β∂Se伽ep∂〟e扉c／ほ帽Cね血f血s  

Inward or outward costophrenic angles:

a simple sign on chest X-ray

for the screening of metabolic syndrome

Tadayuki Yakushiji, Y叫i Oyama, Wataru lgawa, Mario Ono, Takehiko Kida, Seitaro Ebara, Toshitaka Okabe, Kennosuke Yamashita, Myong

Hwa Yamamoto, Shigeo Saito, Koichi Hashimoto, Kisaki Amemiya, Naoei lsomura, Hiroshi Araki, Masahiko Ochiai

Division of Cardiology and Cardiac Catheterization Laboratories Showa University Northern Yokohama Hospital

35-1 Chigasaki^四chuo, Tsuzuki-ku, Yokohama, Kanagawa, 225^同8503, Japan

Corresponding author: Tadayuki Yakushiji

35-1 Chigasaki-chuo, Tsuzukトku, Yokohama, Kanagawa, 225^同8503, Japan

(Running title: Detection of metabolic syndrome by chest X-ray)

Abstract   

Purpose：Preventionofcardiovasculardiseasesisatop−Pr（Orityissuein    Japan．Tothisend，Wehavedeveropedanewscreenlngmethodfor    metab01icsyndrome（MetS）usingchestx−ray．   

Metho由：Werecruited200patientswhovisitedouroutpatient   

Cardio】ogyc［inicfromMarch2014toAugust2014．Patientswithsevere    lungdisease，aCuteCOrOnarySyndrome，andend−Stagerenarfailure    WereeXCruded・WecoIJecteddataoneachpatient smedicalhistory，   

laboratoryresuJts，Waistcircumference（WC），bodyweight，andheight．   

Additional［y，WemeaSuredtwoparametersfromthechestX−ray：（A）   

Widthatthelevelofrightdomeofdiaphragmand（B）widthbetweenthe    COStOPhrenic（CP）angles．Wec［assifiedtheCPangresaseitherinward   

（A≧B）oroutward（A＜B）．IncreasedWCwasdefinedas≧85cmjnmaJes   

and≧90cminfemaJes．   

伽肋gs：PatientswjthoutwardCPangleshadas］gnificant［ylargerWC   

COmParedtothosewithjnwardCPangles（92．3±8．9vs．80．5±7．8cm，   

P＜0・001）・1nparticuIar，thepercentageofmalepatientswithincreased    WC（≧85cm）wassignificantlyhigherinpatientswithoutwardCP    ang］esthaninthosewithinwardCPangles（89．2％vs．41．3％，P＜   

0・001）・BodyweightandBMIwerebothsignificantlyhigherinpatients    WithoutwardCPanglesthaninthosewjthinwardCPangJesinboth   

gendergroups・WhenJaboratorydataandriskfactorswerecompared，  

PatientswithoutwardCPangresandthosewithpositiveWCcriteria    COnSistentrytendedtowardhjghmorbidityfromhypertension，   

dyslipidemJa，anddiabetes．   

Conclusions：Theinward／outwardCPjdentifiedcandidatesforMetS，   

especiaJIyinthema［esubjects．ChestX−rayCOurdbecomeausefuJ    SCreenlngtOO】forthedetectionofincreasedWCandcoronaryrisk   

factors．   

Keywords   

Metabolicsyndrome，Cardiovasculardiseases，Preventivemedicine，   

Obesity，VisceraJfat   

lntroduction  

Metabolicsyndrome（MetS）isaconste ationofatheroscleroticrisk    factors，includingobesity，hypertension，lnSu＝nresistance，and   

dysJipidemia（1）．TheincidenceofcardiovascuJardisease（CVD）anda［］−   

CauSemO止alityisincreasedinpatientswjthMetS，eVenintheabsence   

OfbaselineCVDordiabetes（2−5）．Duetotheincreas山gtrendstowards   

aWesternizeddiet，JapanesepeopJehavegainedvisceraJfat，Whichis    associatedwithatheroscleroticdiseasesandcardiovascularevents（6，   

