A 64-year-old man complaining of resting angina underwent emergent coronary angiogram and significant stenosis in the mid-left anterior descending artery was discovered. Although deployment of the drug-eluting Cypher stent relieved the stenosis, the guiding catheter accidentally induced coronary dissection in the left main coronary artery (LMCA). Then, deployment of another Cypher stent at the lesion successfully managed the complication. 20 days later, although asymptomatic, extensive aortic dissection was detected from the coronary sinus of Valsalva to the femoral artery. 64-Row multidetector computed tomography demonstrated that the dissection originated from the LMCA and retrogradely expanded to the aorta. This type of dissection is a rare complication related to coronary intervention and even in such a clinical setting, asymptomatic delayed progression of retrograde aortic dissection has not previously been reported to our knowledge.

A 48-year-old man suffered from uncontrollable coronary vasospasms, even when taking the maximum dose of vasodilators. The patient had a history of hypereosinophilia, and as the eosinophilia worsened, more frequent and intense coronary spastic angina (CSA) attacks occurred. He was treated with 20 mg/day of oral prednisolone, and the chest symptoms of CSA completely resolved thereafter. We encountered a refractory CSA patient with an allergic predisposition for which the oral administration of corticosteroids was markedly effective. Although the priority of corticosteroid therapy is not clinically high in patients with CSA, it can be effective especially in patients with an allergic background.

he correlation between cardiac disease and liver dysfunction is well documented, but constrictive pericarditis (CP) rarely presents with ischemic hepatitis. Case ReportA 57-year-old woman with disturbed consciousness was transported to the emergency room. Her blood pressure was 104/88 mmHg, pulse rate was 98/min with regular rhythm, and she was afebrile. Her jugular vein was distended and showed venous collapse in the diastolic phase. Her legs were considerably edematous. A grade 2/6 systolic regurgitant murmur was audible at the right sternal border in the 4 th intercostal space, but excess heart sounds were unclear. On pulmonary auscultation, sounds were hardly heard in the left lung field. Computed tomography (CT) did not show any evidence of organic lesion in the brain. Though she had no predisposition to hypoglycemia, her serum glucose level was 23 ng/ml and a venous infusion of glucose restored normal consciousness. The first blood gas analysis under 5 L/min oxygen inhaled when just arriving at the hospital showed severe respiratory acidosis (Table 1). However, after recovery of consciousness, the hypercapnia was soon reversed. In addition to low levels of serum glucose, laboratory results showed high necro-inflammatory activity of the liver with an alanine transferase (ALT) level of 1,755 U/L, aspartate transferase (AST) level of 3,615 U/L, lactate dehydrogenase (LDH) level of 5,160 U/L, 47% prothrombin time ratio, and total bilirubin (T-Bil) level of 3.9 mg/dl (Table 1). She was seronegative for both hepatitis B virus (HBV) and hepatitis C virus (HCV), and had not taken any hepatotoxic medicines. Ultrasonography showed no findings of the abdominal organs but there was a small amount of ascetic fluid. Her recent laboratory data and physical (Received October 29, 2007; revised manuscript received March 6, 2008; accepted April 3, 2008; released online November 11, 2008) Department of Cardiovascular Medicine, *Department of Gastroenterology, Nantan General Hospital, Nantan and **Department of Cardiovascular Medicine, Kyoto Prefectural University School of Medicine, Kyoto, Japan Mailing address: Tetsuya Nomura, MD, Department of Cardiovascular Medicine, Nantan General Hospital, 25 Yagi-Ueno, Yagi-cho, Nantan 629-0197, Japan. E-mail: t2-ya@za2.so-net.ne.jp All rights are reserved to the Japanese Circulation Society. For permissions, please e-mail: cj@j-circ.or.jp Chronic Pericardial Constriction Induced Severe Ischemic Hepatitis Manifesting as Hypoglycemic AttackTetsuya Nomura, MD; Natsuya Keira, MD; Yota Urakabe, MD; Daisuke Naito, MD; Mayuka Nakayama, MD; Atsumichi Kido, MD; Hidetoshi Kanemasa, MD*; Hiroaki Matsubara, MD**; Tetsuya Tatsumi, MD Ischemic hepatitis, otherwise known as "shock liver", is characterized by a massive, but transient increase in serum transaminase levels, usually associated with cardiac failure. A patient who did not have a predisposition to hypoglycemia was discovered at home with disturbed consciousness caused by hypoglycemia. She had been diagnosed as having constrictive pericar...

It is well known that silent myocardial ischemia (SMI) often complicates patients with cerebral infarction and that stroke patients often die of ischemic heart disease. Therefore, it is considered important to treat myocardial ischemia in stroke patients. This study investigated SMI complicating Japanese patients with fresh stroke, using (99m)Tc-tetrofosmin myocardial scintigraphy with pharmacologic stress testing to elucidate their clinical manifestations. This study included 41 patients (26 men, mean age 76.0 ± 10.7 years) with acute cerebral infarction and no history of coronary artery disease. All patients underwent (99m)Tc-tetrofosmin myocardial scintigraphy with intravenous administration of adenosine to diagnose SMI. Of the 41 patients, myocardial ischemia was confirmed in 17 patients (41.5%). Atherosclerotic etiology was the major cause of stroke in the ischemia(+) group and embolic origin was the major cause in the ischemia(-) group. Patients with myocardial ischemia had a higher incidence of diabetes mellitus (52.9 vs 20.8%; P = 0.0323) and more than two conventional cardiovascular risk factors (64.7 vs 25.0%; P = 0.0110) compared with the nonischemic patients. Infarction subtype of atherosclerotic origin was an independent positive predictor of asymptomatic myocardial ischemia in patients with stroke. These findings indicate that the prevalence of asymptomatic myocardial ischemia is relatively high, especially in patients with stroke of atherosclerotic origin. Therefore, it is beneficial for us to narrow the target population who are at the highest risk when screening for SMI in Japanese patients with acute cerebral infarction.

These findings indicate that patients with ET>12 h have a less severe condition and less frequently receive primary PCI compared with patients with ET≤12 h. Although primary PCI is often performed for these patients irrespective of the severity of heart failure, no preferable effect of primary PCI on the in-hospital mortality is demonstrated. In contrary, practice of primary PCI is a significant negative predictor of in-hospital mortality for patients with ET≤12 h.