Comparison of Long-Term Clinical Outcomes after Drug-Eluting Stent Implantation in Patients with Coronary Artery Disease with and without Prior Cerebral Infarction.

OBJECTIVE: To compare the clinical and angiographic outcomes after implantation of drug-eluting stents (DESs) in patients with coronary artery disease (CAD) with or without prior cerebral infarction. MATERIALS AND METHODS: Ninety-eight consecutive patients (130 lesions) who underwent successful coronary DES implantation were prospectively classified into two groups: those with a clinical history of symptomatic cerebral infarction (cerebral infarction group, 49 patients, 69 lesions) and those without a clinical history of symptomatic cerebral infarction (noncerebral infarction group, 49 patients, 61 lesions). The primary endpoint was defined as death, nonfatal myocardial infarction, and cerebrovascular events. RESULTS: The Kaplan-Meier method was used to create a primary endpoint curves to determine the time-dependent cumulative primary endpoint-free rate, which were compared using the log-rank test. The incidence of primary endpoints was higher in the cerebral infarction group than in the noncerebral infarction group (p = 0.0075). The Cox proportional hazards regression model for primary endpoint identified prior cerebral infarction (p = 0.0331, hazard ratio = 2.827) and patients with peripheral artery disease (p = 0.0271, hazard ratio = 2.757) as explanatory factors. CONCLUSION: The results showed that clinical outcomes were poorer in patients with CAD who had prior cerebral infarctions than in those who did not have infarction.

Assessment of left ventricular systolic and diastolic function using ECG-gated technetium-99m tetrofosmin myocardial perfusion SPECT.

Because left ventricular (LV) diastolic dysfunction is frequently the earliest indicator of LV dysfunction in patients with heart failure, the estimation of LV diastolic function is very important. On the other hand, electrocardiography (ECG)-gated technetium (Tc) -99m tetrofosmin single-photon emission computed tomography (SPECT) has been reported to be a useful method for evaluation of LV function. The objective of this study was to examine the usefulness of ECG-gated Tc-99m tetrofosmin SPECT in terms of estimation of cardiac diastolic function. Consecutive 145 patients underwent an ECG-gated Tc-99m tetrofosmin SPECT to estimate systolic and diastolic LV function, and were compared with those evaluated by ultrasound echocardiography (UCG). LV end-diastolic volume, LV end-systolic volume, and LV ejection fraction values obtained by quantitative gated SPECT (QGS) showed significant positive linear correlations with those obtained by UCG. All 145 patients were classified into 3 groups according to diastolic function estimated by UCG. The first-third mean filling rate (1/3 MFR) and peak filling rate (PFR) that revealed the LV diastolic function of the group B (normal systolic function and mild diastolic dysfunction) patients (1.01 ± 0.35, 1.85 ± 0.57) were both significantly lower than those of the group A (normal systolic and diastolic function) patients (1.43 ± 0.37, 2.43 ± 0.56). The 1/3 MFR and PFR of the group C (moderate ~ severe systolic and diastolic dysfunction) patients (0.47 ± 0.34, 0.92 ± 0.62) were also significantly lower than those of the group A and B patients. QGS may be a useful method for the evaluation of cardiac systolic and diastolic function, especially in patients with normal systolic function and diastolic dysfunction.

Does motor dysfunction after cerebral infarction impede the development of angina symptoms? A comparison of coronary angiographic findings in patients with and without prior cerebral infarction.

