A score for decision making during percutaneous coronary intervention in acute myocardial infarction patients with multivessel disease

BACKGROUND/AIMS@#The optimal percutaneous coronary intervention (PCI) strategy in patients with acute myocardial infarction (AMI) with multivessel disease (MVD) is uncertain. This study was designed to develop a novel and simple tool for assessing an individualized and optimized PCI strategy in AMI patients with MVD.@*METHODS@#In total, 5,025 patients with AMI from nine centers at two universities were enrolled in the prospective Convergent Registry of Catholic and Chonnam University for Acute Myocardial Infarction (COREA-AMI) registry from January 2004 through December 2009. From among them, we selected 2,630 patients with MVD who were treated by culprit-only or multivessel (MV) PCI. We investigated major adverse cardiac events (MACEs) during a 1-year clinical follow-up. Using a subgroup analysis, we extracted variables for use in the culprit only versus multivessel revascularization (CONVERSE) score, which showed a preference for MV PCI rather than culprit-only PCI for treating MVD.@*RESULTS@#The CONVERSE score was constructed using eight independent variables (1 point for each variable): age > 65 years, hypertension, diabetes mellitus, high Killip class (III or IV), low left ventricular ejection fraction (≤ 50%), low creatinine clearance (≤ 60 mL/min), high level of high-sensitivity C-reactive protein (≥ 2.0 mg/L), and left anterior descending artery or left main as the nonculprit vessel. The incidence of MACEs increased linearly with the CONVERSE score. The receiver operating characteristic curve showed that the cutoff value was 3 points.@*CONCLUSIONS@#The results suggest that patients with a CONVERSE score of 3 or more should undergo MV PCI.

Erratum: Two-year clinical outcomes in stable angina and acute coronary syndrome after percutaneous coronary intervention of left main coronary artery disease

In the article cited above, fourth line of the first paragraph in Methods part, page 1085, has an error. Chonbuk National University Hospital should be corrected as “Chonnam National University Hospital.”

Erratum: Two-year clinical outcomes in stable angina and acute coronary syndrome after percutaneous coronary intervention of left main coronary artery disease

In the article cited above, fourth line of the first paragraph in Methods part, page 1085, has an error. Chonbuk National University Hospital should be corrected as “Chonnam National University Hospital.”

Optimal Timing of Percutaneous Coronary Intervention for Nonculprit Vessel in Patients with ST-Segment Elevation Myocardial Infarction and Multivessel Disease

BACKGROUND AND OBJECTIVES: In patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD), the optimal timing of staged percutaneous coronary intervention (PCI) remains unclear. SUBJECTS AND METHODS: This study was a retrospective analysis of 753 STEMI patients with MVD who were treated by multivessel PCI in the Convergent Registry of Catholic and Chonnam University for Acute myocardial infarction (MI). Patients were divided into 3 groups according to the time from initial to staged PCI: group 1 (n=316, multivessel PCI performed during the index procedure), group 2 (n=360, staged PCI within 1 week), and group 3 (n=77, staged PCI after 1 week). The endpoint was major adverse cardiac events (MACEs), including all-cause mortality, non-fatal MI, and repeat PCI during 3.4 years follow-up. RESULTS: The incidence of composite MACEs was higher in group 3 than in group 1 (odds ratio [OR]: 1.83, 95% confidence interval [CI]: 1.06 to 3.18, p=0.031). However, the risk of MACEs in groups 1 and 2 was comparable (OR: 1.01, 95% CI: 0.70 to 1.46, p=0.950). In multivariate logistic regression, independent predictors of 3-year MACEs were high Killip class (OR: 2.72, 95% CI: 1.38 to 5.37, p=0.004), left ventricular ejection fraction <45% (OR: 1.57, 95% CI: 1.06 to 2.32, p=0.024), and group 3 (OR: 1.83, 95% CI: 1.06 to 3.18, p=0.009). CONCLUSION: Deferred staged PCI after one week index PCI was associated with the highest MACE, as compared to both simultaneous multivessel PCI and early staged PCI <1 week.