7）．Thus，PreVentionofatherosclerosisinhigh−riskmiddle−agedadurtsis    nowatopp「10ritylSSueforhealthcareinJapan，aCOuntryOfaging    POPulation．  

TheJapaneseversionofdiagnosticcriteriaforMetSwas    estab［ishedin2005bytheJapaneseCommitteeoftheCriteriafor    MetabolicSyndrome（8）andisnowwideIyusedinroutineheaJth   

Checkups；however，therequiredmeasurementofwaistcircumference   

（WC）canbetime−COnSumingandinaccurateinbusydailypractice（9−   

11）rOntheotherhand−ChestX−rayisoneofthemostcommonirnaging    modalitiesusedfordiagnosisandthechrono［ogica［evaluationof   

diseases，andsuchimaglngOftenrevea（SadiJatedlowerthoraxinobese    Patients，POSSiblyduetotheaccumuJationofviscera［fat．Wetherefore   

hypothesizedthatWCcou［dberoutinelyassessedbyfrontaJchestX−ray・  

Methods   

SfL／功／Pop〟ね〟0〃  

AtotaJof200patientswhovisitedouroutpatientcardiologyclinic    fromMarchtoAugust2014wererecruitedtothestudy．ExcJusion   

Criteriawereemergencypresentationssuchasacutecoronary   

Syndrome，SeVerelungdisease，disabirities，andend−Stagerenalfailure．   

［nformedconsentwasobtainedfromaIJpatientsregardingtheuseof   

CJinicaldata．  

D∂ねCo〟ec打0〃  

RiskfactorswerecoHectedbyinterviewandfromthemedicaJ   

records．WCwasmeasuredtothenearestO．5cmattheumbiIicallevel   

Withthepatientinastandingposition．Bodymassindex（BMl）was    Calculatedasthepatient sbodyweight（inkilograms）dividedbybody   

heightsquared（inmeters）．BJoodpressuremeasurementsweretaken    twiceinasittingposjtionuslngaStethoscopeandastandard   

SPhygmomanometer・VariousbiochemicaIparameterswereevaluated；   

however，PlasmagJucosewasnotmeasuredifafastingstatewasnot    POSSibre．   

MetSwasdiagnosedaccordingtotheguideIinesoftheJapanese   

CommitteeoftheCriteriaforMetabolicSyndrome．WCcriteriawere    judgedaspositivewhenthemeasurementwas85cmormoreinmen   

and90cmormoreinwomen．PatientswithpositiveWCcriteriawere    diagnosedashavingMetSinthepresenceoftwoormoreofthe   

foJ［owingrjskfactorsofmetabolicdisorders：dyslipidemia（trig［ycerides≧   

150mg／d［，HDL−Cholesterol＜40mg／dI．orreceivlnglipid−lowerJng    medication），hypertension（SyStOlicbloodpressure≧130mmHg，   

diastolicbloodpressure≧85mmHg，OrreCeivJnganti−hypertensive    medication），andhypergIycemia（fastingp［asmaglucose≧110mg／d10r    receivinghypoglycemicmedication）．  

Meas〟帽me扉Ofc／1eSfX伯γ  

AfrontaJchestX−raytakenduringtheinitia＝10SPitalvisitwas   

assessedvisual［yandquantitativeJy（Figurel）．Forthestudypurpose．   

WePerformedquantitativemeasurementsus［nganeJectronicmedical    recordsystemHOPE／EGMA［N（Fujitsurnc．，Tokyo，Japan）forthe    followingparameters：（A）widthatthereve】ofrightdomeofdiaphragm；   

and（B）widthbetweenthecostophrenic（CP）angles．Wec［assifiedeach    Patient sCPanglesaseitherinward（A≧B）oroutward（A＜B）．  

Sね〟sfわ∂／An∂少S由  

StatisticaranarysISWaSPerfo「medwithJMPso債ware，VerSionll   

（SASInstituteTnc・，Cary，NC）．Categoricalvariableswerepresentedas    frequenciesandcomparedwithchi−SquareStatisticsortheFisherexact  

test．Continuousvarjableswereexpressedasmean±SDandassessed    byStudentrst−teSt．APvalue＜0．05wasconsideredtoindicate   

