Validation of a convolutional neural network for the automated creation of curved planar reconstruction images along the main pancreatic duct

PURPOSE

To evaluate the accuracy and time-efficiency of newly developed software in automatically creating curved planar reconstruction (CPR) images along the main pancreatic duct (MPD), which was developed based on a 3-dimensional convolutional neural network, and compare them with those of conventional manually generated CPR ones.

MATERIALS AND METHODS

A total of 100 consecutive patients with MPD dilatation (≥ 3 mm) who underwent contrast-enhanced computed tomography between February 2021 and July 2021 were included in the study. Two radiologists independently performed blinded qualitative analysis of automated and manually created CPR images. They rated overall image quality based on a four-point scale and weighted κ analysis was employed to compare between manually created and automated CPR images. A quantitative analysis of the time required to create CPR images and the total length of the MPD measured from CPR images was performed.

RESULTS

The κ value was 0.796, and a good correlation was found between the manually created and automated CPR images. The average time to create automated and manually created CPR images was 61.7 s and 174.6 s, respectively (P < 0.001). The total MPD length of the automated and manually created CPR images was 110.5 and 115.6 mm, respectively (P = 0.059).

CONCLUSION

The automated CPR software significantly reduced reconstruction time without compromising image quality.

The real-world effectiveness and safety of edoxaban treatment in 27,333 Global ETNA-AF programme patients with and without a history of heart failure

Background

Heart failure (HF) occurs in approximately 26% of patients with atrial fibrillation (AF). Real-world data of oral anticoagulation with edoxaban in AF patients with HF history are limited.

Purpose

To compare edoxaban effectiveness and safety in AF patients with or without HF history.

Methods

The Global ETNA-AF programme (EU: NCT02944019, Japan: UMIN000017011, South Korea/Taiwan: NCT02951039) integrates data from multiple prospective, observational, noninterventional regional studies of AF patients receiving edoxaban for stroke prevention. This snapshot analysis summarises baseline characteristics and 2-year annualised rates of all-cause death, cardiovascular (CV) death, stroke (haemorrhagic, ischaemic, any), and bleeding (major bleeding [MB], major gastrointestinal [GI] bleeding, intracranial haemorrhage [ICH], clinically relevant nonmajor bleeding [CRNMB], and any bleeding) in patients with or without HF history. Univariate Cox regression models assessed clinical outcomes.

Results

Data from 27,333 patients (5258 with HF history) from Europe, Japan, South Korea, and Taiwan were analysed. Patients with HF history were significantly older and had lower mean body weight and creatinine clearance (P&lt;0.0001 all; Table). Patients with HF history had significantly higher baseline stroke (CHA2DS2-VASc) and bleeding (HAS-BLED) risk scores (P&lt;0.0001 both; Table). Significantly more patients with HF history reported previous experiences with MB (P=0.001) and major GI bleeding (P=0.007); these patients were also more likely to receive 30 mg edoxaban vs 60 mg edoxaban (P&lt;0.0001; Table). Patients with HF history had significantly (P&lt;0.0001 both) higher rates of all-cause (6.1% vs 2.5%; hazard ratio [HR] (95% confidence interval [CI]), 2.41 [2.17–2.68]) and CV death (2.8% vs 1.2%; HR [95% CI], 2.39 [2.05–2.80]), and fatal bleeding (0.3% vs 0.2%; HR [95% CI], 1.86 [1.20–2.89]; Figure). The proportion of all-cause deaths that were fatal bleeding events was 6% and 7% for patients with and without HF, respectively. Additionally, patients with HF history had significantly (P&lt;0.0001 both) higher rates of MB (1.7% vs 0.9%; HR [95% CI], 1.87 [1.53–2.28]) and major GI bleeding (1.1% vs 0.4%; HR [95% CI], 2.69 [2.07–3.49]), with a greater proportion of MB events classified as major GI bleeding (64.5% vs 44.8%; P&lt;0.0001). Patients with HF history also had significantly (P&lt;0.0001 both) higher rates of CRNMB (HR [95% CI], 1.87 [1.58–2.21]) and any bleeding (HR [95% CI], 1.49 [1.34–1.65]). Rates of ICH and haemorrhagic stroke were similar in both groups.

Conclusions

In AF patients receiving edoxaban, the rates of MB, major GI bleeding, and CV or all-cause death were higher when comparing those with versus without HF history. The higher incidence of MB and major GI bleeding in patients with HF history did not lead to proportionally higher fatal bleeding rates among all-cause deaths.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo

Edoxaban treatment in real-world practice is highly concordant with ESC atrial fibrillation guidelines: results from the non-interventional global ETNA-AF program

Background

The ESC atrial fibrillation management guidelines recommend a risk-based approach to oral anticoagulant (OAC) therapy. How clinical practice aligns with these recommendations is of interest.

Purpose

To analyse real world data from Global ETNA-AF program in patient groups stratified by stroke and bleeding risk scores according to ESC guidelines.

Methods

Global ETNA-AF is a multicentre, prospective, noninterventional program evaluating the safety and effectiveness of edoxaban in patients from European and Asian countries. Baseline characteristics and clinical event data at 2-year follow-up were analysed in 4 subgroups defined by CHA2DS2-VASc score (≥3 for female / ≥2 for male [OAC recommended] vs 2 for female / 1 for male [OAC should be considered]) and HAS-BLED score (≥3 [Bleeding risk high] vs &lt;3 [Bleeding risk low]) (Table 1).

Results

Of 27,616 patients included in this analysis, 23,152 (83.8%) were in the “OAC recommended” category and 3,539 (12.8%) were in the “OAC should be considered” category. Only 3.3% of patients did not meet ESC guideline criteria for OAC initiation. Among patients with high bleeding risk, 98% were in the “OAC recommended” category. A similar distribution was observed across regions (Table 2). The recommended edoxaban dose was used in the vast majority (&gt;80%) of patients across all risk stratification subgroups. In the “OAC recommended” category, patients with high bleeding risk had higher rates of thromboembolic, bleeding, and death events than those with low bleeding risk.

Conclusion

Data from routine clinical practice in Global ETNA-AF demonstrate high concordance of edoxaban treatment with ESC guidelines. Edoxaban dose is consistent with label recommendation in the vast majority (&gt;80%) of patients. Clinical event rates were generally low across all risk groups, including acceptable bleeding rates in anticoagulated patients with high bleeding risk.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Table 1. Subgroups as per ESC guidelinesTable 2. Patient characteristics & events

Temporal trend of clinical events in patients with atrial fibrillation on edoxaban therapy: results from the non-interventional global ETNA-AF program

Background

Patients with atrial fibrillation (AF) who initiated vitamin K antagonist (VKA) were at highest risk of stroke and bleeding in the first few months of therapy. Understanding of the temporal trend of clinical events in AF patients on non-VKA oral anticoagulant (NOAC) therapy should aid therapeutic decisions.

Purpose

To evaluate the temporal trend of clinical events in AF patients receiving edoxaban in routine clinical practice in the Global ETNA-AF program.

