Therapeutic Research
Volume 30, Issue 7, 2009
Volumes & issues:
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State of the Art
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- 高血圧臨床研究の動向2009
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Series Mystery of platelet
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- 第2 回生活習慣病と血小板
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Roundtable
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Symposium
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- SUSPECT HIT in Sendai
- 一般講演
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1. 循環器領域でのHIT症例−いつHITを疑ったか−当施設で経験したヘパリン起因性血小板減少症(HIT)を生じた急性心筋梗塞症の3例
30巻7号(2009);View Description Hide Description -
- 特別講演
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- 第33回埼玉不整脈ペーシング研究会
- 一般演題
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歯科治療によりDDD Pacemakerの設定がBack−up VVI Modeに切り替わってしまった1症例
30巻7号(2009);View Description Hide Description症例は69 歳,男性。洞不全症候群の診断にて,2004年4月にDDD ペースメーカー(PM)の植え込みを受けた(レートは70 〜 120/ 分に設定)。術後,併存疾患の発作性心房細動に対してフレカイニドの投与が開始となった。退院後,pacemaker clinic において定期的なチェックを受けていたが,特に問題所見は認められなかった。知覚過敏に対する加療のため某歯科医院を受診し,2008 年4 月から5 月にかけて計3 回の治療を受けた。その後,胸部不快感などの気分不快が続くため,5 月に当科の外来を受診。 12誘導心電図では心室ペーシング調律(60/ 分)となっており,心房波は全心拍のT波上に認められた。PMのinter rogation を行ったところ,back?up VVIモードになっていることが判明した。プログラマーを用いてPMの設定をDDD70 〜 120/ 分に変更した。その後は患者の症状は消失し,安定している。原因調査によりイオン導入器が歯科治療の際に使用されていたことが判明した。本治療器はフッ素を治療部に充填する際,比較的微弱な電流が探触子と対極板の間に流れる仕組みになっている。本治療器の使用により異常が発生した事例の報告は過去になく,PM症例でも使用可能であると歯科業界では考えられてきた。しかし,今回PMのリセットが生じるという重大な合併症が確認されたため,報告する。 -
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広範な低電位領域に存在したIsthmusの同定に種々の設定のVoltage Mapが有用であった心室頻拍の1例
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発作性心房細動に対するPV Isolation時に認められた心房頻拍に対しCARTOが有効であった心房中隔欠損症症例
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心房細動の治療戦略−低侵襲外科治療:胸腔鏡mini Maze−
30巻7号(2009);View Description Hide Description心房細動の外科治療では,Maze 法が満足のいく結果を得ている。しかし,Maze 法は,複雑で難度が高く侵襲も大きいため,わが国においては器質的心疾患を有さない心房細動に対しては受け入れられていない。欧米で2003年より胸腔鏡やRobot を用いた低侵襲外科治療が行われ,わが国でも2007年に導入され良好な結果を得ている。今後,非弁膜症性心房細動の疾病者数の増加が予想され,低侵襲外科治療が治療法の選択肢の一つとして期待されている。胸腔鏡mini Mazeの手術適応は,薬物療法に抵抗性の非弁膜症性心房細動で,左心房のリモデリングを伴わない(左房長径<5cm)症例となる。手術は,分離肺換気による全身麻酔下に行い,人工心肺を使用することなく心拍動下に胸腔鏡を用いて,心房細動の発生と持続の二つの事象に対し,肺静脈隔離術とGanglion焼灼を行う簡略化した治療法である。これまでの報告で死亡例はなく,合併症として術中肺静脈損傷や左心耳からの出血,術後胸腔内出血があるが,致死的合併症は認めない。われわれが日米で施行した20 例では18 例が洞調律へ復帰している。胸腔鏡mini Maze は,カテーテルアブレーションと比べ,全身麻酔が必要であり,胸部に小切開は加わるが,放射線被曝がなく,胸腔鏡の画像で確実に肺静脈隔離術が行え,心外膜直下に存在するganglionを同定し焼灼することが可能である。従来のMaze 法と比べると簡略化した治療法であるが,人工心肺や胸骨正中切開が不要であり低侵襲かつ美容上優れている。胸腔鏡mini Mazeは,薬物療法に抵抗性の非弁膜症性心房細動に対する治療戦略において,有用な治療法の選択肢となりうると考えられる。 -
- 特別講演
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- 第21回神奈川心不全研究会
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1. レジオネラ肺炎を契機に発症した虚血性心疾患を伴う高血圧性心不全に対し血行再建後,睡眠時無呼吸症候群に対しASVが著効した1例
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2. 中枢性睡眠時無呼吸を合併する慢性心不全に対しASV導入により運動時周期性呼吸および心不全が著明に改善した1例
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6. Potential utility of ambulatory blood pressure monitoring in patients with congestive heart failure
30巻7号(2009);View Description Hide DescriptionBlood pressures and heart rates are characterized by circadian changes. However, whether ambulatory blood pressure monitoring can have a useful role in the management of heart failure remains unclear. We studied 6 inpatients with New York Heart Association functional class I or II congestive heart failure (CHF). The subjects underwent 24–hour ambulatory blood pressure moni- toring (ABPM), Holter electrocardiographic (ECG) monitoring, echocardiography, and endocri- nologic evaluations. There were no significant differences between daytime and nighttime systolic or diastolic blood pressures or heart rate. Multivariate linear regression analyses showed that the plasma BNP concentration negatively correlated with nighttime heart rate, daytime blood pres- sure, and ejection fraction, but positively correlated with the plasma noradrenaline concentration. Our results suggest that a reduction in BNP levels might require the maintenance of higher nighttime heart rates and daytime blood pressures in patients with CHF. Chrono–cardiovascular approaches may thus be useful for the management of CHF. -
