be studied by electrophysiological tests was not high. We examined 923 cases, including 63 cases of sustained VT. When we separated patients showing abnormal values of the root mean square voltage of the QRS end part 40 milliseconds (RMS40) into four groups, there was a tendency of a higher incidence of sustained VT with lower value of RMS40. When we conducted electrophysiological tests on 121 cases without sustained VT, it turned out a high induction rate of sustained VT in patients with low RMS40 values (RMS40 < 10 microV, 67%; < 20 microV, 30%; 20 microV, < or = 5%). We conclude abnormally low value (less than 10 microV) of RMS40 can be useful for screening the late potential-positive cases who are high risk for inducible sustained VT.

Supernormal conduction in a case of Mobitz type II atrioventricular block

A 52-year-old woman exhibited Mobitz type II atrioventricular block with right bundle branch block and 1:1 atrioventricular conduction at or slower than 80 beats/min. Electrophysiologic study revealed transient HV interval block followed by recovery from the block at shorter coupling intervals without prolongation of the H1H2 and H2V2 intervals, suggesting true supernormal conduction. Isoproterenol enhanced the supernormal conduction, with shortening of blocked intervals and recovery of atrioventricular conduction, while atropine caused their less marked enhancement. Linking (ie, retrograde concealment of the impulse to the distal His bundle region through the blocked right bundle branch) is considered a possible mechanism of supernormal conduction in this case.

[Reperfusion therapy in acute myocardial infarction today: thrombolysis, balloon angioplasty and stenting]

Prompt restoration of coronary flow is the principal mechanism by which reperfusion therapy improves survival and other clinical outcomes in patients with acute myocardial infarction. Thrombolytic therapy has been the standard for care over the past decade. The use of accelerated administration of tissue plasminogen activator (t-PA) and modified or mutant t-PA which can be administered with a single bolus intravenous injection might bring further benefits. Primary balloon angioplasty (percutaneous transluminal coronary angioplasty: PTCA) is safe and effective when it can be performed quickly by experienced operators, resulting in better coronary flow and short-term survival rates than are obtained with thrombolytic therapy. However, several studies reporting data from more than 5,000 patients, of whom many were treated in low-volume local hospitals showed mortality with primary angioplasty was substantially higher than that reported from high-volume medical centers, and similar to that observed with thrombolysis with accelerated t-PA. The strategy of rapid administration of thrombolytic therapy and subsequent angioplasty only for recurrent ischemia seems to be as effective as primary angioplasty. Recently several reports have indicated that coronary stenting, when performed for suitable lesions and with good technique by experienced operators, is superior to the results obtained with balloon angioplasty and thrombolysis. However, further studies are required to establish the efficacy of primary stenting compared to PTCA.

Impact of sociodemographic and diabetes-related characteristics on depressive state among non-insulin-dependent diabetic patients

One hundred and fifty-one non-insulin-dependent diabetic patients were assessed to detect sociodemographic, psychological and disease-related characteristics that were related to depressive state among diabetic patients. Depressive state in the patients was correlated with poor social support and low economic status, premorbid neurotic personality and the presence of complications, retinopathy in particular. However, depressive state did not correlate with age, gender, education, serum level of HbA1C or duration of diabetes. The severity of the depressive state in diabetic patients may vary with the cultural background of the patient and/or the country in which he or she is living. In treating diabetic patients, doctors need to pay special attention to these factors.

Various problems during long-term percutaneous cardiopulmonary support

A 54-year-old man with a left ventricular free wall rupture following acute anterior myocardial infarction underwent a repair surgery with percutaneous cardiopulmonary support (PCPS). During surgery and postoperatively, PCPS provided sufficient support flow. The patient was successfully weaned from PCPS on the 15th postoperative day and discharged subsequently. In the management of cardiac rupture patients, PCPS has the merit of preventing rupture progression and the advantage of recovery of pulmonary function. However, there are several problems to solve. The support effectiveness and recovery of the patient's heart should be carefully evaluated. Effective left heart decompression also needs to be established. Heparin-coated circuits still need proper anticoagulation treatment to prevent thrombus formation especially while support flow is low. A circuit construction that allows easier maintenance and safer exchange of oxygenators and pump heads is suggested. Ischemia of the cannulated leg should be prevented by femoral artery perfusion.

