The short-term and long-term prognostic analysis in patients with chronic total occlusion acute non-ST segment elevation myocardial infarction / 中华内科杂志

Objectives:To investigate the clinical impacts of chronic total occlusion (CTO) in acute non-ST segment elevation myocardial infarction (NSTEMI) patients underwent primary percutaneous coronary intervention (PCI).Methods:A total of 2 271 acute NSTEMI patients underwent primary PCI from China Acute Myocardial Infarction Registry were enrolled in this study and divided into the CTO group and the non-CTO group according to the angiography. The primary endpoint was in-hospital mortality and mortality during a 2-year follow-up. The secondary endpoint was major adverse cardiovascular events (MACE) including revascularization, death, re-myocardial infarction, heart failure readmission, stroke and major bleeding.Results:Thirteen-point four percent of the total acute NSTEMI patients had concurrent CTO. In-hospital mortality (3.6% vs. 1.4%, P<0.01) and 2-year mortality (9.0% vs. 5.1%, P<0.01) were significantly higher in the CTO group than those in the non-CTO group, respectively. Multiple regression analyses showed that chronic obstructive pulmonary disease ( HR 7.28, 95% CI 1.50-35.35, P=0.01) was an independent risk factor of in-hospital mortality, and advanced age ( HR 1.04, 95% CI 1.01-1.07, P<0.01), and low levels of ejection fraction ( HR 0.95, 95% CI 0.93-0.98, P<0.01) were independent risk factors of 2-year mortality. CTO ( HR1.67, 95% CI 1.10-2.54, P=0.02) was an independent risk factor of revascularization, but not a risk factor of mortality. Conclusions:Although acute NSTEMI patients concurrent with CTO had higher mortality, CTO was only an independent risk factor of revascularization, but not of mortality. Advanced age and low levels of ejection fraction were independent risk factors of long-term death among acute NSTEMI patients.

Long-term prognosis effects of single and staged percutaneous coronary intervention in patients with multi-vessel coronary artery disease / 中国医师进修杂志

Objective:To compare the influence of single and staged percutaneous coronary intervention (PCI) on long-term prognosis in patients with multi-vessel coronary artery disease.Methods:Using prospective research methods, 1 832 patients with multi-vessel coronary artery disease from January to December 2013 in Fuwai Hospital, Chinese Academy of Medical Sciences were selected. According to the time of PCI, the patients were divided into single PCI group (1 218 cases) and staged PCI group (614 cases). The patients were followed up for 2 years, the primary endpoint was major cardiovascular and cerebrovascular event (MACCE), including target vessel-related myocardial infarction (TV-MI), target vessel-related revascularization (TVR), cardiogenic death and stroke, and the secondary endpoint was stent thrombosis. The propensity score matching (PSM) was applied to balance the discrepancies between 2 groups, and the baseline and follow-up data were compared. The Kaplan-Meier survival curves were drawn to evaluate the survival rates events; multifactor Cox proportional risk regression was used to analyze whether staged PCI was an independent risk factor for the endpoint events.Results:The in-hospital stay, duration of procedure and synergy between percutaneous coronary intervention with taxus and cardiac surgery (SYNTAX) score in single PCI group were significantly lower than those in staged PCI group: (5.54±3.09) d vs. (9.50±4.06) d, (43.12±28.55) min vs. (79.54±44.35) min, (14.04±7.63) scores vs. (18.51±7.79) scores, and there were statistical differences ( P<0.01); there were no statistical difference in complete revascularization rate and SYNTAX score after PCI between 2 groups ( P>0.05). Based on 2-year follow-up, the incidences of TV-MI and stent thrombosis in staged PCI group were significantly higher than those in single PCI group: 2.1% (13/614) vs. 0.5% (6/1 218) and 2.0% (12/614) vs. 0.4% (5/1 218), and there were statistical differences ( P<0.01). Kaplan-Meier survival curves analysis results showed that the event-free survival rates of TV-MI and stent thrombosis in single PCI group were better than those in staged PCI group (99.5% vs. 97.9% and 99.6% vs. 98.0%, P<0.01). Multifactor Cox proportional risk regression analysis results showed that staged PCI was an independent risk factor for stent thrombosis ( HR = 3.91, 95% CI 1.25 to 12.18, P = 0.019). After PSM, the incidences of TV-MI and stent thrombosis in staged PCI group were significantly higher than those in single PCI group: 2.1% (13/614) vs. 0.7% (4/614) and 2.0% (12/614) vs. 0.5% (3/614), and there were statistical differences ( P<0.05); Kaplan-Meier survival curve analysis results showed that the event-free survival rates of TV-MI and stent thrombosis in single PCI group were significantly higher than those in staged PCI group: (99.3% vs. 97.9% and 99.5% vs. 98.0%, P<0.05); multifactor Cox proportional risk regression analysis results showed that staged PCI was not an independent risk factor of stent thrombosis ( HR = 2.29, 95% CI 0.58 to 9.00, P = 0.234). Both before and after PSM, there were no evidences for interaction between the type of angina pectoris and staged PCI ( P>0.05). Conclusions:Although a seemingly increase exists in the incidence of TV-MI and stent thrombosis in the staged PCI group, staged PCI is an independent risk factor neither for MACCE and its components, nor for stent thrombosis. In addition single PCI reduces the in-hospital days and duration of PCI procedure, which may be a relatively reasonable approach to clinical practice.