Methods

Global ETNA-AF is a multicentre, prospective, noninterventional program evaluating the safety and effectiveness of edoxaban in patients from European and Asian countries. Thromboembolic, bleeding and death events were analysed separately for the 1st and 2nd year of the follow-up period, using a time-to-first-event estimation of cumulative incidence and annual rate via Kaplan-Meier method.

Results

A total of 27,617 patients were included in this analysis, 48.6% from Europe and 51.4% from Japan, Korea, and Taiwan. Baseline characteristics were consistent with typical AF population in real world studies (Table 1). Approximately 83% of patients received the recommended edoxaban dose. Annualized rates of ischaemic stroke and major bleeding (ISTH) were lower in the 2nd year than in the 1st year: ischaemic stroke 0.59% (95% CI, 0.50–0.70) vs 0.86% (95% CI, 0.75–0.98), p=0.015; major bleeding 0.87% (95% CI, 0.75–1.00) vs 1.15% (95% CI, 1.02–1.29), p=0.036. The trend toward lower rates of ischaemic stroke and major bleeding in the 2nd year was consistent across regions. All-cause mortality increased slightly from the 1st year to the 2nd year, which was not statistically significant and was not driven by cardiovascular (CV) mortality (Table 2).

Conclusion

In routine clinical practice in the Global ETNA-AF program, major bleeding and ischaemic stroke rates in &gt;27,000 patients on edoxaban therapy declined from 1st year to 2nd year. Further analyses will investigate whether such trend is influenced by selection for healthier patients over time. Longer follow-up is needed to better understand long-term trends.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Table 1. Baseline characteristicsTable 2. Annualised clinical event rates

Low bleeding and stroke rates with minor age-dependent increase confirm the safety and effectiveness of edoxaban in patients with atrial fibrillation across age groups: Two-year results from ETNA-AF

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo

Background

Age is a risk factor for ischemic stroke and bleeding in patients with atrial fibrillation (AF). The large dataset from the global prospective, noninterventional ETNA-AF program allows for analysis of the impact of age on clinical events in AF patients treated with edoxaban.

Purpose

Evaluate the safety and effectiveness of edoxaban by age subgroups and the impact of age on clinical events.

Methods

Baseline patient characteristics, thromboembolic and bleeding events, and mortality data were collected from patients with 2-year follow-up in ETNA-AF program and analyzed in defined age subgroups. Cox regression analysis was conducted using age as a continuous variable and clinical events as outcome variables.

Results

A total of 27,617 patients were categorized into four age subgroups: &lt;65, 65-74, 75-84 and ≥85 years. Patient demographics and baseline characteristics are shown in the Table. Percentage of male, mean body weight, and mean creatinine clearance decreased with age, whereas percentages of patients with heart failure, patients on reduced dose edoxaban 30 mg, mean stroke and bleeding risk scores increased with age. The annualized rates of ischemic stroke and major bleeding increased with age, yet remained low. Importantly, the rate of intracranial hemorrhage was low across age groups, including the ≥85 years group.  The hazard ratio (HR) for ischemic stroke was 1.041 (95%CI 1.028-1.053), ie. with a 1-year increase in age, the risk of ischemic stroke increased by 4.1%. The HRs for other clinical events were: major bleeding 1.044 (95%CI 1.033-1.055), intracranial hemorrhage 1.027 (95%CI 1.007-1.046), major gastrointestinal bleeding 1.065 (95%CI 1.048-1.081), all-cause mortality 1.086 (95%CI 1.079-1.093).

Conclusion

Two-year follow-up data from the global ETNA-AF program support the use of edoxaban as a safe and effective treatment for AF patients across all age groups, including the very elderly, in routine clinical care. The impact of age on the risk of ICH was smaller than that of ischemic stroke and major bleeding. &lt;65 yr(N = 4,278) ≥65-74 yr(N = 9,396) ≥75-84 yr(N = 10,728) ≥85 yr(N = 3,214) Age [years], mean (SD)Male, %Weight [kg], mean (SD) 57.3 (6.6)72.580.6 (20.3) 69.9 (2.9)61.973.0 (17.7) 79.1 (2.8)53.968.0 (16.0) 87.9 (2.8)42.260.1 (14.9) CrCL [mL/min], mean (SD)CHA2DS2-VASc, mean (SD)Mod. HAS-BLED≠, mean (SD) 101.8 (33.7)1.6 (1.1)1.4 (1.0) 75.3 (22.3)2.8 (1.2)2.5 (1.1) 57.9 (18.1)4.1 (1.2)2.7 (1.0) 42.5 (14.3)4.4 (1.3)2.7 (1.0) 2-year clinical events Major Bleeding (ISTH)%/yr [95% CI] Intracranial Hemorrhage%/yr [95% CI] Major GI Bleeding%/yr [95% CI] 0.49 [0.35; 0.68] 0.18 [0.09; 0.30] 0.22 [0.13; 0.36] 0.84 [0.70; 0.99] 0.26 [0.18; 0.34] 0.34 [0.26; 0.44] 1.16 [1.00; 1.32] 0.31 [0.23; 0.40]0.60 [0.49; 0.72] 1.88 [1.51; 2.30] 0.46 [0.29; 0.69]1.19 [0.90; 1.53] Any Stroke%/yr [95% CI]Ischemic Stroke%/yr [95% CI]Hemorrhagic Stroke%/yr [95% CI] 0.54 [0.38; 0.73]0.38[0.26; 0.56]0.12[0.06; 0.23] 0.79 [0.66; 0.94]0.59[0.47; 0.71]0.19[0.13; 0.27] 1.15 [1.00; 1.32]0.89[0.76; 1.04]0.23[0.16; 0.31] 1.53 [1.21; 1.92]1.21[0.92; 1.56]0.320.18; 0.52] All-cause Death%/yr [95% CI]CV Death (sensitivity)%/yr [95% CI] 1.05 [0.83; 1.32]0.51[0.36; 0.70] 1.82 [1.62; 2.04]0.83[0.69; 0.98 3.51 [3.25; 3.80]1.65[1.47; 1.84] 9.08 [8.27; 9.96]4.16[3.62; 4.77] ≠Excluding labile INR.

Annualized clinical event rates during two-year follow-up are low in 27,617 atrial fibrillation patients on edoxaban: results from the global noninterventional ETNA-AF program

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo

Background and Purpose

The large global Edoxaban Treatment in routiNe clinical prActice (ETNA)-AF program was designed to assess the safety and effectiveness of edoxaban, complementing randomized clinical trials.

Methods

ETNA collects data on patient characteristics and clinical events in unselected AF patients treated with edoxaban for stroke prevention, integrating data from prospective, noninterventional studies conducted in Europe, Japan, South Korea, and Taiwan.