Statisticarslgnificance．   

Res山ts   

β∂Se伽ep∂〟e扉c／ほ帽Cね血f血s  

Gender，age，riskfactors，medication，bloodpressure，andreason    forhospita［visitarelistedjnTablel．Malepatientsweres［gnificantJy   

younger（61．8±12．5vs．65．4±13．4）andhadhigherratesof    hypertension（58％vs．43％）andsmokinghistory（68％vs．18％）than    femaJepatients・DiastoricbloodpressurewasaJsos］gnificantJyhigherin    malescomparedtofema［es（79±10vs．75±12）．Chestdiscomfortwas    themostcommonreasonofhospitalvisit（43．5％）．  

BoqymeasuIementSbytypeofCPang／es  

AsshowninFigure2，WCwasslgnificantlylargerinpatientswith   

OutWardCPanglesthaninpatientswithinwardCPang］es（92．3±8．9    CmVS・80・5±7・8cm）・Inparticu［ar，thepercentageofma［epatientswith   

WC≧85cmwass■gnifjcantlyhigherinpatientswithoutwardCPang［es    COmParedtothosewithinwardCPang［es（89．2％vs．41．3％）．Tab［e2    1iststheresuJtsofbodymeasurements・BodyweightandBMIwere    S］gnificantlyhigherinpatientswithoutwardCPanglescomparedto   

thosewithinwardCPangles，WhileWC，height，andbodyweightva［ues    WereSlgnificantlymoreinmalepatientsthaninfema［epatients．Table3   

Showsthenumbe「sofpatientswhomeettheWCcriteriaforMetS（OnJy   inpatjentswithfastingglucosemeasurement）accordingtoinwardor  

OutWardCPangles．PatientswjthoutwardCPang］eshadhigher    PerCentageSOfpositiveWCcriteria（74％）andMetS（67％）．When   

dividedbygender，POSitivepredictivevalues（PPV）ofoutwardCP    anglesforpositiveWCcriteriaandMetSwe「e80％and88％，   

respectivery．0ntheotherhand，negativepredictivevalues（NPV）of   

inwardCPangJesfornegativeWCcriteriaandMetSwere86％and90％，   

respectively．  

Co／叩∂ぬ0／10f／∂加）帽foγd∂ねbef〝ee〃9m岬S  

AsshowninTable4，PatientswithoutwardCPangleshad   

SlgnificantlyhighervaluesofallparametersexceptforLDL−Ccompared    tothosewithinwardCPang［es．Similarry，PatientsmeetingpositiveWC    Criteriahadsignificantlyhigherva［uesofparametersexceptforLDLC    andHbAIccomparedtothosewhowereWCnegative．  

P／即a／e〃CeOfco／℃几訓γ／ね〟ねcfo／苫  

Figure3demonstratesthathypertension，dys］ipidemia，andcurrent    SmOkingweremorecommoninpatientswithpositivethannegativeWC   

Criteria．Likewise，hypertension，dyslipidemia，anddiabetesweremore    COmmOninpatientswithoutwardCPangJescomparedtothosewith   

inwardCPang［es．Thus，bothpositiveWCcriteriaandoutwardCP    angleswe‖refJectedthemetabolictendencyofthepatients．  

9   

10   

Discussion  

Themainfindingsofthisstudyareasf01lows：1）1npatientswith    OutWardCPangJes，WeObservedJarge「WC，heavierbodyweight，and    higherBMT；2）OutwardCPanglesidentifiedmostpatientswithpositive    WCcriteria，eSPeCial［yinma（es；3）Bothlaboratorydataandriskfactors    Showedsimilarresultswhenpatientswith／WithoutWCcriteriaandthose    Withinward／outwardCPangleswerecompared．  

Boqymeasurementsk7Patientswithk7WardbutwardCPangles  

Ourstudyc［ear［yshoweddifferencesjnWC，bodyweight，andBMl    inpatientswithinwardversusoutwardCPang］es（Table2）．Wealso   

