Therapeutic Research
Volume 39, Issue 2, 2018
Volumes & issues:
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Information:日本循環器学会 第38回プレスセミナー 心筋梗塞から命を守る:発生機序の解明と緊急心血管病克服への地域社会構築の最前線
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Symposium:第51回ペーシング治療研究会
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- 一般演題
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不整脈治療デバイスチームにおける看護師の役割
39巻2号(2018);View Description Hide DescriptionIn September 2016, we started an arrhythmia therapy device team(device team) with the aim of improving the medical quality for the patients implanted Cardiac Implantable Electronic Devices(CIEDs patient). We considered the roles and operation procedures of device nurses in the device team. First, we prepared Standard Operation Procedure(SOP) and SOP sheets. The SOP sheets are a check sheet for members of the device team to quickly share patient information and cooperate(Fig. 1). The objective of device nurses is to prevent mental and physical exhaustion of patients and to provide the best therapy options. So, we decided the device nurse’s role is to support patients to understand and accept the necessity of devices, and to coach them to live without anxiety. These nursing require the mental characteristics of CIEDs patients and expertise of the device. Continued nursing can be done from before implantation to after discharging, and understanding and peace of mind of CIED patients are improving. Team activities have been smoothly carried out according to SOP. The problems of CIEDs are various and it is possible to respond more safely and quickly by sharing roles in the device teams. Mental nursing can support anxiety reduction in patients with CIEDs, leading to the maintenance or improvement of QOL. As medical quality is regarded as important, team medical care plays a major role in CIED patients. -
ペースメーカ植込み時には良好であった心室ペーシング閾値が慢性期に一過性に急上昇した1例
39巻2号(2018);View Description Hide DescriptionThe patient was a 72 year old with complete atrioventricular block implanted with a DDD pacemaker. At the time of the implantation, the atrial wave amplitude was 3.6–4.0 mV and threshold 0.375 V / 0.4 msec, and the ventricular wave amplitude was negative and threshold 0.375 V / 0.4 msec. Approximately 3 years after the implantation, the ventricular threshold increased(3.0 V / 0.4 msec). No antiarrhythmic drugs, etc. that could increase the threshold were orally administered. No change in the lead position was observed on the chest x –ray compared to that at implantation and no elevation of the inflammatory markers could be confirmed by blood tests. Echocardiography revealed left ventricular hypokinesis, aortic regurgitation and moderate mitral regurgitation(EF=48–53%).Coronary angiography was performed, but there was no significant stenosis. The tilt test (isoproterenol load) also was negative. The results of the electrophysiology study revealed a local threshold increase near the high septal lead. After administering 12 mg of methylprednisolone, the ventricular threshold decreased(4.0 V / 1.5 msec ⇒1.75 V / 1.5 msec). We experienced a case in which the ventricular threshold sharply increased during the chronic phase several years after the implantation. There was no problem with the pacemaker and local inflammation of the ventricle occurred, however, the deterministic cause of the ventricular threshold rise remained unknown. -
周術期におけるユニポーラ極性閾値チェックの有用性を認識した1例
