The potential of dynamic 99mTc-sestamibi cadmium zinc telluride-single-photon emission computed tomography camera assessing myocardial flow reserve in patients with heart failure with preserved ejection fraction.

Aims: Coronary microvascular dysfunction (CMD) is related to the pathophysiology, mortality, and morbidity of heart failure with preserved ejection fraction (HFpEF). A novel single-photon emission computed tomography (SPECT) camera with cadmium zinc telluride (CZT) detectors allows for the quantification of absolute myocardial blood flow and myocardial flow reserve (MFR) in patients with coronary artery disease. However, the potential of CZT-SPECT assessing for CMD has never been evaluated in patients with HFpEF. Methods and results: The clinical records of 127 consecutive patients who underwent dynamic CZT-SPECT were retrospectively reviewed. Rest and stress scanning were started simultaneously with 3 and 9 MBq/kg of 99mTc-sestamibi administration, respectively. Dynamic CZT-SPECT imaging data were analysed using a net-retention model with commercially available software. Transthoracic echocardiography was performed in all patients. The MFR value was significantly lower in the HFpEF group (mean ± SEM = 2.00 ± 0.097) than that in the non-HFpEF group (mean ± SEM = 2.74 ± 0.14, P = 0.0004). A receiver operating characteristic analysis indicated that if a cut-off value of 2.525 was applied, MFR could efficiently distinguish HFpEF from non-HFpEF. Heart failure with preserved ejection fraction had a consistently low MFR, regardless of the diastolic dysfunction score. Heart failure with preserved ejection fraction patients with MFR values lower than 2.075 had a significantly higher incidence of heart failure exacerbation. Conclusion: Myocardial flow reserve assessed by CZT-SPECT was significantly reduced in patients with HFpEF. A lower MFR was associated with a higher hospitalization rate in these patients. Myocardial flow reserve assessed by CZT-SPECT has the potential to predict future adverse events and stratify the severity of disease in patients with HFpEF.

Reduced exercise capacity and clinical outcomes following acute myocardial infarction.

Reduced exercise capacity is known to be an important predictor of poor prognosis and disability in patients with cardiovascular diseases and chronic heart failure, and even members of the general population. However, data about exercise capacity assessed by cardiopulmonary exercise testing (CPX) in acute myocardial infarction (AMI) patients who underwent primary percutaneous coronary intervention (PCI) is scarce. Among 594 consecutive AMI patients who underwent primary PCI, we examined 136 patients (85.3% men, 64.9 ± 11.9 years) who underwent CPX during hospitalization for AMI. CPX was usually performed 5 days after the onset of AMI. Reduced exercise capacity was defined as peak VO2 ≤ 12. Clinical outcomes including all-cause death, myocardial infarction, and hospitalization due to heart failure were followed. Among 136 patients, reduced exercise capacity (peak VO2 ≤ 12) was seen in 38 patients (28%). Patients with reduced exercise capacity were older, more likely to have hypertension, and had lower renal function. In echocardiography, patients with reduced exercise capacity had higher E/e' and larger left atrial dimension. Multivariate logistic analysis showed that E/e' (OR 1.19, 95% CI 1.09-1.31, p < 0.001) was an independent predictor of reduced exercise capacity (peak VO2 ≤ 12). Median follow-up term was 12 months (IQR 9-22). The occurrence of composite endpoints of all-cause death, myocardial infarction, and hospitalization due to heart failure was significantly higher in patients with peak VO2 ≤ 12 than those with peak VO2 > 12 (p < 0.001). Reduced exercise capacity following primary PCI in AMI patients is associated with diastolic dysfunction and may lead to poorer clinical outcomes.

Impact of Diabetes Mellitus on the Aortic Wall Changes as Atherosclerosis Progresses: Aortic Dilatation and Calcification.

