Objective: To investigate factors predicting the development of outward remodelling of the carotid artery in patients with atherosclerosis. Design: 130 patients with carotid artery stenosis (15-85% of the vessel diameter) were divided into two groups, based on the presence or absence of outward remodelling of the sclerotic carotid segment on high resolution ultrasonography. Logistic regression analysis was used to evaluate the contribution of haemodynamic, laboratory, and clinical measurements on the development of remodelling, including age, sex, type of stenosis, extent of plaque, per cent diameter stenosis, underlying disease, selected drug treatment, and plasma concentrations of total cholesterol, high density lipoprotein cholesterol, triglyceride, and uric acid. Results: 64 patients (49%) had outward remodelling. Multivariate regression analysis showed that hypertension, the type of plaque, the thickness of the plaque, and the extent of stenosis were independent factors predicting remodelling. The odds ratios of hypertension, unstable shape of plaque, thickness of plaque, and the extent of the stenosis were 6.70, 3.02, 2.04, and 1.05, respectively. Other measurements did not contribute significantly to the estimation of remodelling. Conclusions: Compensatory enlargement of the vessel occurs in about 50% of carotid artery segments with a diameter stenosis of 15-85%. Hypertension and the shape of the plaque are major determinants of the development of outward remodelling. I t has become apparent that blood vessels can enlarge to accommodate atheromatous plaques, forestalling encroachment on the lumen and hence preserving distal flow. Glagov and colleagues were the first to describe this process in the left main coronary artery in necropsy specimens.1 The findings were confirmed clinically in femoral 2 and coronary arteries, 3 using intravascular and epicardial ultrasonography, and in the carotid artery by body surface ultrasonography. This "outward remodelling" consists of a spectrum of structural changes whereby the vascular wall responds to alterations in its haemodynamic environment. Smoking, 4 aging, 5 and hypercholesterolaemia 6 are also thought to be involved in the development of outward vascular enlargement. However, although attempts have been made to investigate the factors participating in compensatory vascular reconstruction, the mechanism of this type of remodelling remains obscure. Our aim in this study was to determine the prevalence of vascular remodelling and to investigate the factors leading to outward remodelling in the atherosclerotic carotid artery, using high resolution cross sectional ultrasonography. METHODS SubjectsThe study population consisted of 165 consecutive patients with 15-85% diameter stenosis of the carotid artery system, determined by B mode ultrasonographic examination. Exclusion criteria were as follows: a major attack of coronary or cerebrovascular disease within one month of the investigation; overt congestive heart failure; cardiogenic shock; loss of consciousness; si...
he combination of angiotensin II receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEIs) has been reported to offer more complete blockade of the effect of angiotensin II than treatment with ACEI alone, while retaining the benefits of bradykinin potentiation obtained from ACEI treatment. 1,2 In the clinical setting, the combination of ACEI and ARB is more beneficial in preventing left ventricular remodeling and decreasing the plasma concentrations of aldosterone and brain natriuretic peptide (BNP) than either ACEI or ARB alone. 3,4 In addition, the combination therapy has recently been proved to improve prognosis to a greater extent than the monotherapy. 4,5 However, the doses of ACEI and ARB in large-scale trials performed in the USA and Europe have been 3-4-fold higher than the standard doses prescribed in Japan. The aim of this study was to Circulation Journal Vol.68, April 2004 investigate the effects of the combination of ACEI and ARB at the standard doses prescribed in Japan on left ventricular remodeling and neurohumoral factors in patients with chronic heart failure. Methods Study DesignThis is a multicenter, randomized, open-labeled trial to compare the clinical effects of ACEI or ARB monotherapy and their combination for 6 months. All the patients treated in the 26 institutes gave their written informed consent to participate in the trial, which was approved by the institutional review board of the National Cardiovascular Center, Osaka, Japan. EligibilityMen and women, 18 years old or older, with stable chronic heart failure for at least 3 months before the screening were eligible to participate in this study. In addition, they had to have documented left ventricular (LV) systolic dysfunction with an LV ejection fraction (EF) equal to or less than 45%, determined by echocardiography or LV venCirc J 2004; 68: 361 -366 (Received November 13, 2003; revised manuscript received January 20, 2004; accepted January 27, 2004) The institutes particpating in the study are listed in Appendix 1. Background The present multicenter study investigated whether the combination of angiotensin-converting enzyme inhibitor (ACEI) and angiotensin II receptor blocker (ARB) is more beneficial for preventing left ventricular remodeling and suppressing neurohumoral factors than either ACEI or ARB alone. Methods and ResultsOne hundred and six patients with mild-to-moderate congestive heart failure treated in 26 Japanese institutes were randomly assigned to the combination therapy or monotherapy. Changes in physical activity (New York Heart Association functional classes, Specific Activity Scale (SAS)), concentrations of neurohumoral factors (plasma renin activity, angiotensin II, aldosterone, and brain natriuretic peptide (BNP)), and cardiac function for 6 months were compared between the 2 groups. It was found that the combination therapy, which was administered at doses standard in Japan, increased the SAS score (4.5±1.5 to 4.9±1.5, p<0.05) and decreased the plasma BNP concentration (183±163 to 135±1...