ObservedthesameresuJtsinpatientswithpositiveWCcriteria．   

ComparedwithWCcriterja，CPangreshavesimilarmeanlngtOWC   

becausethemeasuredareasofCPanglesandWCareanatomica y   

CIose（Figurel）．  

UsehJh7eSSOfCPang／estopn？dict／aIgerWCandMetS   AsshowninTable3，PPVofoutwardCPangresforpositiveWC   

CriteriaandMetSwerehigherinmalethaninfemarepatients，Whereas    NPVofinwardCPanglesfornegativeWCcriteriaandMetSwerehigher    infemaJes・Consideringtheimportanceofpreventionofchronic    diseases，OurdatasuggestthatCPanglescouldbeusedasascreenlng  

ll   

too】forMetS．ThedifferentresultsbetweenmaJesandfemalesmight   

refIectthedifFerentvisceraJ／Subcutaneousfatdistributionbetween ma［es   

andfemaJes（12，13），Particular［ysincetheCPangJesare［ocatedinside    thechestwarJreg［OnCOnneCtedtotheabdominalwal［，andthusthe   

inward／outwardCPanglesmightbeinfruencedbytheamountofviscera［   

ratherthansubcutaneousfat．lncontrast，WCmeasurement（arequired    COmPOnentOfMetS）includesbothvisceralandsubcutaneousfat（14，   

15）．  

L∂bo帽rO／γdaね∂〃dぬ〟ねCわ侶∂〃∂桓edbyfwod胸帽〃fc／∂SS肋∂fわ〃S  

Weobservedsimirartrendsinlaboratorydataandriskfactorsfor   

boththeCPanglesandWCcriteriaanaJyses．lnaddjtion，itseemedthat    CPanglesdiscriminateddiabetesnumericallybetterthanWCcriteria   

（Table3andFigure2）・Viscera［fataccumulationhasastrong   

COrrelationwithabnormargIucosemetabo［ism（16），anditisplausibIe   

thatoutwardCPanglescouJdreflectvisceralfat，andthereforeabnorma［   

g［ucosemetaboJism，bette「thanpositiveWCcriteria．  

∪〃CeJね血レ∂bo上ノf的ecum〃fc〟ト0触0＝〝CcJ骨e〟a  

AlthoughwestartedthisstudytoreproducetheresuJtofWC   

measurementwiththeparametersobtainedfromchestX−ray，italso    raisedsomediscussionpointsregardingtheJapaneseMetScrjteria．  

TheoriginaIWCcriteria（≧85cminmalesand≧90cminfemaJes）were   derivedfromthecut＿OfFvalueforviscerarfatareaoflOOcm2atwhichthe    averagenumberofcomponentrjskfactorsgoesbeyondl．0（17），   

However，SOmeStudieshaveproposedgender−SPeCificcut−Offvalues   insteadoftheorigina］thresholdoflOOcm2（18，19）．Inaddition，a    numberofstudiesreporteddifferentcut−OffsofWCtopredictthe   

Clusteringofmetabo［icriskfactors（20−25）．A［10ftheseanaJyseswere    Performedtoyieldmaximalsensitivityplusspecificityforpredictingthe    PreSenCeOfoneormorerisks．lnourstudy，WeintroducedanewsimpJe    SCreenrngmethodforidentifyingpatientswithviscera［fataccumulation．   

ShlCeinward／outwardCPanglesisadichotomouscriterion，WeCannOt    SetaCut−Offpoint，butoutwardCPanglesinanundiagnosedmale   

PatientcouldbeanaIarm］ngSlgnandanearJydiagnosticclue．  

C伽／C∂／〟叩〟c∂f／0〃SOf的e5如（か  

Thisstudyhigh［ightsthatchestX−raySObtainedduringroutine   

PraCticecouldbeusedtoidentifyapossib］eMetSpatient，basedonthe    CPangIes，regardressofthereasonforhis／herhospita［visit．Funher   

evaluationofthepatient smetab01icstatusisrecommended．  

⊥〟れ／ね打0／了S  

13   

SeverallimitationsofthepresentstudyshouJdbenoted．Thisisa    S］ngle−CenterObservationalstudywithasmal［numberofpatients．   