Results

The 2-year follow-up analysis included 27,617 patients, the majority of whom (82.6%) received the recommended dose according to the local label. At baseline, the mean age was 73.6 ± 9.8 years and 58.1% were male. Half of the patients (50.5%) were 75 years or older. The CHA2DS2-VASc score was 3.3 ± 1.5, and the modified HAS-BLED score was 2.4 ± 1.1. The rate of ischemic stroke was 0.74%/yr, major bleeding 1.02%/yr, intracranial hemorrhage 0.29%/yr, and major gastrointestinal (GI) bleeding 0.51%/yr. All-cause mortality was 3.13%/yr, and cardiovascular (CV) mortality 1.45%/yr (see Table).

Conclusion

The rates of ischemic stroke and major bleeding events remained low globally and across regions during the two-year follow-up period in AF patients treated with edoxaban. Global(N = 27,617) Japan(N = 11,330) Korea/Taiwan(N = 2,870) Europe(N = 13,417) Age, mean (SD) 73.6 (9.8) 74.2 (10.1) 71.6 (9.5) 73.6 (9.5) Gender, male, % 58.1 59.4 60.2 56.6 Weight [kg], median (IQR) 69 (58, 81) 59 (51, 68) 65 (57, 73) 80 (70, 90) CrCL [mL/min], mean (SD) 68.7 (28.4) 63.9 (25.8) 63.4 (23.7) 74.4 (30.5) CHA2DS2-VASc, mean (SD) 3.3 (1.5) 3.5 (1.7) 3.1 (1.4) 3.2 (1.4) Mod. HAS-BLED≠, mean (SD) 2.4 (1.1) 2.4 (1.1) 2.3 (1.1) 2.5 (1.1) Edoxaban 60mg/30mg, % 53.5 / 46.5 27.6 / 72.4 48.8 / 51.2 76.4 / 23.6 2-year clinical events, N (%/year), [95% CI] Major Bleeding (ISTH) 477 (1.02) [0.93; 1.11] 188 (1.09) [0.94; 1.25] 51 (1.00) [0.74; 1.31] 238 (0.97) [0.85; 1.11] Intracranial Hemorrhage 135 (0.29) [0.24; 0.34] 68 (0.39) [0.30; 0.50] 17 (0.33) [0.19; 0.53] 50 (0.20) [0.15; 0.27] Major GI Bleeding 241 (0.51) [0.45; 0.58] 122 (0.70) [0.58; 0.84] 18 (0.35) [0.21; 0.55] 101 (0.41) [0.33; 0.50] Any Stroke 455 (0.97) [0.88; 1.06] 244 (1.41) [1.24; 1.60] 54 (1.06) [0.80; 1.38] 157 (0.64) [0.54; 0.75] Ischemic Stroke 347 (0.74) [0.66; 0.82] 179 (1.03) [0.89; 1.20] 43 (0.84) [0.61; 1.13] 125 (0.51) [0.42; 0.61] Hemorrhagic Stroke 99 (0.21) [0.17; 0.26] 67 (0.39) [0.30; 0.49] 9 (0.17) [0.08; 0.33] 23 (0.09) [0.06; 0.14] All-cause Death 1479 (3.13) [2.98; 3.30] 470 (2.70) [2.46; 2.96] 72 (1.40) [1.09; 1.76] 937 (3.80) [3.56; 4.05] CV Death 684 (1.45) [1.34; 1.56] 140 (0.80) [0.68; 0.95] 26 (0.50) [0.33; 0.74] 518 (2.10) [1.92; 2.29] ≠Excluding labile INR.

Feasibility and Safety of the Craniocaudal Approach for Superior Sulcus Lesions of the Thorax

Purpose

To evaluate the feasibility and safety of the craniocaudal approach for superior sulcus lesions of the thorax.

Material and Methods

Between October 2010 and December 2020, the data from 22 consecutive patients who underwent drainage or biopsy using a craniocaudal trajectory were retrospectively reviewed. The craniocaudal approach was applied for patients in which the fluid collection or tumor was limited to the superior thoracic sulcus lesion or otherwise inaccessible owing to intervening structures such as pleural dissemination. The indications for this procedure were drainage in 20 patients and biopsy in 2 patients. Technical success, procedure time, complications, and clinical success were evaluated.

Results

Technical and clinical success were achieved in all patients, and no major complications were found. The median procedure time was 25 min (range 15–40 min). This procedure was performed with fluoroscopic guidance in 11 patients and ultrasound guidance in 11 patients. The routes of needle passage were the first intercostal space (n = 16), the second intercostal space (n = 5), and between the clavicle and the first rib (n = 1).

Conclusion

The craniocaudal approach for superior sulcus lesions might be a safe and feasible option for patients in which the conventional intercostal approach is difficult.

Level of Evidence

Retrospective cohort study. Level 4.

Angioscopic evaluation of vascular healing at 1 and 12 months after drug-coated stent implantation

Background

Polymer- and carrier-free Biolimus-A9-coated stent (DCS) is expected better vascular healing compared with conventional durable polymer drug-eluting stents (DES). Moreover, DCS had been demonstrated in clinical trials to allow one-month short dual antiplatelet therapy, which might achieve sufficient healing at only 1 month after implantation. However, the process of vascular healing after DCS implantation has not been elucidated by angioscopic observation.

Purpose

To evaluate the process of vascular healing at 1 month and 12 months after DCS implantation.

Methods

This study included 57 patients treated with DCS or durable polymer everolimus-eluting stents (EES) in our hospital from April 2017 to April 2019. Firstly, the angioscopic findings of DCS at 1 month (n=16) and 12 months (n=14) after implantation were respectively compared with EES at 12 months after implantation (EES-12, n=35) as a standard healing status of DES. Secondary, angioscopic findings of DCS at 1 month and 12 months after implantation were compared among the serially observed eight patients. Neointimal coverage (NIC) grade, yellow colour grade, and the presence of thrombus were evaluated. NIC grade was classified as grade 0 (no neointimal coverage), grade 1 (struts were bulged into lumen but covered), grade 2 (struts were embedded in the neointima but visible), or grade 3 (struts were fully embedded and invisible). Yellow colour grade was classified as grade 0 (white), grade 1 (light yellow), grade 2 (yellow), or grade 3 (intensive yellow).

Results

At 1 month after DCS implantation, dominant NIC grade was lower (0.3±0.5 vs. 1.5±0.7, p&lt;0.001) and the frequency of thrombus was higher (38% vs. 6%, p=0.008) than EES-12. On the other hands, at 12 months after DCS implantation, dominant NIC grade was higher (2.1±0.6 vs. 1.5±0.7, p=0.013) and the frequency of thrombus was not different (7% vs. 6%, p=1.000) in comparison with EES-12. By serial observation of DCS, dominant NIC grade was higher at 12 months than at 1 month (2.3±0.5 vs. 0.4±0.5, p&lt;0.001), while yellow colour grade (1.0±0.5 vs. 1.5±1.2, p=0.227) and the frequency of thrombus adhesion (0% vs. 38%, p=0.200) were not different.

Conclusion

Compared with EES-12, vascular healing of DCS was inferior at 1 month but superior at 12 months.