Long-Term Clinical Outcomes of Transient and Persistent No Reflow Phenomena following Percutaneous Coronary Intervention in Patients with Acute Myocardial Infarction

BACKGROUND AND OBJECTIVES: There is limited information on the transient or persistent no reflow phenomenon in patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI). SUBJECTS AND METHODS: The study analyzed 4329 patients with AMI from a Korean multicenter registry who underwent PCI using coronary stents (2668 ST-elevation and 1661 non-ST-elevation myocardial infarction [MI] patients): 4071 patients without any no reflow, 213 with transient no reflow (no reflow with final thrombolysis in myocardial infarction [TIMI] flow grade 3), and 45 with persistent no reflow (no reflow with final TIMI flow grade≤2). The primary endpoint was all-cause mortality during 3-year follow-up. We also analyzed the incidence of cardiac mortality, non-fatal MI, re-hospitalization due to heart failure, target vessel revascularization, and stent thrombosis. RESULTS: The persistent no reflow group was associated with higher all-cause mortality (hazard ratio [HR] 1.98, 95% confidence interval [CI] 1.08-3.65, p=0.028) and cardiac mortality (HR 3.28, 95% CI 1.54-6.95, p=0.002) compared with the normal reflow group. Transient no reflow increased all-cause mortality only when compared with normal reflow group (HR 1.58, 95% CI 1.11-2.24, p=0.010). When comparing transient and persistent no reflow, persistent no reflow was associated with increased all-cause mortality (46.7 vs. 24.4%, log rank p=0.033). CONCLUSION: The persistent no reflow phenomenon was associated with a poor in-hospital outcome and increased long-term mortality mainly driven by increased cardiac mortality compared to the transient no reflow phenomenon or normal reflow.

Two-year clinical outcomes in stable angina and acute coronary syndrome after percutaneous coronary intervention of left main coronary artery disease

BACKGROUND/AIMS: This study appraised the long term clinical outcomes of patients treated with percutaneous coronary intervention (PCI) for unprotected left main coronary artery (ULMCA) disease. There are limited data regarding long-term clinical outcomes after PCI for ULMCA disease. METHODS: From 2001 to 2011, a total of 448 patients who underwent PCI for ULMCA disease and had 2-year clinical follow-up, were analyzed. The study patients were divided into two groups: group I (stable angina pectoris [SAP], n = 60, 48 men, 62 ± 10 years) and group II (acute coronary syndrome [ACS], n = 388, 291 men, 64 ± 10 years). We evaluated clinical and angiographic characteristics and major adverse cardiac events (MACE) during 2-year clinical follow-up. RESULTS: Mean age of studied patients was 64 ± 10 years with 339 male patients. Average stent diameter was 3.6 ± 0.4 mm and stent length was 19.7 ± 6.3 mm. Stent implantation techniques and use of intravascular ultrasound guidance were not different between two groups. In-hospital mortality was 0% in group I and 7% in group II (p = 0.035). One-month mortality was 0% in group I and 7.7% in group II (p = 0.968). Two-year survival rate was 93% in the group I and 88.4% in the group II (p = 0.921). Predictive factors for 2-year MACE were hypertension, Killip class ≥ 3, and use of intra-aortic balloon pump by multivariate analysis. CONCLUSIONS: Although in-hospital mortality rate was higher in ACS than in SAP, clinical outcomes during 2-year clinical follow-up were similar between SAP and ACS after PCI of ULMCA.

Cardiac Involvement of Churg-Strauss Syndrome as a Reversible Cause of Dilated Cardiomyopathy

A 31-year-old male who had been treated for Churg-Strauss syndrome (CSS) presented with sudden onset of dysarthria. Brain magnetic resonance imaging (MRI) showed acute multifocal bilateral cerebral infarctions suggesting embolic causes. Cardiac MRI showed dilated cardiomyopathy with severe biventricular dysfunction with intracardiac thrombi, and multiple high signal intensity spots in myocardium of the left ventricle with multifocal delayed enhancement suggesting multifocal myocarditis due to small vessel vasculitis associated with CSS. After anticoagulation therapy, treatments for heart failure, and immunosuppressive therapy including parenteral steroids and cyclophosphamide to control CSS, the symptoms and signs of heart failure and cardiac function of the patient were improved. Considering the pathophysiologic mechanism of cardiac involvement in CSS, immunosuppressive therapy to control the disease activity of CSS should be taken into account, besides usual management for heart failure.

