甲谷 友幸

BACKGROUND: The precise details of atrial activation around the triangle of Koch (ToK) remain unknown. We evaluated the relationship between the atrial-activation pattern around the ToK and success sites for slow-pathway (SP) modification ablation in slow-fast atrioventricular reentrant tachycardia (AVNRT). METHODS: Thirty patients with slow-fast AVNRT who underwent successful ablation were enrolled. Atrial activation around the ToK during sinus rhythm was investigated using ultra-high-density mapping pre-ablation. The relationships among features of atrial-activation pattern and success sites were examined. RESULTS: Of 30 patients (22 cryoablation; 8 radiofrequency ablation), 26 patients had a collision site of two wavefronts of delayed atrial activation within ToK, indicating a success site. The activation-search function of Lumipoint software, which highlights only atrial activation with a spatiotemporal consistency, showed non-highlighted area on the tricuspid-annulus side of ToK. In 23 of the patients, a spiky potential was recorded at that collision site outside the Lumipoint-highlighted area. Fifteen cryoablation patients with a success site coincident with a collision site outside the Lumipoint-highlighted area had significantly more frequent disappearances of SP after initial cryoablation (46.7% vs. 0%, p = .029), fewer cryoablations (3.7 ± 1.8 vs. 5.3 ± 1.3, p = .045), and shorter procedure times (170 ± 57 vs. 228 ± 91 min, p = .082) compared to the seven cryoablation patients without such sites. Four patients had transient AV block by ablation inside the Lumipoint-highlighted area with fractionated signals, but no patient developed permanent AV block or recurrence post-procedure (median follow-up: 375 days). CONCLUSIONS: SP modification ablation at the collision site of atrial activation of the tricuspid-annulus side along with a spiky potential could provide a better outcome.

Lack of the typical nocturnal blood pressure (BP) fall, i.e non-dipper, has been known as a cardiovascular risk. However, the influence of non-dipper on atrial fibrillation (AF) recurrence after pulmonary vein isolation (PVI) has been unclear. We investigated the clinical impact of non-dipping as evaluated by 24-hour ambulatory BP monitoring on the long-term outcome of AF recurrence post-PVI in 76 AF patients with a history of increased BP. The PVI procedure was successful in all 76 patients (mean age, 66±9years; antihypertensive medication, 89%; non-paroxysmal AF, 24%). Twenty patients had AF recurrence during a median follow-up of 1138 days. There was no difference in BP levels between the AF recurrence and non-recurrence groups (average 24 h systolic BP:126 ± 17 vs.125 ± 14 mmHg; P = 0.84). On the other hand, the patients with non-dipper had a higher AF recurrence than those with dipper (38.9% vs.15.0%; P = 0.018). In Cox hazard analysis adjusted by age, non-paroxysmal AF and average 24-hr systolic BP level, the non-dipper was an independent predictor of AF recurrence (HR 2.78 [95%CI:1.05-7.34], P = 0.039). Non-dipper patients had a larger left atrial (LA) volume index than the dipper patients (45.9 ± 17.3 vs.38.3 ± 10.2 ml/m2, P = 0.037). Among the 58 patients who underwent high-density voltage mapping in LA, 11 patients had a low-voltage area (LVA) defined as an area with a bipolar voltage < 0.5 mV. However, there was no association of LVA with non-dipper or dipper (22.2% vs.16.1%, P = 0.555). Non-dipper is an independent predictor of AF recurrence post-PVI. Management of abnormal diurnal BP variation post-PVI may be important.