Figure 1

Funding Acknowledgement

Type of funding source: None

Edoxaban treatment of elderly patients with atrial fibrillation in routine clinical practice: 1-year results of the non-interventional Global ETNA-AF program

Background

The prevalence of atrial fibrillation (AF) and the need for appropriate anticoagulation increase with age. The benefit/risk profile of direct oral anticoagulants such as edoxaban in elderly population with AF in regular clinical practice is therefore of particular interest.

Purpose

Analyses of Global ETNA-AF data were performed to report patient characteristics, edoxaban treatment, and 1-year clinical events by age subgroups.

Methods

Global ETNA-AF is a multicentre, prospective, noninterventional program conducted in Europe, Japan, Korea, Taiwan, and other Asian countries. Demographics, baseline characteristics, and 1-year clinical event data were analysed in four age subgroups.

Results

Of 26,823 patients included in this analysis, 50.4% were ≥75 years old and 11.6% were ≥85 years. Increase in age was generally associated with lower body weight, lower creatinine clearance, higher CHA2DS2-VASc and HAS-BLED scores, and a higher percentage of patients receiving the reduced dose of 30 mg daily edoxaban. At 1-year, rates of ISTH major bleeding and ischaemic stroke were generally low across all age subgroups. The proportion of intracranial haemorrhage within major bleeding events was similar across age groups. All-cause mortality increased with age more than cardiovascular mortality.

Conclusion

Data from Global ETNA-AF support the safety and effectiveness of edoxaban in elderly AF patients (including ≥85 years) in routine clinical care with only a small increase in intracranial haemorrhage. The higher all-cause mortality with increasing age is not driven by cardiovascular causes.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Daiichi Sankyo

Recommended and non-recommended edoxaban dosing in patients with atrial fibrillation (AF): one-year clinical events from the Global ETNA-AF non-interventional study (NIS)

Background

In AF patients on direct oral anticoagulants (DOAC), safety and effectiveness vary with dose. This might impact treatment decisions.

Purpose

To investigate the effects of dosing of the DOAC edoxaban in AF patients on safety and effectiveness during 1-year observation in a real-world setting.

Methods

The Global ETNA-AF NIS included 26,823 patients. Baseline data by edoxaban dosing (60mg/30mg) and their influences on the safety (major bleeding [MB], clinically relevant non-major bleeding [CRNMB]), and effectiveness (stroke, systemic embolism, myocardial infarction [MI], death) were investigated (Table).

Results

Figure shows the breakdown by dose (60mg vs 30mg) and recommended (rec) vs non-recommended (non-rec) dosing. Patients on non-rec 30mg vs on rec 60mg edoxaban were older (mean ± SD: 74±9 vs 70±9 y); had lower creatinine clearance (72.2±20.6 vs 85.8±26.8 mL/min); and had more comorbidities, history of MB (2.1% vs 1.1%), and strokes (11.0% vs 8.6%). Non-rec 60mg vs rec 30mg patients were younger (75±9 vs 78±9 y), had fewer comorbidities, history of MB (1.2% vs 2.6%), and strokes (10.2% vs 16.4%). In non-rec 30mg vs rec 60mg, MB was not lower and ischaemic events were not higher. In non-rec 60mg vs rec 30mg, no increase in MB, CRNMB or ischaemic events was seen.

Conclusion

Edoxaban was prescribed at the label recommended dose in the vast majority of patients. Non-rec 30mg patients were sicker than rec 60mg patients while non-rec 60mg patients were less sick than rec 30mg patients. Overall event rates were low, and ischaemic event rates of non-rec 30mg and bleeding event rates of non-rec 60mg were not numerically higher than that of corresponding rec dosing groups.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Daiichi Sankyo

P92 A novel method of correcting the left ventricular stroke volume by Doppler echocardiography: comparison with multidetector computed tomography

Background

Although transthoracic Doppler echocardiography is widely used for estimating left ventricular stroke volume (SV), accelerated blood flow in the left ventricular (LV) outflow tract may lead to overestimation. SV can be calculated accurately from left ventricular end-systolic and end-diastolic volume determined by multi-detector computed tomography (MDCT). However, radiation exposure as well as the use of contrast medium hampers its routine use.

Purpose

The purpose of this study was to examine whether the correction of SV measured by pulsed wave Doppler echocardiography (SVdop) can accurately predicts SV obtained by MDCT (SVct).

Methods： We enrolled consecutive 61 patients who underwent both MDCT and transthoracic echocardiography. Patients with moderate or severe valvular diseases and valve replacement surgery were excluded. Correction of SV was explored with SVct as a reference.

Results： Univariate analysis showed that SVdop (r = 0.42, P = 0.0007) and patient age (r=-0.50, P &lt; 0.0001) were significantly correlated with SVct. On the other hand, left ventricular ejection fraction calculated by Teicholz method (EFteich) (r = 0.19, P = 0.14), systolic blood pressure (r = 0.07, P = NS), and LV mass index (r=-0.02, P = NS) were not correlated with SVct. Multivariate analysis showed that SVdop, patient age and EFteich were the independent predictive factors for SVct (R2 = 0.49, P &lt; 0.0001). Based on these correlations, we postulated SV as: corrected SV = SVdop × 0.40 + EFteich × 0.46 – age × 0.67 + 44.77. As expected, the correlation between corrected SV and SVct significantly improved (r = 0.70, P &lt; 0.0001). Bland-Altman plot analysis showed that corrected SV significantly reduced the variation between SVdop and SVct, and diminished the overestimation of SVdop (Figure).

Conclusion： The new correction formula of SVdop may correct the overestimation of SV obtained by pulsed wave Doppler echocardiography, although the formula remains to be validated in a separate cohort of patients.

Abstract P92 Figure

P4785Clinical characteristics and 1-year outcomes in atrial fibrillation patients with or without history of intracranial haemorrhage treated with edoxaban: snapshot analysis of the Global ETNA-AF program

Background

Patients with atrial fibrillation (AF) who survive an intracranial haemorrhage (ICH) are at high risk of stroke, death, and recurrent haemorrhage. Effectiveness and safety of the nonvitamin K antagonist oral anticoagulant (NOAC) edoxaban in this patient population has not been reported.

Purpose

This snapshot analysis from the global ETNA-AF program compared 1-year outcomes in AF patients with and without history of ICH treated with edoxaban from Europe, Japan, and Korea/Taiwan.

Methods

Global ETNA-AF (EU: NCT02944019, Japan: UMINehz745.116117011, Korea/Taiwan: NCT02951039) is a multinational, multicentre, prospective, noninterventional program of AF patients receiving edoxaban in regular clinical care. Demographics, baseline characteristics, and outcomes at 1-year follow-up were reported for 19416 patients with and without a history of ICH.

Results

Of the 19416 patients, 297 had a history of ICH. At 1-year follow-up, incidences of International Society on Thrombosis and Haemostasis (ISTH) major bleeding (including ICH) and clinically relevant nonmajor bleeding (CRNMB) were generally low. The rate of ischaemic stroke was higher in patients with a history of ICH than in those without prior ICH.