AIM: An inverse association between diabetes mellitus (DM) and aortic dilatation has recently been reported. However, little is known about the association between DM and the progression of aortic dilatation/calcification as atherosclerosis progresses. METHODS: We identified 216 patients who had undergone percutaneous coronary intervention (PCI) and abdominal computed tomography (CT) during the PCI and follow-up phases. The patients were classified into two groups: those with DM (DM+ group; n=107) and those without DM (DM- group; n=109). The infrarenal aortic diameter and aortic calcification index (ACI) were measured, and annual changes were calculated using measurement results obtained during the PCI and follow-up phases. RESULTS: Infrarenal aortic diameters were significantly shorter in the DM+ group than in the DM- group during the PCI phase, and no significant ACI differences were observed between the DM+ and DM- groups. The median duration between the PCI and follow-up phase CT was 3.0 years. The growth rate of the infrarenal aortic dilatation from the PCI phase in the DM+ group was similar to that in the DM- group. Annual ACI changes were significantly larger in the DM+ group than in the DM- group. Multivariate logistic regression analysis indicated that the prevalence of DM was an independent predictor of rapid aortic calcification progression (odds ratio: 2.51; 95% confidence interval: 1.23-5.14; p=0.01). CONCLUSION: Our findings suggest that DM negatively affects aortic dilatation during an earlier phase of atherosclerosis progression and positively affects the progression of aortic calcification in a later phase.

Early versus delayed invasive strategy in patients with non-ST-elevation acute coronary syndrome and concomitant congestive heart failure.

BACKGROUND: Although there are guidelines that recommend an early invasive strategy in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) and concomitant congestive heart failure (CHF), optimal timing of the invasive strategy remains controversial. METHODS: Among 2045 patients who were admitted owing to NSTE-ACS or CHF, 300 presented with NSTE-ACS and concomitant CHF. Of the 300 patients, we enrolled 160 patients for whom coronary angiography (CAG) during their hospital stay was planned at the time of admission; 64 of these patients were classified into the early invasive group (<24h) and 96 were classified to the delayed invasive group (≥24h). We evaluated the primary outcome which was defined as a composite of cardiac mortality, life-threatening arrhythmia, and non-fatal myocardial infarction (MI). RESULTS: The median time between presentation and CAG was 2h in the early invasive group and 240h in the delayed group. During follow-up, the primary outcome was significantly lower in the early invasive group [hazard ratio (HR), 0.52; 95% confidence interval (CI), 0.30-0.87; p=0.01]. After the adjustment of confounding factors, the primary outcome was significantly less frequent (HR, 0.44; 95% CI, 0.23-0.78; p=0.004) in the early invasive group compared to the delayed invasive group. CONCLUSIONS: The early invasive strategy was associated with a lower risk of the composite primary outcome in the long-term follow-up of patients with NSTE-ACS and concomitant CHF.

Impact of Postdischarge Bleeding on Long-Term Mortality in Percutaneous Coronary Intervention Patients Taking Oral Anticoagulants.

Although postdischarge bleeding (PDB) is known to negatively affect long-term outcome in patients undergoing percutaneous coronary intervention (PCI) with antiplatelet therapy (APT), the prognostic importance of PDB in patients who require both oral anticoagulants (OACs) and APT has not been fully elucidated. Among 3718 consecutive patients who underwent PCI, 302 patients were treated with both OACs and APT. We evaluated the association between PDB and 3-year all-cause mortality, as estimated by a time-updated Cox proportional hazard regression model. We performed nearest-neighbor matching on the propensity score to adjust the differences in baseline characteristics. Among 302 patients treated with OACs and APT, PDB was observed in 98 patients at a median time of 239 days. Patients experienced PDB had significantly higher incidence of 3-year all-cause mortality in the overall cohort and 94 propensity-score-matched pairs (hazard ratio 6.21, 95% confidence interval 3.29-11.72, P < 0.0001; and hazard ratio 6.13, 95% confidence interval 2.68-14.02, P < 0.0001, respectively). The risk of subsequent mortality was the highest within 180 days after PDB (58.3% within 180 days and 75.0% within 1 year). In conclusion, PDB was significantly associated with long-term mortality in patients taking both OACs and APT after PCI.

Performance of HAS-BLED, ORBIT, PRECISE-DAPT, and PARIS risk score for predicting long-term bleeding events in patients taking an oral anticoagulant undergoing percutaneous coronary intervention.