Association between plasma HDL-C levels and coronary artery severity and impact on outcomes of patients underwent percutaneous coronary intervention / 中华心血管病杂志

Objective@#To analyze the association between plasma high-density lipoprotein cholesterol (HDL-C) levels and the severity of coronary artery disease, and to evaluate the impact of HDL-C levels on long-term outcomes in patients underwent percutaneous coronary intervention (PCI).@*Methods@#A total of 10 458 consecutive patients underwent PCI from January 2013 to December 2013 at Fuwai hospital were enrolled in this study. Patients were divided into three groups according to HDL-C tertiles: low HDL-C group (HDL-C≤0.89 mmol/L, n=3 525), median HDL-C group (HDL-C>0.89-1.11 mmol/L, n=3 570) and high HDL-C group (HDL-C>1.11 mmol/L, n=3 363). SYNTAX score was used to evaluate the severity of coronary artery disease, linear regression was used to analyze the relationship of HDL-C and SYNTAX score. Kaplan-Meier survival analysis was used to compare the outcomes among the three groups. Multivariate Cox regression was used to define the potential associations of HDL-C and outcomes.@*Results@#The HDL-C level was (1.03±0.28) mmol/L and the SYNTAX score was 11.7±8.1. Patients were older, proportion of female, stable angina pectoris, successful PCI and left ventricular eject fraction value were higher, while incidence of diabetes mellitus was lower, hyperlipidemia, old myocardial infraction, smoking history and left main and three vessels disease were lower in high HDL-C group (all P<0.05). Patients in high HDL-C group also had the lowest SYNTAX score (12.2±8.4 vs. 11.7±8.1 vs. 11.2±7.8, P<0.001). Both univariate and multivariate linear regression analysis showed that HDL-C was negatively associated with SYNTAX score, e.g. Univariate analysis: β=-0.046, P<0.001; Multivariate analysis: β=-0.058, P=0.001. And 10 400 (99.4%) patients completed 2-year follow up. At 2-year follow-up, there were no difference in all-cause death, cardiac death, myocardial infarction, revascularization, stroke, major adverse cardiovascular and cerebral events (MACCE) and stent thrombosis among three groups (P for trend>0.05), while patient in high HDL-C group experienced the highest BARC type 2 bleeding events (P for trend=0.018). Multivariate Cox regression analysis showed that HDL-C level was not an independent risk factor of 2-year adverse ischemia events (P>0.05) and 2-year bleeding events (P>0.05).@*Conclusion@#In patients underwent PCI, plasma HDL-C level is negatively associated with SYNTAX score, but not an independent risk factor of ischemic and bleeding events post PCI.

Predictive value of neutrophil to lymphocyte ratio on long-term outcomes of acute myocardial infarction patients with multivessel disease / 中华心血管病杂志

Objective@#Patients with acute coronary syndrome due to multivessel disease (MVD) were at the highest risk of adverse cardiovascular events. Neutrophil to lymphocyte ratio (NLR) was proposed as a marker of cardiovascular risk. Present study evaluated the independent predictive value of NLR for acute myocardial infarction (AMI) patients with MVD.@*Methods@#AMI patients with MVD (n=1 433) underwent percutaneous coronary intervention (PCI) between January 2013 and December 2013 were followed up for 2 years. Patients were divided into 2 sub-groups based on an optimal cut off value of NLR to predict 2-year all-cause mortality. The primary endpoint was all-cause death. The secondary endpoint was long-term major adverse cardiovascular and cerebrovascular events (MACCE).@*Results@#By receiver operating characteristics curve analysis, the optimal cut-off value of admission NLR to predict 2-year all-cause mortality was 3.39 (area under the curve 0.765, sensitivity 71%, specificity 73%). The high NLR group(n=396) had higher prevalence of prior myocardial infarction, prior PCI and intra-aortic balloon pump use (IABP)(P<0.01). Compared to the low NLR group (n=1 037), patients in the high NLR group were older, had higher level of neutrophil count and high-sensitivity C-reactive protein (hs-CRP) (P<0.001), but lower level of lymphocyte count, estimated glomerular filtration rate (eGFR) and ejection fraction (P<0.001). During the follow-up period, rate of long-term all-cause death was significantly higher in the high NLR group than in the low NLR group (5.1% (20/396) vs. 0.8% (8/1 037), P<0.001). Cardiac death (4.0% (16/396) vs. 0.7% (7/1 037), P<0.001) and MACCE (21.7% (86/396) vs. 12.6% (131/1 037), P<0.001) were also significantly higher in the high NLR group than in the low NLR group. Multivariate Cox analysis showed that NLR ≥ 3.39 was determined as an independent predictor of 2-year all-cause mortality (HR=3.23, 95%CI 1.38-7.54, P=0.007) and MACCE (HR=1.58, 95%CI 1.19-2.10, P=0.002) in this patient cohort after adjusting for other risk factors. Correlation analysis showed that the NLR was positively correlated with hs-CRP levels (r=0.241, P<0.001).@*Conclusion@#Our study demonstrates that admission NLR ≥ 3.39 is an independent predictor of long term all cause death and MACCE in AMI patients with MVD post PCI.

Impact of coronary artery lesion calcification on the long-term outcome of patients with coronary heart disease after percutaneous coronary intervention / 中华心血管病杂志

Objective@#To investigate the impact of coronary lesion calcification on the long-term outcome of patients with coronary heart disease after percutaneous coronary intervention.@*Methods@#In this prospective observational study, a total of 10 119 consecutive patients with coronary heart disease undergoing percutaneous coronary intervention from January 1 to December 31, 2 103 in our hospital were enrolled. The patients were divided into non/mild calcification group (8 268 cases) and moderate/severe calcification group (1 851 cases) according to the angiographic results. The primary endpoint was one-year major adverse cardiovascular events (MACE), including all-cause death, myocardial infarction, and target vessel revascularization.@*Results@#The patients were (58.3±10.3) years old, and there were 2 355 females (23.3%). Compared with non/mild calcification group, patients in the moderate/severe calcification group were older ((60.0±10.6) years vs. (57.9±10.2) years, P<0.01), and had higher proportion of female (25.4% (470/1 851) vs. 22.8% (1 885/8 268), P=0.02), debates (33.9% (628/1 851) vs. 29.0% (2 399/8 268), P<0.01), hypertension (68.0% (1 259/1 851) vs. 63.7% (5 264/8 268), P<0.01), coronary artery bypass grafting (4.6% (85/1 851) vs. 3.2% (268/8 268), P<0.01), stroke (12.6% (233/1 851) vs. 10.4% (861/8 268), P=0.01), and renal dysfunction (6.2% (115/1 851) vs. 3.7% (303/8 268), P<0.01). Compared with non/mild calcification group, patients in themoderate/severe calcification group experienced longer procedure time (37 (24, 61) min vs. 27 (17,40) min, P<0.01) and stent length was longer (32 (23,48) mm vs. 27 (18,38) mm, P<0.01), and percent of rotational atherectomy was higher (2.56%(57/2 229) vs. 0.03% (3/11 930), P<0.01). One-year follow-up results showed that MACE (7.5% (139/1 846) vs. 4.9% (402/8 243), P<0.01), all-cause death (1.0% (19/1 846) vs. 0.6% (49/8 243), P=0.04), myocardial infarction (2.2% (41/1 846) vs. 1.4% (114/8 243), P=0.01), and target vessel revascularization (5.0% (92/1 846) vs. 3.2% (266/8 243), P<0.01) were all significantly higher in moderate/severe calcification group than in non/mild group. Multivariate Cox regression analysis showed that moderate/severe calcification was an independent predictor of MACE at one-year after the procedure (HR=1.41, 95%CI 1.16-1.72, P<0.01).@*Conclusion@#Moderate/severe calcification in coronary lesion is an independent predictor of long-term poor prognosis in coronary heart disease patients undergoing percutaneous coronary intervention.