EvaluationofbloodpressureandlaboratorydatawasdifficuJtduetothe   

SrgnificantnumberofpatjentsreceivJngmedicationtocontroJriskfactors．   

AlthoughweexcIudedpatientswithseverelungdisease，therewerea   

S［gnificantnumberofpatientswitha smokinghistory，Whichcou［dalso    haveaffectedthemeasurementsonchestx−ray．Thefindingsobtained    fromthepatientpopu］ationofourstudyarethereforenotnecessarJly   

appIicab［etootherpatjentpopurationsorhealthyindividuaJs．   

lnaddition，Chron0log［Ca［changesinCPanglesandJong−termCrinical   

OutCOmeSOfthepatientswerenotincludedinthestudy．Therefore，   

fu州1erlarge−SCa］e，long−termClinicaIstudiesarewarrantedtodetermine    theclinicaIimportanceofinward／outwardCPangJesfo「MetSdiagnosis    andprevention．  

Conclusions   

ChestX−rayJSauSefuIandreadilyavai］ablescreen］ngtOOlforthe    detectionofincreasedWC・lnpanicu］ar，theinward／outwardCPangles    bychestX−ray■SaSimpJes●gnthatcouldhelpidentifythecandidatesof    MetS，eSPeCia［］yamongthema）epopu［ation．  

Conf［ictofjnterest  

Theauthorshavenoconf［jctofinteresttodec［are．  

15   

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Tablel．Patientcharacteristicsandreasonforhospita［visit  

