Impact of atherothrombotic risk stratification in patients with heavily calcified lesions following rotational atherectomy.

BACKGROUND: Patients who undergo percutaneous coronary intervention (PCI) with rotational atherectomy (RA) are at high risk of adverse clinical outcomes, and there are few clinical risk stratification tools for these patients. METHODS: We conducted a study with 196 patients who underwent PCI with RA out of 7391 patients who underwent PCI using a multicenter, prospective cohort registry. Patients were divided into three groups according to the tertiles of the Thrombolysis in Myocardial Infarction (TIMI) Risk Score for Secondary Prevention (TRS 2°P): 65 patients in the T1 group (TRS 2°P < 3), 66 patients in the T2 group (TRS 2°P = 3), and 65 patients in the T3 group (TRS 2°P > 3). The primary endpoint was the cumulative 2-year incidence of major adverse cardiovascular and cerebrovascular events (MACCE), defined as a composite of cardiac death, acute coronary syndrome, and ischemic stroke. RESULTS: Cumulative 2-year MACCE occurred in 41 patients (24 %) during the follow-up period. The cumulative incidence of MACCE was significantly higher in the T3 group than in the T1 group (log-rank test, p = 0.02). Multivariate Cox analyses revealed that the T3 group was associated with an increased risk of MACCE compared to that of the T1 group (adjusted hazard ratio, 2.66; 95 % confidence interval, 1.04-6.77; p = 0.04). The addition of TRS 2°P to conventional risk factors, including male sex, number of diseased vessels, and low-density lipoprotein cholesterol levels, improved the net reclassification improvement (NRI) and integrated discrimination improvement (IDI) (NRI 0.39, p = 0.027; IDI 0.072, p < 0.001). CONCLUSIONS: Atherothrombotic risk stratification using TRS 2°P was useful in identifying high-risk patients with heavily calcified lesions following RA.

Predictive Value of CHADS2, CHA2DS2-VASc and R2-CHADS2 Scores for Short- and Long-Term Major Adverse Cardiac Events in Non-ST-Segment Elevation Myocardial Infarction.

BACKGROUND: Non-ST-elevation myocardial infarction (NSTEMI) carries a poor prognosis, and accurately prognostication has significant clinical importance. In this study, we analyzed the predictive value of the CHADS2, CHA2DS2-VASc, and R2-CHADS2scores for major adverse cardiac events (MACE) following percutaneous coronary intervention (PCI) in patients with NSTEMI using data from a prospective multicenter registry.Methods and Results: The registry included 440 consecutive patients with NSTEMI and coronary artery disease who underwent successful PCI. Patients were clinically followed for up to 3 years or until the occurrence of MACE. MACE was defined as a composite of all-cause death and nonfatal MI. During the follow-up period, 55 patients (12.5%) experienced MACE. Risk analysis of MACE occurrence, adjusted for the multivariable model, demonstrated a significant increase in risk with higher CHADS2, CHA2DS2-VASc, and R2-CHADS2scores. Kaplan-Meier analysis showed a higher incidence of MACE in patients with higher CHADS2, CHA2DS2-VASc, and R2-CHADS2scores, both in the short- and long-term periods. CONCLUSIONS: Patients with NSTEMI and higher CHADS2, CHA2DS2-VASc, and R2-CHADS2scores displayed a greater incidence of MACE.

Haemodialysis patient with chronic kidney disease and pulmonary hypertension treated effectively with pulmonary vasodilators.

A male patient in his 70s on periodic haemodialysis complained of dysdialysis several months prior and was diagnosed subsequently with pulmonary hypertension (PH). To confirm this diagnosis, a catheter examination was performed after haemodialysis in the dry state. Pulmonary artery wedge pressure (PAWP), mean pulmonary artery (PA) pressure, cardiac index (CI) and pulmonary vascular resistance (PVR) were 9 mm Hg, 42 mm Hg, 2.63 L/min/m2 and 5.9 WU, respectively. The pathophysiological diagnosis was precapillary PH, which mimicked idiopathic PH. The pulmonary vasodilators were administered in a careful sequential manner. After initiation of therapy, dysdialysis disappeared within a few months, while mean PA pressure, CI and PVR improved to 24 mm Hg, 3.47 L/min/m2 and 2.3 WU, respectively. Although the cause of PH in haemodialysis patients is multifactorial, catheter examination in the dry state is useful for clarifying a patient's haemodynamic state. In a haemodialysis PH patient with precapillary PH, pulmonary vasodilators are an effective treatment option.

A Stratified Analysis of the Risk Associated With Low Body Mass Index for Patients After Percutaneous Coronary Intervention.