Increase in heart rate after radiofrequency catheter ablation is mediated by parasympathetic nervous withdrawal and related to site of ablation

To assess the mechanism for the increased sinus rate after radiofrequency catheter ablation performed for atrioventricular nodal reentrant tachycardia (AVNRT), we studied heart rate variability before and after radiofrequency catheter ablation in 17 patients with AVNRT and in 38 patients with an accessory pathway. The accessory pathway was located at the left ventricular free wall, the right ventricular free wall, or the posterior interventricular septum. An increased sinus rate was observed in patients with AVNRT or with the accessory pathway at the posterior septum or left free wall after radiofrequency ablation. In these groups, high-frequency power, root mean square of successive difference and percent of adjacent cycles that were more than 50 ms apart, all of which are indices reflecting parasympathetic nervous activity, were decreased. The ratio of low-frequency to high-frequency power reflecting sympathovagal balance, was increased in patients with AVNRT or with an accessory pathway at the posterior septum or left free wall. Increases in sinus rate were correlated with decreases in high-frequency power, and percent of adjacent cycles more than 50 ms apart that the increase in heart rate was due to parasympathetic nervous withdrawal.

A psychophysiological study of the development of delirium in coronary care units

This is a longitudinal investigation of the psychophysiological mechanism for the development of delirium in coronary care units (CCUs). Ten patients satisfying DSM-III-R diagnostic criteria for delirium (group D) and 10 controls (group C) were drawn from patients admitted to CCU. Electroencephalogram (EEG) and eye movement recordings were observed over the days that patients were admitted to CCU and on a control day of admission and compared for each group and between each day. In the D group, slowing of background EEG activity, particularly on day 2, and many R (rapid) group eye movements and RS type (rapid superimposed on slow) eye movements, particularly on day 3, were observed. That is, from days 2 to 3, EEG findings showed an improvement in consciousness, and eye movement recordings manifested signs of anxiety and tension. These psychophysiological findings can be used to explain the transition from prodromal delirium to obvious delirium, and are supported by clinical features.

A prospective, randomized, double-blind multicenter trial of a single bolus injection of the novel modified t-PA E6010 in the treatment of acute myocardial infarction: comparison with native t-PA. E6010 Study Group

OBJECTIVES

This prospective, randomized, double-blind multicenter trial evaluated the efficacy and safety of a single bolus injection of the novel modified tissue-type plasminogen activator (t-PA) E6010 in the treatment of acute myocardial infarction compared with that of native t-PA.

BACKGROUND

E6010 is a novel modified t-PA with a prolonged half-life (t1/2 alpha > or = 23 min) compared with native t-PA (t1/2 alpha = 4 min). E6010 can be administered in patients as a single intravenous bolus injection, and early recanalization can be expected.

METHODS

The efficacy of E6010 was compared with that of native t-PA in 199 patients with acute myocardial infarction who were treated within 6 h of onset in a prospective, randomized, double-blind multicenter trial. Patients were given either 0.22 mg/kg body weight of E6010 intravenously over 2 min or native t-PA (tisokinase) 28.8 mg or 14.4 million IU (10% of the total dose over 1 to 2 min, the remainder infused over 60 min).

RESULTS

The primary end point was the recanalization rate of the infarct-related coronary artery at 60 min after the start of treatment. Time to reperfusion was shorter in the E6010 group than in the native t-PA group. Thrombolysis in Myocardial Infarction flow grade 2 or 3 recanalization at 15, 30, 45 and 60 min after administration was observed in 37%, 62%, 74% and 79% (95% confidence interval [CI] 70% to 87%) of the E6010-treated patients and in 14%, 32%, 50% and 65% (95% CI 55% to 74%) of native t-PA-treated patients, respectively (p = 0.032 at 60 min).

CONCLUSIONS

The present study indicates that, compared with native t-PA, a single bolus injection of E6010 over 2 min produces a higher rate of early recanalization of the infarct-related coronary artery without fatal bleeding complications.