Clinical Outcome Comparison of Everolimus- and Biolimus-eluting Stents in Patients with Acute Myocardial Infarction / 대한내과학회지

BACKGROUND/AIMS: We compared the efficacy and safety of the second-generation everolimus-eluting stent (EES) and the third generation biolimus-eluting stent (BES) in patients with acute myocardial infarction (AMI). METHODS: We analyzed 629 consecutive patients (mean age 65.1 +/- 11.2 years, 426 males) with AMI undergoing percutaneous coronary intervention from February 2008 to April 2012. They were divided into two groups according to stent type (EES group, n = 426; BES group, n = 203). The primary end-point was 2-year major adverse cardiac events (MACEs), defined as the composite of all-cause death, myocardial infarction, target vessel revascularization, non-target vessel revascularization and target lesion revascularization. The secondary end-point was 2-year target lesion failure (TLF). RESULTS: There were no significant differences in baseline characteristics, except that the patients with EES had a significantly higher prevalence of diabetes mellitus (34.7 vs. 22.7%, p = 0.002) and were older (67.1 +/- 11.3 vs. 64 +/- 12.9 years, p = 0.039) compared with the patients with BES. After propensity score matching, 2-year clinical outcomes showed no differences in composite MACEs or TLF between the two groups. Multivariate Cox regression analysis showed that stent type was not a predictor of 2-year mortality or MACEs. However, older age (hazard ratio [HR] 1.037, 95% confidence interval [CI] 1.014-1.060, p = 0.001), diabetes mellitus (HR 2.247, 95% CI 1.426-3.539, p = 0.001) and a left ventricular ejection fraction < or = 45% (HR 3.007, 95% CI 1.978-4.573, p = 0.001) were independent predictors for 2-year MACEs in patients undergoing EES or BES. CONCLUSIONS: Patients with BES had similar clinical 2-year outcomes compared with EES patients with AMI.

Comparison of Clinical Outcomes after Implantation of First- and Second-Generation Overlapping Drug-Eluting Stents to Treat Diffuse Long Coronary Lesions / 대한내과학회지

BACKGROUND/AIMS: Despite improved revascularization techniques, the clinical outcomes of patients with diffuse coronary artery lesions after percutaneous coronary intervention are unsatisfactory. However, few studies have compared the efficacy of first- and second-generation drug-eluting stents (DES) in patients with diffuse long coronary artery lesions. METHODS: Between January 2006 and July 2012, 364 patients who were treated with DES for long coronary artery stenosis (> 30 mm) were enrolled in this study and assigned to either Group I (first-generation DES, 62.3 +/- 10.4 years, 136 males, n = 183) or Group II (second-generation DES, 64.3 +/- 10.7 years, 134 males, n = 181). The incidence of major adverse cardiac events (MACE) was compared between the two groups over 2 years of follow-up, and predictive factors associated with MACE were evaluated through a multivariate analysis. RESULTS: Although several coronary angiographic characteristics were different between the two groups, most demographic and baseline clinical variables were the same. The cumulative incidence of MACE was significantly higher in Group I than in Group II (25.7 vs. 6.6%; p < 0.001), mainly due to reduced target lesion revascularization (21.9 vs. 2.2%; p < 0.001). According to the results of the multivariate analysis, the use of a paclitaxel-eluting stent (PES) (hazard ratio [HR], 5.168; 95% confidence interval [CI], 2.515-10.617; p < 0.001), decreased left ventricular function (< or = 45%; HR, 3.586; 95% CI, 1.839-6.990; p < 0.001), and diabetes mellitus (HR, 2.984; 95% CI, 1.605-5.548; p < 0.001) were independent contributors to MACE. CONCLUSIONS: For patients with diffuse long coronary artery stenosis, the use of second-generation DES improved the clinical outcome compared with first-generation DES. In addition, the use of a PES, left ventricular dysfunction, and diabetes were predictors of MACE after overlapping stenting.