AIMS: The relationship between low body mass index (BMI) and prognostic factors for patients with coronary artery disease, commonly observed in elderly individuals in Japan, is important. Few studies have evaluated the prognosis for patients with low BMI after percutaneous coronary intervention (PCI). Using a multivariable-adjusted model and data from a prospective cohort registry, we analyzed the risk associated with low BMI for patients after PCI. METHODS: This prospective, multicenter registry included 5965 consecutive patients with coronary artery disease who underwent successful PCI. The patients were followed-up clinically for up to 3 years or until the occurrence of major adverse cardiac events. The primary endpoint was all-cause death and nonfatal myocardial infarction composite. RESULTS: Primary events occurred in 639 (10.7%) patients during the follow-up period. A risk analysis of the primary endpoint adjusted for the multivariable model showed a significant increase in risk for elderly individuals, underweight individuals [HR 1.43 (95% confidence interval (CI), 1.10-1.85), P＜0.001], those with diabetes mellitus (DM), peripheral artery disease, low left ventricular ejection fraction or acute coronary syndrome (ACS), and smokers. A stratified adjusted risk analysis based on BMI levels showed that the risk associated with underweight status was significantly pronounced for male patients, those aged 60-74 years, and those with DM or ACS. CONCLUSION: Underweight patients with several risk factors significantly increased risk after PCI. Furthermore, the risk associated with low BMI was significantly more pronounced for men, individuals aged 60-74 years, and patients with DM or ACS.

Optimal medical therapy after percutaneous coronary intervention in very elderly patients with coronary artery disease.

BACKGROUND: It is still unclear whether optimal medical therapy (OMT) after percutaneous coronary intervention (PCI) has beneficial effects on long-term clinical outcomes in patients aged ≥80 years with coronary artery disease (CAD). METHODS: This study analyzed the time to the first major adverse clinical event including death or nonfatal myocardial infarction (MI), for up to 3 years after PCI using multicenter registry data. Data for 1056 patients aged > 80 years successfully treated with PCI were included in the analysis. OMT was defined as a combination of antiplatelet drug, statin, beta-blocker, and angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker. RESULTS: In total, 204 (19%) patients in this study received OMT and 852 (81%)　received sub-OMT. During a median follow-up of 725 days, adverse clinical events occurred in 183 patients (death, n=177; nonfatal MI, n=6). Kaplan-Meier analysis showed that patients who received OMT had a lower probability of adverse clinical events than those who received sub-OMT (p<0.01, log-rank test). Propensity score matching yielded 202 patient-pairs treated with OMT or sub-OMT, in whom 64 adverse clinical events (death, n=56, nonfatal MI, n=4) occurred during follow-up. OMT remained significant in the reduction of the risk of adverse clinical events in a multivariate Cox proportional hazards model (hazard ratio 0.44; 95% confidence interval 0.26-0.75; p=0.003). CONCLUSIONS: OMT after PCI was associated with significantly fewer adverse clinical events, including all-cause death and nonfatal MI, in patients aged ≥ 80 years with CAD. OMT might be safe and effective for these very elderly patients.

A Propensity Score Matched Analysis of Statin Effects on Major Adverse Cardiac Events after Percutaneous Coronary Intervention in Patients Over 75 Years Old.

Objective In an extremely aging society, it is beneficial to reconsider the value of medical treatment for extremely elderly patients. We therefore focused on the efficacy of statin therapy in extremely elderly patients. This study investigated the efficacy of statins for secondary prevention in patients over 75 years old. Methods This prospective multicenter registry included 1,676 consecutive extremely elderly patients with coronary artery disease who underwent successful percutaneous coronary intervention (PCI). The patients were followed up clinically for up to three years or until the occurrence of major adverse cardiac events (MACEs), defined as a composite of all-cause death and non-fatal myocardial infarction. Using propensity score methodology to eliminate selection bias, in a 1:1 matching ratio, we selected 466 pairs of patients for the analysis. Results During the median follow-up period of 25 months, MACEs occurred in 176 patients. The Kaplan-Meier analysis showed that statin treatment correlated with a lower probability of initial MACE occurrences within 30 days compared with no statin treatment (log-rank test, p<0.001). According to a landmark analysis at day 30, statin treatment still showed consistent effectiveness for reducing MACE occurrence during the follow up period (p=0.04). A multivariable Cox hazard analysis showed that statin therapy significantly reduced MACE occurrence (hazard ratio 0.55 [0.40-0.75], p<0.001). In the stratification analysis, statin therapy was especially beneficial in patients without symptomatic heart failure. Conclusion Statins were effective in preventing MACEs in extremely elderly patients after PCI.