Clinical characteristics and prognosis between male and female patients with premature coronary artery disease after intervention / 中华心血管病杂志

Objective@#To compare the clinical characteristics and long-term prognosis between male and female patients with premature coronary artery disease (PCAD) post coronary intervention, and analyse the risk factors of major adverse cardio-cerebrovascular events (MACCE) and bleeding events.@*Methods@#This was a prospective single-center observational study. From January 2013 to December 2013, 4 744 patients diagnosed as PCAD and treated with percutaneous coronary intervention (PCI) in Fuwai Hospital were enrolled. The general clinical data, laboratory results and interventional treatment data of all patients were collected, and patients were followed up for 2 years after PCI and the incidence of events including MACCE and bleeding was analyzed. The baseline data and clinical events of PCAD patients of different genders were compared. Survival curves were estimated by Kaplan-Meier method. Univariate and multivariate Cox regression were used to analyze whether gender was an influencing factor of different clinical events of PCAD patients within 2 years after PCI, and other relevant influencing factors of MACCE and bleeding events.@*Results@#Among the 4 744 PCAD patients included, there were 3 390 (71.5%) male aged (47.0±5.4) years old and 1 354 (28.5%) female aged (57.0±5.8) years old. Compared with female patients, male patients had higher body mass index, higher proportion of hyperlipidemia, smoking, myocardial infarction, previous PCI, preoperative estimated glomerular filtration rate, ST-segment elevation myocardial infarction, radial artery approach, intravenous ultrasound use and chronic occlusive lesions (all P<0.05). Age, left ventricular ejection fraction, prevalence of hypertension, diabetes mellitus, past stroke history, non-ST-segment elevation acute coronary syndrome (NSTE-ACS) and the use of calcium channel blockers were lower in male patients than in female patients (all P<0.05). The 2-year follow-up results showed that the incidence of BARC type 1 hemorrhage was significantly higher in female patients than in male patients (6.9%(92/1 343) vs. 3.7%(126/3 378), P<0.001); however, the incidence of MACCE, all-cause death, cardiac death, recurrent myocardial infarction, revascularization (target vessel revascularization and target lesion revascularization), stent thrombosis, stroke and BARC type 2-5 hemorrhage were similar between the two groups (all P>0.05). Multivariate Cox regression analysis showed that gender was an independent risk factor for BARC type 1 bleeding in PCAD patients (HR=2.180, 95%CI 1.392-3.416, P<0.001), but it was not an independent risk factor for MACCE and BARC type 2-5 bleeding(all P>0.05). Hyperlipidemia, preoperative SYNTAX score, multivessel lesions and NSTE-ACS were the independent risk factors for MACCE in PCAD patients with PCI (the HRs(95%CI) were 1.289(1.052-1.580), 1.030(1.019-1.042), 1.758(1.365-2.264), 1.264(1.040-1.537), respectively); gender (HR=1.579, 95%CI 1.085-2.297, P=0.017), hyperlipidemia (HR=1.305, 95%CI 1.005-1.695, P=0.046), anticoagulant drugs including low molecular weight heparin (HR=1.321, 95%CI 1.002-1.741, P=0.048) or sulfonate(HR=1.659, 95%CI 1.198-2.298, P=0.002) were the independent risk factors for bleeding events.@*Conclusions@#There are differences in clinical and coronary artery lesion characteristics between different genders in patients with PCAD. The incidence of minor bleeding is significantly higher in female PCAD patients than in male PCAD patients. Hyperlipidemia, preoperative SYNTAX score, multivessel lesions and NSTE-ACS are the independent risk factors for MACCE, and gender, hyperlipidemia, anticoagulant drugs including low molecular weight heparin or sulfonate are the independent risk factors for bleeding events in patients with PCAD.

Prognostic value of TIMI and GRACE risk scores for in-hospital mortality in Chinese patients with non-ST-segment elevation myocardial infarction / 中华心血管病杂志

Objective@#To evaluate the prognostic value of the thrombolysis in myocardial infarction (TIMI) and global registry of acute coronary events (GRACE) risk scores for in-hospital mortality in Chinese non-ST-segment elevation myocardial infarction (NSTEMI) patients.@*Methods@#Data of present study derived from the prospective, multi-center registry trial of Chinese AMI (CAMI). Among 31 provinces, municipalities or autonomous districts in China, at least one tertiary and secondary hospital was selected. From January 2013 to September 2014, 5 896 consecutive non-ST-segment elevation myocardial infarction patients who were admitted to 107 hospitals within 7 days of symptom onset were enrolled. For each patient, TIMI and GRACE risk scores were calculated using specific variables collected at admission. Their prognostic value was evaluated by the endpoint of in-hospital mortality.@*Results@#Among 5 896 NSTEMI patients (age was (65.4±12.1) years old), 68.2% (n=4 020) were males. The in-hospital mortality was 6.0% (n=353) and the median length of hospital stay was 10.0 (7.0, 13.0) days. The incidence of pre-hospital cardiac arrest was 3.6% (n=213) among 5 896 NSTEMI patients. Six hundreds and forty five patients (10.9%) received primary percutaneous coronary intervention, and 6 patients underwent emergent coronary artery bypass grafting surgery (0.1%), and the median time of reperfusion was 529.5 (256.0, 1 065.0) minutes. The prescription percentage of statins, β-blocker, angiotensin converting enzyme inhibitors or angiotensin Ⅱ receptor blockers, and aldosterone antagonists were 94.8% (n=5 587), 71.7% (n=4 228), 65.5% (n=3 864) and 26.0% (n=1 533) respectively. The area under the curve of GRACE risk score for in-hospital mortality (0.7930 (95%CI 0.767-0.818)) was better than that of TIMI risk score (0.5588 (95%CI 0.532-0.586), P<0.001).@*Conclusion@#GRACE risk score demonstrates better predictive accuracy than TIMI risk score for in-hospital mortality in NSTEMI patients in this patient cohort.