A New Risk Score to Predict 1-Year Mortality in Acute Non-ST Elevation Myocardial Infarction / 대한내과학회지

BACKGROUND/AIMS: Accurate risk stratification is important in the management of patients with acute myocardial infarction (AMI). This study aimed to develop a new assessment tool for the prediction of 1-year mortality in patients with AMI, including biochemical markers. The author developed a new assessment tool (new risk score) that takes biochemical markers into account for 1-year mortality in patients with non-ST elevation myocardial infarction (NSTEMI) and identifies the risk factors related to 1-year mortality. METHODS: A total of 1,427 patients (65 +/- 11.8 years of age, 985 males) who were admitted to the Chonnam National University Hospital with NSTEMI from November 2005 to March 2012 were retrospectively analyzed for score derivation. Multivariable Cox-regression analysis was used to select correlates of 1-year mortality that were subsequently weighted and integrated into an integer scoring system. RESULTS: Seven variables selected from the initial multivariate model were weighted proportionally to their respective hazard ratio for 1-year mortality; age > or = 65 years (2 points), N-terminal pro-brain natriuretic peptide (NT pro-BNP) > 991 pg/mL (1 point), baseline left ventricular ejection fraction 3 mg/dL (1 point), glomerular filtration rate (GFR) 82 beats/min (2 points), and final thrombolysis In myocardial infarction flow < 3 (2 points). CONCLUSIONS: In NSTEMI patients, our new score that incorporates seven risk factors accurately predicts the 1-year mortality. Additionally, the biochemical markers hs-CRP, NT pro-BNP, and GFR are reliable predictors of 1-year mortality.

Cardioprotective Effect of Fimasartan, a New Angiotensin Receptor Blocker, in a Porcine Model of Acute Myocardial Infarction

Cardioprotective effect of fimasartan, a new angiotensin receptor blocker (ARB), was evaluated in a porcine model of acute myocardial infarction (MI). Fifty swine were randomized to group 1 (sham, n=10), group 2 (no angiotensin-converting enzyme inhibitor [ACEI] or ARB, n=10), group 3 (perindopril 2 mg daily, n=10), group 4 (valsartan 40 mg daily, n=10), or group 5 (fimasartan 30 mg daily, n=10). Acute MI was induced by occlusion of the left anterior descending artery for 50 min. Echocardiography, single photon emission computed tomography (SPECT), and F-18 fluorodeoxyglucose cardiac positron emission tomography (PET) were performed at baseline, 1 week, and 4 weeks. Iodine-123 meta-iodobenzylguanidine (MIBG) scan was done at 6 weeks for visualization of cardiac sympathetic activity. Left ventricular function and volumes at 4 weeks were similar between the 5 groups. No difference was observed in groups 2 to 5 in SPECT perfusion defect, matched and mismatched segments between SPECT and PET at 1 week and 4 weeks. MIBG scan showed similar uptake between the 5 groups. Pathologic analysis showed similar infarct size in groups 2 to 5. Infarct size reduction was not observed with use of fimasartan as well as other ACEI and ARB in a porcine model of acute MI.

Impact of Smoking on Clinical Outcomes in Female Patients with Acute Myocardial Infarction

BACKGROUND AND OBJECTIVES: Cigarette smoking has been recognized as a prominent threat to women's health. We investigated the impact of smoking on clinical outcomes in Korean female patients after acute myocardial infarction (AMI). SUBJECTS AND METHODS: Out of the AMI patients who enrolled in the Korea AMI Registry, 4444 female patients were included in this study. Patients were divided into two groups-non-smoker and smoker-according to their current smoking status. We compared in-hospital mortality and major adverse cardiac events (MACE), including cardiac death, myocardial infarction, repeated percutaneous coronary intervention (PCI), or coronary artery bypass grafting during the one-year clinical follow-up period between two groups. RESULTS: The non-smoker group had more hypertension (HTN) and diabetes mellitus. The levels of total cholesterol, triglyceride, and low-density lipoprotein cholesterol were higher in the non-smoker group. However, in-hospital mortality was significantly higher in the smoker group (1.0% vs. 2.4%, p=0.002), and cardiac death during the 12-month clinical follow-up was significantly more frequent in the smoker group (2.2% vs. 4.5%, p=0.003). Total MACEs during the 12 months were higher in the smoker group (4.9% vs. 6.8%, p=0.014). Smoking and HTN were independent predictors of MACE {odds ratio (OR): 1.742, 95% confidence interval (CI): 1.010-3.000, p=0.046; OR: 1.573, 95% CI: 1.003-2.466, p=0.049, respectively}. CONCLUSION: Female smokers with AMI showed significantly higher in-hospital mortality and MACE rates during the one-year clinical follow-up period.