OBJECTIVE: This study aimed to investigate the association between heart failure (HF) severity measured based on brain natriuretic peptide (BNP) levels and future bleeding events after percutaneous coronary intervention (PCI). BACKGROUND: The Academic Research Consortium for High Bleeding Risk presents a bleeding risk assessment for antithrombotic therapy in patients after PCI. HF is a risk factor for bleeding in Japanese patients. METHODS: Using an electronic medical record-based database with seven tertiary hospitals in Japan, this retrospective study included 7160 patients who underwent PCI between April 2014 and March 2020 and who completed a 3-year follow-up and were divided into three groups: no HF, HF with high BNP level and HF with low BNP level. The primary outcome was bleeding events according to the Global Use of Streptokinase and t-PA for Occluded Coronary Arteries classification of moderate and severe bleeding. The secondary outcome was major adverse cardiovascular events (MACE). Furthermore, thrombogenicity was measured using the Total Thrombus-Formation Analysis System (T-TAS) in 536 consecutive patients undergoing PCI between August 2013 and March 2017 at Kumamoto University Hospital. RESULTS: Multivariate Cox regression showed that HF with high BNP level was significantly associated with bleeding events, MACE and all-cause death. In the T-TAS measurement, the thrombogenicity was lower in patients with HF with high BNP levels than in those without HF and with HF with low BNP levels. CONCLUSIONS: HF with high BNP level is associated with future bleeding events, suggesting that bleeding risk might differ depending on HF severity.

AIMS: The relationship between local unipolar voltage (UV) in the pulmonary vein (PV)-ostia and left atrial wall thickness (LAWT) and the utility of these parameters as indices of outcome after atrial fibrillation (AF) ablation remain unclear. METHODS AND RESULTS: Two-hundred seventy-two AF patients who underwent AF ablation were enrolled. Unipolar voltage of PV-ostia was measured using a CARTO system, and LAWT was measured using computed tomography. The primary endpoint was atrial tachyarrhythmia (ATA) recurrence including AF. The ATA recurrence was documented in 74 patients (ATA-Rec group). The UV and LAWT of the bilateral superior PV roof to posterior and around the right-inferior PV in the ATA-Rec group were significantly greater than in patients without ATA recurrence (ATA-Free group) (P < 0.001). The UV had a strong positive correlation with LAWT (R2 = 0.446, P < 0.001). The UV 2.7 mV and the corresponding LAWT 1.6 mm were determined as the cut-off values for ATA recurrence (P < 0.001, respectively). Multisite LA high UV (HUV, ≥4 areas of >2.7 mV) or multisite LA wall thickening (≥5 areas of >1.6 mm), defined as LA hypertrophy (LAH), was related to higher ATA recurrence. Among 92 LAH patients, 66 had HUV (LAH-HUV) and the remaining 26 had low UV (LAH-LUV), characterized by history of non-paroxysmal AF and heart failure, reduced LV ejection fraction, or enlarged LA. In addition, LAH-LUV showed the worst ablation outcome, followed by LAH-HUV and No LAH (log-rank P < 0.001). CONCLUSION: Combining UV and LAWT enables us to stratify recurrence risk and suggest a tailored ablation strategy according to LA tissue properties.

BACKGROUND: While most VVI pacemakers in bradycardic patients are set to a low limit of 60/min, the optimal lower limit rate for VVI pacemakers in atrial fibrillation has not been established. Although an increase in heart rate within the normal range in the setting of a VVI pacemaker might be expected to lead to an increase in cardiac output with the shortening of the diastolic time, the changes in cardiac output at different pacemaker settings have not been fully clarified. METHODS: We included 11 patients with bradycardic atrial fibrillation who had VVI pacemakers implanted. Stroke volume was measured using the electrical cardiometry method (AESCULONⓇ mini; Osypka Medical) without pacing and at ventricular pacings of 60, 70, 80, and 90/min. RESULTS: Stroke volume decreased stepwise at ventricular pacing rates of 60, 70, 80, and 90/min (63.6 ± 11.2, 61.9 ± 10.6, 59.3 ± 12.2, and 57.5 ± 12.2 mL, p < .001), but cardiac output increased (3.81 ± 0.67, 4.33 ± 0.74, 4.74 ± 0.97, and 5.17 ± 1.09 L/min, p < .001). The rate of increase in cardiac output at a pacing rate of 70/min compared to 60/min correlated with left ventricular end-systolic volume (r = 0.711, p = .014). CONCLUSIONS: Cardiac output increased at a pacing rate of 70 compared to 60 in bradycardic atrial fibrillation patients, and the rate of increase in cardiac output was greater in those with larger left ventricular end-systolic volume.