Impact of short-time anticoagulant therapy after selective percutaneous intervention on prognosis of patients with coronary artery disease / 中华心血管病杂志

Objective@#To observe the safety and impact of short-term anticoagulant therapy on prognosis after selective percutaneous coronary intervention (PCI) in patients with coronary artery disease.@*Methods@#From January 2013 to December 2013, 9 769 consecutive patients underwent selective PCI in Fuwai Hospital were retrospectively included in this study. Patients were divided into two groups, including non-post-PCI anticoagulant therapy group and low-dose and short-time post-PCI anticoagulant therapy group (enoxaparin 0.4 ml/12 h or fondaparinux 2.5 mg/day by subcutaneous injection for 2-3 days after PCI). All patients were evaluated at 30 days, 180 days and 12 months for major adverse coronary and cerebral events (MACCE) including all-cause death, myocardial infarction, revascularization and stroke as well as in-stent thrombosis and bleeding events. Data from 1 755 pairs of patients were analysis after propensity score matching. The clinical outcomes were compared between groups by using Kaplan-Meier survival analysis before and after propensity score matching. Multivariable Cox analysis was used to define the impact and determinants of post-PCI anticoagulation on clinical outcomes.@*Results@#one thousand seven hundred and fifty-five (18.0%) patients didn′t receive post-PCI anticoagulation and 8 014 (82.0%) patients received post-PCI anticoagulation, 5 666 (58.0%) patients received enoxaparin and 2 348 (24.0%) patients received fondaparinux. Patients were younger and incidence of female patients was less, incidence of renal dysfunction and acute coronary syndrome were higher in low-dose and short-time post-PCI anticoagulant therapy group than in non-post-PCI anticoagulation group (all P<0.05). Similarly, patients with post-PCI anticoagulation were associated with more left main coronary artery lesion and branch lesion (P<0.05). Post-PCI anticoagulation patients were associated with less trans-femoral process, more drug-eluting stents implantation and less simple balloon dilatation (all P<0.05). Nine thousand seven hundred and seventeen (99.5%) patients completed 2 years follow up. Post-PCI anticoagulation patients had significantly lower 30-day all-cause death (0.05% (4 cases) vs. 0.46% (8 cases), P<0.001) and stroke (0 vs. 0.11% (2 cases), P=0.003), lower 180-day all-cause death (0.17% (14 cases) vs. 0.57% (10 cases), P=0.002), revascularization (2.07% (166 cases) vs. 3.71% (65 cases), P<0.001) and MACCE (3.49% (280 cases) vs. 5.47% (96 cases), P<0.001), lower 2-year revascularization (7.61% (610 cases) vs. 12.84% (225 cases), P<0.001) and MACCE (10.92 (875 cases) vs. 16.01% (281 cases), P<0.001). Multivariable Cox regression analysis showed that post-PCI anticoagulant therapy was an independent protective factor of 30-day (HR=0.17, 95%CI 0.05-0.62, P=0.007), 180-day all-cause death (HR=0.37, 95%CI 0.16-0.87, P=0.023) and MACCE (HR=0.74, 95%CI 0.58-0.94, P=0.013), 2-year MACCE (HR=0.71, 95%CI 0.62-0.81, P<0.001). After propensity score matching, post-PCI anticoagulation therapy remained as an independent protective factor of 30-day all-cause death (HR=0.11, 95%CI 0.01-0.92, P=0.042) and 2-year MACCE (HR=0.81, 95%CI 0.68-0.96, P=0.015).@*Conclusions@#Low-dose and short-time post-PCI anticoagulant therapy may decrease 30-day all-cause death, 180-day all-cause death and MACCE and 2-year MACCE, and meanwhile this option does not increase bleeding risk in patients underwent selective PCI.

Antithrombotic therapy in elderly patients with acute coronary syndrome / 中华老年医学杂志

Elderly adults constitute a rapidly increasing subgroup of patients presenting with acute coronary syndrome.Due to a higher risk of bleeding and more multiple complications in the elderly,the treatment of acute coronary syndrome is more conservative in these patients than in younger patients.The scarcity of evidence from randomized controlled trials makes antithrombotic therapy in elderly patients particularly challenging and controversial.This article reviews the current evidence on antithrombotic therapy for acute coronary syndrome in the elderly.

A Comparison of Transradial and Transfemoral Percutaneous Coronary Intervention in Chinese Women Based on a Propensity Score Analysis

BACKGROUND AND OBJECTIVES@#Over the past decades, transradial approach for percutaneous coronary intervention (PCI) has been increasingly adopted in clinical practice. Women represent a large population who will possibly benefit from PCI, but they are often under-represented in clinical studies. Therefore, the role of TRI in women remains to be further defined. This study sought to compare safety and efficacy for transradial intervention (TRI) and transfemoral intervention (TFI) in women undergoing PCI in China.@*METHODS@#The study population consisted of 5,067 women undergoing PCI at Fuwai Hospital, Beijing, China between 2006 and 2011 (TRI: n=4,105, TFI: n=962). Incidence rates of clinical outcomes during hospitalization and at 1-year follow-up were compared between TRI and TFI. In order to minimize potential biases, a 1:1 propensity score matching (PSM) was performed. A total of 899 pairs were matched.@*RESULTS@#Baseline and procedural characteristics were well-balanced between TRI and TFI groups after controlling for confounders using PSM. TRI was associated with reduced major post-PCI bleeding (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.54–0.76; p 0.05).@*CONCLUSIONS@#In this propensity score-based analysis of TRI versus TFI in Chinese women, TRI showed advantages of safety and feasibility over TFI. A wider adoption of TRI in women has the potential to improve outcomes in treatment of coronary artery diseases.

