Ticagrelor Monotherapy After 3-Month Dual Antiplatelet Therapy in Acute Coronary Syndrome by High Bleeding Risk: The Subanalysis From the TICO Trial

Background and Objectives@#Identifying patients with high bleeding risk (HBR) is important when making decisions for antiplatelet therapy strategy. This study evaluated the impact of ticagrelor monotherapy after 3-month dual antiplatelet therapy (DAPT) according to HBR in acute coronary syndrome (ACS) patients treated with drug eluting stents (DESs). @*Methods@#In this post-hoc analysis of the TICO trial, HBR was defined by 2 approaches: meeting Academic Research Consortium for HBR (ARC-HBR) criteria or Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent DAPT (PRECISEDAPT) score ≥25. The primary outcome was a 3–12 months net adverse clinical event (composite of major bleeding and adverse cardiac and cerebrovascular events). @*Results@#Of the 2,980 patients without adverse events during the first 3 months after DES implantation, 453 (15.2%) were HBR by ARC-HBR criteria and 504 (16.9%) were HBR by PRECISE-DAPT score. The primary outcome rate was higher in HBR versus non-HBR patients (by ARC-HBR criteria: hazard ratio [HR], 2.87; 95% confidence interval [CI], 1.76– 4.69; p<0.001; by PRECISE-DAPT score: HR, 3.09; 95% CI, 1.92–4.98; p<0.001). Ticagrelor monotherapy after 3-month DAPT was associated with lower primary outcome rate than ticagrelor-based 12-month DAPT regardless of HBR by ARC-HBR criteria, with similar magnitudes of therapy effect for HBR and non-HBR patients (p-interaction=0.400). Results were consistent by PRECISE-DAPT score (p-interaction=0.178). @*Conclusions@#In ACS patients treated with DESs, ticagrelor monotherapy after 3-month DAPT was associated with lower rate of adverse clinical outcomes regardless of HBR, with similar magnitudes of therapy effect between HBR and non-HBR.Trial Registration: ClinicalTrials.gov Identifier: NCT02494895

Predictors of Severe or Moderate Coronary Artery Disease in Asymptomatic Individuals with Extremely Low Coronary Calcium Scores

PURPOSE: To evaluate predictors of severe or moderate coronary artery disease (CAD) in individuals with zero or very low (<10) coronary artery calcium (CAC) scores. MATERIALS AND METHODS: The 1175 asymptomatic persons with zero or very low (<10) CAC scores were analyzed for CAD stenosis using coronary computed tomography angiography. Moderate and severe CADs were defined as having more than 50% and more than 70% stenosis in any of the major coronary arteries, respectively. Age, gender, body mass index, hypertension, type II diabetes, dyslipidemia, lipid profile, creatinine, and smoking status were evaluated as predictors for moderate and severe CAD. RESULTS: In the study population, moderate and severe CADs were found in 7.5% and 3.3%, respectively. Among evaluated risk factors, age [odds ratio (OR) 1.04, 95% confidence interval (CI) 1.02−1.07, p<0.001], current smoking status (OR 3.12, 95% CI 1.82−5.34, p<0.001), and CAC 1−9 (OR 1.80, 95% CI 1.08−3.00, p=0.024) were significantly associated with moderate CAD. Meanwhile, age (OR 1.05, 95% CI 1.02−1.08, p=0.003), low high density lipoprotein (HDL) (OR 0.96, 95% CI 0.93−0.99, p=0.003), and current smoking status (OR 2.34, 95% CI 1.14−5.30, p=0.022) were found to be significantly associated with severe CAD. Improvement of discrimination power for predicting severe CAD was observed when smoking and HDL cholesterol were serially added into the age model. CONCLUSION: Smoking showed significant correlations with moderate or severe CAD, and low HDL cholesterol also proved to be a predictor of severe CAD in asymptomatic individuals with extremely low CAC scores.