A 23-year-old man with no significant medical history was rushed to a hospital due to transient loss of consciousness with incontinence. The patient had developed a fever after his second dose of coronavirus disease 2019 (COVID-19) vaccine, and the patient was found groaning in bed approximately 40 hours after the vaccination in the early morning. The patient was diagnosed with Brugada syndrome (BrS) based on a drug-provocation test. His father had been diagnosed with BrS and died suddenly at 51 years of age. Young adults with a family history of BrS should be cautioned about fever following COVID-19 vaccination.

INTRODUCTION: Beyond pulmonary vein isolation (PVI), additional therapeutic strategies for atrial fibrillation (AF) have not been established. Remodeling of the left atrium (LA) could impact AF recurrence post-PVI. We investigated the impact of unipolar voltage (UV) criteria for the LA posterior wall (LA-PW) on AF recurrence post-PVI. METHODS: We reviewed the cases of 106 AF patients (mean age 63.8 years, nonparoxysmal AF: 59%) who underwent extensive encircling PVI by radiofrequency ablation guided by a 3-dimension mapping system, investigating the impact on AF recurrence of the UV criteria of the LA. RESULTS: Out of all patients, 26 patients had AF recurrence during post-PVI follow-up [median 603 days]. They showed a higher percentage of nonparoxysmal AF (80.8 vs. 52.5%, p = .011), longer AF duration (2.9 ± 2.7 vs. 1.0 ± 1.7 years, p = .002), and larger area size of UV < 2.0 mV in LA-PW (2.8 ± 1.8 vs. 1.0 ± 1.5 cm2 , p < .001) than those without recurrence. Cox Hazard analysis for AF recurrence adjusted by age, gender, AF duration, body mass index and left atrial volume index revealed that an area size over 2.0 cm2 of UV < 2.0 mV in LA-PW (HR 6.9 [95% CI:1.3-35.5], p = .021) posed independent risks for AF recurrence post-PVI. The atrial arrhythmia-free survival rate was higher in those with no area of UV < 3.0 mV in LA-PW compared to those with a sizable area (>2.0 cm2 ) of UV < 3.0 mV and <2.0 mV (95.0% vs. 74.2% vs. 57.1%, Log-Rank: p < .001). In the AF etiology of patients with AF recurrence, 9 of 14 patients who underwent the 2nd procedure had no PV reconnection, and 8 patients required the LA-PW isolation for their non-PV AF. CONCLUSION: UV criteria of LA-PW is a useful parameter for AF-recurrence post-PVI. Lower UV in LA-PW as an indication of electrical remodeling could indicate a higher risk of AF recurrence and the need for further therapeutic strategies.

BACKGROUND: Inconsistencies between office and out-of-office blood pressure (BP) values (described as white-coat hypertension or masked hypertension) may be attributable in part to differences in the BP monitoring devices used. METHODS: We studied consistency in the classification of BP control (well-controlled BP vs. uncontrolled BP) among office, home, and ambulatory BPs by using a validated "all-in-one" BP monitoring device. In the nationwide, general practitioner-based multicenter HI-JAMP study, 2,322 hypertensive patients treated with antihypertensive drugs underwent office BP measurements and 24-h ambulatory BP monitoring (ABPM), consecutively followed by 5-day home BP monitoring (HBPM), for a total of seven BP measurement days. RESULTS: Using the thresholds of the JSH2019 and ESC2018 guidelines, the patients with consistent classification of well-controlled status in office (<140 mmHg) and home systolic BP (SBP) (<135 mmHg) (n=970) also tended to have well-controlled 24-h SBP (<130 mmHg) (n=808, 83.3%). The patients with consistent classification of uncontrolled status in office and home SBP (n=579) also tended to have uncontrolled 24-h SBP (n=444, 80.9%). Among the patients with inconsistent classifications of office and home BP control (n=803), 46.1% had inconsistent ABPM-vs.-HBPM out-of-office BP control status. When the 2017 ACC/AHA thresholds were applied as an alternative, the results were essentially the same. CONCLUSIONS: The combined assessment of office and home BP is useful in clinical practice. Especially for patients whose office BP classification and home BP classification conflict, the complementary clinical use of both HBPM and ABPM might be recommended.