Predictors of Progression and Prognosis of Paroxysmal Atrial Fibrillation / 대한내과학회지

BACKGROUND/AIMS: Significant numbers of patients with paroxysmal atrial fibrillation (AF) proceed to persistent AF and have poor clinical outcomes despite the use of antiarrhythmic agents or direct-current cardioversion. We compared the CHADS2, CHA2DS2-VASc, and HATCH scoring systems to predict AF progression and prognosis and identify the most useful scoring system in Korea. METHODS: A total of 559 consecutive patients with paroxysmal symptomatic AF were analyzed. The progression of AF and clinical outcomes were determined after at least 1 year of follow-up. Clinical outcomes were defined as the composite of death, hospitalization due to heart failure, and new-onset stroke. Each score was calculated, and its predictive accuracy for AF progression and prognosis was compared. RESULTS: A total of 147 patients with paroxysmal AF (26.3%) proceeded to persistent AF. The HATCH score (area under the curve [AUC], 0.601; p or = 6: 55.6%, linear p < 0.001) than the CHADS2 (AUC, 0.720) and HATCH scoring systems (AUC, 0.723). CONCLUSIONS: Although the CHADS2, CHA2DS2-VASc, and HATCH scoring systems were useful predictors of progression from paroxysmal to persistent AF, the CHA2DS2-VASc score was the most useful and accurate for the prediction of clinical outcomes.

Effect of Pretreatment of Ezetimibe/Simvastatin on Arterial Healing and Endothelialization after Drug-Eluting Stent Implantation in a Porcine Coronary Restenosis Model

BACKGROUND AND OBJECTIVES: We sought to evaluate the effect of the early use of ezetimibe/simvastatin (Vytorin(R)) on arterial healing and endothelialization after the implantation of a drug-eluting stent (DES) in a porcine model of coronary restenosis. MATERIALS AND METHODS: A total of 20 pigs (40 coronary arteries) were randomly allocated to a pretreatment or no treatment group. The pretreatment group (n=20) received oral ezetimibe/simvastatin (10/20 mg) daily for 7 days before stenting and the no pretreatment group (n=20) did not. All pigs were treated with ezetimibe/simvastatin (10/20 mg) daily after stenting for 4 weeks. Stenting was performed using a bare-metal stent (BMS, n=10) and three types of DES: biolimus A9-eluting stent (BES, n=10), zotarolimus-eluting stent (ZES, n=10), and everolimus-eluting stents (EES, n=10). Four weeks later, pigs underwent a follow-up coronary angiography and were sacrificed for histopathologic analysis. RESULTS: There were no significant differences between the pretreatment and no pretreatment groups in the internal elastic lamina area, lumen area, neointima area, stenotic area, injury score, fibrin score, and inflammation score. In both groups, the fibrin score was higher in pigs with DES than in BMS, particularly in ZES and EES. The inflammatory score was not different between DES and BMS. CONCLUSION: In a porcine model of coronary restenosis, pretreatment with ezetimibe/simvastatin before DES implantation failed to improve arterial healing and endothelialization compared to treatment after stenting.

Effect of revascularization strategy in patients with acute myocardial infarction and renal insufficiency with multivessel disease