Catheter ablation for the common type of atrioventricular nodal reentrant tachycardia

Radiofrequency (RF) catheter ablation of the slow AV nodal pathway was attempted in 34 patients with common type of AV nodal reentrant tachycardia (AVNRT). Radiofrequency energy of 18-32 watts was applied for 30-60 seconds at sites exhibiting atrial-slow pathway potentials or slow potentials. These potentials were recorded at the mid or posterior septum, anterior to the coronary sinus ostium. A mean of two radiofrequency applications successfully eliminated AVNRT in all patients. The incidence of junctional ectopy was significantly higher during 34 effective applications of radiofrequency energy than during 36 ineffective applications (100% versus 17%). Thus, the recording of atrial-slow pathway potentials or slow potentials, and the development of junctional ectopy can be used as a marker for successful ablation. Slow AV nodal conduction was eliminated in 22 patients and persisted without inducible AVNRT in 12. None of the patients had recurrences of AVNRT over a mean follow-up interval of 12 months, and all had preserved AV conduction. Long-term follow-up studies with an electrophysiological method confirmed that the ablation was effective. Transient AV block was observed in only 1 patient, and no major complications were noted. Thus, radiofrequency catheter ablation of the slow AV nodal pathway is highly effective and safe, with a low rate of complication, for the treatment of common type of AVNRT.

[Tricuspid and mitral regurgitation due to congenital hypoplasia of atrioventricular valves in the aged: a case report]

A 76-year-old woman with a history of repeated right-sided cardiac failure during the past 2 years presented with tricuspid and mitral regurgitation due to congenital hypoplasia of atrioventricular valves. Two-dimensional echocardiography demonstrated enlarged right atrium and right ventricle, and discoaptation between the leaflets. Color Doppler echocardiography revealed severe tricuspid regurgitation through the gap between the leaflets. Autopsy showed congenital hypoplasia of the leaflets and the chordae tendineae in the tricuspid and mitral valvular apparatus.

A case of cardiac sarcoidosis with remarkable atrophy of the left ventricular septum on two-dimensional echocardiography

Sarcoidosis is a multisystem granulomatous disorder of unknown etiology which mainly affects the lungs, skin, the lymphoreticular system, and the heart. We report a case of cardiac sarcoidosis in which a remarkably thin ventricular septum was demonstrated on two-dimensional echocardiography.

Hemodynamic effects and pharmacokinetics of oral milrinone for short-term support in acute heart failure

The present study evaluated the acute hemodynamic response, effects on subjective symptoms and physical findings, and the pharmacokinetics of a single oral dose (2.5, 5, or 10 mg) of milrinone in 31 patients with acute or decompensated heart failure. We found a significant increase in cardiac index (29, 31, and 29%, respectively, p < 0.01) and a significant decrease in pulmonary capillary wedge pressure (39, 43, and 47%, respectively, p < 0.01) accompanied with improvement in subjective symptoms and physical findings. These hemodynamic effects persisted for 4-8 h after each dosage of milrinone. Dose-dependent hemodynamic response was observed between the drug concentration and percent maximum changes in pulmonary capillary wedge pressure (peak milrinone concentration, 2.5 mg: 99.99 +/- 57.49, 5 mg: 187.11 +/- 71.37, and 10 mg: 300.94 +/- 158.5 ng/ml). The finding, together with results of the Prospective Randomized Milrinone Survival Evaluation (PROMISE) study, suggests lower dose of milrinone will be useful for the short-term inodilator support in patients with acute or decompensated heart failure.

Factors for transient entrainment of ventricular tachycardias by rapid atrial pacing

Thirteen patients with sustained ventricular tachycardia (VT) were studied to elucidate predisposing factors for the development of constant and progressive fusion by rapid atrial pacing. All patients demonstrated transient entrainment by rapid ventricular pacing during VT. Constant and progressive fusion were observed in 7 patients (positive group) during rapid atrial pacing, but not in 6 (negative group). In the positive group, VT was induced by atrial pacing in 2 patients. The demonstration of constant and progressive fusion by atrial pacing was not dependent on QRS morphology or ventriculoatrial conduction during VT. VT cycle length in the positive group (363 +/- 59 ms) was longer than in the negative group (297 +/- 31 ms; p = 0.033). The maximal atrial pacing rate producing 1:1 atrioventricular (AV) conduction in the positive group was 171 +/- 18 beats/min compared with 125 +/- 22 beats/min in the negative group (p = 0.002). There were distinct differences between the positive and negative groups in the ratio of VT cycle length to minimal atrial cycle length causing 1:1 AV conduction (1.02 +/- 0.12 vs 0.61 +/- 0.12; p = 0.0001). It is concluded that AV conduction, VT cycle length and especially their ratio are important factors for the development of transient entrainment by rapid atrial pacing during VT. Therefore, atrial pacing can be used as an easy and useful method to examine transient entrainment during VT.