BACKGROUND: Non-dipper and riser patterns of nocturnal blood pressure (BP) are risk factors for cardiovascular disease (CVD), including heart failure (HF). However, the risk associated with a disrupted nocturnal pattern of heart rate is not well known. OBJECTIVES: To investigate whether the nighttime heart rate is a risk factor for HF, alongside nighttime BP phenotype. METHODS: The practitioner-based, nationwide, prospective Japan Ambulatory Blood Pressure Monitoring Prospective (JAMP) study included patients with ≥ 1 CVD risk factor but without symptomatic CVD at baseline. All patients underwent 24-h ambulatory BP monitoring at baseline and were followed annually. Nocturnal heart rate dipping (%) was calculated as 100•[1 - nighttime/daytime heart rate]. RESULTS: During a mean 4.5 years' follow-up in 6,359 patients (mean age 68.6 years), there were 306 CVD events (119 stroke, 99 coronary artery disease, and 88 HF). A 10-beats/min increase in nighttime heart rate was significantly associated with a 36-47% increase in the risk of total CVD, stroke and HF events independently of office SBP and nighttime SBP (all p < 0.005). The CVD and HF risk associated with nocturnal heart rate dipping status was independent of office and 24-h systolic BP and nocturnal BP dipping status (p < 0.001). Performance of the final model for predicting HF including BP parameters was significantly improved by the addition of nocturnal heart rate dipping patterns (p = 0.038; C-statistic 0.852). CONCLUSION: Nighttime non-dipper and riser patterns of heart rate were associated with CVD especially HF, independently and additively of nocturnal BP dipping status, indicating the importance of antihypertensive strategies targeting nighttime hemodynamics. CLINICAL TRIAL REGISTRATION: URL: https://www.umin.ac.jp/ctr/ ; Unique identifier: UMIN000020377.

BACKGROUND: The causal relationship between hyperuricemia and cardiovascular diseases is still unknown. We hypothesized that hyperuricemic patients after percutaneous coronary intervention (PCI) had a higher risk of major adverse cardiovascular events (MACE). METHODS: This was a large-scale multicenter cohort study. We enrolled patients with chronic coronary syndrome (CCS) after PCI between April 2013 and March 2019 using the database from the Clinical Deep Data Accumulation System (CLIDAS), and compared the incidence of MACE, defined as a composite of cardiovascular death, myocardial infarction, and hospitalization for heart failure, between hyperuricemia and non-hyperuricemia groups. RESULTS: In total, 9,936 patients underwent PCI during the study period. Of these, 5,138 patients with CCS after PCI were divided into two group (1,724 and 3,414 in the hyperuricemia and non-hyperuricemia groups, respectively). The hyperuricemia group had a higher prevalence of hypertension, atrial fibrillation, history of previous hospitalization for heart failure, and baseline creatinine, and a lower prevalence of diabetes than the non-hyperuricemia group, but the proportion of men and age were similar between the two groups. The incidence of MACE in the hyperuricemia group was significantly higher than that in the non-hyperuricemia group (13.1 vs. 6.4%, log-rank P < 0.001). Multivariable Cox regression analyses revealed that hyperuricemia was significantly associated with increased MACE [hazard ratio (HR), 1.52; 95% confidential interval (CI), 1.23-1.86] after multiple adjustments for age, sex, body mass index, estimated glomerular filtration rate, left main disease or three-vessel disease, hypertension, diabetes mellitus, dyslipidemia, history of myocardial infarction, and history of hospitalization for heart failure. Moreover, hyperuricemia was independently associated with increased hospitalization for heart failure (HR, 2.19; 95% CI, 1.69-2.83), but not cardiovascular death or myocardial infarction after multiple adjustments. Sensitive analyses by sex and diuretic use, B-type natriuretic peptide level, and left ventricular ejection fraction showed similar results. CONCLUSION: CLIDAS revealed that hyperuricemia was associated with increased MACE in patients with CCS after PCI. Further clinical trials are needed whether treating hyperuricemia could reduce cardiovascular events or not.