A   

（n＝200）（n＝111） （n＝89）  

Patientcharacteristics   Fvalue  

Age，yearS±SD  

Hypertension，n（％）  

Anti−hypertensivedrugusage，n（％）  

Dyslipidemia，n（％）  

Lipid−loweringdrugusage，n（％）  

FamiJyhistory，n（％）  

Smoking，n（％）  

Currentsmoking，n（％）  

Diabetes，n（％）  

Oraldiabeticagentusage，n（％）  

rnsuJinusage，n（％）  

Systolicbroodpressure，mmHg   Diastolicbloodpressure，mmHg  

PuIserate，beats／min  

63．4±13．0 61．8±12．5  

102（51） 64（58）  

94（47） 52（47）  

94（47） 56（52）  

79（40） 43（39）   

8（4）    6（5）  

91（46） 75（68）  

32（16） 27（24）  

38（19） 22（20）  

24（12） 16（14）   

2（1）   1（1）  

132±18  131±15  

77±11   79±10   67±13   66±14  

65．4±13．4  ＜0．05   38（43） 0．04  

42（47）  

38（43）  

36（40）  

2（2）   

16（18） ＜0．0001    5（6） ＜0．0001  

16（18）  

8（9）   

1（1）  

133±20   0．35   75±12   0．03   69±13   0．07   All  Males Females 

Reasonforhospita］visit   

P・Value  

（n＝200）（n＝111）（n＝89）  

Chestdiscomfort，n（％）  

ECGabnormaJities，n（％）  

Fo ow−uPVisitafterPCl，n（％）  

Arrhythmia−relatedsymptoms，n（％）  

Dyspnea，n（％）  

Abnormalcarotidechofindings，n（％）  

Edema，n（％）  

Others，∩（％）  

87（43．5）   

25（12．5）  

21（10．5）  

17（8．5）  

16（8）   7  

13（6．5）   

4（2）  

17（8．5）  

0．14   

TabIe2．Comparisonofbod   measurementsbetween  

lnwardCPangles OutwardCPangles P・VaJue   Variable  

M＝46，F＝50   M＝65，F＝39  

Male（∩＝111）  

Female（n＝89）  

Ma】e（n＝111）  

Female（n＝89）  

Male（∩＝111）  

Fema［e（n＝89）  

Male（∩＝111）  

Female（n＝89）  

94．4±8．7    89．1±8．3    73．2±14．7   

58．3±8．5    168．0±7．0    152．3±7．2   

25．8±4．0    25．2±3．4  

＜0．0001   

＜0．0001    く0．0001    0．0010  

0．42   0．08   

＜0．0001   

＜0．0001   82．0±6．5   

79．0±8．8    60．5±8．8    51．8±9．4    166．9±6．7    154．9±6．3   

21．8±3．6    21．6±3．6  

Waist  

Circumference（Cm）   

Bodyweight（kg）  

Height（Cm）  

BMl（kg／m2）  

WCcriteria（・）    WCcriteria（＋）  

P＿Value   Variable  

M＝34，F＝63  

M＝77，F＝26   

Female（n＝89）  

Male（n＝111）  

Female（n＝89）  

Male（∩＝111）  

Female（∩＝89）  

Male（n＝111）  

Female（n＝89）  

78．5±4．4    78．7±7．1    58．4±7．2    52．1±8．4    165．8±6．8    153．9±6．5  

21．3±3   22±3．5   

94±7．8    94．9±5．2    72．2±14．3  

61±9．1    168．3±6．7    153．5±7．5   

25．4±4．2    25．9±3．6  

く0．0001   

＜0．0001   

＜0．0001   

＜0．0001   0．08   0．80   

＜0．0001   

＜0．0001  

Waist  

Circumference（Cm）  

Bodyweight（kg）  

Height（Cm）  

BMl（kg／m2）  

Variable  

OveralI（n＝200） MaIes（n＝111）    Females（n＝89） P・Value  

Circumference（Cm）  

Bodyweight（kg）   

Height（Cm）  

BMl（kg／m2）  

86．7±10．3   62．1±13．9   161．4±9．7  

23．7±4．1  

89．3±10．0   67．9±14．0   167．5±6．8  

24．2±4．3  

83．5±9．9   ＜0．0001   54．7±9．5   ＜0．0001   153．8土6．8   ＜0．0001   23．1±3．9   0．09  

Va）uesaremean±SD．WCcriteria，Waistcircumferencecriteria；CPang］e，COStOPhrenic  

angle；BMl，bodymassindex．WCcriteriawasjudgedpositivewhenWCwas85cmormore  

in menor90cmormoreinwomen．   

Table3．Numbersofpatientswithinward／outwardCPangres  

0verall（n＝200）   Males（∩＝111）   FemaIes（n＝89）  

Outward   Jnward  

Outward   lnward  

Outward   lnward  

CPangJes   CP angles  CPangles   CP anqles  CPangJes   CP angles   

VVCcriteria   

←÷j   

77    26    58    19   

WCcrjteria   

圏   

²⁷   

20   

○verall（n＝134）   Male（∩＝78）   Fema［e（n＝56）  

Outward   lnward  

Outward   lnward  

Outward   lnward  

CPangles   CP an91es  

CPangles   CP an〔Iles  

MetS（＋）    50    12    39    9    3   

MetS（−）    25    47    10   

20   

27   

CPang］es，COStOPhrenicangles；WC，Waistcircumference；MetS，metabolicsyndrome．WC   CriteriawasjudgedpositivewhenWCwas85cmormoreinmenor90cmormoreinwomen．  

MetSwasassessedonlyinpatientswithfastingplasmagJucosemeasurementaccordingto   thedefinitionbyJapaneseCommitteeoftheCriteriaforMetaboricSyndrome．   