BACKGROUND: No standardized tool exists for weighting bleeding risk before selecting an antithrombotic regimen in patients undergoing percutaneous coronary intervention (PCI) who require both oral anticoagulant (OAC) and antiplatelet agents. METHODS: We performed PCI in 3718 consecutive patients between April 2011 and March 2017, 302 of whom were treated with both OAC and antiplatelet agents. We retrospectively evaluated the predictive performance of four major bleeding risk scores (HAS-BLED, ORBIT, PRECISE-DAPT, and PARIS score). Patients were followed for up to 3 years for bleeding events, defined as a composite of major and minor bleeding according to the Thrombolysis in Myocardial Infarction (TIMI) criteria and the Bleeding Academic Research Consortium (BARC) criteria. RESULTS: TIMI significant bleedings (major, minor, and requiring medical attention) were seen in 90 patients (29.8%); whereas the BARC class ≥3 bleedings were seen in 53 patients (17.5%). Regarding TIMI significant bleedings, HAS-BLED, ORBIT, and PRECISE-DAPT scores equally categorized high-risk patients, but the PARIS score could not [high-risk versus non-high-risk: hazard ratio (HR), 1.74; 95% confidence interval (CI), 1.15-2.64; p=0.01; HR, 1.63; 95% CI, 1.08-2.48; p=0.02; HR, 1.62; 95% CI, 1.06-2.51; p=0.03; HR, 1.05; 95% CI, 0.70-1.63; p=0.79, respectively); regarding BARC class ≥3 bleeding, all four scores could stratify high-risk patients (high-risk versus non-high-risk: HR, 2.23; 95% CI, 1.30-3.88; p=0.004; HR, 2.25; 95% CI, 1.31-3.96; p=0.003; HR, 3.87; 95% CI, 2.06-7.91; p<0.0001; HR, 1.85; 95% CI, 1.04-3.47; p=0.04, respectively). CONCLUSIONS: In patients taking an OAC undergoing PCI, HAS-BLED, ORBIT, and PRECISE-DAPT scores predicted TIMI significant bleeding events better than the PARIS score; whereas all four scores could predict BARC class ≥3 bleeding events.

Impact of Nutritional and Inflammation Status on Long-Term Bleeding in Patients Undergoing Percutaneous Coronary Intervention with an Oral Anticoagulant.

AIM: Patients undergoing percutaneous coronary intervention (PCI) who require both oral anticoagulant (OAC) and antiplatelet therapy (APT) are exposed to a serious risk of bleeding. The aim of this study was to clarify the relationship among nutritional and inflammation status and long-term bleeding in patients requiring both OACs and APT after PCI. METHODS: We performed PCI in 3,718 consecutive patients between April 2011 and March 2017, 302 of whom were treated with both OACs and APT. Patients were followed for up to 3 years for bleeding events, defined as the Bleeding Academic Research Consortium (BARC) class ≥3 bleeding. We retrospectively evaluated the ability of the Geriatric Nutritional Risk Index (GNRI) and high-sensitivity C-reactive protein (hs-CRP) to detect bleeding events. RESULTS: During a median follow-up of 1,080 days, bleeding events were observed in 53 (17.5%) patients. Bleeding events were associated with a low GNRI (≤98) (hazard ratio [HR], 3.16; 95% confidence interval [CI], 1.84-5.45; p＜0.0001) and hs-CRP level ≥2.5 mg/L (HR, 2.75; 95% CI, 1.61-4.78; p=0.0003). A low GNRI＋high hs-CRP showed a 5.12-fold increase in the incidence of BARC class ≥3 bleeding (95% CI, 2.68-9.91; p＜0.0001) compared with a normal GNRI＋low hs-CRP. The addition of the GNRI and hs-CRP to the PRECISE-DAPT score improved C-statistics from 0.67 to 0.71 and enhanced the net reclassification improvement (NRI) and integrated discrimination improvement (IDI) (NRI, 0.36, p＜0.0001; IDI, 0.066, p＜0.0001). CONCLUSIONS: The GNRI and hs-CRP were novel predictors of the long-term bleeding risk in patients requiring both OACs and APT after PCI.

Association between the ratio of anti-angiogenic isoform of VEGF-A to total VEGF-A and adverse clinical outcomes in patients after acute myocardial infarction.