Previous studies based on coronary angiography or computed tomography coronary angiography have demonstrated a high prevalence of coronary stenosis in patients with cerebral infarction and no prior history of coronary artery disease (CAD). The purpose of the present study was to compare the coronary angiographic findings of patients with prior cerebral infarction with those of patients with no prior cerebral infarction. Consecutive patients (n = 126) who underwent a first coronary angiography for suspected CAD but had no prior history of CAD were classified into 2 groups, those with a clinical history of cerebral infarction (cerebral infarction group) and those without a clinical history of cerebral infarction (noncerebral infarction group). The incidences of diabetes mellitus, peripheral artery disease, coronary stenosis, and multivessel disease were significantly higher in the cerebral infarction group than in the noncerebral infarction group. Multiple logistic regression analysis relating to coronary stenosis identifi ed prior cerebral infarction (P = 0.0027, odds ratio = 4.414) and diabetes mellitus (P = 0.0446, odds ratio = 2.619) as explanatory factors. Thirty-four of 78 patients (44%) with coronary stenosis did not have angina symptoms. Multiple logistic regression analysis regarding the lack of angina symptoms identified motor dysfunction (modified Rankin scale ≥ 2) (P = 0.0028, odds ratio = 8.323) as an explanatory factor. The results of the present study suggest that compared with patients without cerebral infarction those with the disorder have a high prevalence of coronary stenosis, and indicate that the development of angina symptoms is influenced by the severity of motor dysfunction.

Insulin resistance functionally limits endothelium-dependent coronary vasodilation in nondiabetic patients.

Insulin resistance (IR) is now considered to be a risk factor for coronary arterial atherosclerosis and is likely to be involved in a limited endothelium-dependent vasodilatory function in peripheral circulation. We investigated whether IR impairs endothelial vasodilator function in the noninfarcted coronary artery. In 14 nondiabetic patients (10 males, 66 +/- 6 years) who were selected from 214 patients underwent IR evaluation by glucose clamp, a Doppler flow wire was used to measure coronary flow changes (percent volume flow index, %VFI) during intracoronary administration of papaverin (10 mg) and stepwise administration of acetylcholine (Ach; 1, 3, 10 microg/ml per minute) into the non-infarcted left circumflex coronary artery. Insulin resistance was comparatively evaluated by an euglycemic hyperinsulinemic glucose clamp (M value, mg/m(2) per minute) or by a 75g-oral glucose tolerance test (120-min immunoreactive insulin; 120' IRI, pmol/l). Eight patients (57%) were defined as having IR on the basis of results obtained by both the glucose clamp method (M values <167 mg/m(2) per minute) and 120' IRI (>384 pmol/l). There was no difference between papaverin-induced %VFI increases in IR and non-IR subjects (328% +/- 43% vs. 361% +/- 87%). However, IR subjects showed significantly lower Ach-induced %VFI increases in a dose-dependent manner (P < 0.05), especially when low (1 microg/ml per minute) and moderate (3 microg/ml per minute) doses of Ach were used (165% +/- 18% or 248% +/- 29% in non-IR subjects vs. 130% +/- 20% or 183% +/- 41% in IR subjects, P < 0.001, respectively). Moreover, %VFI increase at a low dose of Ach infusion significantly correlated with M values or 120' IRI ([%VFI Ach 1 microg] = 85.9 + 0.35 [M values], r = 0.58, P = 0.038; [%VFI Ach 1 microg] = 176.8 - 0.47.[120' IRI], r = -0.57, P = 0.035). Insulin resistance limits endothelium-dependent coronary vasodilation in association with the severity of IR in non-diabetic patients.

Comparison of long-term clinical outcome after sirolimus-eluting stent implantation in patients with and without hemodialysis.