Stratification Analysis of Statin Effect on Major Adverse Cardiac Events After Percutaneous Coronary Intervention in Patients on Hemodialysis.

ABSTRACT: The statin use in patients on hemodialysis remains controversial, and no beneficial effects of statin on the reduction of adverse cardiovascular events have been reported in these patients. This study used stratification analysis to examine the clinical factors in patients on hemodialysis who could benefit from statin for secondary prevention. This prospective multicenter study included 234 consecutive patients on hemodialysis with coronary artery disease who underwent successful reperfusion therapy with percutaneous coronary intervention. The patients were followed up for up to 3 years or until the occurrence of major adverse cardiac events (MACEs; defined as a composite of all-cause death and nonfatal myocardial infarction). Inverse probability of treatment weighting adjustment was used to remove the selection bias. During the median follow-up period of 30 months, MACEs occurred in 55 patients. Patients with MACEs had significantly lower statin therapy (P < 0.001). Multivariable Cox proportional hazards analysis showed that the patients on statins had a significantly reduced rate of MACE occurrence [adjusted hazard ratio 0.30 (0.11-0.81), P = 0.02]. The stratification analysis of outcomes according to the presence of clinical factors showed that beneficial effects of statin were associated with man, elderly, lower body mass index, lower abdominal circumference, hypertension, diabetes, higher C-reactive protein, symptomatic heart failure, lower left ventricular function, nonacute coronary syndrome, and shorter stent length. Statin was effective for the prevention of MACEs in patients on hemodialysis who underwent percutaneous coronary intervention. We identified specific clinical factors affecting statin effectiveness for secondary prevention.

Primary percutaneous coronary intervention of anomalous origin of a high take-off of right coronary artery arising from ascending aorta with percutaneous cardiopulmonary support in acute myocardial infarction.

Coronary angiography of high take-off right coronary artery (RCA) arising from ascending aorta under percutaneous cardiopulmonary support may be more effective at the site distal to RCA ostium rather than proximal. Guide extension catheters (GECs) may be useful to strengthen backup of percutaneous coronary interventions (PCI) system and to contrast coronary lesions clearly during PCI of these RCAs.

Nine-year trend of oral anticoagulant use in patients with embolic stroke due to nonvalvular atrial fibrillation.

BACKGROUND: Direct oral anticoagulants (DOACs) are increasingly used as an alternative to warfarin in patients with nonvalvular atrial fibrillation (NVAF). However, whether there is sufficient prescription of oral anticoagulants (OACs) to decrease the incidence of embolic stroke remains unclear. METHODS AND RESULTS: We conducted a retrospective observational study of patients hospitalized with ischemic stroke between January 1, 2010 and December 31, 2018. During the 8 years, the annual incidence ratio of embolic stroke to all ischemic strokes did not decrease over time (21-33%) except for that in 2018. The proportion of OAC users did not also change over time (from 23% to 45% [overall 31%], P = .78). Among the OAC users, 19% patients were warfarin users, and 12% patients were DOAC users. In 73% of warfarin users, prothrombin time was subtherapeutic, whereas in 60% of DOAC users, the dose was adequately prescribed. OACs were prescribed more often in patients with high CHADS2 score than in those with low score (P = .01). The number of patients who had no medical history of a doctor visit before admission increased significantly in the recent period of 2015-2018 (22% vs 8% in the previous period of 2010-2014) (P = .01). CONCLUSIONS: The incidence of embolic stroke patients without OACs did not decrease over time, and OACs in patients with NVAF have not been sufficient, even in DOAC era. In recent years, the incidence of undiagnosed AF has increased. To prevent embolic stroke, a correct AF diagnosis beforehand is important.

Failure of drug-coated balloon angioplasty to treat bare metal in-stent restenosis accompanied by late stent thrombosis but successful treatment of binary in-stent restenosis.

Drug-coated balloons (DCB) are effective in treating in-stent restenosis (ISR) with neointimal proliferation after bare-metal stent (BMS) implantation, but it is unclear whether DCB are effective in treating BMS-ISR accompanied by thrombosis. An 84-year-old man with previous inferior myocardial infarction and atrial fibrillation developed acute myocardial infarction (AMI) during hospitalization for intracerebral hemorrhage. Emergent coronary angiography (CAG) revealed severe stenosis of the distal left circumflex coronary artery. We implanted a BMS to avoid long-term triple antithrombotic therapy. He received aspirin, clopidogrel, and rivaroxaban for 1 month and then received clopidogrel and rivaroxaban. Seventy days after BMS implantation, he developed AMI, and emergent CAG revealed occlusion of the BMS due to late stent thrombosis. After thrombus aspiration, intravascular ultrasound showed incomplete neointimal healing in the proximal portion of the stent and excessive neointimal proliferation in the distal portion of the stent. DCB angioplasty of the entire BMS was performed after scoring balloon pre-dilation. Seven months after BMS implantation, follow-up CAG revealed binary ISR. DCB angioplasty of the entire BMS was performed again after scoring balloon pre-dilation. Thirteen months after BMS implantation, follow-up CAG did not reveal recurrence of ISR. .