Effect of thrombocytopenia on the onset of immune complex glomerulonephritis

The effect of platelets on the development of immune complex glomerulonephritis (GN) was examined using bovine serum albumin (BSA) GN with platelet depletion. To clarify the role of platelets in the initial stage of BSA GN, thrombocytopenia was induced before BSA infusion. In 18 New Zealand white rabbits, BSA was intravenously injected twice after the presensitization. Eight of these BSA GN rabbits were injected daily with goat anti-rabbit platelet antiserum to induce thrombocytopenia, and platelet counts were maintained below 5 x 10(4)/microliters throughout the experiment. In the thrombocytopenic group, the degree of proteinuria was significantly decreased compared to the control group. Glomerular polymorphonuclear leukocyte infiltration, mononuclear cell proliferation, exudation and glomerular enlargement were significantly suppressed in the thrombocytopenic group. The results suggest that platelets may be quite important in the initiation and development of immune complex GN.

Double Ventricular Responses to a Single Atrial Depolarization in a Patient with Dual AV Nodal Pathways

Electrophysiological study was performed in a patient with atrioventricular nodal reentrant tachycardia (AVNRT). Double ventricular responses through dual AV nodal pathways were observed by atrial extrastimulus technique followed by initiation of AVNRT. The difference in conduction time between the slow and fast AV nodal pathways was longer than 320 msec. A ventricular extrastimulus delivered during sinus rhythm, which was not followed by ventriculoatrial conduction, also induced AVNRT. These findings indicated the presence of an antegrade critical delay and retrograde block in the slow AV nodal pathway, criteria necessary for the occurrence of a double ventricular response.

Association of humps on monophasic action potentials and ST-T alternans in a patient with Romano-Ward syndrome

A case of Romano-Ward syndrome had episodes of torsade de pointes preceded by ST-T alternans. ST-T alternans was induced by isoproterenol and abolished by verapamil, lidocaine, mexiletine and MgSO4. A monophasic action potential (MAP) showed humps in MAPs at the right ventricular outflow tract but not at the right ventricular apex in alternate beats. Differences in the MAP duration were noted between the two areas and were associated with ST-T alternans. Atrial pacing abolished both humps and ST-T alternans. These results suggest that humps are a possible reflection of early afterdepolarizations and their appearance is limited to localized regions of the ventricles, which produces regional disparity of repolarization and ST-T alternans.

Efficacy of disopyramide and mexiletine used alone or in combination in the treatment of ventricular premature beats

The efficacy of oral disopyramide and mexiletine used alone or in combination was studied in 75 patients with frequent ventricular premature beats (VPBs). The efficacy was evaluated with 24-hour ambulatory ECG and greater than or equal to 75% reduction in the number of VPBs was defined as effective. When disopyramide or mexiletine were ineffective or not tolerated, the alternative drug was administered and the efficacy was again evaluated. If the single administration of neither drug was effective, the combination of disopyramide and mexiletine was then given. Either disopyramide or mexiletine was effective in 48 patients, and neither drug was effective in 19 patients. In 19 patients unresponsive to both drugs, combination therapy was effective in six patients (32%). Both drugs caused side effects or one drug caused side effects and another drug was ineffective in eight patients. In five out of those patients, we attempted combined therapy with a reduced dosage of those drugs that caused side effects. This therapy was effective in two patients without intolerable side effects. Thus, when the single use of neither disopyramide nor mexiletine single-drug therapy is effective, it is worthwhile to try combination therapy. Also, combination therapy with a reduced dosage of the drugs that caused side effects might be the therapy of choice in patients who have developed dose-dependent side effects.

Bilateral coronary ostial stenosis associated with aortitis syndrome

A patient with aortitis syndrome showed severe stenosis of the bilateral coronary ostium. We discuss the coronary angiographic findings and the treatment.