Europe (N=7672) Korea/Taiwan (N=1701) Japan (N=10043) History of ICH, n (%) Yes No Yes No Yes No 36 (0.5) 636 (99.5) 27 (1.6) 1674 (98.4) 234 (2.3) 9809 (97.7) Age, median (IQR) 75 (69, 78) 74 (68, 80) 70 (66, 76) 72 (66, 77) 76 (71, 82) 75 (68, 81) Gender, male % 72.2 57.4 70.4 59.9 60.7 59.3 Weight, median (IQR) kg 80.0 (75.0, 88.0) 80.0 (70.0, 92.0) 68.0 (54.0, 77.0) 65.0 (58.0, 73.0) 57.0 (50.0, 65.0) 59.0 (51.0, 68.0) CHA2DS2-VASc, mean (SD) 4.2 (1.44) 3.1 (1.38) 3.9 (1.63) 3.0 (1.43) 4.0 (1.56) 3.4 (1.64) HAS-BLED, mean (SD) 4.3 (1.23) 2.6 (1.12) 3.9 (1.55) 2.4 (10.7) 3.7 (1.07) 2.3 (1.12) CrCl [mL/min], median (IQR) 70.5 (58.8, 85.1) 70.4 (53.8, 90.1) 63.7 (45.8, 84.2) 61.6 (48.4, 78.1) 58.5 (46.0, 73.2) 60.2 (46.1, 77.0) Edoxaban 60/30 mg, % 83.3 / 16.7 77.1 / 22.9 55.6 / 44.4 50.2 / 49.8 21.8 / 78.2 27.8 / 72.2 1-year outcome, n (%/year)   Major bleeding (ISTH) 2 (5.94) 66 (0.92) 0 (0) 13 (0.82) 3 (1.92) 66 (0.96)   Intracranial haemorrhage 1 (2.91) 19 (0.26) 0 (0) 5 (0.32) 1 (0.64) 18 (0.26)   Major GI* bleeding 0 (0.00) 20 (0.28) 0 (0) 2 (0.13) 2 (1.28) 30 (0.43)   CRNMB 0 (0.00) 102 (1.43) 0 (0) 11 (0.70) 6 (3.82) 219 (3.20)   Ischaemic stroke 1 (2.93) 41 (0.57) 1 (4.04) 11 (0.70) 4 (2.57) 78 (1.13) *Gastrointestinal.

Conclusion

Our data underpin the need for effective stroke prevention. In AF patients with a history of ICH, data suggest that edoxaban can be safely and effectively administered in patients with and without prior ICH in regular clinical care.

Acknowledgement/Funding

Daiichi Sankyo

Circadian variation of the onset of acute myocardial infarction in the Osaka area, 1998-1999: characterization of morning and nighttime peaks

The onset of acute myocardial infarction (AMI) shows characteristic circadian variations; that is, a definite morning peak related to biologic rhythms and a vague nighttime peak related to socioeconomic factors. The recent economic recession in Japan may change the circadian variation, especially the nighttime peak. This study evaluated the recent circadian variation of AMI in Osaka and specified the patient subgroups showing either a morning or nighttime peak predominantly. Of 1,609 consecutive patients with AMI registered from April 1998 to January 2000, 1,252 whose onset of AMI was definitely identified were studied. The day was divided into six 4-h periods with a morning peak between 08.01 h and 12.00h, and nighttime peak between 20.01 h and 24.00h. When subgroup analysis was performed, female patients aged 65 years or more showed a morning peak alone and male patients aged less than 65 years with an occupation and the habits of cigarette smoking and alcohol intake showed a nighttime peak alone. Thus, in Osaka nighttime socioeconomic factors may currently be more potent triggers of AMI than the morning surges in younger male workers who smoke and drink.

Transmural heterogeneity of myocardial integrated backscatter in diabetic patients without overt cardiac disease

It is important to detect early changes in diabetic myocardium, because some diabetic patients suffer from diabetic cardiomyopathy, especially those with poorer glycemic control or hypertension (HT). To clarify whether ultrasonic tissue characterization can noninvasively detect ultrastructural changes in diabetic myocardium, we analyzed the transmural heterogeneity in myocardial integrated backscatter (THIB) in 20 diabetic patients and 16 normal subjects. THIB was defined as the absolute value of difference of integrated backscatter between the endocardial and epicardial half of the myocardium. THIB in diabetic patients was significantly greater than that in normal subjects. In diabetic patients, there was a significant correlation between glycosylated hemoglobin and THIB, and the greater THIB was shown in patients with HT compared with those without HT. Early changes in the myocardium, related to increased interstitial collagen deposition or other occult cardiomyopathic changes, may be detected on the basis of quantitative analysis of THIB in diabetic patients.

Successful launch of cardiac transplantation in Japan. Osaka University Cardiac Transplant Program

Cardiac transplantation has been established as a therapeutic strategy for patients with end-stage heart failure. In Japan, however, cardiac transplantation has not been performed since the first case in 1968, and even now, after legislation for the approval of brain death was passed in 1997, it is still not performed regularly. Following long and steady efforts to enlighten Japanese society about the concept of brain death and the importance of organ transplantation, the first cardiac transplantation under the new legislation was successfully performed at Osaka University Hospital on February 1999. The patient was 47-year-old male in the dilated phase of hypertrophic cardiomyopathy who had been supported with an implantable left ventricular assist device. This article briefly reviews the situation prior to the first case of cardiac transplantation under the new legislation and discusses the current status of the therapy in Japan.

Plasma adenosine levels and platelet activation in patients with atrial fibrillation

Platelet activation is observed in patients with atrial fibrillation (AF). P-selectin, which is expressed on platelet activation, plays an important role in the formation of thromboemobli. Because adenosine is known to attenuate platelet activation, we evaluated adenosine levels and 2 indicators of platelet activation, i.e., expression of P-selectin on platelets and plasma levels of beta-thromboglobulin, in 28 patients with AF (20 men and 8 women, age range 64+/-2 years) with sex- and age-matched (+/-2 years) subjects with sinus rhythm. The incidence of risk factors for stroke except for coronary heart disease and in echocardiographic parameters did not differ between the 2 groups. Plasma adenosine levels were lower (p <0.05) in patients with AF than in controls (mean [interquartile range] 13.4 [19.3-9.3] vs 19.1 [30.8-11.9] nmol/L). The expression of P-selectin on platelets (6.8% [13.6-3.4] vs 4.0% [8.8-1.8]) and plasma levels of beta-thromboglobulin were higher (p <0.05) in patients with AF. Flow cytometric analysis revealed that an antagonist of adenosine receptors, 8-sulfophenyltheophylline, increased the expression of P-selectin on platelets in a dose-dependent manner in the in vitro study. These results suggest that decreased plasma levels of adenosine were associated with platelet activation in patients with AF. Substitution of adenosine may provide a strategy for preventing platelet activation in these patients.