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原著
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The renoprotective effects of benidipine in Chinese senile hypertensive patients
30巻7号(2009);View Description Hide DescriptionObjective:This study examines the protective effect of benidipine on the renal function of Chinese senile mild to medium hypertensive patients over a period of 1 year.Methods:Chinese senile mild to medium hypertensive patients were screened and took benidipine for 1 year. Changes in blood pressure, heart rate, serum creatinine, and urinary micro−albumin excretion were compared. Results:After treatment with benidipine alone for 2 weeks, blood pressure was reduced to below the target leve(l 140/90 mmHg)in 6 of the 15 participating patient(s 40%).Diuretics and/or β−receptor blockers were additionally administered to 9 patients. After medication for 8 weeks, 11 patients(73.3%)attained the target blood pressure level. Mean blood pressure was decreased significantly from 151.4/88.4 mmHg before medication to 137.4/81.3 mmHg after medication and remained stable at the designated target level.Serum creatinine was lowered from 78.1±16.9μmol/L before medication to 66.9±15.1μmol/L after 1 year(p=0.02). Urinary micro−albumin was also reduced from 8.28±15.27mg/dL to 1.61±0.93 mg/dL(p=0.055).Conclusions:Benidipine has a stable, long−acting antihypertensive effect and protects renal function. -
Antihypertensive and organ−protective effects of valsartan in essential hypertension patients showing inadequate response to a combined antihypertensive drug regimen including olmesartan medoxomil
30巻7号(2009);View Description Hide DescriptionObjective:This study was conducted in essential hypertension patients showing inadequate response to a combined antihypertensive drug regimen including olmesartan medoxomil, to clarify whether additional antihypertensive and organ−protective effects could be obtained by substituting olmesartan medoxomil with valsartan.Methods:In 14 patients(8 males, 6 females;mean age, 71 years)who showed systolic blood pressure readings of 140 mmHg or over despite 6 months or longer treatment with oral olmesartan medoxomil at 20 to 40 mg/day, the systolic blood pressure, diastolic blood pressure, pulse rate, and urinary albumin excretion were measured. Then, olmesartan medoxomil 20 mg/day was switched to valsartan 80 mg/day, and olmesartan medoxomil 40mg/day to valsartan 160 mg/day. Until 1 year after the drug switch, the same measurements were performed every 3 months. In addition, echocardiography and brachial−ankle pulse wave velocity(baPWV)measurement were performed at the time of the drug switch to valsartan and at 1 year after the drug switch.Results:Significant reduction of both the systolic and diastolic blood pressures were obtained following the drug switch from olmesartan medoxomil to valsartan(p=0.0010, p=0.0369). No significant change in the heart rate was detected(p=0.4169). Urinary albumin excretion was also significantly reduced by the switch to valsartan(p=0.0443). No significant change was detected in the left ventricular diameter or left ventricular wall thickness when comparing the echocardiograms obtained before and after the drug switch to valsartan, but the peak systolic wall stress and baPWV were significantly reduced after the change to valsartan(p=0.0417, 0.0229).Conclusions:In patients who failed to show adequate control of the blood pressure while receiving a combined antihypertensive drug regimen including olmesartan medoxomil,significant antihypertensive and organ−protective effects were produced when olmesartan medoxomil was switched to valsartan. The present results suggest that a change of olmesartan medoxomil to valsartan in patients receiving, but showing poor response, to a combined antihypertensive drug regimen containing the former might prove effective in achieving the treatment objectives. -
Candesartan reduces the progression of eGFR in hypertension patients