ithium carbonate is widely used for the treatment of manic -depressive disorders, but it has various cardiovascular side-effects, the majority of which involve sinus node dysfunction (SND) and sino-atrial blockage, according to previous reports. [1][2][3][4][5][6] We report an exceptional case of a patient with manic -depressive psychosis who had complete atrioventricular block (CAVB) during lithium treatment, necessitating permanent pacemaker implantation. Case ReportA 57-year-old male without history of syncope was admitted to hospital for the treatment of manic -depressive disorder in February 2005. His history showed no evidence of organic heart disease. Physical examination and noninvasive cardiovascular tests, including electrocardiography, prior to therapy had indicated first-degree atrioventricular (AV) block (Fig 1). Lithium carbonate and carbamazepine had been administered 6 days before admission, at a daily dose of 300 mg and 300 mg, respectively. On admission, zotepine, promethazine, nitrazepam, chlorpromazine, and phenobarbiturate were additionally administered. The serum lithium level was below the therapeutic range, at 0.3 mmol/L (normal range, 0.60-1.20 mmol/L). A chest radiograph revealed no abnormality. Laboratory test results were normal for blood electrolytes, renal function, cardiac enzymes, and thyroid function.Five days after admission the patient felt discomfort and experienced sudden bradycardia with low systolic pressure and the attached cardiac monitor revealed paroxysmal CAVB without ventricular escape for a maximum of approximately 5 s causing an Adams-Stokes attack (Fig 2). Circulation Journal Vol.72, May 2008During transportation to the emergency room, he had a cardiopulmonary arrest caused by ventricular fibrillation. After successful resuscitation by defibrillation, with epinephrine and atropine sulfate administration, a temporary pacemaker was inserted. Transient liver and renal function disorders because of the cardiogenic shock and hypoxia occurred after resuscitation.Treatment with carbamazepine was discontinued because it can cause AV block, as indicated by the prescription information.Because of the low serum lithium concentration and deteriorated psychotic status, lithium was resumed at a daily dose of 300 mg, and then increased to 500 mg. As the adverse cardiovascular effect of tachyarrhythmia is described in the prescription information for 3 of the other medications [zotepine, promethazine and chlorpromazine], these were also withdrawn.No further ventricular tachycardia or CAVB occurred for 7 days under backup pacing after the syncopal attack, and temporary pacing was removed. Residual first-degree AV block with changing PP interval (240-280 ms) was observed. Without lithium administration, there was no worsening of AV block related to the heart rate increase.Valproate sodium and levomepromazine were added for depressive mood 7 days later. Additional haloperidol and piperidine chloride were administered. Because general fatigue, retarded sinus bradycardia, and depressiv...
yocardial infarction (MI) is now one of the most frequent causes of death in elderly subjects in Japan; in 1999 approximately 15,000 cardiac deaths occurred in Japan and the majority was related to myocardial infarction (MI). 1 Furthermore, among survivors of an acute MI (AMI), the incidence of a subsequent MI is increased 3-to 6-fold, and the risk of any cardiovascular event is as high as 80%. 2 Because patients with a previous history of cardiovascular events are at high risk for a future MI, 3 aggressive management, including risk factor modification, is mandatory in this patient group. [4][5][6] Considerable evidence indicates that a secondary prevention program to reduce cardiovascular risk factors can favorably affect cardiovascular mortality and morbidity. 7,8 Although there are many available studies from North America and Europe regarding the risk factors for recurrent MI after the recovery from AMI, 9-11 little is known concerning the Japanese population. 12 Racial differences, including genetic factors, life style, and the environmental circumstances of the patients, will affect the factors that accelerate coronary atherosclerosis and advance to subsequent MI, so we evaluated the risk factors of a recurrent MI in Japanese patients after recovery from the first AMI. Methods Study PatientsThe study group consisted of patients experiencing their first episode of AMI who were admitted to Iwakuni National Hospital from January 1, 1991 to December 31, Circulation Journal Vol.66, October 20022000 within 48 h of developing chest pain and who were discharged after recovery.The diagnosis of AMI was established by the presence of 2 of the following 3 criteria: (1) elevation of serum creatine kinase (CK) more than triple the upper normal limit, (2) characteristic chest pain, or (3) ECG findings of ST-T change with evolution of the Q wave. Non-Q wave infarction was diagnosed by typical ST segment and/or T wave changes associated with serum CK elevation.All patients were in New York Heart Association functional class I or II at discharge. The patients were followed up at the hospital or by mail at 6 and 12 months, and 5 and 10 years after discharge, and follow-up data was available from more than 90% of patients at 1 year post discharge. Patients who died from an unknown cause were excluded. Because most of the patients who had a second MI were admitted to Iwakuni National Hospital, there was no apparent difficulty in obtaining information regarding the second cardiac event.Risk factors identified from the medical history, physical findings, laboratory data, ECG and chest X-ray were reviewed. The standard 12-lead ECG was recorded on admission, 3 h later and then once a day for 4 days. The ECG in leads CM5 and NASA was continuously monitored for at least 48 h after admission. The location of the infarction was divided into 2 groups based on involvement of the left ventricular anterior wall: (1) anterior and (2) other. Serum low-density lipoprotein-cholesterol (LDL-C) concentration was calculated from the values of t...
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