The role of electrophysiologic study for prediction and treatment of life-threatening arrhythmias

The prognostic significance of drug therapy based on the electrophysiologic study (EPS) was examined during a mean follow-up period of 32 months in 45 patients with sustained ventricular tachycardia (SVT) and in 87 with nonsustained VT (NSVT), and in 7 survivors of cardiac arrest. The drug treatment during the follow-up period was divided into EPS-guided therapy and empirical therapy; in the former therapy, an effective drug for prevention of induced VT by EPS was given and in the latter therapy, an empirical drug was used because there was no effective drugs by EPS. Occurrence of SVT or sudden cardiac death was considered as an arrhythmic event. Of 45 patients with SVT, Group I consisted of 32 cases with organic heart disease (OHD) and Group II, 13 without OHD. In Group I, arrhythmic event occurred in only 2 of 15 patients with EPS-guided therapy, whereas 9 of 13 cases with empirical therapy had arrhythmic event (p less than 0.01). In Group II, no arrhythmic event was observed in the 9 patients with EPS-guided therapy, whereas it was seen in 3 of the 4 patients with empirical therapy (p less than 0.05). Of 87 patients with NSVT, 61 cases had OHD (Group III). SVT was induced by EPS in 13 patients in Group III. Arrhythmic event was not observed in 8 patients with EPS-guided therapy, whereas it was seen in 3 of the 5 patients with empirical therapy (p less than 0.05). Arrhythmic event occurred in 2 survivors of cardiac arrest who underwent empirical therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

[Effects of oral flecainide treatment of refractory tachyarrhythmias]

Oral flecainide treatment was given to five patients who were refractory to conventional antiarrhythmic agents. The five patients included one with atrioventricular reentrant tachycardia (AVRT), one with non-sustained ventricular tachycardia (nsVT) and three with sustained VT (sVT). Flecainide produced favorable responses in patients of AVRT, nsVT and sVT with arrhythmogenic right ventricular dysplasia (ARVD). In the case of AVRT, flecainide exhibited a preventive effect on tachycardia induced by programmed electrical stimulation (PES). In the case of nsVT, flecainide markedly reduced the number of VPC and abolished the VT on the Holter ECG. In the case of sVT with ARVD, sVT was not induced by PES after the flecainide. Long-term treatment with flecainide on these three cases produced complete prevention of tachycardias. As an adverse effect of flecainide, an aggravation of congestive heart failure was recognized in one case with cardiac sarcoidosis. PQ interval and QRS interval in all the cases were prolonged after flecainide. The results indicate that flecainide is a useful antiarrhythmic agent for tachyarrhythmias refractory to treatment with conventional drugs.

[Lassa fever associated with effusive constrictive pericarditis and bilateral atrioventricular annular constriction: a case report]

A case of Lassa fever associated with effusive constrictive pericarditis and bilateral atrioventricular annular constriction was reported. A 49-year-old man, who had been diagnosed by indirect fluorescent antibody test as the first case of Lassa fever in Japan, was referred to the Hiroo Hospital because of syncope, progressive hepatomegaly, ascites and pericardial effusion in spite of pericardiocentesis and corticosteroid therapy. On admission, his blood pressure was 92/60 mmHg and he had a paradoxical pulse. Two-dimensional echocardiography revealed a localized pericardial effusion adjacent to the right ventricular wall and behind the left ventricular posterior wall. Bilateral atrioventricular annular constriction was also present. On pulsed Doppler echocardiography, the peak inflow velocities of the right and left ventricles increased during atrial systole. Right heart catheterization revealed a mean diastolic pressure gradient of 8 mmHg across the tricuspid valve. After pericardiectomy, a diastolic dip and plateau pattern became evident in the right ventricular pressure tracing, suggesting the presence of residual constriction. However, the atrioventricular annular constriction was no longer evident on two-dimensional echocardiography. This is considered the first reported case of subacute effusive constrictive pericarditis caused by Lassa fever.

A clinicopathologic study of the accessory bypass tracts in six cases of Wolff-Parkinson-White syndrome

A clinical and histologic correlation study was conducted to examine the accessory bypass tracts in 6 cases of Wolff-Parkinson-White syndrome. (1) Types A, B (Rosenbaum) and C (Ueda) were found in 2 cases each. From the polarity of the delta waves, the site of the bypass tract was assumed to be in the left posterior and left lateral free wall in type A, the right lateral and right posterior paraseptal regions in type B and in the right posterior paraseptal and right anterior paraseptal areas in type C. (2) In 6 cases 19 bypass tracts were found, consisting of 18 Kent bundles and 1 Mahaim fiber, from a total of 146,400 serial sections. The site of the bypass tract was the left lateral and left posterior walls in 2 type A cases, and the right lateral and right posterior walls in 2 type B cases, with good correspondence to our assumption. In both type C cases it was biventricular, composed of left posterior paraseptal and right lateral regions with an additional Mahaim fiber in 1 case. (3) A total of 46 cases of WPW syndrome were collected from the literature and the present paper; they consisted of 16 cases of type A, 20 of type B, 4 of type A + B and 6 of type C. Seventy % of type A cases showed a bypass tract in the left heart, and 64% of type B in the right heart. In 6 cases of type C, the bypass tract was found in various sites and in various combinations, requiring further investigation.

