Objective: We assessed whether there is dissociation between ambulatory blood pressure (BP) reduction and clinic BP reduction by antihypertensive medication in hypertensive patients with and without diabetes mellitus (DM). Design and Method: We formerly performed randomized, multicenter, open-label trial in essential hypertensives. 105 patients with clinic BP ≥ 140/90 mmHg with amlodipine 5 mg were randomly allocated to aliskiren (150–300 mg)/amlodipine (5mg) (ALI/AML) or high-dose amlodipine (10 mg) (h-dAML) group and were treated for 16 weeks. Ambulatory BP and clinic BP were measured at baseline and at the end of the study. In current post-hoc analysis study, we divided 86 patients (age 77.1 years) who completed treatment period into Non-DM (n = 75) or DM (n = 11) group, and compared ambulatory BP reduction and clinic BP reduction. We defined ‘DM’ as antidiabetic treated DM patients or baseline HbA1c ≥ 6.5, and ‘Non-DM’ as the other patients. No type 1 DM patient is included in this study. Results: There was no significant difference in clinic BP and ambulatory BP at baseline. The reduction of clinic SBP were similar between the Non-DM and DM group (−10.7 ± 18.7 vs. −5.8 ± 18.0 mmHg, p = 0.42), whereas the reduction of 24-h SBP (−7.7 ± 10.9 vs. 1.7 ± 11.5 mmHg, p = 0.01) and daytime SBP (−7.8 ± 13.4 vs. 3.6 ± 13.8 mmHg, p = 0.01) were significantly smaller in the DM group than in the Non-DM group. 24-h SBP and daytime SBP were significantly decreased by treatment only in the Non-DM group. Conclusions: Although the magnitude of clinic SBP reduction were similar, 24-h SBP reduction and daytime SBP reduction were significantly smaller in DM compared with in Non-DM. Our data suggest that ambulatory BP reduction by antihypertensive medication is insufficient in hypertensive patients with DM.
Abstract Objectives We evaluated the in‐hospital outcomes of percutaneous coronary intervention (PCI) for bypass graft vessels (GV‐PCI) compared with those of PCI for native vessels (NV‐PCI) using data from the Japanese nationwide coronary intervention registry. Methods We included PCI patients ( N = 748,229) registered between January 2016 and December 2018 from 1,123 centers. We divided patients into three groups: GV‐PCI ( n = 2,745); NV‐PCI with a prior coronary artery bypass graft (pCABG) ( n = 23,932); and NV‐PCI without pCABG ( n = 721,552). Results GV‐PCI implementation was low, and most cases of PCI in pCABG patients were performed in native vessels (89.7%) in contemporary Japanese practice. The risk profile of patients with pCABG was higher than that of those without pCABG. Consequently, GV‐PCI patients had a significantly higher in‐hospital mortality than NV‐PCI patients without pCABG after adjusting for covariates (odds ratio [OR] 2.36, 95% confidence interval [CI] 1.66–3.36, p < .001). Of note, embolic protection devices (EPDs) were used in 18% ( n = 383) of PCIs for saphenous vein grafts (SVG‐PCI) with a significant variation in its use among institutions (number of PCI: hospitals that had never used an EPD vs. EPD used one or more times = 240 vs. 345, p < .001). The EPDs used in the SVG‐PCI group had a significantly lower prevalence of the slow‐flow phenomenon after adjusting for covariates (OR 0.45, 95% CI 0.21–0.91, p = .04). Conclusion GV‐PCI is associated with an increased risk of in‐hospital mortality. EDP use in SVG‐PCI was associated with a low rate of the slow‐flow phenomenon. The usage of EPDs during SVG‐PCI is low, with a significant variation among institutions.
We report the case of a 79-year-old man with acute myocardial infarction caused by left main trunk lesion, who experienced cardiogenic shock during percutaneous coronary intervention (PCI). To reverse the cardiogenic shock, we initiated veno-arterial extra corporeal membrane oxygenation (VA-ECMO) without an intra-aortic balloon pump (IABP) due to the severe tortuosity of the left external iliac artery. Although PCI was successful, arterial pressure monitoring revealed that the pulse pressure was too low to recover from the cardiogenic shock of decreased cardiac contraction function (the left ventricular ejection fraction was 30%). Thus, we decided to use IABP from the brachial artery to improve the hemodynamics. Immediately after the deployment of a 6-Fr IABP system (Takumi) from the left brachial artery, the pulse pressure was restored and finally VA-ECMO was withdrawn from the patient without complications. Although using IABP in combination with VA-ECMO is a reasonable strategy for cardiogenic shock, the effectiveness of this combination remains controversial. In this case, IABP added to VA-ECMO clearly achieved an improvement of pulse pressure and vital signs. Based on this result, monitoring of the pulse waveform is an effective tool to determine whether the concomitant use of IABP with VA-ECMO is indicated. Moreover, when it is difficult to insert IABP from the femoral arteries, the use of a 6-Fr IABP system (Takumi) approaching from the brachial artery should be considered.