Impact of aortic root morphology on the implantation depth of aortic valve prosthesis during trans-catheter aortic valve replacement in patients with native bicuspid aortic valve stenosis / 中华心血管病杂志

Objective@#To investigate the impact of aortic root morphology on the implantation depth of aortic valve prosthesis during trans-catheter aortic valve replacement (TAVR) in bicuspid aortic valve patients.@*Methods@#Clinical data of 40 patients with native bicuspid aortic valve stenosis who underwent TAVR using the self-expandable prosthesis (the Venus A-valve) from 2014 to 2017 in Fuwai Hospital was retrospectively analyzed. The patients were divided into non-deep implantation group (implant depth ≤10 mm by instant angiogram after implantation,29 cases) and deep implantation group (implant depth> 10 mm by instant angiogram after implantation,11 cases).Pre-procedural aortic root characteristics (e.g. calcification, angle and dimensions) were assessed by CT. The impact of aortic root morphology on the implantation depth and clinical outcomes were also evaluated.@*Results@#The age was (75.1±5.9) years with equal representation from the raphe-type and non-raphe type (52.5%(21/40) and 47.5%(19/40)).The bigger aorta angle ((56.5±4.5)° vs. (47.4±9.4)°, P=0.004),more frequent mild-calcification (HU850, <200 mm3) or severe-calcification(HU850, >1 000 mm3) of aortic leaflets (7/11 vs. 4/29, P=0.006), as well as higher ratio of left ventricular outflow tract perimeter to annulus perimeter ((109.2±7.5)% vs. (101.5±6.5)%, P=0.004) were found in the deep implantation group compared to the non-deep implantation group. The new in-hospital onset of bundle-branchheart-block or atrioventricular block conduction disturbance rate was higher in the deep implantation group than in the non-deep implantation group (6/11 vs. 2/29, P=0.030).Left ventricular ejection fraction was similar between deep implantation group and non-deep implantation group at baseline((49.9±8.9)% vs. (55.8±10.4)%, P=0.117), and was significantly lower in the deep implantation group than in the non-deep implantation group at 30 days after implantation ((51.6±12.8)% vs. (60.9±8.1)%, P=0.020).@*Conclusion@#Aortic root morphology of bicuspid aortic valve patients is associated with implantation depth of the prosthesis during TAVR, which affects the conduction system and left ventricular function during and post TAVR.

Comparison on the predictive value of different scoring systems for risk of short-term death in patients with acute myocardial infarction complicating cardiogenic shock / 中华心血管病杂志

Objective@#To compare predictive value of the current 7 scoring systems and CADILLAC-plus scoring system for risk of short-term deathin patients with acute myocardial infarction complicating cardiogenic shock.@*Methods@#A total of 126 acute myocardial infarction patients complicating cardiogenic shock hospitalized in Fuwai hospital from June 2014 to January 2018 were enrolled in this study, the clinical data were retrospectively analyzed. The patients were divided into survival group(49 cases) and death group(77 cases) according to survival or not at 28 days after diagnosis of cardiogenic shock.The scores of APACHE Ⅱ,APACHE Ⅲ,SAPS Ⅱ,PAMI, TIMI-STEMI,TIMI-NSTEMI,and CADILLAC were calculated within 24 hours in coronary care unit (CCU),and scores of CADILLAC-plus, which is an improved score derived from CADILLAC, was also calculated. The predictive value of the different scoring systems for 28 day smortality of acute myocardial infarction patients complicating cardiogenic shock were compared in this patient cohort. @*Results@#Scores of APACHEⅡ,APACHEⅢ,SAPSⅡ,PAMI,TIMI-STEMI, TIMI-NSTEMI,CADILLAC,and CADILLAC-plus were all significantly higher in death group than in survival group: (28.9±10.2 vs. 21.8±8.3,94.0 (57.0,114.0) vs. 57.0 (45.4,81.5) ,62.0 (46.0,81.0) vs. 47.0 (41.5,60.5) ,7.0 (6.0,9.0) vs. 6.0 (6.0,7.5) ,10.0 (9.0,11.0) vs. 9.0 (8.0,10.0) ,4.0 (3.0,5.0) vs. 3.0 (3.0,4.0) ,10.0 (7.0,12.0) vs. 7.0 (5.0,9.0) ,and 10.0 (8.0,14.0) vs. 7.0 (5.0,10.0) , respectively, all P<0.01).The area under the curve(AUC) of receiver operating characteristic(ROC) curve for predicting 28 days death of APACHE Ⅱ,APACHE Ⅲ,SAPS Ⅱ,PAMI, TIMI-STEMI,TIMI-NSTEMI,and CADILLAC scoring systems were 0.820,0.797,0.785,0.667,0.657,0.711,and 0.821,respectively and cut-off value was 27.5,79.5,66.0,8.5,10.5,3.5,and 8.5, respectively and the sensitivity was 0.766,0.844,0.649,0.494,0.494,0.740,and 0.753, respectively and specificity was 0.816,0.755,0.837,0.204,0.796,0.571,and 0.755,respectively.The AUC of ROC of CADILLAC-plus scoring system was 0.885,cut-off value was 9.5, sensitivity was 0.896,and specificity was 0.735. The predicting efficacy of CADILLAC-plus scoring system was superior to other scoring systems.@*Conclusion@#The 7 current scoring systems are all suitable for predicting theshort-term death in acute myocardial infarction patients complicating cardiogenic shock, and the predicting efficacy of the improved CADILLAC-plus score is superior to other scoring systems in this patient cohort.