A 95-year-old woman with no cardiac history presented with symptomatic complete atrioventricular block. She underwent temporary cardiac pacing via the cervical vein, but a pacing lead could not be introduced via the usual route because of a mediastinal tumor. A leadless pacemaker (Micra™; Medtronic, Minneapolis, MN, USA) was implanted at the right ventricular septum via the right femoral vein. The procedure time was 40 minutes, with no complications noted. Over the two-year follow-up period, the threshold and impedance remained stable. The implantation of a leadless pacemaker was useful for improving the symptoms of a super-elderly woman with a mediastinal tumor.

Cardiovascular event rates of patients with a dipper blood pressure (BP) and dipper heart rate (HR) pattern are lower than those of patients with nondipper BP and HR patterns. However, how the pacemaker mode affects the diurnal BP and HR patterns remains unclear.We enrolled nine patients (average age 74.4 ± 6.6 years, 4 males and 5 females) with sick sinus syndrome who required atrial pacing. We investigated sequential 6-month pacing regimens (DDD mode at 60 bpm and sleep rate mode). We set the lower rate of sleep rate mode as follows: 60 bpm during the daytime and 50 bpm during the nighttime. The order of pacing mode was randomized, with crossover design. Ambulatory BP monitoring was performed at baseline, 6 months, and 12 months, BP category was classified into four groups (extreme dipper, dipper, nondipper, and riser pattern), and HR was classified into dipper and nondipper patterns.Nighttime HR during the sleep rate mode was significantly lower than that at DDD (57.1 ± 6.2 versus 63.5 ± 3.8 bpm, P = 0.001). The dipper HR pattern was increased in the sleep rate mode compared with those at baseline or DDD mode (versus baseline: 89% versus 44%, P = 0.035; versus DDD: 89% versus 22%, P = 0.004). The dipper BP pattern significantly increased in the sleep rate mode compared with the baseline (56% versus 11%, P = 0.035), but the difference between the sleep rate mode and DDD mode was statistically marginal (56% versus 22%, P = 0.081).The pacemaker settings in the sleep rate mode increased the dipper HR and BP patterns in pacemaker-dependent patients with sick sinus syndrome.

BACKGROUND: Ambulatory and home blood pressure (BP) monitoring parameters are better predictors of cardiovascular events than are office BP monitoring parameters, but there is a lack of robust data and little information on heart failure (HF) risk. The JAMP study (Japan Ambulatory Blood Pressure Monitoring Prospective) used the same ambulatory BP monitoring device, measurement schedule, and diary-based approach to data processing across all study centers and determined the association between both nocturnal hypertension and nighttime BP dipping patterns and the occurrence of cardiovascular events, including HF, in patients with hypertension. METHODS: This practitioner-based, nationwide, multicenter, prospective, observational study included patients with at least 1 cardiovascular risk factor, mostly hypertension, and free of symptomatic cardiovascular disease at baseline. All patients underwent 24-hour ambulatory BP monitoring at baseline. Patients were followed annually to determine the occurrence of primary end point cardiovascular events (atherosclerotic cardiovascular disease and HF). RESULTS: A total of 6,359 patients (68.6±11.7 years of age, 48% men) were included in the final analysis. During a mean±SD follow-up of 4.5±2.4 years, there were 306 cardiovascular events (119 stroke, 99 coronary artery disease, 88 HF). Nighttime systolic BP was significantly associated with the risk of atherosclerotic cardiovascular disease and HF (hazard ratio adjusted for demographic and clinical risk factors per 20-mm Hg increase: 1.18 [95% CI, 1.02-1.37], P=0.029; and 1.25 [95% CI, 1.00-1.55], P=0.048, respectively). Disrupted circadian BP rhythm (riser pattern, nighttime BP higher than daytime BP) was significantly associated with higher overall cardiovascular disease risk (1.48 [95% CI, 1.05-2.08]; P=0.024), and especially HF (2.45 [95% CI, 1.34-4.48]; P=0.004) compared with normal circadian rhythm. CONCLUSIONS: Nighttime BP levels and a riser pattern were independently associated with the total cardiovascular event rate, in particular for HF. These findings suggest the importance of antihypertensive strategies targeting nighttime systolic BP. Registration: URL: https://www.umin.ac.jp/ctr/; Unique identifier: UMIN000020377.