BACKGROUND: Vascular endothelial growth factor-A (VEGF-A) promotes neovascularization and is attracting considerable attention as a remarkable risk factor in patients after acute myocardial infarction (AMI). In contrast, the association between VEGF-A165b, which is the main anti-angiogenic isoform of VEGF-A, and adverse clinical outcomes after AMI remains unclear. The present study aimed to investigate the association between serum VEGF-A165b and major adverse cardiac and cerebrovascular events (MACCEs) after percutaneous coronary intervention (PCI) for AMI. METHODS: We evaluated 23 patients with AMI who underwent primary percutaneous coronary intervention. VEGF-A and VEGF-A165b levels were measured on admission (day 1) and at days 3, 7, and 30 after PCI. RESULTS: The levels of total VEGF-A tended to be lower, while the ratio of VEGF-A165b to total VEGF-A tended to be higher in patients with MACCEs than in those without. The patients with a high ratio of VEGF-A165b to total VEGF-A had a significantly higher risk of MACCEs using the cut-off values for MACCEs at day 30 after PCI (0.87 vs. 0.25, log-rank test, p = 0.0058). CONCLUSION: The assessment of VEGF-A165b combined with VEGF-A may be a valuable screening tool for predicting MACCEs in clinical practice.

Impact of high-density lipoprotein 3 cholesterol subfraction on periprocedural myocardial injury in patients who underwent elective percutaneous coronary intervention.

BACKGROUND: Periprocedural myocardial injury (PMI) is a major complication of percutaneous coronary intervention (PCI) and is associated with atherosclerotic coronary plaque and worse clinical outcomes. High-density lipoprotein cholesterol (HDL-C) is a protective factor for cardiovascular disease. However, the role of HDL-C subfractions, such as HDL2 cholesterol (HDL2-C) or HDL3 cholesterol (HDL3-C), in cardiovascular disease remains unclear. The purpose of the study was to investigate the relationship between HDL2-C and HDL3-C subfractions and the incidence of PMI in patients who underwent elective PCI. METHODS: We enrolled 129 patients who underwent elective PCI for stable angina pectoris. PMI was defined as an increase in high-sensitivity troponin T levels > 5 times the upper normal limit (> 0.070 ng/mL) at 24 h after PCI. Serum HDL-C subfractions (HDL2-C and HDL3-C) were assessed using ultracentrifugation in patients with and those without PMI. RESULTS: HDL3-C levels were significantly lower in patients with PMI than in those without (15.1 ± 3.0 mg/dL vs. 16.4 ± 2.9 mg/dL, p = 0.016) and had an independent and inverse association with PMI (odds ratio, 0.86; 95% confidence interval, 0.74-0.99; p = 0.038). When divided by the cut-off value of HDL3-C for PMI (14.3 mg/dL), the incidence of PMI was significantly higher in low HDL3-C patients than in high HDL3-C patients (51.2% vs. 30.2%, p = 0.020). CONCLUSIONS: HDL3-C was an independent inverse predictor of PMI in patients who underwent elective PCI.

Balance between angiogenic and anti-angiogenic isoforms of VEGF-A is associated with the complexity and severity of coronary artery disease.

INTRODUCTION: Assessing the complexity of coronary artery disease (CAD) is clinically important. Vascular endothelial growth factor A (VEGF-A) is a powerful and the most important regulator of angiogenesis. It has been reported that the anti-angiogenic isoform of VEGF-A (VEGF-A165b) inhibits angiogenesis. The purpose of this study was to evaluate the relationship between the complexities of CAD using the Syntax score (SS) and the levels of circulating total VEGF-A or VEGF-A165b. METHODS: A total of 268 patients who underwent percutaneous coronary intervention (PCI) were enrolled. Of these, 73 patients without acute coronary syndrome or previous revascularization were included in this study. These subjects were divided into two groups according to the SS. Circulating total VEGF-A and VEGF-A165b levels were measured using an enzyme-linked immunosorbent assay. RESULTS: Circulating levels of total VEGF-A were significantly higher in the SS>22 (high SS) group than in the SS≤22 (low SS) group (p=0.018). Moreover, the ratio of VEGF-A165b to total VEGF-A was significantly lower for the high SS group (p=0.004). The levels of total VEGF-A independently predicted high SS after adjusting for other significant variables among patients who underwent PCI (odds ratio, 1.004; 95% CI, 1.001 to 1.006; p=0.01). CONCLUSIONS: These data indicated that high SS was associated with circulating levels of total VEGF-A and the ratio of VEGF-A165b to total VEGF-A in patients with complex CAD.

Clinical Impact of Circulating Irisin on Classified Coronary Plaque Characteristics.