Glycemic variability is associated with myocardial damage in nondiabetic patients with ST-elevation myocardial infarction.

BACKGROUND: Glycemic variability (GV) induces coronary microcirculatory disturbance and myocardial damage in diabetic patients with acute myocardial infarction. However, in nondiabetic acute myocardial infarction patients, the relationship between GV and myocardial damage remains unclear. PATIENTS AND METHODS: We investigated GV with a continuous glucose monitoring system in nondiabetic ST-segment elevation myocardial infarction patients treated with emergent percutaneous coronary intervention. GV was expressed as the mean amplitude of glycemic excursions (MAGE). Myocardial damage was estimated by myocardial blush grade and ST-segment resolution (STRes). STRes was defined as complete (>70%), partial (30-70%), or none (<30%). RESULTS: Consecutive patients (n=73) were enrolled and classified into a lower or higher MAGE group on the basis of the median MAGE. The higher MAGE group showed lower levels of myocardial blush grade (2.41±0.76 vs. 1.72±0.85, P=0.001) and STRes (complete: 56.8 vs. 33.3%, P=0.044; partial: 32.4 vs. 36.1%, P=0.741; none: 10.8 vs. 30.6%, P=0.037). CONCLUSION: GV was associated with myocardial damage after percutaneous coronary intervention in nondiabetic ST-segment elevation myocardial infarction patients.

Acute myocardial infarction due to simultaneous spasm of 3 coronary arteries that worsened over time.

Coronary artery spasm (CAS) rarely worsens from single-vessel to simultaneous multivessel CAS naturally, and simultaneous multivessel CAS leads to serious conditions such as cardiopulmonary arrest (CPA). A 77-year-old Japanese man who took medications for CAS was transferred to our hospital due to persistent chest pain. On arrival, his vital signs were stable, but his electrocardiogram (ECG) showed ST-segment elevation in leads II, III and aVF. Ventricular fibrillation developed suddenly. Although routine cardiopulmonary resuscitation (CPR) including intravenous administration of epinephrine was performed immediately, he could not be resuscitated. After initiation of percutaneous cardiopulmonary support (PCPS), there was a return of spontaneous circulation. His ECG showed exacerbation of myocardial ischemia with ST-segment elevation in leads I, II, III, aVL, aVF and V3-V6. Emergency coronary angiography revealed severe CAS of the right and left coronary arteries, which was relieved completely by intracoronary administration of nitrates. He was diagnosed with acute myocardial infarction due to simultaneous 3-vessel CAS that progressed over time. About 6h after arrival, he developed hemodynamic instability and died. CAS worsened from single-vessel to simultaneous 3-vessel spasm, and intracoronary administration of nitrates was effective in relieving CAS, which was documented by the ECG and coronary angiogram. Since CAS can progress over time, nitrates must be administered immediately. When CAS leads to CPA, epinephrine may be ineffective in CPR because of its vasoconstrictive effect on coronary arteries; therefore, PCPS should be initiated, and intracoronary nitrates should be administered.

Cardiac Sarcoidosis Presenting as Acute Progressive Heart Failure with Abdominal Lymphadenopathy.

A 77-year-old Japanese woman presented with asymptomatic abdominal lymphadenopathy. Soluble interleukin-2 receptor (sIL2R) and angiotensin-converting enzyme (ACE) levels were elevated, and a pathological examination of lymph-node biopsies revealed non-caseating granulomas, which was consistent with sarcoidosis. Fluorodeoxyglucose-positron emission tomography did not show a clear accumulation in the mediastinal lymph-nodes or heart. Five months later, she presented with acute progressive heart failure that was refractory to conventional treatment. Her sIL2R and ACE levels decreased spontaneously over time, without steroid treatment. Autopsy findings revealed non-caseating granulomas. Cardiac sarcoidosis presenting as acute, progressive, treatment-refractory heart failure is rare. Steroid therapy after the resolution of inflammation did not affect the clinical outcome.

Activated inflammation is related to the incidence of atrial fibrillation in patients with acute myocardial infarction.