Safety and efficacy of a novel abluminal groove-filled biodegradable polymer sirolimus-eluting stent for the treatment of de novo coronary lesions: 5-year results of the TARGET Ⅱ trial / 中华心血管病杂志

Objective@#This study sought to evaluate the safety and efficacy of FIREHAWK, a novel abluminal groove-filled biodegradable polymer sirolimus-eluting stent (SES) in patients with moderate-complex coronary lesions (including patients with small vessel disease, long lesion and multi vessel disease), and to validate the ability of the SYNTAX score (SS) to predict clinical outcomes in patients treated with FIREHAWK stent. @*Methods@#TARGETⅡ was a prospective, multicenter, single-arm clinical trial, a total of 730 patients who underwent percutaneous coronary intervention (PCI) of de novo lesions in native coronary arteries in 24 medical centers in China from August 2011 to February 2012 were enrolled in this study. All patients were exclusively treated with the FIREHAWK stent. Clinical data including patients with diabetes, small vessel disease, long lesion and multi vessel disease were analyzed. The primary composite endpoint was the target lesion failure (TLF) of cardiac death, target vessel-related myocardial infarction (TV-MI), or target lesion revascularization (TLR). The secondary composite endpoint was patient-oriented endpoint (PoCE), a composite of all death, all myocardial in farction (MI), or any repeat revascularization; definite/probable stent thrombosis (ST) (including acute, late, and very late thrombosis) . SS was calculated in lesions with stenosis more than 50% with coronary artery diameter greater than 1.5 mm. Patients were grouped by tertiles of SS (≤7, >7 to ≤12, >12). Follow-up was performed up to 5 years. @*Results@#A total of 730 patients were enrolled in the TARGET Ⅱ trial. The average SS was 10.9±6.9. 683 (93.6%) patients completed 5-year clinical follow-up. The 5-year incidence of TLF was 8.5%(58/683). The incidence of TLF components was as follows: cardiac death 2.0%(14/683), TV-MI 4.4%(30/683), TLR 3.4%(23/683). The incidence of PoCE was 16.4%(112/683). The incidence of definite/probable stent thrombosis was 0.7%(5/683).Multivariable Cox regression analysis showed that the diabetes subgroup (HR=1.123, 95%CI 0.623-2.026, P=0.699), the small vessel disease subgroup (HR=0.909, 95%CI 0.526-1.570, P=0.732), the long lesion subgroup (HR=1.561, 95%CI 0.922-2.640, P=0.097), and the multi vessel disease subgroup (HR=1.062, 95%CI 0.611-1.846, P=0.830) did not increase the HR of TLF compared with the counterpart subgroups. Multivariable Cox regression analysis showed that the hazard of TLF was not increased in the middle and high SS groups as compared with the low SS group (HR=1.203,95%CI 0.607-2.385,P=0.597;HR=1.548,95%CI 0.829-2.892,P=0.171). @*Conclusions@#The 5 years follow-up results of TARGET Ⅱ trial shows that the biodegradable polymer of FIREHAWK stents have long-lasting safety and efficacy for patients with moderate-complex coronary lesions. SS is not the predicting factor for the occurrence of TLF in FIREHAWK treated patients with moderate-complex coronary lesions. Trial Registration Clinical Trials.gov, NCT0141264.

Predictive value of the GRACE discharge score on the long-term out-of-hospital coronary thrombotic events after implantation of drug-eluting stents / 中华心血管病杂志

Objective@#To evaluate the predictive value of GRACE discharge score on the long-term out-of-hospital coronary thrombotic events (CTE) after percutaneous coronary intervention (PCI) with drug-eluting stents.@*Methods@#Present study was a prospective, observational, single center study. 10 724 consecutive patients underwent PCI in Fuwai Hospital between January and December 2013 were included, stents were implanted with conventional method. After PCI, patients were prescribed aspirin 100 mg once daily indefinitely, and either clopidogrel 75 mg once daily or ticagrelor 90 mg twice daily for at least 1 year. A total of 9 782 patients were included in the final analysis after excluding patients who did not undergo successful stent implantation, who were not discharged on dual anti-platelet therapy (DAPT), who only underwent bare-metal stents, who experienced in-hospital major bleeding, stent thrombosis, myocardial infarction (MI) or death,and who lost follow up. Clinical data were collected from all patients. 9 543 patients with complete baseline data were further analyzed for risk stratification and predictive value of GRACE discharge score. CTE was defined as stent thrombosis or spontaneous myocardial infarction. All patients were followed through Fuwai Hospital Follow-up Center, and evaluated either by phone, letter, or clinic visits or at 1, 6, 12 and 24 months after PCI. Risk stratification was performed according to the GRACE discharge score, and the predictive value of the GRACE discharge score was assessed using the receiver operating characteristic (ROC) curve.@*Results@#After 2 years follow-up, there were 95 CTE among the 9 782 patients. The patients were divided into 2 groups according to the presence or absence of CTE: CTE group (95 cases) and no CTE group (9 687 cases). GRACE discharge score was significantly higher in CTE group than no CTE group (82.98±27.58 vs. 75.51±22.46, t=-2.57, P=0.012). According to risk stratification of GRACE discharge score, the patients were divided into low-risk (≤88) group (n=6 902), moderate-risk (89-118) (n=2 988) and high-risk (>118) (n=343) groups. As compared to the low-risk group, CTE risk in moderate- and high-risk groups was 1.59 times (HR 1.59, 95%CI 1.01-2.52, P=0.046) and 3.89 times higher (HR 3.89, 95%CI 1.98-7.65, P<0.001), respectively. Further analysis showed that the GRACE score had predictive value in the total cohort for CTE (area under the receiver operating characteristic (AUROC) 0.576, 95%CI 0.512-0.640, P=0.012) and in the acute coronary syndromes(ACS) subgroup for CTE: (AUROC 0.594, 95%CI 0.509-0.680, P=0.019), but not in the non-ACS subgroup: (AUROC 0.561, 95%CI 0.466-0.657, P=0.187).@*Conclusion@#GRACE discharge score can predict the long-term out-of-hospital CTE in patients undergoing PCI with drug-eluting stents and treated with DAPT, and patients can be stratified into the low-, moderate- and high-risk groups of CTE by the GRACE discharge score.