Increased expression of P-selectin on platelets is a risk factor for silent cerebral infarction in patients with atrial fibrillation: role of nitric oxide

BACKGROUND

Platelet activation and decreased levels of nitrite and nitrate (NOx), stable end products of nitric oxide (NO), are reported in patients with atrial fibrillation (AF). We examined the time-course changes in plasma NOx levels and the expression of P-selectin on platelets after the onset of AF in a canine model and determined whether these parameters could be risk factors for silent cerebral infarction in patients with AF.

METHODS AND RESULTS

AF was induced by rapid atrial pacing in the canine model of AF. Plasma NOx levels were significantly decreased and the levels of P-selectin on platelets and of neutrophil/platelet conjugates were significantly increased after the onset of AF in this model. The in vitro experiments demonstrated that the inhibition of NO synthesis increased the expression of P-selectin on platelets. Plasma NOx levels (19.7+/-2.4 versus 27.5+/-2.8 micromol/L) were significantly lower in 25 patients with AF compared with age- (+/-2 years) and sex-matched control subjects. Conversely, the levels of P-selectin on platelets (7.6+/-0.8% versus 4.8+/-0.7%) and of neutrophil/platelet conjugates (14.8+/-0.9% versus 8.1+/-0.6%) were significantly higher in patients with AF. Multiple regression analysis revealed that increased P-selectin on platelets and advanced age were associated with the number of foci of silent cerebral infarction.

CONCLUSIONS

An irregular heart rate that is characteristic of AF appeared to blunt NO synthesis. The increased expression of P-selectin on platelets associated with the reduced NO levels was a risk factor for silent cerebral infarction in patients with AF.

Sustained left ventricular diastolic dysfunction after exercise in patients with dilated cardiomyopathy

OBJECTIVE

To investigate the recovery process of exercise induced diastolic dysfunction in heart failure, using Doppler echocardiographic techniques.

DESIGN AND PATIENTS

Transmitral flow velocity profiles and standard noninvasive haemodynamic indices were obtained serially over seven days after symptom limited bicycle exercise tests in 18 patients with dilated cardiomyopathy and eight normal subjects. In three patients with cardiomyopathy we also measured the pulmonary capillary wedge pressure for 24 hours after exercise.

RESULTS

The intensity of exercise, as assessed by respiratory gas analysis, was lower in patients with dilated cardiomyopathy than in normal subjects. Despite the higher exercise level, all haemodynamic variables returned to baseline within one hour after exercise in normal subjects. In contrast, patients with dilated cardiomyopathy showed a sustained decrease in the peak early diastolic filling velocity and a sustained increase in the deceleration time of early filling for 24 hours or more after exercise. Because other haemodynamic variables recovered within one hour after exercise even in patients with dilated cardiomyopathy, the postexercise changes in ventricular filling were not explained by changes in loading conditions.

CONCLUSIONS

Exercise induced diastolic left ventricular dysfunction of the failing heart persists for 24 hours or more after exercise. The efficacy of exercise training on a daily basis in dilated cardiomyopathy requires further evaluation.

Mechanism for the cardioprotective effects of the calcium channel blocker clentiazem during ischemia and reperfusion

To elucidate whether or not Ca channel blockers have an intrinsic benefit that cannot be attributed to the reduction of Ca2+ entry by pretreatment, time-averaged intracellular Ca2+ concentration ([Ca2+]i) and energy-related phosphates were measured in isolated ferret hearts using nuclear magnetic resonance. In the drug-free ischemic group, [Ca2+]i increased significantly during 30 min of global ischemia at 30 degrees C and during 0-5 min of reperfusion. After 30 min of reperfusion, isovolumic left ventricular developed pressure recovered only to 63+/-7% of the pre-ischemic level (mean+/-SEM; N=5). Pretreatment with the Ca channel blocker clentiazem (10(-7) mol/L) itself depressed developed pressure by 53+/-9%. In the clentiazem group, [Ca2+]i showed no significant changes during ischemia or reperfusion. Recovery of developed pressure (87+/-8% of untreated level) was significantly higher than in the non-treated group (p<0.05). Nevertheless, when the negative inotropism of clentiazem was offset by increasing [Ca]o from 2 to 3 mmol/L, no beneficial effects of clentiazem were observed; [Ca2+]i increased significantly during 0-5 min of reperfusion, and developed pressure recovered only 60+/-7% of untreated level. These results indicate that reduction of Ca2+ entry from the extracellular space to the myocyte, as reflected by negative inotropism during pretreatment, is required for clentiazem to protect myocardium in a model of global ischemia and reperfusion.

Increased release of nitric oxide in ischemic hearts after exercise in patients with effort angina

OBJECTIVES

The aim of this study was to determine whether the release of nitric oxide (NO) from the ischemic heart increases during exercise in patients with effort angina.

BACKGROUND

Myocardial ischemia increases NO production in the canine heart, but no such increase has been demonstrated in the ischemic human heart.

METHODS

Fifteen patients with effort angina underwent supine ergometer exercise tests. All patients had severe proximal stenosis (>90%) in the left anterior descending coronary artery. The control group consisted of 17 subjects without coronary artery disease or systemic hemodynamic abnormalities.

RESULTS

Neither the lactate extraction ratio (LER) nor the difference in NO concentration between coronary venous and arterial blood (deltaVA[NO]) was affected by exercise in the control subjects. In patients with effort angina, neither variable differed from that in the control group at rest; however, exercise markedly decreased LER and significantly increased deltaVA(NO) (from 4.7 +/- 0.3 to 16.5 +/- 1.6 micromol/liter, p < 0.001) in the patient group. The extent of decrease in LER was significantly correlated with the extent of increase in deltaVA(NO) in the patients with effort angina (r2 = -0.837, p < 0.001).

CONCLUSIONS

Provocation of myocardial ischemia by exercise stress increases NO production in the hearts of patients with effort angina.

Elevation of plasma adenosine levels may attenuate the severity of chronic heart failure

Adenosine is known to be an endogenous cardioprotective substance. Since we have reported that adenosine levels increase in patients with chronic heart failure, we tested whether further elevation of the adenosine levels due to dipyridamole or dilazep for 6 months modulates the pathophysiology of chronic heart failure. In patients with chronic heart failure, either dipyridamole (300 mg/d n = 17) or dilazep (300 mg/d n = 5) were administered for 6 months. Twenty-two patients (mean +/- SE age 58 +/- 4 years old) attending a specialized chronic heart failure (CHF) clinic over 6 months and judged as in New York Heart Association (NYHA) function class II or III were examined. The other drugs used for the treatment of CHF were not altered during the study. There were 5 patients with CHF caused by ischemic heart diseases, and 17 patients with either valvular heart diseases or dilated cardiomyopathy. We found that increases in the plasma adenosine levels (202 +/- 34 and 372 +/- 74) nmol/L before and after dipyridamole administration, P < 0.005 ameliorate the severity of CHF (NYHA: 2.1 +/- 0.5 to 1.7 +/- 0.2). Both ejection fraction and maximal oxygen consumption increased. These improvements in the severity of chronic heart failure returned to baseline levels 6 months after discontinuation of dipyridamole. Comparable results were obtained in the dilazep protocol. We suggest that the elevation of plasma adenosine levels improves the pathophysiology of CHF.