Coronary Computed Tomographic Angiography Does Not Accurately Predict the Need of Coronary Revascularization in Patients with Stable Angina

PURPOSE: To evaluate the ability of coronary computed tomographic angiography (CCTA) to predict the need of coronary revascularization in symptomatic patients with stable angina who were referred to a cardiac catheterization laboratory for coronary revascularization. MATERIALS AND METHODS: Pre-angiography CCTA findings were analyzed in 1846 consecutive symptomatic patients with stable angina, who were referred to a cardiac catheterization laboratory at six hospitals and were potential candidates for coronary revascularization between July 2011 and December 2013. The number of patients requiring revascularization was determined based on the severity of coronary stenosis as assessed by CCTA. This was compared to the actual number of revascularization procedures performed in the cardiac catheterization laboratory. RESULTS: Based on CCTA findings, coronary revascularization was indicated in 877 (48%) and not indicated in 969 (52%) patients. Of the 877 patients indicated for revascularization by CCTA, only 600 (68%) underwent the procedure, whereas 285 (29%) of the 969 patients not indicated for revascularization, as assessed by CCTA, underwent the procedure. When the coronary arteries were divided into 15 segments using the American Heart Association coronary tree model, the sensitivity, specificity, positive predictive value, and negative predictive value of CCTA for therapeutic decision making on a per-segment analysis were 42%, 96%, 40%, and 96%, respectively. CONCLUSION: CCTA-based assessment of coronary stenosis severity does not sufficiently differentiate between coronary segments requiring revascularization versus those not requiring revascularization. Conventional coronary angiography should be considered to determine the need of revascularization in symptomatic patients with stable angina.

Impact of Cigarette Smoking: a 3-Year Clinical Outcome of Vasospastic Angina Patients

BACKGROUND AND OBJECTIVES: Cigarette smoking is a risk significant factor in coronary artery disease (CAD) and vasospastic angina (VSA). However, it is largely unknown whether smoking adds to any long-term clinical risk in VSA patients. SUBJECTS AND METHODS: A total of 2797 patients without significant CAD underwent acetylcholine (Ach) provocation test between November 2004 and October 2010. Patients were divided into three groups, based on the presence of coronary artery spasm (CAS) and smoking habits (non-CAS group: n=1188, non-smoking CAS group: n=1214, smoking CAS group: n=395). All CAS patients were prescribed with anti-anginal medications for at least 6 months. The incidence of major clinical outcomes and recurrent angina of these groups were compared up to 3 years. RESULTS: There were considerable differences in the baseline clinical and angiographic characteristics among the three groups, but there was no difference in the endpoints among the three groups (including individual and composite hard endpoints) such as death, myocardial infarction, de novo percutaneous coronary intervention, cerebrovascular accident, and major adverse cardiac events. However, there was a higher incidence of recurrent angina in both the non-smoking CAS group and smoking CAS group, as compared to the non-CAS group. In multivariable adjusted Cox-proportional hazards regression analysis, smoking CAS group exhibited a higher incidence of recurrent angina compared with the non-CAS group (hazard ratio [HR]; 2.46, 95% confidence interval [CI]; 1.46-4.14, p=0.001) and non-smoking CAS group (HR; 1.76, 95% CI; 1.08-2.87, p=0.021). CONCLUSION: Cigarette smoking CAS group exhibited higher incidence of recurrent angina during the 3-year clinical follow-up compared with both the non-CAS group and non-smoking CAS group. Quitting of smoking, paired with intensive medical therapy and close clinical follow-up, can help to prevent recurrent angina.

Current Practice of Transradial Coronary Angiography and Intervention: Results from the Korean Transradial Intervention Prospective Registry

BACKGROUND AND OBJECTIVES: Although increasing evidence has indicated that radial access is a beneficial technique, few studies have focused on Korean subjects. The aim of this study was to evaluate current practice of coronary angiography (CAG) and percutaneous coronary intervention (PCI) using radial access in South Korea. SUBJECTS AND METHODS: A total of 6338 subjects were analyzed from Korean Transradial Intervention prospective registry that was conducted at 20 centers in Korea. After evaluating the initial access, subjects intended for radial access were assessed for their baseline, procedure-related, and complication data. Subjects were categorized into three groups: group of overall subjects (n=5554); group of subjects who underwent PCI (n=1780); and group of subjects who underwent primary percutaneous coronary intervention (PPCI) (n=167). RESULTS: The rate of radial artery as an initial access and the rate of access site crossover was 87.6% and 4.4%, respectively, in overall subjects. Those rates were 82.4% and 8.1%, respectively, in subjects who underwent PCI, and 60.1% and 4.8%, respectively, in subjects who underwent PPCI. For subjects who underwent CAG, a 6-F introducer sheath and a 5-F angiographic catheter was the most commonly used. During PCI, a 6-F introducer sheath (90.6%) and a 6-F guiding catheter were standardly used. CONCLUSION: The large prospective registry allowed us to present the current practice of CAG and PCI using radial access. These data provides evidence to achieve consensus on radial access in CAG and PCI in the Korean population.