Poor clinical outcomes for hemodialysis (HD) patients compared to non-HD patients after coronary intervention have been reported. Although coronary intervention using sirolimus-eluting stents (SESs) might be expected to reduce restenosis in HD patients, little is known about the efficacy of the SESs. The purpose of the present study was to compare the clinical and angiographic outcomes of HD patients with non-HD patients after SES implantation. The study population consisted of 170 consecutive patients (234 lesions) who had undergone successful coronary SES implantation. The patients were classified into 2 groups, an HD group (18 patients, 27 lesions) and a non-HD group (152 patients, 207 lesions). The incidence of any clinical event was significantly higher in the HD group than in the non-HD group (50.0% versus 12.5%, P < 0.0001). Target lesion revascularization was necessary in 6 patients (33.3%) in the HD group and in 7 patients (4.6%) in the non-HD group (P < 0.0001). The Cox proportional-hazards regression model on cardiac events identified HD patients (P = 0.0301, hazard ratio = 2.704) as an explanatory factor. Moreover, the Cox proportional-hazards regression model on target lesion revascularization identified HD (P = 0.0004, hazard ratio = 6.921) and in-stent re-stenosis lesion (P = 0.0293, hazard ratio = 3.323) as explanatory factors. The present study suggests that compared with non-HD patients, HD patients with coronary artery disease treated by SESs have a poorer clinical outcome.

Long-term outcome after primary stenting versus balloon angioplasty for acute myocardial infarction.

The objective of the present prospective multicenter case-control study was to investigate the long-term clinical outcome (5 years) of primary stenting compared to primary percutaneous transluminal coronary angioplasty (PTCA) without stenting (POBA) in patients with acute myocardial infarction at 7 cardiovascular centers in Hokkaido, Japan. Forty-one patients with acute myocardial infarction treated with successful primary stenting (stent group: case) and paired with 41 matched control subjects with acute myocardial infarction treated by successful primary PTCA without stenting (POBA group: control) were analyzed. After 1 year, the stent group had a lower incidence of the combined clinical endpoint (death, rehospitalization due to congestive heart failure, nonfatal myocardial infarction, repeat angioplasty, CABG, or cerebrovascular events) compared to the POBA group (17.1% versus 39.0%, P = 0.049). After 5 years, the incidences of congestive heart failure and cardiac death were the same in both groups. However, compared to the POBA group, the stent group had a lower combined clinical endpoint (34.1% versus 61.0%, P = 0.027). The Kaplan-Meier event-free survival curves of the stent group showed a significantly lower occurrence of clinical events compared to the POBA group (P = 0.0116). Multiple logistic regression analysis of clinical events identified age > or = 69 years (P = 0.0092, odds ratio = 4.179) and stenting (P = 0.0158, odds ratio = 0.279) as explanatory factors. Compared with POBA, primary stenting for acute myocardial infarction results in a better long-term clinical outcome.

Clinical and angiographic outcomes after multi-link PENTA stent implantation in Japanese patients with coronary artery disease.

The flexibility of the Multi-Link (ML) PENTA stent with platform 0.09 to 0.12-mm-thick struts and 12% to 16% metal/artery coverage was improved to facilitate safe delivery in complex coronary lesions. The present study was designed to evaluate the clinical (9-month) and angiographic (6-month) results of the ML PENTA stent in complex coronary lesions (modified American College of Cardiology/American Heart Association lesion type B2 or C) and to determine independent factors correlated with target lesion revascularization. The study population consisted of 86 consecutive patients who had undergone successful coronary ML PENTA stent implantation for coronary artery disease from May 2003 to July 2004 in our hospital. During the follow-up period, cardiac events were documented in 21 (24.4%) of the 86 patients. Target lesion revascularization was required in 16 (18.6%) of the 86 patients. Single logistic regression analysis showed that target lesion revascularization was significantly correlated with lesion length > 2.0 cm, residual percent diameter stenosis after the procedure > 20%, and multiple stents. Multiple logistic regression analysis showed that residual percent diameter stenosis after procedure > 20% (P = 0.0125, odds ratio = 11.585) was the significant explanatory factor of target lesion revascularization. The results of the present study suggest that 9-month clinical and 6-month angiographic outcomes in patients with coronary artery disease treated using the ML PENTA stent were excellent and target lesion revascularization after coronary ML PENTA stent implantation was influenced by residual percent diameter stenosis after the procedure.

Prognostic value of the Tei index combining systolic and diastolic myocardial performance in patients with acute myocardial infarction treated by successful primary angioplasty.