Occurrence of sustained increase in QT dispersion following exercise in patients with residual myocardial ischemia after healing of anterior wall myocardial infarction

Our objective was to evaluate the effect of exercise on QT dispersion over the next 3 hours, as seen on a standard 12-lead electrocardiogram in patients with healed myocardial infarction with or without residual ischemia. We measured QT and QTc dispersion before, immediately after, and 1 and 2 hours after symptom-limited, dynamic treadmill exercise tests in 28 patients with healed anterior wall myocardial infarction with (group I, n = 18) and without (group II, n = 10) residual ischemia. The same protocol was followed in 5 group I patients after successful performance of coronary angioplasty. QT and QTc dispersion did not change immediately after exercise in group II. These parameters increased in group I (QT dispersion at rest [mean +/- SD] 57 +/- 22 ms, and after exercise 87 +/- 27 ms; QTc dispersion at rest 62 +/- 25 ms, and after exercise 114 +/- 36 ms). The increases in QT and QTc dispersion were sustained for at least 2 hours. After a successful coronary angioplasty in 5 patients, these parameters no longer increased with exercise. Thus, QT dispersion increased for at least 2 hours after exercise in patients who had residual ischemia after healing of myocardial infarction. Data obtained in 5 of these patients after coronary angioplasty support the idea that residual ischemia plays a key role in the sustained increase in QT dispersion after exercise.

Plasma levels of nitrite/nitrate and platelet cGMP levels are decreased in patients with atrial fibrillation

Patients with atrial fibrillation have been reported to exhibit abnormal hemostasis. Since nitric oxide (NO) exerts antithrombotic effects and attenuates platelet function, we evaluated two indicators of plasma NO levels, the plasma levels of nitrite and nitrate (NOx), and the levels of cGMP in platelets. We also examined whether indicators of plasma NO levels were associated with abnormalities in parameters related to platelet function, blood coagulation, and fibrinolysis. We evaluated 45 patients with chronic sustained atrial fibrillation (33 men and 12 women, age range 63 +/- 2 years) compared with 45 sex- and age- (+/- 2 years) matched nonhospitalized subjects with sinus rhythm. There were no significant differences between the two groups in the incidence of risk factors for stroke except for ischemic heart disease or in echocardiographic parameters. Plasma levels of NOx measured using the Greiss reagent (mean [interquartile range]: 15.6 [9.5 to 25.7] versus 24.1 [14.2 to 40.8] mumol/L, n = 45) and the platelet cGMP levels (0.33 [0.16 to 0.67] versus 0.63 [0.31 to 1.29] pmol/10(9) platelets, n = 9) were significantly (P < .05) lower in the patients with atrial fibrillation than in the control subjects. Plasma levels of D-dimer, beta-thromboglobulin, and fibrinogen were significantly (P < .05) higher in the patients with atrial fibrillation. The two groups did not differ as to the plasma levels of tissue plasminogen activator or plasminogen activator inhibitor-1. Our findings suggest that a decrease in plasma NO levels may account for the hemostatic abnormalities observed in patients with atrial fibrillation.

Respiratory oxygen cost for dead space challenge is characteristically increased during exercise in patients with chronic heart failure: does it further decrease exercise capacity?

BACKGROUND

Although the work of the respiratory muscles is markedly increased during exercise in patients with chronic heart failure, the role of this abnormality in exercise intolerance is still controversial. This issue may be clarified directly by dead space challenge, as this technique increases minute ventilation. Therefore, in this study, the effects of an external dead space on exercise ventilation, gas exchange data, and exercise capacity in patients with chronic heart failure were examined.

METHODS AND RESULTS

Dead space challenge was performed by adding an external dead space to the airway in 20 patients with chronic heart failure and 10 normal subjects. Two hours after completion of the control maximal bicycle exercise, the second exercise was performed under application of an external dead space equivalent to 10% of peak tidal volume. Respiratory gas exchange data were collected during exercise. Aerobic exercise capacity was assessed from the exercise time and the time to anaerobic threshold. The sensation of exertional dyspnea was assessed using Borg's rating scale. As compared with data during the control exercise, minute ventilation was increased by approximately 25% with the external dead space throughout exercise in both groups. A parallel 20% increase in systemic oxygen uptake was observed in the heart failure group, likely reflecting an increase in respiratory muscle work. This response was not observed in the normal group. Despite an additional increase in respiratory muscle work, neither aerobic exercise capacity nor exertional dyspnea was exacerbated in the heart failure group by the external dead space.

CONCLUSIONS

Dead space challenge appears to be a unique technique that characteristically increases the work of respiratory muscles during exercise in patients with chronic heart failure. By use of this technique, it was demonstrated that an increase in respiratory muscle work is not important in reducing exercise capacity of patients with chronic heart failure.

Effect of acute dynamic exercise on circulating plasma nitric oxide level and correlation to norepinephrine release in normal subjects

Physical exercise increased the levels of the end product of nitric oxide in normal subjects. The increased nitric oxide may contribute to vasodilation during exercise.

Studies on the response of nitroglycerin oral spray compared with sublingual tablets for angina pectoris patients with dry mouth. A multicenter trial

Nitroglycerin (glyceryl trinitrate, CAS 55-63-0, NTG) administered with an oral spray may be more effective in relieving anginal pain than sublingual tablets especially when the patient's mouth is dry. In this study, the effect of a NTG oral spray (Myocor Spray) on exercise-induced angina was compared with that of a sublingual tablet in relation to the oral dryness. In 17 patients with effort angina, graded bicycle exercise was performed twice at an interval of one week. Exercise was discontinued upon the onset of moderate anginal pain. Immediately after exercise, the oral dryness was evaluated by touching the tip of the tongue with a blotting paper for a moment. Then, 0.3 mg of NTG was administered by either a squirt of spray or a sublingual tablet in a randomized crossover fashion. Exercise results were reproducible between two exercise tests. According to the extent of the wet area of the blotting paper, the subjects were divided into two groups. In 7 patients of the wet group, the remission times of chest pain and ST segment depression were not significantly different by the formulation of NTG. In 10 patients of the dry group, however, both chest pain and ST depression more rapidly recovered with use of the oral spray (p < 0.05 and p < 0.05, respectively). These results strongly suggest that the NTG oral spray is superior to the sublingual tablet in relieving anginal attacks, when the oral wetness is decreased.