Missing Right Coronary Artery in a Patient with Acute Inferior ST Segment Elevation Myocardial Infarction: A Case of Extremely Rare Variation of Coronary Anatomy

We recently encountered an interesting case of acute inferior ST segment elevation myocardial infarction (STEMI). This patient had a rare anatomic variation, single coronary artery. The right coronary artery originate from the left circumflex proper artery, not from aorta, was totally obstructed with thrombi. Though it took more time to figure out the patient's coronary anatomy and the culprit lesion, we successfully performed primary percutaneous coronary intervention within the guideline-recommended time period. We performed left coronary angiography at the beginning. This strategy could be helpful in determining the culprit lesion and preventing unnecessary procedural delay in acute inferior STEMI.

Endovascular Management of Spontaneous Superficial Femoral Artery Pseudoaneurysm in a Renal Allograft Patient

We report a case of a superficial femoral artery pseudoaneurysm in 52-year old patient with a history of having renal allograft. The pseudoaneurysm spontaneously developed while standing up from squatting position after defecation, and it was successfully managed by an endovascular repair with an endograft. This case suggests that an atherosclerotic superficial femoral artery is vulnerable to torsion and tension movement during changing position from squatting to standing, which is repeatedly practiced by the people using the Korean traditional toilet. The endovascular therapy is also recommended for elderly patients with poor clinical conditions such as having a renal allograft and diffuse atherosclerosis of peripheral arteries.

The Correlation Between Achilles Tendon Thickness and Cardiovascular Risk Factors

BACKGROUND: Achilles tendon thickness (ATT) has been associated with increased cardiovascular risk in patients with familial hypercholesterolemia (FH). The aim of this study is to establish the correlation among ATT, obesity and established cardiovascular risk factors such as diabetes mellitus, hypertension, coronary artery disease, peripheral artery disease, smoking, and dyslipidemia. METHODS: In total, 19 patients (male 31.5%, mean age 60.0+/-12.5) with dyslipidemia and 96 control (male 64.6%, mean age 62.3+/-8.5) were enrolled. ATT was measured by ultrasonography. Anterioposterior diameter which represents the ATT was measured bilaterally, 4 cm above the insertion of Achilles tendon to the tuber calcite. Dyslipidemia was defined as elevated total cholesterol, triglyceride, or LDL cholesterol, or low levels of HDL cholesterol. RESULTS: There was no significant differences including ATT between the two groups (for ATT, dyslipidemia group, 0.44+/-0.04 vs control, 0.45+/-0.02 cm, p=0.783). There was no significant correlation between ATT and other cardiovascular risk factors except weight (r=0.34, p=0.007) and body mass index (r=0.63, p<0.001). Dyslipidemia was not significantly correlated with ATT (r=0.02, p=0.783). Use of statin was not significantly correlated with ATT (r=0.04, p=0.605). CONCLUSION: ATT was not significantly increased in patients with dyslipidemia. Lipid accumulation of Achilles tendon was not found in patients with dyslipidemia in this study.

Iodinated Contrast Media Can Induce Long-Lasting Oxidative Stress in Hemodialysis Patients

PURPOSE: Due to their comorbidities, dialysis patients have many chances to undergo radiologic procedures using iodinated contrast media. We aimed to assess time-sequenced blood oxidative stress level after contrast exposure in hemodialysis (HD) patients compared to those in the non-dialysis population. MATERIALS AND METHODS: We included 21 anuric HD patients [HD-coronary angiography (CAG) group] and 23 persons with normal renal function (nonHD-CAG group) scheduled for CAG, and assessed 4 oxidative stress markers [advanced oxidation protein products (AOPP); catalase; 8-hydroxydeoxyguanosine; and malondialdehyde] before and after CAG, and subsequently up to 28 days. RESULTS: In the nonHD-CAG group, only AOPP increased immediately after CAG and returned to baseline within one day. However, in the HD-CAG group, all four oxidative stress markers were significantly increased starting one day after CAG, and remained elevated longer than those in the nonHD-CAG group. Especially, AOPP level remained elevated for a month after contrast exposure. CONCLUSION: Our study showed that iodinated contrast media induces severe and prolonged oxidative stress in HD patients.