Cardiomyopathy characterized by abnormal accumulation of desmin-type intermediate filaments in cardiac muscle fibers. A case report and review of the literature

A 42-year-old Japanese male, who had been suffering from congestive heart failure and electrocardiographic abnormalities (A-V block, intraventricular conduction disturbance, ventricular tachycardia), died after a clinical course of 2 years and 1 month. Macroscopic investigation revealed dilation of the left ventricle and thickening of the right ventricular wall. The unique finding in this case was a circumferential fibrous scar in the median circular layer and outer oblique layer of the left ventricular wall. Biopsy and autopsy materials revealed diffuse loss of myofibrils in the central zone of cardiac muscle fibers, and replacement with aniline blue-positive homogeneous material (17-35% of the area of one muscle fiber). Electron microscopy revealed abnormal accumulation of fine filamentous material (7.5-25 nm in diameter), which was immunohistochemically proved to be desmin-type intermediate filament. Moreover, sarcoplasmic reticulum-like material was detected in the degenerated area. At autopsy, degeneration was detected all over the heart. The ventricular muscle fibers were more severely affected than the atrial muscle fibers. The conduction system was also affected, in some parts more severely than the surrounding ordinary muscle fibers. The pathogenesis of this disorder remains to be clarified.

Platelet adenine nucleotides in patients with primary glomerular disease

Total platelet adenosine diphosphate (ADP) and adenosine triphosphate (ATP) contents and amounts of ADP and ATP released from platelets by 3 micrograms/ml of collagen were studied in 20 patients with primary glomerular disease (PGD) to examine the metabolism of these platelet substances in the disease. ADP and ATP were measured by Holmsen's firefly luciferase method. The patients had significantly lower total platelet ATP compared with controls and total platelet ATP was significantly lower in nephrotic patients than in patients whose serum albumin levels were normal. Releasable platelet ADP and ATP were both significantly decreased in patients. Releasable ADP: total ADP ratio and releasable ATP: total ATP ratio were both significantly lower in patients' platelets than in normal platelets. There was no significant difference in platelet counts between patients and controls. Platelet aggregation induced by ADP and adrenaline were significantly higher in patients compared with controls. We conclude that total ATP content and the amount of ADP and ATP released by collagen are decreased in PGD patients' platelets.

Intracoronary urokinase in acute myocardial infarction: prevalence of total coronary occlusion during the early hours, effects on myocardial infarct size and left ventricular function, and outcome of residual coronary stenosis

The effects of intracoronary thrombolysis (ICT) were studied in 88 acute myocardial infarction patients. Total coronary occlusion was observed in 67 of the 88 patients (76.1%) who were evaluated within 6 hours of the onset of symptoms. Among these 67 patients 42 (62.7%) were successfully recanalized by intracoronary urokinase. The recanalization rate was higher in the lesion at the left anterior descending artery, in younger patients (49 years or less) and in patients with a shorter history of pre-infarction angina. Eight of 11 patients (72.7%) with subtotal coronary occlusion and 17 of 35 patients (48.6%) with recanalization after ICT showed spontaneous regression of the residual coronary stenosis at the chronic stage angiography. There was no re-occlusion in the subtotal occlusion group and only 6 cases of re-occlusion (17.1%) in the recanalization group. The majority of re-occlusions progressed from the lesion with 99% residual stenosis and delayed filling. Accordingly the true value of additional percutaneous transluminal coronary angioplasty would be limited to the latter cases. Reduction in infarct size and improvement in left ventricular function were limited to those patients with incomplete or subtotal coronary occlusion and were not seen in cases with total obstruction which was recanalized by ICT.