39巻2号(2018);View Description Hide DescriptionA 75 years old patient with recurrent syncope caused by sick sinus syndrome was admitted for permanent pacemaker implantation. Pacemaker leads were screwed in right atrial lower septum and right ventricular lower septum and confirmed satisfactory pacing parameters, threshold and sensing, in both leads. However, there was no problem in the result of the bipolar electrogram in right ventricular(RV) lead next day, RV pacing failure was revealed by unipolar electrogram threshold test. Although, non–dislodgement of RV lead tip position screwed in RV lower septum near the free–wall was confirmed by echocardiogram, but distal side of helix was seemed to be reached to epicardium. RV lead was replaced to RV apex from lower septum to prevent cardiac perforation. Perforation of the RV free wall during pacemaker implantation is often clinically silent. Only lead impedance test, without unipolar and bipolar electrogram threshold test, could not predict cardiac perforation like this case. It is important to perform both unipolar and bipolar electrogram threshold test in the postoperative period to avoid complications and detect possible risk for implant permanent pacemaker. -
遠隔モニタリングシステムから得られた心不全・不整脈アラートの有用性
39巻2号(2018);View Description Hide DescriptionIn recent years, cardiac implantation devices having a remote monitoring system are increasing. From January to September 2017, clinical usefulness of alerts was examined for 25 heart failure alerts and 33 arrhythmia alerts by remote monitoring. Inquiries on telephone inquiries, visits and hospitalization were evaluated for cases in which alerts occurred. The patient background was an average age 67±12 years old, 44 men(76%) male. Heart failure alerts were 12% weight gain, 56% reduction in pacing rate, 32% reduction in thoracic impedance, 32% interview, 32% visit and 24% treatment. Arrhythmia alert was VT 36% , VF 15% , AF 49% , interview 88% , visit 58% , hospitalization 42% . Regarding alert handling of RMS, it is necessary to decide policy and procedure for each facility, and it is highly expertise to interpret and judge exactly transmitted data and comprehensive information obtained from inquiries by phone etc. It is thought that it is desirable to evaluate the necessity of visits etc. -
ILR植込み後遠隔モニタリングシステムを活用しペースメーカの植込みが可能となった神経調節性失神に合併した洞不全症候群の1例
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ワイヤーによるリードの挿入時間の短縮効果の検討
39巻2号(2018);View Description Hide DescriptionBefore implanting a new device, venography is recommended to confirm venous condition. Instead of contrast medium, we are using the guide wire as safe and useful tool. We compared 34 consecutive patients with an indication for a new pacemaker. Before implantation, half of the patients underwent venography as usua(l Contrast group). For the other half patients we inserted a guide wire from peripheral vein near elbow instead of venography(Wire group). The time from entering room to skin incision was significantly longer in the Wire group than in the Contrast group(p=0.01). On the other hand, the time from skin incision to lead insertion was significantly shorter in the wire group than in the contrast group(p=0.02). The guide wire shortened lead insertion time instead of contrast medium. Since the guide wire is constantly visible under fluoroscopy, we can confirm venous running during procedure. We can easily find cephalic vein because the vessel containing black color wire is distinguished from other vessels visually. -
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原著
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2 型糖尿病患者における週1 回投与DPP‒4 阻害薬トレラグリプチンの臨床的有用性と治療意欲への影響―トレラグリプチン開始後のアンケート解析結果より―
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血糖コントロールが不十分な2型糖尿病患者に対するダパグリフロジンの24 ヵ月間長期投与
39巻2号(2018);View Description Hide Description目的:実地臨床におけるダパグリフロジンの24 ヵ月間の長期投与による糖代謝および各種臨床検査値への影響について検討した。方法:2 型糖尿病患者31 例にダパグリフロジン5 mg/日を24 ヵ月間追加投与した。また,腎機能別に有効性を評価するために,患者をeGFR 値が90 mL/min/1.73 m2以上あるいは未満で2 群に分け,サブグループ解析を行った。結果:29 例が24 ヵ月後までダパグリフロジンの投与を継続した。HbA1c は投与開始時7.6±1.1(平均値±標準偏差)%であったが,24 ヵ月後には7.1±0.8%と有意に減少した(p=0.039)。グリコアルブミンは投与開始時18.9±4.3%,24 ヵ月後18.5±3.4%と有意な変化は認められなかった(p=0.531)。BMI および腹囲は,投与開始時はそれぞれ28.0±3.7 kg/m2,98.6±8.6 cm であり,24 ヵ月後には26.2±3.5kg/m2,94.0±10.0 cm といずれも有意に減少した(p<0.001)。未知あるいは重篤な副作用の発現は認められなかった。サブグループ解析では,eGFR≧90 mL/min/1.73 m2群のみがHbA1cおよびグリコアルブミンの有意な減少を示した。BMI および腹囲は,両群ともに投与開始時からの有意な減少を示した。結論:ダパグリフロジンは24ヵ月間にわたる長期投与の結果,糖代謝と肥満を改善する効果が認められた。また,eGFR<90 mL/min/1.73m2群でも肥満改善効果が確認された。 -