Preventive Effect of Pretreatment with Intravenous Nicorandil on Contrast-Induced Nephropathy in Patients with Renal Dysfunction Undergoing Coronary Angiography (PRINCIPLE Study)

PURPOSE: To investigate the effect of pretreatment with intravenous nicorandil on the incidence of contrast-induced nephropathy (CIN) in patients with renal dysfunction undergoing coronary angiography. MATERIALS AND METHODS: This randomized controlled multicenter study enrolled a total of 166 patients (nicorandil n=81; control n=85) with an estimated glomerular filtration rate 0.5 mg/dL increase or >25% rise in serum creatinine (SCr) concentration within 48 hours of contrast exposure compared to baseline. RESULTS: The final analysis included 149 patients (nicorandil n=73; control n=76). The baseline characteristics and the total volume of the used contrast (Iodixanol, 125.6+/-69.1 mL vs. 126.9+/-74.6 mL, p=0.916) were similar between the two groups. The incidence of CIN also did not differ between the nicorandil and control groups (6.8% vs. 6.6%, p=0.794). There was no difference between the two groups in the relative change in SCr from baseline to peak level within 48 hours after coronary angiography (-1.58+/-24.07% vs. 0.96+/-17.49%, p=0.464), although the nicorandil group showed less absolute change in SCr than the control group (-0.01+/-0.43 mg/mL vs. 0.02+/-0.31 mg/mL, p=0.005). CONCLUSION: Prophylactic intravenous infusion of nicorandil did not decrease the incidence of CIN in patients with renal dysfunction undergoing coronary angiography.

Recurrence of Coronary-Subclavian Steal Syndrome After Successful Angioplasty of Malfunctioning Arteriovenous Fistula

We report a case of coronary-subclavian steal syndrome, which had been masked by a malfunctioning hemodialysis access vessel and then reappeared after a successful angioplasty of multiple stenoses in the arteriovenous fistula of the left arm in a 61-year-old man. This case suggests that coronary-subclavian steal syndrome should be considered before a coronary artery bypass grafting surgery using internal mammary artery conduit is done, especially when hemodialysis using the left arm vessels is expected.

A Case of Severe Pulmonary Thromboembolism in a Young Male With Klinefelter Syndrome

A young male patient diagnosed with Klinefelter syndrome was admitted to our hospital via the emergency room with chief complaints of acute chest pain and dyspnea. Pulmonary thromboembolism was diagnosed from his chest CT images. His symptoms improved after he underwent thrombolysis and anticoagulation treatment. Klinefelter syndrome has a tendency towards hypercoagulability due to hormonal imbalance and one or more inherited thromophilic factors. Thus, Klinefelter syndrome patients with a past medical history of venous thromboembolism require continuous oral anticoagulation therapy for a period of at least six months.

Association of Coronary Artery Disease and Osteoporotic Vertebral Fracture in Korean Men and Women

BACKGROUND: The association of osteoporotic vertebral fracture or osteoporosis with coronary artery disease (CAD) was investigated in Korean men and women. METHODS: Four hundred consecutive postmenopausal women and men aged 50 years and older, undergoing coronary angiography, were enrolled for the evaluation of established or suspected coronary artery disease. CAD was diagnosed if there was narrowing of > 50% diameter in one or more major coronary artery. Morphometric vertebral fracture was assessed using lateral thoracic and lumbar spine radiographs. Bone mineral density was performed using dual-energy x-ray absorptiometry. RESULTS: Of the 400 subjects in the study (mean age of 61.9 +/- 11.6 years), 256 patients had CAD. Vertebral fracture was observed in 94 (23.5%) patients. There was no difference in vertebral fracture according to the presence or absence of CAD. In logistic regression analysis, vertebral fracture was not significantly associated with CAD after adjustment for multiple risk factors. Although women had lower BMD at any given site than men, BMD was not associated with the presence or absence of CAD among 191 patients. CONCLUSION: Our study demonstrated that osteoporotic vertebral fracture or osteoporosis was not associated with coronary artery disease in Korean men and women.