The aim of this study was to compare the differences in the levels of a highly sensitive cardiac troponin T (Hs-cTnT) between Losartan (LOS) plus hydrochlorothiazide (HCTZ) and amlodipine. Seventy-eight hypertensive patients were randomized to receive LOS/HCTZ or amlodipine for 8 weeks. Both treatments decreased clinic and 24-hour blood pressure to the same extent. The Hs-cTnT level was significantly reduced in the amlodipine group (P < .05), but such a reduction was not found in the LOS/HCTZ group in the upper half group of Hs-cTnT level at baseline. Amlodipine had a more beneficial effect than LOS/HCTZ in patients with high Hs-cTnT levels.
Several guidelines recommend that home blood pressure (HBP) be measured both in the morning and in the evening. However, there have been fewer reports about the clinical significance of morning HBP than about the clinical significance of evening HBP. Our study included 4,310 patients recruited for the Japan Morning Surge Home Blood Pressure Study who had one or more cardiovascular risk factors. We measured morning and evening HBP, urinary albumin–creatinine ratio (UACR), left ventricular mass index (LVMI), brachial-ankle pulse wave velocity (baPWV), maximum carotid intima media thickness (IMT), N-terminal pro-brain–type natriuretic peptide (NT-proBNP), and high-sensitivity cardiac troponin T (Hs-cTnT). The correlation coefficients for the associations between morning systolic BP (SBP) and log-transformed baPWV, NT-proBNP, or Hs-cTnT were significantly greater than the corresponding relationships for evening SBP (all P < 0.01). The goodness-of-fit of the associations between morning home SBP and UACR (P < 0.05) or baPWV (P < 0.01) was improved by adding evening home SBP to the SBP measurement. In contrast, the goodness-of-fit values of the associations between evening SBP and UACR (P < 0.001), LVMI (P < 0.05), baPWV (P < 0.001), NT-proBNP (P < 0.001), and Hs-cTnT (P < 0.001) were improved by adding morning home SBP to the SBP measurement. Morning BP and evening BP provide equally useful information for subclinical target organ damage, yet multivariate modeling highlighted the stand-alone predictive ability of morning BP.
The aim of this study was to compare the effects of direct renin inhibitor, aliskiren, and amlodipine combination therapy with those of high-dose amlodipine monotherapy on endothelial function in elderly hypertensive patients.Participants included 105 patients (mean age 77 years) who had receive 5mg amlodipine for 4 weeks. Patients were allocated to the aliskiren/amlodipine group (AL/AM) or the high-dose amlodipine (AM) group. The AL/AM group received 150mg aliskiren in addition to 5mg amlodipine for 8 weeks; then the dose of aliskiren was doubled to 300mg for another 8 weeks. The AM group received 10mg amlodipine for 16 weeks. Of the 105 patients, 87 who underwent measurements of brachial flow-mediated vasodilation (FMD) and nitroglycerin-mediated vasodilation (NMD) before and after the study were included in the analysis.Blood pressure-lowering effects were similar in the 2 groups. Plasma renin activity significantly decreased in the AL/AM group (P < 0.001) but increased in the AM group (P < 0.001). Improvement of FMD was found in the AL/AM group (2.6% to 3.7%, P = 0.001) but not in the AM group, while NMD did not change in either group. The changes in 24-hour systolic blood pressure (r = -0.60, P < 0.001) and diastolic blood pressure (r = -0.46, P = 0.004) were significantly correlated with improvement of FMD in the AL/AM group but not in the AM group.Addition of aliskiren improved endothelial function in elderly hypertensive patients treated with amlodipine.UMIN000010163.