30巻7号(2009);View Description Hide DescriptionBackground and purpose:Recently the demand for dialysis and kidney transplantation from chronic kidney disease(CKD)has increased. However, the ratio of patients with CKD, which causes cardiovascular disease(CVD), is greater than the ratio of those that progress to end stage renal disease(ESRD). This study investigated whether candesartan reduced the progression of CKD. Methods:This study investigated the background factors, such as the type of antihypertensive agents, blood pressure(BP)and body mass index(BMI)for 119 essential hypertensive outpatients who took candesartan for more than one year. The patients were classified into stages following the CKD stage classification using the revised estimated glomerular filtration rate(GFR). Results:There was progression to CKD stage 3 in all subjects and the ratio of the subjects achieving their target BP by using candesartan significantly improved from 25.2% to 68.9%. The ratio of it with CKD stage 3 also improved significantly from 8.8% to 44.1%. The average eGFR showed no significant change over 4 years following admission. When the subjects were classified by the CKD stage, the ratio of achieving a systolic BP <130 mmHg by the use of candesartan rose significantly from 15.4% to 61.5% in improving CKD stage group. The improving CKD stage group had a higher BMI. The eGFR improved significantly from 53.8 mL/min/1.73 m2 to 59.4 mL/min/1.73 m2 in the subjects with CKD stage 3 over 3 years and the majority of these patients took the maximum dose(12 mg).Conclusions:This analysis confirmed that angiotensin I I receptor blocker(ARB)was necessary and high dose ARB was important for renoprotection. Furthermore, renoprotective effects were expected in the cases that strictly achieved at the target BP and in the cases of higher BMI. -
本態性高血圧患者においてL/N型カルシウムチャネル拮抗薬シルニジピンが腎機能と血管硬度に及ぼす影響
30巻7号(2009);View Description Hide Descriptionシルニジピンは従来の Ca 拮抗薬と異なり,L型のみならず N 型 Ca チャネルを阻害する L/N 型 Ca 拮抗薬である。交感神経活動を抑制して糸球体の輸出細動脈を拡張し,糸球体高血圧を改善することが報告されている。さらに,高血圧性の臓器障害に対しても予防効果が期待できる。本研究は,Ca 拮抗薬以外の降圧薬を投与されている患者および未治療の本態性高血圧患者を対象に,シルニジピンを 12 ヵ月間投与して尿中アルブミンおよび血清クレアチニン(Cr)を指標に腎保護作用を検討した。また,動脈硬化の指標として pulse wave velocity(PWV)を測定した。収縮期および拡張期血圧は投与 6 ヵ月後から低下がみられ,12 ヵ月後においても安定した降圧作用が観察された(収縮期血圧 p=0.001,拡張期血圧 p=0.04)。シルニジピン投与12 ヵ月後において尿中アルブミン(p=0.04)および血清 Cr(p=0.04)の有意な低下がそれぞれみられた。一方,PWV においては投与 12 ヵ月後に有意な低下が観察された(p=0.003)。以上の結果より,シルニジピン投与は本態性高血圧患者において降圧作用を示すとともに腎機能および動脈硬化を改善することが示唆された。 -
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Blockade of angiotensin II type 1 receptor by telmisartan suppressed activation of human hepatic stellate cells
30巻7号(2009);View Description Hide DescriptionAims:Recent evidences indicate that obesity progress some hepatic diseases characterized progressive fibrosis involving the hepatic renin−angiotensin system, so−called nonalcoholic fatty liver disease(NAFLD)or nonalcoholic steatohepatitis(NASH).Main methods:We evaluated the effects of telmisartan on the transforming growth factor(TGF)−β−induced activation of the human hepatic stellate cell line, LX2 cells, by measurement of the regulation of angiotensin I I type 1 receptor(AT1−R)and peroxisome proliferator−activated receptor−γ(PPARγ)mRNA and quantifying the markers of the hepatic fibrosis, such as α1 procollagen, α−smooth muscle actin(αSMA), and matrix metalloproteinase 13(MMP13)mRNA, using quantitative real time PCR analysis.Key findings:Both telmisartan and losartan suppressed some TGF−β−induced fibrotic markers, such as α1 procollagen, αSMA, and MMP13 mRNA, and AT1−R mRNA,and increased in TGF−β1−decreased PPARγ mRNA in LX2 cells. The effects on expression of α1 procollagen and αSMA mRNA and rapid suppression of MMP13 mRNA by telmisartan, which antagonizes AT1−R and activates PPARγ, compared with those of losartan indicate that the combined property of telmisartan may be more effective on hepatic fibrosis than blockade of AT1−R alone.Significance:The present results show that telmisartan may ameliorate hepatic fibrosis induced by obesity in addition to the effects by blockade of AT1−R alone and be an alternative choice of the treatment for hepatic fibrotic diseases related to obesity, such as NAFLD and NASH.
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