非アルコール性脂肪肝疾患を有する高血圧患者においてオルメサルタンは肝機能および肝線維化マーカー(TGF‒β1)を改善させる
39巻2号(2018);View Description Hide DescriptionBackground:Because of westernization of lifestyle in recent years, the number of patients with lifestyle diseases, including obesity, metabolic syndrome, hypertension, dyslipidemia and diabetes mellitus, are increasing steadily. Recently, it has been noted that non‒alcoholic fatty liver disease(NAFLD)alone can cause liver cirrhosis or liver cancer. Angiotensin typeⅡ receptor blocker (ARB)is widely used in clinical practice as an antihypertensive agent. In addition to the antihypertensive effect by inhibiting the renin‒angiotensin system, ARB has been demonstrated to protect the multiple organs damage, including brain, heart and kidney. In recent years, many reports suggest that the renin‒angiotensin system is involved in the development of liver fibrosis. Objectives:We examined the protective effect of olmesartan on hepatic insufficiency and hepatic fibrosis marker in hypertensive patients with NAFLD. Methods:Olmesartan was administered to eleven hypertensive patients with NAFLD for 12 weeks. Results:Both office systolic blood pressure and diastolic blood pressure decreased from 141±3/82±2 mmHg to 130±7/76±4 mmHg(p=0.035). AST decreased significantly from 48.8±4.5 IU/L to 42.2±4.6 IU/L(p=0.011), AST from 71.7±7.8 IU/L to 59.8±8.5 IU/L(p=0.046), γ‒GTP from 102.3±21.6 IU/L to 90±20.3 IU/L(p=0.049). Finally, regarding TGF‒β1, a significant change was observed from 14898±3101 pg/mL to 10738±2405 pg/mL(p=0.017). Conclusions:Olmesartan ameliorates hepatic insufficiency in hypertensive patients with NAFLD. Olmesartan may not only have a class effect of ARB but also have a drug effect, especially on NAFLD. -
月1 回イバンドロネート静注剤の骨量増加効果について―Treat to Target の観点からの検討―
39巻2号(2018);View Description Hide DescriptionObjective:We had reported efficacy on fracture risk reduction of monthly intravenous ibandronate( Ⅳ IBN) 1 mg in the MOVER study in Japanese osteoporotic patients. This post‒hoc analysis presents additional 3‒year data on bone mineral density (BMD) gains with respect to achieving the BMD T‒score target. Material and Methods:MOVER was a randomised, double‒blind study in ambulatory patients aged≧60 years with fragility fracture. 1265 patients received monthly Ⅳ IBN(0.5 mg, 1 mg)or oral risedronate(RIS)as active comparator. Results:The per‒protocol set comprised 1134 patients(IBN 1 mg n=382, RIS n=376). Baseline patient characteristics were balanced across the groups. In patients with lumbar spine (LS) BMD T‒score≦-2.5 SD at baseline, the proportion of patients with LS BMD T‒score>-2.5 SD was:27.0% and 20.5% after 1 year;34.6% and 22.0% after 2 years;and 42.2% and 25.3% after 3 years, with 1 mg IBN and RIS, respectively. The proportion of patients with LS BMD T‒score>-2.5 SD increased with treatment duration in all treatment groups. These findings were consistent for proximal femur BMD gains:the proportion of patients with hip BMD T‒score>-2.5 SD was:19.4% and 16.8% after 1 year;20.4% and 19.2% after 2 years;and 21.3% and 15.2% after 3 years, respectively. Conclusions:Monthly Ⅳ IBN 1 mg demonstrated the greatest BMD gains amongst treatments in the MOVER study. In the current analysis, Ⅳ IBN 1 mg also showed the greatest proportion of patients with LS BMD T‒score>-2.5 SD. The proportion of patients achieving a BMD T‒score>-2.5 SD increased with treatment duration. These findings suggest that treatment adherence is important for effective disease management with osteoporotic agents.
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