[Transient obstruction of the left ventricular outflow tract induced by excessive alcohol intake: a case report]

A case of transient obstruction of the left ventricular outflow tract after excessive intake of alcohol was reported. This 41-year-old man was admitted to the Hiroo Hospital because of a syncopal attack experienced while walking. He had been drinking excessively for one week until the day before admission. On admission, physical examination revealed a bifid carotid pulse and a grade 3/6 systolic ejection murmur accentuated by Valsalva maneuvers and prompt standing. The second heart sound was paradoxically split. Echocardiography showed typical systolic anterior motion of the mitral valve (SAM). The interventricular septal and left ventricular posterior wall thicknesses were 13 mm and 11 mm, respectively. No enlargement or displacement of the papillary muscles was noted. The redundant mitral chordae tendineae protruded into the left ventricular outflow tract in systole, and both the anterior and posterior mitral valve leaflets were retracted upwards approximating the interventricular septum by these chordae, resulting in obstruction of the left ventricular outflow tract. All signs of left ventricular outflow obstruction, including SAM, disappeared within several days after admission, and prolapse of the anterior mitral leaflet became evident. Since ejection fraction was markedly increased and the corrected QT interval was prolonged on admission, this patient was considered to be in hyperadrenergic state induced by excessive alcohol intake. In this case, left ventricular outflow tract obstruction was attributed to hyperadrenergic state and a redundant mitral apparatus.

Influence of lipids metabolism on platelet activation in vivo

Platelet aggregability and plasma factor VIII-related antigen (F. VIIIR:AG) level in 16 ischemic heart disease (IHD) patients were increased by isometric exercise and these changes were prevented by administration of a lipid lowering agent, simfibrate, a derivative of clofibrate. Serum total cholesterol (TC) level decreased and the high density lipoprotein-cholesterol (HDL-C)/TC ratio increased with the treatment. Another 7 hyperlipidemics were administered with simfibrate. Platelet malondialdehyde (MDA) production decreased with improvement in lipid profile. In an in vitro study, platelet aggregability and the plasma level of von Willebrand factor (vWF) and F.VIIIR:AG of normal citrated blood were increased by passing it through a glass bead column. Combining above results of the three separate studies, it would be suggested that hyperlipidemia might enhance platelet activation in vivo, which occurred through contact of platelets to atherosclerotic rough vessel surface. The anti-platelet effect of simfibrate might be mediated through its effect on arachidonic pathway in platelets.

Activation of platelets in cancer, especially with reference to genesis of disseminated intravascular coagulation

Seventy-five cancer patients were evaluated on a scale of coagulation abnormalities related to DIC, one point given for each of the following criteria fulfilled and the score (0 to 4) being used. 1. Platelet count less than 150 x 10(3)/mu 1. 2. PT prolonged more than 1 sec over control or APTT prolonged more than 10 sec over control. 3. Fibrinogen less than 250 mg/dl (mean fibrinogen value of the cancer patients minus 1SD). 4. FDP greater than or equal to 20 micrograms/ml. The patients were distributed with 27% for score 0, 38% for 1, 20% for 2, 7% for 3 and 8% for 4. Platelet mode volume in score 4 was smaller than that of the other groups. Platelet aggregation by epinephrine was decreased in score 3 and 4 (P less than 0.01), while it was increased in score 0 (P less than 0.05). ADP-induced aggregation was increased in score 0 and 1 (P less than 0.01 - 0.05). The mean value of beta-thromboglobulin in cancer patients (44 +/- 24 ng/ml) was significantly higher than that of control (22 +/- 13 ng/ml) (P less than 0.01). These results suggest the existence of hyperfunction of platelets in cancer patients and possibility of a triggering mechanism of such activated platelets in the genesis of DIC in cancer.

Activation of platelets in patients with chronic proliferative glomerulonephritis and the nephrotic syndrome

Platelet count, volume and aggregation and plasma levels of beta-thromboglobulin (beta-TG) and platelet factor 4 (PF-4) were measured in 54 patients with chronic glomerulonephritis (CGN). Platelet count and platelet aggregation induced by ADP, adrenaline and collagen were significantly higher in the patients than in normal subjects, and platelet aggregation was markedly increased in the cases with progressive glomerular lesions. Plasma levels of beta-TG and PF-4 were significantly higher in the patients than in the normal subjects. There was a significant inverse correlation between plasma beta-TG and creatinine clearance. Nephrotic patients showed significantly smaller platelet volume and markedly elevated plasma beta-TG levels when compared to the controls. Plasma beta-TG decreased remarkably in 3 out of 4 patients with markedly increased beta-TG levels when they were given antiplatelet drugs. The results suggest that platelet aggregation and the release reaction were increased in patients with CGN. Activated platelets may be an important factor in the genesis of the thrombotic tendency in the nephrotic syndrome.