Sudden Cardiac Arrest with Acute Myocardial Infarction Induced by Left Subclavian Artery Occlusion in a Patient with Prior Coronary Artery Bypass Surgery

Multivascular preventive and therapeutic approaches are necessary in patients with coronary artery disease because atherosclerosis has a common systemic pathogenesis. We present a rare case of sudden cardiac arrest with acute myocardial infarction induced by the total occlusion of left subclavian artery (LSCA) in a patient with a history of previous coronary artery bypass surgery using the left internal mammary artery. We initially performed blind-puncture of left brachial artery, attempting percutaneous coronary intervention because pulses were absent in both upper and lower extremities. However, the cause of sudden cardiac arrest was atherosclerotic total occlusion of LSCA. The patient was stabilized after successful revascularization of LSCA by percutaneous transluminal angioplasty with stent insertion.

Retraction: Aortic Dissection and Rupture in a Child

No abstract available.

Aortic Dissection and Rupture in a Child

After developing sudden severe chest pain, an 11-year-old boy presented to the emergency room with chest pain and palpitations and was unable to stand up. The sudden onset of chest pain was first reported while swimming at school about 30 minutes prior to presentation. Arterial blood pressure (BP) was 150/90 mmHg, heart rate was 120/minute, and the chest pain was combined with shortness of breath and diaphoresis. During the evaluation in the emergency room, the chest pain worsened and abdominal pain developed. An aortic dissection was suspected and a chest and abdomen CT was obtained. The diagnosis of aortic dissection type B was established by CT imaging. The patient went to surgery immediately with BP control. He died prior to surgery due to aortic rupture. Here we present this rare case of aortic dissection type B with rupture, reported in an 11-year-old Korean child.

Unusual Presentation Chronic Pulmonary Embolism due to Calcified Right Ventricular Mass

Cardiac calcified amorphous tumors (CATs) can arise in all four chambers of the heart. Cardiac CATs can cause diverse symptoms according to their locations, and mass or embolic effects. Pulmonary emboli arising from cardiac CATs have been reported, but the true incidence is unknown due to their rarity. Herein we report a rare case with diffuse CATs in the right ventricle which caused a calcific pulmonary embolism and right-sided heart failure. Echocardiography, chest non-contrast computed tomography, and cardiac magnetic resonance imaging helped us diagnose the CATs. We recommend the usefulness of a multimodality imaging approach to characterize intracardiac masses and their complications accurately.

Isolated Pulmonary Arterial Hypertension-Janus' Faces of Hyperthyroidism

We describe a 54-year-old woman with isolated pulmonary arterial hypertension accompanied by hyperthyroidism due to Graves' disease. Her pulmonary artery hypertension resolved spontaneously after restoration of euthyroidism. This case suggests that hyperthyroidism should be considered a reversible cause of pulmonary arterial hypertension.

Right Atrial Lipoma Presenting with Angina

We report a case of a cardiac lipoma arising from the free wall of right atrium, which was diagnosed as the presumed source of angina by compressing the right coronary artery in a 54-year-old woman. Surgical excision of the tumor was performed well. She continues to do well for six months without angina.

A Sirolimus: Eluting Stent Fracture Combined with a Coronary Artery Aneurysm

A stent fracture combined with a coronary artery aneurysm is a rare event. As these events can lead to a harmful outcome, such as the development of myocardial ischemia by in-stent restenosis or thrombosis, repeated coronary intervention may be required. We report a case of a stent fracture combined with a coronary artery aneurysm. The fracture was thought to have developed by mechanical stress produced from a change of regional wall motion after an anteroseptal myocardial infarction. As detected by the use of intravascular ultrasound, neither in-stent restenosis nor a thrombus in the fractured stent was present. A cardiac magnetic resonance image showed that no viable myocardium in the anteroseptal wall was present. Therefore, the patient underwent medical treatment without intervention of the fractured stent.