苅尾 七臣

A 45-year-old hypertensive Japanese woman presented with epigastric pain on inspiration, fever, complete atrioventricular block and polyarthritis. Her antistreptolysin O levels were markedly elevated. A diagnosis of rheumatic fever was made according to the modified Jones criteria. She was prescribed loxoprofen sodium, which was partially effective for her extracardiac clinical symptoms. However,

<b><i>Background:</i></b>SYMPLICITY HTN-Japan is a prospective, randomized, controlled trial comparing renal artery denervation (RDN) with standard pharmacotherapy for treatment of resistant hypertension (systolic blood pressure [SBP] ≥160 mmHg on ≥3 anti-hypertensive drugs including a diuretic for ≥6 weeks). When SYMPLICITY HTN-3 failed to meet the primary efficacy endpoint, the HTN-Japan enrollm

症例は 53 歳女性。完全房室ブロックで発症し、心臓の形態異常や 収縮障害を認めず、FDG-PET で心室中隔、左室自由壁に FDG の 集積を認めた症例である。諸検査より、心サルコイドーシスと診 断し、房室ブロックの改善目的でステロイドパルス療法(メチルプ レドニゾロン 1g/日×3 日間)を施行したところ、2日目より洞調律 に回復し、パルス療法に続いて、経口プレドニゾロンを 30mg か ら徐々に漸減、7.5mg で維持していた。その後、外来フォロー中、 洞調律は維持されていたが、心電図上 PR 間隔が 138→166ms、 QRS 幅が 94→116ms と徐々に延⻑を認めていた。発症から 2 年 後に施行した FDG-PET で心筋での活動性の再燃を認め、MTX 6mg 投与を開始したところ、PR 間隔が 142ms、QRS 幅が 103ms へ減少した。本症例は、完全房室ブロック

腎交感神経焼灼術（renal denervation：RDN）と経皮的腎血管形成術（percutaneous transluminal angioplasty：PTRA）は高血圧治療のデバイスを使った治療である．RDNについては，ヨーロッパを中心に盛んに行われているが，薬物治療と比較した試験で有用性が示されなかったため，現在，本邦での導入は進んでいない．PTRAも同様に，薬物治療と比較し有用性が示された試験はないが，現在，臨床現場では行われている治療である．重要なのは，両者とも適応をしっかり見極めることであり，究極の個別療法である．

A 45-year-old hypertensive Japanese woman presented with epigastric pain on inspiration, fever, complete atrioventricular block and polyarthritis. Her antistreptolysin O levels were markedly elevated. A diagnosis of rheumatic fever was made according to the modified Jones criteria. She was prescribed loxoprofen sodium, which was partially effective for her extracardiac clinical symptoms. However,

<b><i>Background:</i></b>SYMPLICITY HTN-Japan is a prospective, randomized, controlled trial comparing renal artery denervation (RDN) with standard pharmacotherapy for treatment of resistant hypertension (systolic blood pressure [SBP] ≥160 mmHg on ≥3 anti-hypertensive drugs including a diuretic for ≥6 weeks). When SYMPLICITY HTN-3 failed to meet the primary efficacy endpoint, the HTN-Japan enrollm

循環器疾患をより早く検出し，的確に診療するうえで，注目されている臨床検査の最新情報をまとめる．バイオマーカーでは，心不全のBNPやNT-ProBNP，心筋障害の高感度トロポニンT，血小板機能，血液凝固線溶のD-dimer，プロトロンビンF1+2，PAI-1，腎臓の推定糸球体濾過量とアルブミン尿，炎症の高感度CRP等の臨床的有用性が高い．血管検査は，脈波伝搬速度，内皮機能検査（FMD），中心血圧，頸動脈エコーの最大IMTがある．また，家庭血圧測定に加え，24時間血圧測定（ABPM）で，24時間血圧レベル，サーカディアンリズムとモーニングサージが評価でき，パルスオキシメーターで睡眠時無呼吸がスクリーニングできる．これらの最新検査は，的確な臨床状況においてこそ，その力を発揮する．十分な病歴聴取のもとに，適切な対象者への活用が望まれる．<br>