Cardiac systolic (left ventricular ejection fraction) and diastolic (mitral inflow velocity pattern and/or mitral deceleration time) function were reported as predictors of clinical outcome or left ventricular remodeling in patients with acute myocardial infarction (AMI). Recently, a new index (Doppler-derived index combining systolic and diastolic myocardial performance; Tei index) for combined systolic and diastolic ventricular function has been reported to be a useful and convenient method for evaluation of global ventricular function. We therefore investigated the usefulness of the Tei index by echocardiography for evaluation of infarct size and clinical outcome in patients with AMI treated by successful primary angioplasty. We analyzed 10 age-matched control subjects and 43 consecutive patients with first AMI treated by successful primary angioplasty. The Tei index of the AMI patients was significantly greater than that of the control subjects (0.630 +/- 0.106 vs 0.375 +/- 0.036, P << 0.0001). Also, the Tei index showed a significant positive correlation with peak creatine kinase values and (99m)Tc-tetrofosmin scores. Moreover, multiple logistic regression analysis showed that the Tei index >>0.70 ( P = 0.0313, odds ratio = 14.14) was the only significant explanatory factor for cardiac death or developed congestive heart failure. The Tei index combining systolic and diastolic myocardial performance reflects infarct size and might be a predictor of clinical outcome in patients with AMI treated by successful primary angioplasty.

Incremental prognostic implications of brain natriuretic peptide, cardiac sympathetic nerve innervation, and noncardiac disorders in patients with heart failure.

UNLABELLED: Plasma brain natriuretic peptide (BNP) level and cardiac autonomic function are closely related to prognosis in patients with heart failure. However, their correlation and incremental prognostic values in human heart failure are unclear. We sought to evaluate the correlation between BNP level and cardiac sympathetic innervation assessed by (123)I-metaiodobenzylguanidine ((123)I-MIBG) and the prognostic value of combined assessment of risk factors for mortality in patients with heart failure. METHODS: After conventional examinations and measurements of plasma BNP level and heart-to-mediastinum ratio (HMR) of cardiac (123)I-MIBG activity, 158 patients with heart failure were prospectively followed with an endpoint of cardiac death for 16 mo. RESULTS: Fifteen deaths due to pump failure and 2 sudden cardiac deaths were documented. Plasma BNP level correlated with HMR significantly but not so tightly (r = 0.330, P < 0.0001). Univariate analysis identified plasma BNP level, HMR, chronic renal dysfunction, diabetes mellitus, age, and use of nitrates as significant predictors of fatal pump failure, and multivariate Cox analysis showed that plasma BNP level was the most powerful predictor of cardiac death. Patients with both plasma BNP level of > or = 172 pg/mL and late HMR of < or =1.74 had a greater annual rate of fatal pump failure than did those without (17.5%/y vs. 0%-3.9%/y, respectively). The hazard ratio of plasma BNP level (7.2) or cardiac (123)I-MIBG activity (10.1) increased to 34.4 when both variables were used, and prevalence of fatal pump failure significantly increased from 22% to 62.5% when diabetes mellitus and chronic renal dysfunction were present with a higher plasma BNP level and low cardiac (123)I-MIBG activity. CONCLUSION: Plasma BNP level is a stronger predictor than other risk factors for mortality in heart failure patients and is statistically significantly, but roughly, related to cardiac sympathetic nerve innervation. Impaired cardiac sympathetic nerve innervation and the presence of diabetes mellitus and chronic renal dysfunction, however, improve risk stratification of patients with heart failure and increased plasma BNP concentration.

Comparison of three-year clinical outcome of the multi-link stent with the Palmaz-Schatz stent in Japanese patients with coronary artery disease: a case control study.