4  

Table4．Comparisonoflaboratorydatabetweengroups  

Variable   lnwardCPangle OutwardCPang［e P−VaJue  

127．2±40（∩＝75）   

6．2±0．8（∩＝98）   

25．6±27．4（n＝31）  

113．4±31．4（∩＝100）  

51．3±13．3（∩＝102）  

193．9±280．7（∩＝102）   

5．9±1．5（n＝102）   

0．8±0．2（∩＝103）   

0．16±0．2（n＝36）   

PG，mg／dl  

HbAIc，％  

lRl，〃∪／m】  

LDLC，mg／dI   HDL−C，mg／dl   TG，m9／dl  

UA，mg／dl   Cr，m9／dl  

hs−CRP．mg／d7  

105．4±35．2（∩＝59）   

5．9±0．6（∩＝90）  

10．9±9．9（∩＝24）  

119．6±28．6（∩＝93）  

62．1±16．6（n＝95）  

115．6±62．6（n＝95）   

5±1．2（n＝95）   

0．7±0．2（n＝96）  

0．06±0．07（n＝24）  

0．001    0．0031    0．0085  

0．16   

＜0．0001    0．0071   

＜0．0001    0．0418   

0．012  

Variable  

WCcriteria（・）    WCcriteria（＋）    P・Value  

PG，mg／dl   HbAIc，％  

lRl，〟U／ml   LDL−C，mg／dl   HDL−C，mg／d［  

TG，mg／dl  

UA，mg／dl   Cr，mg／d［  

hs−CRP，mg／dl  

108．4±38．7（n＝58）   

5．9±0．6（n＝89）  

11．7±10．3（n＝19）  

119．1±31．6（∩＝94）  

62．4±16．6（n＝95）  

111．1±49（n＝95）   

4．9±1（∩＝95）   

0．7±0．2（n＝96）  

0．06±0．07（∩＝19）  

124．4±38．6（n＝77）   

6．1±0．8（n＝99）  

23．2±26．2（∩＝36）  

113．8±28．7（∩＝99）  

51．1±13（∩＝102）  

198±282（n＝102）  

6．1±1．5（∩＝102）  

0．8±0．2（∩＝103）  

0．15±0．18（n＝41）   

0．018   0．10   0．025   0．23   

＜0．0001    0．0028   

＜0．0001   

＜0．0001    0．0063  

Va［uesaremean±SD．WCcriteria，Waistcircumferencecriteria；CPangle，COStOPhrenic   ang］e；PG，P（asmag］ucose；［RI，immunoreactiveseruminsulin；LDL−C，10W−densityllPOPrOtein  

Cholestero】；HDL−C，high−densityllPOPrOteincholesterol；TG，triglyceride；UA，uricacid；Cr，  

Creatinine；hs−CRP，highsensitivec−reaCtiveprotein．WCcriteriawasjudgedpositivewhen  

WCwas85cmormorein menor90cm ormoreinwomen．   

Figurel．Conceptofinward／outwardcostophrenic（CP）angIes  

ShowsoutwardCPangleswithcorrespondingcoronalcomputedtomographyimageonthe  

right，reSPeCtive［y．  

Quantitativeassessment：Patient sCPang［eswereclassifiedasinward（A≧B）orasoutward  

（AくB）   

Figure2．Waistcircumferencesinpatientswithinwardvs．outwardcostophrenic（CP）angres  

Females（n＝89）  

Males（n＝111）   

12￣   

110 一  

■  

120   80．5±7．8cmvs．92．3±8．9cm  

（P＜0．001）      ■ヽ       ヽ  

︵∈0︶  

●   

●   

●  

●  

i．  

−  

●l■   

●  

I  

● ′  

︼  

￠Ou2ぜ∈コ2．61S葡≧r   ︵U O  ︵U   9  1   ⁚・芋Iヽ  

＋         ＋  

】         ＋         ＋         】         ＋         】      】 】  

90−−−−−−●●−−−−−−…  

8。  す  

′l●  

●  

70  ．モ・  

●  

60   ヽ  

0   0  8   7  

60」  

lnward Outward   CPang［es CPangres  

（∩＝50）   （∩＝39）   

lnward CP Outward CP    angles   angles  

（∩＝96）   （n＝104）  

Inward   Outward   CPang［es CPang］es  

（n＝46）   （∩＝65）  

Figure3．PrevaIenceofriskfactorsbetweengroups   

％ ％ ％ ％ ％ ％  

￣￣￣  

−こ− 

こI1一ー‥二  

（B）  

100％   

80％   

60％   

40％   

20％  

0％  

∴￣  ∴ご  

：  ：  二  

＿＿  ー 

Patientsw？「edividedintotwogroupsby（A）waistcircumferenceand（B）inward／outward   COStOPhrenlCangles