A longer stent length is known to be a predictor of adverse events after a percutaneous coronary intervention (PCI). However, the evaluation of the stent length on the outcome of ST-segment elevation myocardial infarction (STEMI) patients is not enough.A total of 686 STEMI patients who underwent primary PCI were divided into four groups according to the total stent length as follows: short (<18 mm, n=183), lower-medium (18-23 mm, n=256), upper-medium (24-31 mm, n=155), and long (≥32 mm, n=92). We compared the all-cause mortality, major adverse cardiovascular events (MACEs; composite of cardiovascular death, myocardial infarction, and stroke after discharge), target lesion revascularization, and target vessel revascularization with a median follow-up of 1213 days among these four groups.There were no significant differences in MACEs (10.4% in the short, 7.0% in the lower-medium, 6.5% in the upper-medium, 7.6% in the long, P=0.633) among the different stent length groups. The all-cause mortality, target lesion revascularization, and target vessel revascularization also did not differ among the four groups. In the drug-eluting stent (n=237) and bare-metal stent subgroups (n=449), all outcomes were comparable among the groups. However, in the diabetes subgroup (n=265), the rate of MACEs was higher in the long group than in the other groups, although the difference was not significant (6.6% in the short, 9.6% in the lower-medium, 3.4% in upper-medium, 16.7% in long group, P=0.095).A long stent length was not associated with adverse clinical outcomes in STEMI patients who underwent primary PCI.
Abstract Background The optimum timing of revascularization strategy for stenoses in nonculprit vessels in patients with ST‐segment elevation myocardial infarction (STEMI) and multivessel disease (MVD) remains unclear. At present, there is no evidence investigating the outcome of staged percutaneous coronary intervention (PCI) within two weeks from admission among STEMI patients with MVD. Methods A total of 210 STEMI patients with MVD who underwent primary PCI were analyzed. We compared the all‐cause mortality and major adverse cardiovascular events (MACE) (cardiovascular death, myocardial infarction, heart failure, unstable angina, and stroke) with median follow‐up of 1200 days among the patients who underwent staged PCI within two weeks from admission (staged PCI ≤2 W) ( n = 75), staged PCI after two weeks from admission (staged PCI >2 W) ( n = 37) and culprit‐only PCI ( n = 98) in patients with STEMI and MVD. Results The staged PCI ≤2 W showed lower all‐cause mortality than culprit‐only PCI (4.0 vs 29.6%, log‐rank P = 0.001), and lower incidence of MACE than the staged PCI >2 W group (1.3 vs 18.9%, log‐rank P = 0.001) and culprit‐only PCI group (1.3 vs 22.5%, log‐rank P = 0.001). In the multivariable Cox regression analysis, the staged PCI ≤2 W was a predictor of lower all‐cause mortality (hazard ratio [HR], 0.176; 95% confidence interval [CI], 0.049‐0.630; P = 0.008) and lower incidence of MACE (HR, 0.068; 95% CI, 0.009‐0.533; P = 0.011), but staged PCI >2 W was not. Conclusion In conclusion, staged PCI within two weeks after admission showed more favorable outcomes compared with staged PCI after two weeks from admission or culprit‐only PCI in STEMI patients with MVD.
Our aim is to determine the optimal time schedule for home blood pressure (BP) monitoring that best predicts stroke and coronary artery disease in general practice. The Japan Morning Surge-Home Blood Pressure (J-HOP) study is a nationwide practice-based study that included 4310 Japanese with a history of or risk factors for cardiovascular disease, or both (mean age, 65 years; 79% used antihypertensive medication). Home BP measures were taken twice daily (morning and evening) over 14 days at baseline. During a mean follow-up of 4 years (16 929 person-years), 74 stroke and 77 coronary artery disease events occurred. Morning systolic BP (SBP) improved the discrimination of incident stroke ( C statistics, 0.802; 95% confidence interval, 0.692–0.911) beyond traditional risk factors including office SBP (0.756; 0.646–0.866), whereas the changes were smaller with evening SBP (0.764; 0.653–0.874). The addition of evening SBP to the model (including traditional risk factors plus morning SBP) significantly reduced the discrimination of incident stroke ( C statistics difference, −0.008; 95% confidence interval: −0.015 to −0.008; P =0.03). The category-free net reclassification improvement (0.3606; 95% confidence interval, 0.1317–0.5896), absolute integrated discrimination improvement (0.015; SE, 0.005), and relative integrated discrimination improvement (58.3%; all P <0.01) with the addition of morning SBP to the model (including traditional risk factors) were greater than those with evening SBP and with combined morning and evening SBP. Neither morning nor evening SBP improved coronary artery disease risk prediction. Morning home SBP itself should be evaluated to ensure best stroke prediction in clinical practice, at least in Japan. This should be confirmed in the different ethnic groups. Clinical Trial Registration— URL: http://www.umin.ac.jp/ctr/ . Unique identifier: UMIN000000894.