OBJECTIVE: The purpose of this study was to investigate the relationship between the new onset of atrial fibrillation (AF) and inflammation in the early phase of acute myocardial infarction (AMI). Background Serial interaction between inflammation and the incidence of AF is not fully understood in the early phase of AMI. METHODS: Two hundred fifty-nine consecutive patients with AMI were studied. electrocardiogram monitoring was recorded continuously for >7 days. Serial inflammation markers, cardiac enzymes, coronary angiogram and echocardiography were obtained in all patients. RESULTS: One hundred seventy-six patients were enrolled. AF was present in 24 patients (14%), and occurred on day 2.7 ± 1.4 after admission. Serial measurements of WBC and C-reactive protein (CRP) with/without AF were as follows. WBC levels of day 5-7 were 9.3 ± 3.5 vs. 7.5 ± 2.4 × 10(3)/µL, p=0.04, and CRP levels of day 2-4, 5-7, 8-14 were 12.6 ± 9.4 vs. 4.7 ± 5.3 mg/dL, p<0.001, 12.3 ± 10.4 vs. 5.2 ± 5.2 mg/dL, p=0.01, and 8.5 ± 7.7 vs. 2.7 ± 4.2 mg/dL, p=0.005, respectively. Those were significantly higher in the patients with AF. In multivariate logistic regression analysis, CRP levels of day 2-4 were independently higher in the patients with AF (odds ratio (OR) 1.15, 95% confidence (CI) 1.04-1.27). CONCLUSION: AF in the early phase of AMI occurs a few days after the onset of AMI, which is independently related to the activated inflammation. AF in this period persists for only a short duration.

Low adiponectin levels predict late in-stent restenosis after bare metal stenting in native coronary arteries.

BACKGROUND: Adiponectin, the most abundant protein secreted from adipose tissue, possesses anti-atherogenic properties. This study tested whether adiponectin plasma levels predict in-stent restenosis (ISR) after successful percutaneous coronary intervention (PCI) with bare-metal stents. METHODS: The study included 148 consecutive patients who had elective PCI with bare-metal stents in de novo lesions of native coronary arteries for symptomatic coronary artery disease. Adiponectin levels were measured by ELISA 3 days or less before PCI. RESULTS: Angiographic ISR (defined as >50% diameter stenosis) was found in 49 (33%) patients during 6 months of the follow-up. Adiponectin levels were lower in patients with ISR than those without ISR (3.5+/-0.3 vs. 6.9+/-0.4 microg/ml, respectively, p<0.01). Adiponectin levels were inversely correlated with late luminal loss of the stented lesions (r=-0.40, p<0.01). Using multivariate logistic regression analysis, low adiponectin levels (<4.5 microg/ml, arbitrarily determined from a receiver operating characteristic curve) served as a predictor of ISR that was independent of angiographic and procedural variables, and clinical factors known to be associated with ISR (odds ratio, 7.9; 95% CI, 3.0-21; p<0.01). Furthermore, low adiponectin levels also independently predicted target lesion revascularization (n=35) during follow-up (odds ratio, 3.7; 95% CI, 1.4-9.7; p<0.01). CONCLUSIONS: Low adiponectin levels have a predictive value for late ISR after PCI with bare-metal stents in native coronary arteries.

High prevalence of paroxysmal atrial fibrillation and/or atrial flutter in metabolic syndrome.

BACKGROUND: Because metabolic syndrome is associated with cardiovascular diseases, its association with the risk of paroxysmal atrial fibrillation (PAF) and/or atrial flutter (PAFL) was examined in the present study. METHODS AND RESULTS: A prospective analysis was performed in 592 consecutive hospitalized patients without obvious structural heart diseases. Sinus rhythm was confirmed by electrocardiography in all patients. PAF/PAFL occurred in 32 (5%) and metabolic syndrome was present in 127 (21%) of the patients enrolled. PAF/PAFL occurred in 12 (9%) of the patients with metabolic syndrome, but only 20 (4%) of patients without metabolic syndrome (p=0.02). Multivariate logistic regression analysis showed that metabolic syndrome was a significant risk factor for PAF/PAFL that was independent of left atrial diameter (> 44 mm) or age (> 70 years) (odds ratio (OR) 2.8, 95% confidence interval (CI) 1.3-6.2, p<0.01). Among the 5 components of the metabolic syndrome, body mass index > or = 25 kg/m2 was the most strongly associated with PAF/PAFL (OR; 3.0, 95% CI 1.2-7.4, p=0.02). CONCLUSIONS: Metabolic syndrome is highly associated with PAF/PAFL in patients without structural heart diseases and obesity may be an underlying mechanism for the higher prevalence.