Decreased baroreflex sensitivity in patients with stable coronary artery disease is correlated with the severity of coronary narrowing

Although studies have shown that arterial baroreflex sensitivity (BRS) is decreased in patients with acute myocardial infarction, BRS changes in patients with stable coronary artery disease (CAD) have not been studied extensively. We assessed BRS by the phenylephrine method in 55 normotensive and nondiabetic patients with chronic effort angina, old myocardial infarction, or both. The control group consisted of 24 age-matched patients without coronary lesions. To identify factors that determine BRS in stable CAD, we performed multivariate analysis using age, sex, left ventricular ejection fraction, pulmonary artery wedge pressure, resting systolic blood pressure, resting heart rate, the number of stenotic coronary arteries, history of myocardial infarction, and the presence or absence of angina pectoris as variables. BRS was significantly lower in patients with CAD than in control subjects (5.9 +/- 2.9 vs 6.9 +/- 2.4 ms/mm Hg, p < 0.05). In patients with CAD, BRS was inversely correlated with age, the resting heart rate, and the number of stenotic coronary vessels (p < 0.001, p < 0.005, and p < 0.005, respectively), but was independent of other clinical parameters, including the history of myocardial infarction. In control subjects, BRS was significantly correlated only with age. These results indicate that BRS is decreased in patients with stable CAD, and this decrease is correlated with the extent and severity of coronary narrowing.

Pharmacological effects of concomitant administration of beta-adrenoceptor blocker and agonist in normal subjects: characterization by heart rate response to exercise. Effects of beta-blocker combined with beta-agonist

The effects of a combination regimen of metoprolol and beta 1-adrenoceptor agonist denopamine on resting and exercise heart rate have been studied in 10 normal volunteers. Maximal ramp upright bicycle exercise was performed three times at 1-week intervals. Two hours before each exercise test, 5 mg metoprolol plus 20 mg denopamine, 5 mg metoprolol plus a denopamine placebo, or two placebos were orally administered in a double-blind fashion. During exercise after placebo administration, heart rate increased in parallel with the exercise intensity. Compared to the placebo values, resting heart rate was significantly decreased by an average of 10 beats.min-1 by 5 mg metoprolol, whereas it was not altered by the combination regimen. During exercise, however, both the combination regimen and metoprolol alone showed a significant negative chronotropic effect, decreasing peak exercise heart rate by an average of 14 and 21 beats.min-1, respectively. Peak oxygen uptake was also significantly decreased by both regimens. We conclude that concomitant administration of 5 mg metoprolol and 20 mg denopamine exerts an effective beta-adrenoceptor blocking action during exercise but a minimal effect at rest in normal subjects. The combination regimen appears to have a favourable pharmacological profile for beta-adrenoceptor blocker therapy in patients with chronic heart failure.

High prevalence of atrial fibrosis in patients with dilated cardiomyopathy

OBJECTIVES

We examined the extent of fibrotic changes in the left atrium of cardiomyopathic human hearts and investigated the relation of mechanical overload caused by left ventricular dysfunction to fibrosis of the left atrium.

BACKGROUND

Left atrial dysfunction in dilated cardiomyopathy may contribute to progression of heart failure. In contrast to fibrosis of the left ventricle, atrial fibrosis has not been extensively studied in cardiomyopathic hearts.

METHODS

The extent of fibrosis in the left atrium and left ventricle was determined by an automatic image analyzer in 38 autopsied hearts obtained from 9 patients who died of noncardiac illness (control group), 16 patients with dilated cardiomyopathy, 6 patients with hypertrophic cardiomyopathy with features mimicking dilated cardiomyopathy and 7 patients with a previous myocardial infarction. Transverse sections were obtained at the upper margins of the foramen ovale and left auricle in the left atrium and the median level of the left ventricle.

RESULTS

There were no significant differences in extent of left atrial dilation, left ventricular dysfunction or duration of illness among the three groups with cardiac disease. Percent area of left atrial fibrosis (mean +/- SD) was significantly greater in the specimens from patients with dilated cardiomyopathy (13.1 +/- 6.1%, p < 0.01) and hypertrophic cardiomyopathy mimicking dilated cardiomyopathy (26.5 +/- 9.5%, p < 0.01) than in those from patients with an old myocardial infarction (3.8 +/- 1.1%). Percent area of left ventricular fibrosis in hearts from patients with dilated cardiomyopathy (12.9 +/- 8.6%) was significantly smaller than that in hearts from patients with hypertrophic cardiomyopathy mimicking dilated cardiomyopathy (35.8 +/- 11.9%, p < 0.01) and a previous myocardial infarction (38.4 +/- 8.0%, p < 0.01). Percent area of atrial fibrosis was significantly correlated with left ventricular ejection fraction in the group with a previous myocardial infarction but not in the other groups.

CONCLUSIONS

There was a high degree of fibrotic change in the left atrium in the groups with dilated cardiomyopathy and hypertrophic cardiomyopathy mimicking dilated cardiomyopathy. Our findings suggest that atrial fibrosis in these patients may not have been related to mechanical overload of the left atrium but to some other, still unknown mechanisms.

Progressive decreases in coronary vein flow during reperfusion in acute myocardial infarction: clinical documentation of the no reflow phenomenon after successful thrombolysis

OBJECTIVES

This study was undertaken to examine the effects of coronary flow dynamics after thrombolysis on infarct size limitation.

BACKGROUND

It has been commonly accepted that early thrombolysis does not necessarily salvage infarcted myocardium. Plausible causes for myocardial necrosis include such factors as elapsed time to reperfusion, residual stenosis, collateral vessels, hemodynamic loads, preconditioning and reperfusion injury. Recently, the no reflow phenomenon has been elucidated to be associated with infarct extension in clinical studies employing contrast echocardiography or thallium scintigraphy.

METHODS

Nineteen patients with early reperfusion in acute anterior myocardial infarction and comparable clinical background were studied. The patients were classified into two groups on the basis of pattern of thermodilution measurements of great cardiac vein flow after reperfusion: group A, 9 patients with a progressive decrease in great cardiac vein flow during the 1st 24 h of the onset of infarction; and group B, 10 patients without this observation. Left ventricular ejection fraction and thallium perfusion defect were compared between the two groups at follow-up.

RESULTS

There were no significant differences in systemic hemodynamic variables between groups A and B, and neither group had recurrent ischemic events suggesting reocclusion or restenosis during the study. In group A, both great cardiac vein flow (mean +/- SD 44 +/- 17% reduction) and oxygen extraction (38 +/- 15% reduction) were progressively decreased after the onset of reperfusion. Compared with group B, this group showed a lower left ventricular ejection fraction (36 +/- 7% vs. 63 +/- 15%, p < 0.01) and a larger thallium-201 defect severity index (1,091 +/- 366 U vs. 247 +/- 261 U, p < 0.01) at follow-up. Although other patient characteristics were comparable between the two groups, antecedent angina occurred in 90% of group B patients in contrast to only 33% of group A patients.

CONCLUSIONS

Salvage of myocardium from infarction by successful thrombolysis was not observed in the patients demonstrating progressive decreases in great cardiac vein flow (group A). In those patients, inadequate myocardial reperfusion on a microvascular basis might be associated with a much larger myocardial infarction. Antecedent angina may protect against a progressive decrease in coronary flow and may have beneficial effects on infarct size limitation.