Relationship between thrombolysis in myocardial infarction risk index and the severity of coronary artery lesions and long-term outcome in acute myocardial infarction patients undergoing percutaneous coronary intervention / 中华心血管病杂志

Objective@#To investigate the relationship between thrombolysis in myocardial infarction risk index(TRI) and the severity of coronary artery lesions and long-term outcome in acute myocardial infarction(AMI) patients undergoing percutaneous coronary intervention(PCI).@*Methods@#A total of 1 663 consecutive AMI patients undergoing PCI between January and December 2013 in Fuwai hospital were prospectively included in this study. The severity of coronary artery lesions was evaluated using the SYNTAX score. Receiver operating characteristic(ROC) curve was used to analyze the optimal cut-off value of TRI on predicting all-cause mortality at 2 years after PCI.The patients were divided into 2 groups based on the optimal cut-off value of TRI:high TRI group (TRI ≥ 23.05, 465 cases) and low TRI group(TRI<23.05, 1 198 cases). Multivariate logistic regression analyses were used for determining the relationship between TRI and SYNTAX scores≥33. A multivariate Cox regression analyses was used to identify the influence factors of long-term outcome after PCI.@*Results@#SYNTAX score was higher in high TRI group than in low TRI group (13.00(7.00, 20.50) vs.10.25(7.00, 17.00), P<0.001). TRI was independently associated with SYNTAX score ≥ 33 (OR=1.09,95% CI 1.03-1.16, P=0.004). After the 2 years follow-up, rates of all-cause death (4.1% (19/465) vs. 0.3% (4/1 198) , P<0.001), cardiac death (2.6% (12/465) vs. 0.2% (2/1 198) , P< 0.001) and stent thrombosis (1.7% (8/465) vs. 0.5% (6/1 198) , P=0.015) were all significantly higher in high TRI group than in low TRI group. Multivariate Cox regression analyses showed that TRI≥ 23.05 was an independent risk factor of all-cause death (HR=5.22, 95%CI 1.63-16.72, P=0.005), cardiac death (HR=8.48, 95%CI 1.75-41.07, P=0.008) and stent thrombosis(HR=3.87, 95%CI 1.32-11.41, P=0.014) at 2 years after PCI in AMI patients, but which was not the independent risk factor of major adverse cardiovascular and cerebrovascular events (HR=0.96, 95%CI 0.69-1.36, P=0.834) .The area under ROC curve of TRI ≥ 23.05 on predicting 2 years all-cause mortality in AMI patients undergoing PCI was 0.803(95%CI 0.711-0.894, P<0.001).@*Conclusions@#TRI is independently associated with SYNTAX score ≥ 33. TRI is also an independent risk factor of 2 years all-cause death, cardiac death and stent thrombosis in AMI patients undergoing PCI.

Impact of direct bilirubin on the long-term outcome of patients with acute coronary syndrome post percutaneous coronary intervention / 中华心血管病杂志

Objective@#To investigate the impact of direct bilirubin on long-term prognosis of acute coronary syndrome (ACS) patients post percutaneous coronary intervention(PCI).@*Methods@#As a prospective and observational cohort study, a total of 6 431 consecutive ACS patients underwent PCI from January to December 2013 in Fuwai hospital were included. Patients were divided into 3 groups according to tertiles values of direct bilirubin as follows: low direct bilirubin group(<2.2 μmol/L, n=2 219), moderate direct bilirubin group(2.2-3.0 μmol/L, n=2 016), and high direct bilirubin group(>3 μmol/L, n=2 196). The clinical characteristics were compared among the 3 groups, and the impact of direct bilirubin on clinical adverse events (main adverse cardiovascular and cerebrovascular events included cardiogenic death, myocardial infarction, revascularization, stroke, and stent thrombosis) were analyzed at 2 years after PCI.@*Results@#(1) Percent of male patients was 66.5%(1 475/2 219), 78.0%(1 572/2 016), and 86.2%(1 892/2 196), body mass index was(25.7±3.1), (26.0±3.3),and (26.0±3.2) kg/m2, the ratio of the history of old myocardial infarction was 11.9%(264/2 219), 13.0%(263/2 016),and 14.9%(328/2 196), the ratio of the current smoker was 56.3%(1 249/2 219), 59.1%(1 192/2 016),and 60.0%(1 317/2 196) in low, moderate and high direct bilirubin groups respectively, and the differences were statistically significant (P<0.01 or 0.05). (2) Two years after PCI, the all-cause mortality was 0.8%(17/2 219), 1.8%(36/2 016), and 1.5%(33/2 196) (P=0.011),the cardiogenic mortality was 0.5%(12/2 219), 1.3%(26/2 016), and 0.6%(13/2 196) (P=0.010),the ratio of myocardial infarction was 2.2%(49/2 219), 2.4%(49/2 016), and 1.4%(31/2 196)(P=0.044),the ratio of revascularization was 8.8%(195/2 219), 8.3%(168/2 016),and 8.9%(196/2 196)(P=0.783),the ratio of stroke was 1.4%(30/2 219),1.1%(22/2 016), and 1.9%(42/2 196)(P=0.076),the ratio of stent thrombosis was 0.9%(19/2 219), 1.2%(24/2 016),and 0.7%(15/2 196)(P=0.210) in low, moderate and high direct bilirubin groups, respectively. (3) Multivariable Cox regression analysis showed that, patients in moderate direct bilirubin group faced increased the risk of all-cause mortality compared with patients in the low direct bilirubin group (HR=2.23, 95%CI 1.23-4.05, P= 0.009), and the risk of all-cause mortality was similar between high direct bilirubin group and low direct bilirubin group (HR=1.84, 95%CI 0.99-3.38, P= 0.051). There were no statistically significant difference in the risks of main adverse cardiovascular and cerebrovascular events,cardiogenic death, myocardial infarction, revascularization, stroke, and stent thrombosis in moderate and high direct bilirubin groups compared with low direct bilirubin group (all P>0.05).@*Conclusion@#Moderate direct bilirubin level is associated with increased risk of all-cause death at 2 years after PCI compared with low level of direct bilirubin group.