BACKGROUND/AIMS: The aim of this study was to compare the risk of complications and outcome between infarct-related artery (IRA)-only revascularization and multivessel (MV) revascularization in patients with acute myocardial infarction (MI) with renal insufficiency and MV disease. METHODS: A total of 1,031 acute MI patients with renal insufficiency and MV disease who were registered in the Korea Working Group on Myocardial Infarction were enrolled. They were divided into two groups (IRA-only revascularization group, n = 404; MV revascularization group, n = 627), and investigated the cumulative incidence of major adverse cardiac events (MACE) and the incidence of complications after percutaneous coronary intervention (PCI). RESULTS: Complications after PCI occurred in 19.9% of all patients (206/1,031). Complications after PCI occurred more frequently in the MV revascularization group compared with the IRA-only revascularization group (20.1% [126/627] vs. 15.3% [62/404], respectively; p = 0.029]. The overall in-hospital mortality rate was 6.3%, and there was no significant difference between the groups (5.2% in the IRA-only revascularization group vs. 7.0% in the MV revascularization group; p = 0.241). The total incidence of MACE was 11.1%, and there was no significant difference between the groups (11.6% in the IRA-only revascularization group vs. 10.7% in the MV revascularization group; p = 0.636). CONCLUSIONS: The incidence of complications after PCI was significantly lower in the IRA-only revascularization group compared with the MV revascularization group. However, there were no significant difference in the 12-month outcomes between groups in patients with acute MI and renal insufficiency with MV disease.

Coronary Artery Fistula with Giant Aneurysm and Coronary Stenosis Treated by Transcatheter Embolization and Stent

Coronary artery fistula (CAF) with giant aneurysm and accompanied by coronary artery stenosis is a very rare disease. Herein, we report a case of a 76-year-old woman having a complex coronary-to-pulmonary artery fistula associated with a giant aneurysm and accompanied by coronary artery stenosis. The patient was successfully treated using transcatheter coil embolization and coronary stent implantation. Eight years later, we performed a follow-up coronary angiogram, which revealed the CAF and the aneurysm were completely occluded and previous stent patency.

Characteristics, In-Hospital and Long-Term Clinical Outcomes of Nonagenarian Compared with Octogenarian Acute Myocardial Infarction Patients

We compared clinical characteristics, management, and clinical outcomes of nonagenarian acute myocardial infarction (AMI) patients (n=270, 92.3+/-2.3 yr old) with octogenarian AMI patients (n=2,145, 83.5+/-2.7 yr old) enrolled in Korean AMI Registry (KAMIR). Nonagenarians were less likely to have hypertension, diabetes and less likely to be prescribed with beta-blockers, statins, and glycoprotein IIb/IIIa inhibitors compared with octogenarians. Although percutaneous coronary intervention (PCI) was preferred in octogenarians than nonagenarians, the success rate of PCI between the two groups was comparable. In-hospital mortality, the composite of in-hospital adverse outcomes and one year mortality were higher in nonagenarians than in octogenarians. However, the composite of the one year major adverse cardiac events (MACEs) was comparable between the two groups without differences in MI or re-PCI rate. PCI improved 1-yr mortality (adjusted hazard ratio [HR], 0.50; 95% confidence interval [CI], 0.36-0.69, P<0.001) and MACEs (adjusted HR, 0.47; 95% CI, 0.37-0.61, P<0.001) without significant complications both in nonagenarians and octogenarians. In conclusion, nonagenarians had similar 1-yr MACEs rates despite of higher in-hospital and 1-yr mortality compared with octogenarian AMI patients. PCI in nonagenarian AMI patients was associated to better 1-yr clinical outcomes.

The Association of Socioeconomic Status with Three-Year Clinical Outcomes in Patients with Acute Myocardial Infarction Who Underwent Percutaneous Coronary Intervention

The aim of this study was to evaluate whether the clinical outcomes were associated with socioeconomic status (SES) in patients with acute myocardial infarction (AMI) who underwent percutaneous coronary intervention (PCI). The author analyzed 2,358 patients (64.9 +/- 12.3 yr old, 71.5% male) hospitalized with AMI between November 2005 and June 2010. SES was measured by the self-reported education (years of schooling), the residential address (social deprivation index), and the national health insurance status (medical aid beneficiaries). Sequential multivariable modeling assessed the relationship of SES factors with 3-yr major adverse cardiovascular events (MACEs) and mortality after the adjustment for demographic and clinical factors. During the 3-yr follow-up, 630 (26.7%) MACEs and 322 (13.7%) all-cause deaths occurred in 2,358 patients. In multivariate Cox proportional hazards regression modeling, the only lower education of SES variables was associated with MACEs (hazard ratio [HR], 1.41; 95% confidence interval [CI], 1.04-1.91) and mortality (HR, 1.93; 95% CI, 1.16-3.20) in the patients with AMI who underwent PCI. The study results indicate that the lower education is a significant associated factor to increased poor clinical outcomes in patients with AMI who underwent PCI.