BACKGROUND: Myokines are hormones secreted by skeletal muscles during physical activity. Low myokine levels may contribute to metabolic dysfunction and cardiovascular disorders. Irisin, a newly identified myokine, has been the focus of recent research. The aim of the present study was to analyze the association between circulating irisin levels and tissue characteristics of nonculprit left main coronary artery (LMCA) plaques with the use of integrated backscatter (IB) intravascular ultrasound (IVUS). METHODS: This observational study enrolled 55 Japanese patients following successful percutaneous coronary intervention for lesions in the left anterior descending arteries or left circumflex arteries. Circulating myokine levels, including myostatin, brain-derived neurotrophic factor, and irisin, were measured by an enzyme-linked immunosorbent assay. Tissue characteristics of LMCA plaque were evaluated by IB-IVUS. RESULTS: Circulating irisin levels were negatively associated with percent lipid volume (%LV) [r = -0.31 (95% CI, -2.52 to -0.21), P = 0.02] and positively associated with percent fibrous volume (%FV) [r = 0.32 (95% CI, 0.22-2.20), P = 0.02]. The optimal cutoff value of circulating irisin for the prediction of lipid-rich LMCA plaques was 6.02 µg/mL [area under the curve = 0.713, P < 0.01 (95% CI, 0.58-0.85)]. Multivariate linear regression analysis identified circulating irisin levels as independent predictors for %LV and %FV of the LMCA [ß = -0.29 (95% CI, -2.53 to -0.07), P = 0.04 and ß = 0.30 (95% CI, 0.10-2.23), P = 0.03, respectively]. CONCLUSIONS: Circulating irisin levels are significantly associated with tissue characteristics of nonculprit LMCA plaques.

Impact of post-dilatation on longitudinal stent elongation: An in vitro study.

OBJECTIVES: To evaluate whether balloon inflation for post-dilatation causes longitudinal stent deformation (LSD). METHODS AND RESULTS: Two stents, sized 2.5mm×28mm and 3.5mm×28mm (Nobori®, biodegradable polymer biolimus-eluting stent; Ultimaster®, biodegradable polymer sirolimus-eluting stent; Terumo Co., Tokyo, Japan), were deployed at nominal pressure in straight and tapered silicon vessel models. Then, post-dilatation was performed in two ways: dilatation from the distal (D-P group) or proximal (P-D group) side of the stent. Microscopic findings showed that the stents were elongated during every step of the procedure regardless of the post-dilatation method and type of vessel model. The D-P group showed linear elongation during each step of post-dilatation (straight model: 28.7±0.3mm vs. 29.9±0.3mm, p=0.002; tapered model: 28.0±0.1mm vs. 29.9±0.1mm, p<0.001). In contrast, in the P-D group, the most significant change was observed in the first step of post-dilatation and only slight changes were observed thereafter (straight model: 28.6±0.1mm vs. 29.5±0.1mm, p<0.001; tapered model: 28.2±0.1mm vs. 29.5±0.1mm, p<0.001). Optical frequency domain imaging analysis showed that the frequency of stent strut malapposition was positively correlated with the percentage change in stent length (r=0.74, p<0.0001). CONCLUSION: LSD was observed during every step of post-dilatation in both the straight and tapered vessel models. However, some differences were observed between the D-P and P-D groups. Minimizing stent strut malapposition may reduce the risk of LSD.

Decreased Serum Albumin Predicts Bleeding Events in Patients on Antiplatelet Therapy After Percutaneous Coronary Intervention.

BACKGROUND: Antiplatelet therapy (APT) after percutaneous coronary intervention (PCI) prevents ischemic events with increased risk of bleeding. Little is known about the relationship between hypoalbuminemia and bleeding risk in patients receiving APT after PCI. This study investigated the association between serum albumin level and bleeding events in this population.Methods and Results:We enrolled 438 consecutive patients who were prescribed dual APT (DAPT; aspirin and thienopyridine) beyond 1 month after successful PCI without adverse events. The patients were divided into 3 groups according to serum albumin tertile: tertile 1, ≤3.7 g/dL; tertile 2, 3.8-4.1 g/dL; and tertile 3, ≥4.2 g/dL. Adverse bleeding events were defined as Bleeding Academic Research Consortium criteria types 2, 3, and 5. During the median follow-up of 29.5 months, a total of 30 adverse bleeding events were observed. Median duration of DAPT was 14 months. The tertile 1 group had the highest risk of adverse bleeding events (event-free rate, 83.1%, 94.3% and 95.8%, respectively; P<0.001). On Cox proportional hazards modeling, serum albumin independently predicted adverse bleeding events (HR, 0.10, 95% CI: 0.027-0.39, P=0.001, for tertile 3 vs. tertile 1). CONCLUSIONS: Decreased serum albumin predicted bleeding events in patients with APT after PCI.