OBJECTIVE: To examine the association between polarity of atrial premature complexes (APCs) and stroke. DESIGN: A prospective study. SETTING AND PARTICIPANTS: A total of 11 092 participants in the Jichi Medical School cohort study were included after excluding patients with atrial fibrillation. We analysed stroke events in patients with (n=136) and without (n=10 956) APCs. With regard to polarity of APCs, patients were subcategorised into having (1) negative (n=39) or non-negative (n=97) P waves in augmented vector right (aVR), and (2) positive (n=28) or non-positive (n=108) P waves in augmented vector left (aVL). OUTCOME MEASURES: The primary endpoint was stroke. RESULTS: Patients with APCs were significantly older than those without APCs (64.1±9.2 vs 55.1±11.6 years, p<0.001). The mean follow-up period was 11.8±2.4 years. Stroke events were observed in patients with (n=13 events) and without (n=411 events) APCs. This difference was significant (log-rank 12.9, p<0.001); however, APCs were not an independent predictor of stroke after adjusting for age, sex, height, body mass index, current drinking, diabetes, systolic blood pressure, prior myocardial infarction, prior stroke and high-density lipoprotein-cholesterol (p=0.15). The incidence of stroke in patients with APCs and non-negative P wave in aVR was significantly higher than in patients without APCs (log-rank 20.1, p<0.001), and non-negative P wave in aVR was revealed to be an independent predictor of stroke (HR 1.84, 95% CI 1.02 to 3.30). The incidence of stroke in patients with APC with non-positive P wave in aVL was also significantly higher than in patients without APC (log-rank 15.3, p<0.001), and non-positive P wave in aVL was an independent predictor of stroke (HR 1.92, 95% CI 1.05 to 3.54). CONCLUSIONS: The presence of APCs with non-negative P wave in aVR or non-positive P wave in aVL on 12-lead ECG was associated with a higher risk of incident stroke.

The value of the cardio-ankle vascular index (CAVI) increases with age. All large-scale studies of the CAVI have investigated patients <80 years old. Thus, the clinical characteristics of high CAVI in patients aged 80 or more remain unclear. Therefore, we investigated (1) the CAVI in very elderly patients and (2) the determinants of a high CAVI in high-risk patients, including very elderly patients. The Cardiovascular Prognostic Coupling Study in Japan (Coupling Registry) is a prospective observational study of Japanese outpatients with any cardiovascular risk factors. We enrolled 5109 patients from 30 institutions (average age 68.7 ± 11.4 years, 52.4% males). We investigated the determinants of the CAVI by separating the patients into three groups: 970 middle-aged (<60 years), 3252 elderly (60-79 years), and 887 very elderly (≥80 years) patients. The CAVI values of the males were significantly higher those of the females in all age groups (<60 years: 7.81 ± 1.11 vs. 7.38 ± 0.99, P < .001; 60-79 years: 9.20 ± 1.29 vs. 8.66 ± 1.07, P < .001; ≥80 years: 10.26 ± 1.39 vs. 9.51 ± 1.12, P < .001). In all age groups, the CAVI of the patients with diabetes/glucose tolerance disorder was higher than that of the patients without diabetes/glucose tolerance disorder (<60 years: 7.82 ± 1.22 vs 7.58 ± 1.03, P = .002; 60-79 years: 9.23 ± 1.20 vs 8.78 ± 1.19, P < .001; ≥80 years: 10.04 ± 1.24 vs 9.75 ± 1.32, P = .002). The determinants of the CAVI in these very elderly patients were age, male sex, low BMI, and mean blood pressure. Diabetes/glucose tolerance disorder and glucose were independently associated with the CAVI in the patients aged <60 years and 60-79 years, but not in those aged ≥80 years after adjusting for other covariates.