Comparison of Coronary Plaque and Stenosis Between Coronary Computed Tomography Angiography and Virtual Histology-Intravascular Ultrasound in Asymptomatic Patients with Risk Factors for Coronary Artery Disease

OBJECTIVES: The purpose of the study was to compare plaque characteristics by coronary computed tomography angiography (CCTA) with those by virtual histology-intravascular ultrasound (VH-IVUS). METHODS: We enrolled 50 asymptomatic patients with diabetes mellitus or more than two risk factors for coronary artery disease such as hypertension, smoking, and hyperlipidemia. If the patient had a coronary lesion (plaque with more than 50% stenosis or calcium score more than 100), we recommended coronary angiography and VH-IVUS and compared CCTA findings with VH-IVUS findings. RESULTS: 35 patients (70%) had coronary lesions, and we performed both CCTA and VH-IVUS in 23 patients. All 23 patients had multiple risk factors, and the majority of target lesions were located at left anterior descending artery (73.9%), and calcium score of lesion site was 106+/-162 with plaque volume of 232+/-153 mm3 by CCTA. Calcium score of lesion site was significantly greater in diabetic patients (n=14) than non-diabetic patients (n=9) (118+/-159 vs. 88+/-175, p=0.038). By VH-IVUS, plaque volume was 174+/-127 mm3, absolute necrotic core (NC) volume was 22+/-21 mm3, and relative NC volume was 20.8+/-8.7%. Absolute dense calcium (DC) volume and absolute NC volumes were significantly greater in diabetic patients than non-diabetic patients (11.5+/-13.8 mm3 vs. 9.1+/-11.0 mm3, p=0.028, and 23.9+/-24.7 mm3 vs. 18.1+/-14.3 mm3, p=0.035, respectively). Plaque volume by CCTA correlated with that of VH-IVUS (r=0.742, p<0.001), and plaque volume by CCTA correlated with absolute NC volume by VH-IVUS (r=0.621, p<0.001), and calcium score of lesion site by CCTA correlated with absolute dense calcium volume by VH-IVUS (r=0.478, p=0.028). CONCLUSION: Coronary lesion was detected by CCTA in 70% of asymptomatic patients with multiple coronary risk factors, and parameters detected by CCTA correlated well with those detected by VH-IVUS.

Mesenchymal stem cells reciprocally regulate the M1/M2 balance in mouse bone marrow-derived macrophages

Mesenchymal stem cells (MSCs) have been widely studied for their applications in stem cell-based regeneration. During myocardial infarction (MI), infiltrated macrophages have pivotal roles in inflammation, angiogenesis and cardiac remodeling. We hypothesized that MSCs may modulate the immunologic environment to accelerate regeneration. This study was designed to assess the functional relationship between the macrophage phenotype and MSCs. MSCs isolated from bone marrow and bone marrow-derived macrophages (BMDMs) underwent differentiation induced by macrophage colony-stimulating factor. To determine the macrophage phenotype, classical M1 markers and alternative M2 markers were analyzed with or without co-culturing with MSCs in a transwell system. For animal studies, MI was induced by the ligation of the rat coronary artery. MSCs were injected within the infarct myocardium, and we analyzed the phenotype of the infiltrated macrophages by immunostaining. In the MSC-injected myocardium, the macrophages adjacent to the MSCs showed strong expression of arginase-1 (Arg1), an M2 marker. In BMDMs co-cultured with MSCs, the M1 markers such as interleukin-6 (IL-6), IL-1beta, monocyte chemoattractant protein-1 and inducible nitric oxide synthase (iNOS) were significantly reduced. In contrast, the M2 markers such as IL-10, IL-4, CD206 and Arg1 were markedly increased by co-culturing with MSCs. Specifically, the ratio of iNOS to Arg1 in BMDMs was notably downregulated by co-culturing with MSCs. These results suggest that the preferential shift of the macrophage phenotype from M1 to M2 may be related to the immune-modulating characteristics of MSCs that contribute to cardiac repair.