Impact of Skeletal Muscle Mass on Long-Term Adverse Cardiovascular Outcomes in Patients With Chronic Kidney Disease.

Sarcopenia, defined as skeletal muscle loss and dysfunction, is attracting considerable attention as a novel risk factor for cardiovascular events. Although the loss of skeletal muscle is common in chronic kidney disease (CKD) patients, the relation between sarcopenia and cardiovascular events in CKD patients is not well defined. Therefore, we aimed to investigate the relation between skeletal muscle mass and major adverse cardiovascular events (MACE) in CKD patients. We enrolled 266 asymptomatic CKD patients (median estimated glomerular filtration rate: 36.7 ml/min/1.73 m2). To evaluate skeletal muscle mass, we used the psoas muscle mass index (PMI) calculated from noncontrast computed tomography. The patients were divided into 2 groups according to the cut-off value of PMI for MACE. There were significant differences in age and body mass index between the low and high PMI groups (median age: 73.5 vs 69.0 years, p = 0.002; median body mass index: 22.6 vs 24.2 kg/m2, p <0.001, respectively). During the follow-up period (median: 3.2 years), patients with low PMI had significantly higher risk of MACE than those with high PMI (31.7% and 11.2%, log-rank test, p <0.001). The Cox proportional hazard model showed that low PMI is an independent predictor of MACE in CKD patients (hazard ratio 3.98, 95% confidence interval 1.65 to 9.63, p = 0.0022). In conclusion, low skeletal muscle mass is an independent predictor of MACE in CKD patients. The assessment of skeletal muscle mass may be a valuable screening tool for predicting MACE in clinical practice.

Nutrition Status Predicts Severity of Vascular Calcification in Non-Dialyzed Chronic Kidney Disease.

BACKGROUND: Vascular calcification is a major complication in chronic kidney disease (CKD) that increases the risk of adverse clinical outcomes. Geriatric nutritional risk index (GNRI) is a simple nutritional assessment tool that predicts poor prognosis in elderly subjects. The purpose of the present study was to evaluate the correlation between GNRI and severity of vascular calcification in non-dialyzed CKD patients.Methods and Results:We enrolled 323 asymptomatic CKD patients. To evaluate abdominal aortic calcification (AAC), we used aortic calcification index (ACI) determined on non-contrast computed tomography. The patients were divided into three groups according to GNRI tertile. Median ACI significantly decreased with increasing GNRI tertile (15.5%, 13.6%, and 7.9%, respectively; P=0.001). On multivariate regression analysis GNRI was significantly correlated with ACI (ß=-0.15, P=0.009). We also investigated the combination of GNRI and C-reactive-protein (CRP) for predicting the severity of AAC. Low GNRI and high CRP were significantly associated with severe AAC, compared with high GNRI and low CRP (OR, 4.07; P=0.004). CONCLUSIONS: GNRI was significantly associated with AAC in non-dialyzed CKD patients.

Impact of nutritional assessment and body mass index on cardiovascular outcomes in patients with stable coronary artery disease.

BACKGROUND: An inverse association between obesity, as defined by body mass index (BMI) and prognosis has been reported in patients with cardiovascular disease ("obesity paradox"). The aim of this study was to investigate whether adding nutritional information to BMI provides better risk assessment in patients undergoing elective percutaneous coronary intervention (PCI). METHOD: This study comprised 1004 patients undergoing elective PCI. We calculated each patient's controlling nutritional status (CONUT) score for nutritional screening at baseline. Patients were divided into 4 groups based on CONUT score (low, 0-1 [<75th percentile]; or high, ≥2 [≥75th percentile]) and BMI (normal, 18.5-24.9kg/m2; or high, ≥25kg/m2). The endpoint was major adverse cardiac events (MACE) defined as cardiac death and/or myocardial infarction. RESULTS: Low CONUT score+normal BMI, low CONUT score+high BMI, high CONUT score+normal BMI, and high CONUT score+high BMI were determined in 374, 242, 275, and 113 patients, respectively. During a median follow-up of 1779 days, 73 events occurred. High CONUT score+normal BMI showed a 2.72-fold increase in the incidence of MACE (95% CI 1.46-5.08, p=0.002) compared with low CONUT score+normal BMI after adjusting for confounding factors. On the other hand, no significant difference in the incidence of MACE was observed in the other three groups. CONCLUSION: The combination of CONUT score and BMI was a useful predictor of MACE in this population. Using BMI to assess the cardiovascular risk may be misleading unless the nutritional information is considered.