Results of trials using the ACS Multi-Link (ML) stent, one of the new generation stents, were similar to or slightly better than those of trials using the Palmaz-Schatz (PS) stent. The purpose of this study was to compare long-term (3-year) clinical outcomes of patients with coronary artery disease treated with the ML stent to those treated with the PS stent. The present study consisted of 52 patients who underwent successful coronary ML stent implantation (ML group) and 52 matched control patients who underwent successful coronary PS stent implantation (PS group) from October 1997 to September 1999. During follow-up periods, cardiac events occurred in 11 patients (21%) in the ML group and 14 patients (27%) in the PS group, respectively (p = NS). Angiographic restenosis rates of American College of Cardiology/American Heart Association (ACC/AHA) lesion type A or B1 were 8.3% in both groups, and ACC/AHA lesion type B2 or C were 39.3% in the ML group and 35.7% in the PS group, respectively (p = NS). In addition, angiographic restenosis rates of ACC/AHA lesion type A or B1 were significantly lower than those of lesion type B2 or C in both groups. The results of the present study suggest that 6-month angiographic and 3-year clinical outcomes in patients with coronary artery disease treated by coronary stenting with the ML stent were comparable to those with the PS stent.

Coronary stent implantation in patients with a single coronary artery--a report of 3 cases.

An isolated single coronary artery is a rare congenital anomaly and a cause of cardiac ischemia, congestive heart failure, and sudden cardiac death. Reported here are 3 cases of single coronary artery with acute myocardial infarction in which coronary stenting was performed. Also reported are the coronary blood flow patterns of the right coronary artery arising from the single left coronary artery.

Clinical and angiographic results after MULTI-LINK stent implantation and their relation to aggregation of risk factors: two-year follow-up.

Results of trials using the ACS MULTI-LINK (ML) stent, one of the new generation stents, were similar to or slightly better than those of trials using the Palmaz-Shatz stent. The purpose of this study was to evaluate relatively long-term (2 years) clinical outcomes of patients with coronary artery disease treated with the ML stent and to determine independent factors correlated with target lesion revascularization and cardiac events. The present study consisted of 82 consecutive patients who had undergone successful coronary ML stent implantation from January 1997 to December 1999. During the follow-up period, cardiac events occurred in 16 (19.5%) patients. All patients underwent follow-up angiography and 12 (14.6%) of the 82 patients underwent target lesion revascularization. Multiple logistic regression analysis showed that aggregation of risk factors (> or = 3 risk factors) (p = 0.0274, odds ratio=5.14) and percent diameter stenosis >20% (p = 0.0395, OR = 4.586) were the significant explanatory factors of target lesion revascularization. In addition, aggregation of risk factors (> or = 3 risk factors) exhibited a tendency to correlate with cardiac events (p = 0.0528) on multiple logistic regression analysis. The results of the present study suggest that target lesion revascularization after coronary ML stent implantation was influenced by aggregation of major coronary risk factors and residual percent diameter stenosis and that long-term clinical outcome is influenced by the aggregation of risk factors.

Long-term follow-up after coronary stent implantation in patients with coronary artery disease.

Prospective randomized trials of coronary stenting in patients with coronary artery disease have shown a reduced incidence of cardiac events. However, little is known of the late outcome of patients treated with coronary stenting. The purpose of this study was to evaluate the relatively long-term clinical outcomes (3 to 6 years) of patients treated with successful coronary stenting. The long-term clinical outcome was studied in 101 consecutive patients (78 males and 23 females) who had undergone successful coronary stent implantation for coronary artery disease in our hospital from October 1994 to September 1997. During a follow-up period of 48.9+/-9.5 months (range, 6-73 months), cardiac events were documented in 37 patients. The rate of survival free of cardiac events was 67% at 3 years. Multiple logistic regression analysis showed that ACC/AHA lesion type and residual percent diameter stenosis greater than 20% after stenting were the significant explanatory factors of adverse cardiac events. Long-term clinical outcome in patients with coronary artery disease treated with successful coronary stenting was influenced by the ACC/AHA lesion type of stented lesion and residual percent diameter stenosis after stent implantation.