Status of intra-aortic balloon pump application and related factors in Chinese patients with acute myocardial infarction / 中华心血管病杂志

Objective@#To investigate the current status of application of intra-aortic balloon pump(IABP) and analyze the factors which might impact the application of IABP in patients with acute myocardial infarction complicated with cardiac shock in China.@*Methods@#In China Acute Myocardial Infarction (CAMI) Registry,a nationwide, multicenter(107 hospitals), prospective study, 26 592 patients with acute myocardial infarction were enrolled consecutively between January 1, 2013 and September 30, 2014. After excluding of 30 cases due to missing important data,26 562 cases were analyzed.The application status of IABP was analyzed and multivariate logistic regression analysis was performed to determine the factors related to IABP application.@*Results@#A total of 785(3.0%) patients with acute myocardial infarction received IABP implantation, and 381(49.9%) patients belonged to preventive application of IABP before primary percutaneous coronary intervention,and 6(0.8%) patients were complicated with mechanical complications.There were 118(15.0%) patients with cardiac shock received IABP implantation, which accounted for 12.0%(118/984) of all patients with cardiac shock.Multivariate logistic regression analysis showed that the clinical independent factors of the decision of IABP insertion included dyslipidemia (OR=2.858, 95%CI 1.397-5.846, P=0.004),left ventricular ejection fraction (OR=0.977, 95%CI 0.961-0.994, P=0.009),usage of dopamine (OR=2.817, 95%CI 1.495-5.308, P=0.001), left main disease (OR=2.817, 95%CI 1.495-5.308, P=0.001), GRACE score (OR=1.006, 95%CI 1.000-1.011, P=0.034), receiving primary percutaneous coronary intervention (OR=4.508, 95%CI 1.673-12.146, P=0.003), teritiary hospitals (OR=2.562, 95%CI 1.498-4.384, P=0.001), and higher education of the patients (OR=2.183, 95%CI 1.056-4.509, P=0.016).@*Conclusions@#Among the Chinese acute myocardial infarction patients who received IABP implantation, nearly half application of IABP are preventive implantation before primary percutaneous coronary intervention. Only a few patients complicated with cardiac shock received IABP insertion. The clinical conditions, grade of hospitals, degree of education impact the decision of IABP insertion for the patients with acute myocardial infarction. Clinical Trial Registry National Institutes of Health, NCT018746.

A Comparison of Transradial and Transfemoral Percutaneous Coronary Intervention in Chinese Women Based on a Propensity Score Analysis

BACKGROUND AND OBJECTIVES: Over the past decades, transradial approach for percutaneous coronary intervention (PCI) has been increasingly adopted in clinical practice. Women represent a large population who will possibly benefit from PCI, but they are often under-represented in clinical studies. Therefore, the role of TRI in women remains to be further defined. This study sought to compare safety and efficacy for transradial intervention (TRI) and transfemoral intervention (TFI) in women undergoing PCI in China. METHODS: The study population consisted of 5,067 women undergoing PCI at Fuwai Hospital, Beijing, China between 2006 and 2011 (TRI: n=4,105, TFI: n=962). Incidence rates of clinical outcomes during hospitalization and at 1-year follow-up were compared between TRI and TFI. In order to minimize potential biases, a 1:1 propensity score matching (PSM) was performed. A total of 899 pairs were matched. RESULTS: Baseline and procedural characteristics were well-balanced between TRI and TFI groups after controlling for confounders using PSM. TRI was associated with reduced major post-PCI bleeding (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.54–0.76; p 0.05). CONCLUSIONS: In this propensity score-based analysis of TRI versus TFI in Chinese women, TRI showed advantages of safety and feasibility over TFI. A wider adoption of TRI in women has the potential to improve outcomes in treatment of coronary artery diseases.

Short-term Echocardiography and Blood NT-proBNP Changes in Aortic Stenosis Patients After Transcatheter Aortic Valve Replacement / 中国循环杂志

Objective: To explore the cardiac function and outcomes in patients of aortic stenosis (AS) after transcatheter aortic valve replacement (TAVR) within 6 months in order to provide the guidance for clinical treatment. Methods: A total of 49 consecutive severe AS patients with surgical contradiction or STS high risk score and received successful TAVR in our hospital from 2013-12 to 2015-12 were studied. Echocardiography and blood levels of NT-proBNP were examined at pre- and 1 month, 6 months after TAVR. Left ventricular ejection fraction (LVEF), aortic valve mean gradient (MG), peak gradient (PG) and peak velocity (PV) were recorded. Based on pre-operative LVEF, the patients were divided into 2 groups: Cardiac dysfunction group, LVEF<50%,n=15 (30.6%) and Normal cardiac function group, LVEF≥50%, n=34 (69.4%). Post-operative cardiac function and blood levels of NT-proBNP were compared between 2 groups. Results: In all 49 patients, the following parameters were significantly improved within 7 days after TAVR: LVEF (56.0±14.6) % vs (52.5±13.8)%, MG (11±5) mmHg vs (58±18) mmHg, PG (21.7±9.5) mmHg vs (93.0±28.6) mmHg, PV (2.3±0.5) m/s vs (4.8±0.7) m/s, blood NT-proBNP level [1831 (1098-3363)] pg/ml vs [3842 (1763-8664)] pg/ml and aortic valve area (1.57±0.43) cm2 vs (0.58±0.23) cm2 allP<0.05. Within 6 months after TAVR, LVEF was continuously increasing especially in Cardiac dysfunction group; MG, PV and NT-proBNP level were continuously decreasing, NYHA grade was continuously improving, allP<0.05. Conclusion: TAVR was an effective treatment in AS patients with surgical contradiction or STS high risk score; it may continuously improve cardiac function, especially in patients with left heart dysfunction.

Relationship Between Blood Big Endothelin Level and Contrast-induced Acute Kidney Injury in Patients With Emergent Percutaneous Coronary Intervention / 中国循环杂志

To explore the relationship between blood level of big endothelin and contrast-induced acute kidney injury (CI-AKI) in patients with emergent percutaneous coronary intervention (PCI). Methods: A total of 1061 consecutive patients received emergent PCI in our hospital from 2013-01 to 2015-06 were enrolled. According to blood levels of big endothelin, the patients were divided into 2 groups: Normal big endothelin group, n=236 and Elevated big endothelin group, n=825. The baseline condition, procedural features, occurrence rate of CI-AKI and composite endpoint events at 6 and 12 months post-operation were studied which including nonfatal myocardial infarction, revascularization, stroke and all-cause death. The risk factors for CI-AKI occurrence were identified by Logistic analysis. Results: The overall occurrence rate of CI-AKI was 22.7% (241/1061). Compared with Normal big endothelin group, Elevated big endothelin group had the higher incidence of CI-AKI, increased composite endpoint events at 6 and 12 months post-operation with P=0.041, P=0.040 and P=0.021, respectively. With adjusted covariates, elevated blood level of big endothelin, no matter as a continuous variable or categorical variable had the enhanced risk of CI-AKI incidence in patients after emergent PCI. Conclusion: Elevated blood level of big endothelin may significantly increase the risk of CI-AKI in patients with emergent PCI.