Background: Anticoagulant activity and blood pressure increase in the morning. The aim of this study was to evaluate changes of anticoagulant activity, blood pressure and target organ damage in patients with nonvalvular atrial fibrillation (AF) given combination treatment with Xa inhibitor and antihypertensive agent.Methods: We enrolled 72 patients with nonvalvular AF. Rivaroxaban (10-15 mg) was continuously administered once daily over 8 weeks (study period I). For subjects (n = 50) who exhibited uncontrolled morning hypertension (home systolic blood pressure [SBP]≥125 mmHg) at the end of study period I (at 8 weeks), nifedipine CR (20-40 mg) was added at bedtime, and rivaroxaban administration was continued an additional 8 weeks. We assessed prothrombin fragment 1 + 2 (optimal range: 69-229 pmol/L) and D-dimer (negative D-dimer measurement: <1.0 μg/mL).Results: The percentage of patients with optimal-range prothrombin fragment 1 + 2 was significantly increased at 4 weeks compared to baseline (70.8% vs. 86.1%, p = .033). In period II, office and home morning SBP were reduced at 12 compared to 8 weeks (office SBP: 135.2 ± 15.7 vs. 125.6 ± 18.4mmHg, p < .001; home morning SBP: 133.5 ± 10.5 vs. 119.9 ± 12.1mmHg, p<.001).The percentage of patients with negative D-dimer  was increased at 8 weeks compared to baseline (92% vs. 100%, p = .044), and remained at 100% at 16 weeks.Conclusions: Xa inhibitor therapy improved anticoagulant activity, and additional antihypertensive therapy maintained the anticoagulant activity in patients with nonvalvular AF.

Vascular biomarkers, including the cardio-ankle vascular index (CAVI), are increasingly being recognized as important indicators of cardiovascular risk. CAVI has been shown to have good discriminative ability for detecting new-onset hypertension, but results of studies investigating cardiovascular risk prediction are inconsistent. Furthermore, there is a lack of data on the prognostic value of changes in CAVI over time. The Cardiovascular Prognostic Coupling study was designed to determine the impact of baseline CAVI and changes in CAVI on cardiovascular events in a Japanese cohort. The design of the ongoing, multicenter, prospective, observational registry and baseline characteristics of the enrolled population are reported. Eligible consecutive patients were aged ≥30 years, had ≥1 cardiovascular risk factor, and were being treated according to relevant Japanese guidelines. The primary outcome is time to onset of a major cardiovascular event (a composite of cerebral infarction, cerebral hemorrhage, subarachnoid hemorrhage, stroke of unknown etiology, myocardial infarction, cardiovascular intervention for angina pectoris, and sudden death). Screening and enrollment occurred over a period of 3 years, followed by ≥7 years of follow-up, with CAVI determined annually. A total of 5279 patients were registered, of whom 5109 had baseline data available and will be included in future analyses. Mean CAVI at baseline was 8.8 ± 1.4. The proportion of patients with CAVI of <8, 8-10 or >10 was 25.3%, 57.0%, and 17.7%, respectively. Data from this registry should provide information on the significance of baseline CAVI and change in CAVI as indicators of cardiovascular prognosis in a representative patient population.