Hypertension is the most powerful risk factor for stroke. Blood pressures (BP) measured out of clinic, such as self-measured BP at home and ambulatory BP are the better predictor of stroke than clinic BP. As well as higher 24-hr BP level, disruption of diurnal BP variation is also associated with increased risk for stroke. Recent prospective studies clearly demonstrated that the riser pattern with higher nocturnal BP than daytime BP and nocturnal hypertension per se are closely associated with cardiovascular death and cardiovascular events such as stroke and cardiac disease. The following pathological conditions are closely associated with this riser and non-dipper patter: increased circulating blood volume such as chronic kidney disease and congestive heart failure, autonomic nervous dysfunction such as diabetes particularly with neuropathy, and poor sleep quality such as sleep apnea syndrome. We have developed nocturnal hypoxia-triggered BP monitoring, and have detected marked midnight BP surges at the time of sleep apnea episodes. As the cardiovascular risk is increased in a sleep period in patients with obstructive sleep apnea, this surge may trigger the sleep-onset stroke. Considering that morning BP surge is the risk of stroke in a general population, the time of BP surge may be the time of increased cardiovascular risk. The perfect 24-hr BP control with diminishing exaggerated BP surge may achieve more effective prevention in stroke in hypertensive patients.<br>

欧米あるいはわが国における地域住民を対象としたさまざまなエビデンスから、JNC7において前高血圧(pre-hypertension)と定義された群の心血管あるいは脳血管イベントのリスク上昇が指摘されてきた。また地域住民を対象とした自治医科大学コホート研究においては、3分の1がpre-hypertensionであり、この群における規定因子は心血管イベントのハイリスクとされてきた肥満、脂質異常症、糖代謝異常によるものであったこと、また欧米と比較し、軽度の肥満であってもpre-hypertensionへの有意な関連があることを報告した。本稿では、わが国におけるpre-hypertensionの特徴を示し、この群へのハイリスクアプローチの必要性を解説する。(著者抄録)

INTRODUCTION: No epidemiological data exist concerning the influence of an earthquake on the risk of stroke. Whether the incidence of cerebrovascular stroke increased after the 1995 Hanshin-Awaji earthquake (EQ) in Japan and whether seismic intensity affected stroke risk dose-dependently was examined. METHODS: A retrospective cohort study was conducted among residents, who were living in two towns on the island of Awaji and were participants of the National Health Insurance (NHI) program. The two towns were divided into 11 districts and their respective damage and socioeconomic states were investigated. Reviewing the NHI documents issued before and after the EQ, people who had strokes (9th International Classification of Diseases, codes 430-431 or 433-434.9) were identified. Risk of stroke in relation to the seismic intensities, was assessed with the Cox proportional hazard model. RESULTS: Among subjects aged 40 to 99 years, 45 of 8,758 (0.514%) had a stroke the year before the EQ 72 of 8,893 (0.810%) had a stroke in the first year following the EQ, and 49 of 8,710 (0.566%) had a stroke in the second year following the EQ. In districts where the earthquake's intensity was < or = 9.5 on the modified Mercalli intensity (MMI), compared with the year prior to the EQ, the relative risk (RR) of stroke was 2.4 (95% confidence interval (CI) = 1.1, 5.0) in the first year following the EQ, after adjusting for age, gender, and income. In that year, compared with MMI of < 8.5-9.0, RRs for 9.0-9.5 and > or = 9.5 were 1.6 (CI = 0.9, 2.1) and 2.0 (CI = 1.1, 3.7), respectively (p for trend 0.02). No trend for the RR was observed in the year before the EQ or in the second year following the EQ. CONCLUSION: The incidence of stroke increased in the first year following the EQ. The increase was associated with seismic intensity in a dose-response manner. Results suggest a potential threshold for RR of > or = 2.0 in areas near 9.5 on the MMI scale.

Objective. We conducted a large-scale cross-sectional study to assess the prevalence of Chlamydia pneumoniae and clarify the association between seropositivity and risk factors, such as smoking status, physical activity and body mass index in Japanese rural districts. Methods. A total of 1,063 men and 1,573 women aged 18-94 years participated in 1999. Serum index values (ID) of IgA and IgG antibodies to C pneumoniae were measured by ELISA. Index values were categorized as "negative" (ID&lt 1.10), "positive" (ID ≧ 1.10) and "high positive" (ID ≧ 3.00). Logistic regression analysis was performed to estimate the crude and adjusted odds ratios for C. pneumoniae seropositivity. Results. The overall prevalence of C. pneumoniae IgA seropositivity was 52.5%, and that of IgG was 55.2%. Each seropositivity significantly increased with age. The prevalence among men was significantly higher than in women in C. pneumoniae IgG "high positive" subjects. Compared with never-smokers, the adjusted odds ratio of current smokers was 2.00 (95%CI: 1.45-2.77) for C. pneumoniae IgA seropositivity. The adjusted odds ratio of the higher tertiles of physical activity for C. pneumoniae IgG seropositivity was 1.42 (1.12-1.80) compared with the lower tertiles. In "high positive" subjects, smoking was associated with both immune complexes. Conclusion. We confirmed a high prevalence of C. pneumoniae seropositivity among healthy Japanese adults. The results indicated that smoking and high physical activity were associated with C. pneumoniae infection.