A 68-year-old Japanese man was admitted to our hospital with right eye pain, a sudden worsening of his eyesight, and a fever. He was diagnosed with endogenous bacterial endophthalmitis due to infectious endocarditis (IE) of Group B Streptococcus (GBS) on the day of admission. He recovered systemically, but his right eye became phthisical only with the administration of antibiotics. We conducted a review of the reported cases of IE caused by GBS complicated with endogenous bacterial endophthalmitis. IE should be considered when an undetermined etiology of endogenous endophthalmitis is encountered. The prompt diagnosis and treatment of IE will improve patients' outcomes.

© 2019 The Japanese Society of Internal Medicine. Objective To examine case reports presented at the Regional Meeting of the Japanese Society of Internal Medicine in order to clarify the underlying disease and prognosis of heart failure, which is often caused by non-cardiovascular diseases. Methods We examined 49,693 case reports from the Japanese Society of Internal Medicine database. A total of 2,893 reports were included after excluding 46,022 reports that did not include the term “heart failure” and 778 reports with no indications of symptoms of heart failure. We assessed each patient’s basal disease, and according to the abstracts, we reported their prognosis as dead or alive. Results Of the 2,893 reports included, 1,952 (67.5%) and 941 (32.5%) had cardiovascular and non-cardiovascular diseases as the causes, respectively; these cases were attributed to 725 different diseases, 196 (27.0%) and 529 (73.0%) of which were cardiovascular and non-cardiovascular diseases, respectively. In addition, 91 different side effects were identified. The percentage of cases of heart failure-related mortality was significantly higher among the patients with non-cardiovascular diseases than in those with cardiovascular diseases (17.8% vs. 10.8%; p <0.001). Of the diseases reported as causes of heart failure in more than 10 reports, pulmonary tumor thrombotic microangiopathy (87%), multiple myeloma (50%), and amyloidosis (47%) accounted for the highest percentages of heart failure-related mortality. Conclusion Because heart failure is often caused by non-cardiovascular diseases, a broad study of case reports on internal medicine is important for cardiologists.

The authors evaluated a new algorithm for detecting atrial fibrillation (AF) using a home blood pressure monitor. Three serial blood pressure values were measured by the monitor in 16 patients with AF and 20 patients with sinus rhythm. The authors defined monitor AF in irregular pulse peak (IPP) 25 as follows: (1) IPP: |interval of pulse peak-the average of the interval of the pulse peak| the average of the interval of the pulse peak x25%; (2) irregular heart beat: beats of IPP total pulse x20%; and (3) monitor AF: two or more irregular heart beats of the three blood pressure measurements. Cutoff IPP values were set at 20% (IPP20) and 15% (IPP15). The monitor's AF specificity was 1.0 in IPP25, IPP20, and IPP15, and its sensitivity was 0.88 in IPP25, 0.94 in IPP20, and 1.0 in IPP15. The new algorithm had high diagnostic accuracy for detecting AF and a low false-positive rate.

This study aimed to investigate the relationship between nondipper pulse rate (PR) and hypertensive target organ damage. Ambulatory blood pressure monitoring was conducted in 940 high-risk Japanese patients enrolled in the Japan Morning Surge Home Blood Pressure Study. Nondipper PR was defined as (awake PR-sleep PR)/awake PR &lt;0.1. The authors measured the patients' brain natriuretic peptide (BNP) and left ventricular mass index (LVMI). The nondipper PR group (n=213) had a significantly higher prevalence of high BNP (35pg/mL, 39.9% vs 26.1%; P&lt;.001) than the dipper PR group (n=727). LVMI was significantly higher in the nondipper PR patients compared with the dipper PR patients among the women (mean LVMI: 111.3 +/- 32.4 vs 104.2 +/- 26.7g/m(2), P=.03) but not the men (mean LVMI: 117.6 +/- 32.0 vs 117.2 +/- 33.1g/m(2), P=.92). In conclusion, the nondipper PR was associated with cardiac overload.