Correlations between geriatric nutritional risk index and peripheral artery disease in elderly coronary artery disease patients.

AIM: Malnutrition is associated with the development of atherosclerosis and an increased risk of cardiovascular mortality in elderly patients. The present study aimed to investigate the association between the Geriatric Nutritional Risk Index (GNRI), a simple nutritional assessment tool, and the prevalence of peripheral artery disease (PAD) in elderly coronary artery disease patients. METHODS: We evaluated 228 elderly coronary artery disease patients (mean age 74.0 ± 5.7 years). Ankle-brachial index (ABI) measurements were routinely carried out to investigate the prevalence of lower extremity PAD. Patients showing ABI <0.9 were defined as having PAD. RESULTS: Based on our findings, 20.6% of the study patients had PAD. The median GNRI values were significantly lower in patients with PAD than those in patients without PAD (93.8 vs 100.0, P < 0.001). Even after multivariate adjustment, GNRI values were independently associated with PAD (odds ratio 0.94; 95% confidence interval 0.89-0.99; P = 0.024). Furthermore, patients with low GNRI and high C-reactive protein levels had a 5.5-fold higher risk of having PAD than those with high GNRI and low C-reactive protein levels. CONCLUSIONS: GNRI values showed a strong relationship with PAD in elderly coronary artery disease patients. These data reinforce the utility of GNRI as a screening tool in clinical practice. Geriatr Gerontol Int 2017; 17: 1057-1062.

The combination assessment of lipid pool and thrombus by optical coherence tomography can predict the filter no-reflow in primary PCI for ST elevated myocardial infarction.

The usefulness of distal protection devices is still controversial. Moreover, there is no report on thrombus evaluation by using optical coherence tomography (OCT) for determining whether to use a distal protection device. The aim of the present study was to investigate the predictor of filter no-reflow (FNR) by using OCT in primary percutaneous coronary intervention (PCI) for ST-elevated acute myocardial infarction (STEMI).We performed preinterventional OCT in 25 patients with STEMI who were undergoing primary PCI with Filtrap. FNR was defined as coronary flow decreasing to TIMI flow grade 0 after mechanical dilatation.FNR was observed in 13 cases (52%). In the comparisons between cases with or without the FNR, the stent length, lipid pool length, lipid pool + thrombus length, and lipid pool + thrombus index showed significant differences. In multivariate analysis, lipid pool + thrombus length was the only independent predictor of FNR (OR 1.438, 95% CI 1.001 - 2.064, P < .05). The optimal cut-off value of lipid pool + thrombus length for predicting FNR was 13.1 mm (AUC = 0.840, sensitivity 76.9%, specificity 75.0%). Moreover, when adding the evaluation of thrombus length to that of lipid pool length, the prediction accuracy of FNR further increased (IDI 0.14: 0.019-0.25, P = .023).The longitudinal length of the lipid pool plus thrombus was an independent predictor of FNR and the prediction accuracy improved by adding the thrombus to the lipid pool. These results might be useful for making intraoperative judgment about whether filter devices should be applied in primary PCI for STEMI.

Impact of Geriatric Nutritional Risk Index on cardiovascular outcomes in patients with stable coronary artery disease.

BACKGROUND: The association between malnutrition and cardiovascular prognosis in patients with stable coronary artery disease remains unclear. The aim of this study was to evaluate the association between Geriatric Nutritional Risk Index (GNRI), a simple tool to assess nutritional risk, and long-term outcomes after elective percutaneous coronary intervention (PCI). METHODS: This study consisted of 802 patients (age, 70±10 years, male, 69%) who underwent elective PCI. GNRI was calculated at baseline as follows: GNRI=[14.89×serum albumin (g/dl)+[41.7×(body weight/body weight at body mass index of 22)]]. Patients were then divided into three groups as previously reported: GNRI <92, 92 to ≤98, and >98. The endpoint of this study was the composite of cardiac death or non-fatal myocardial infarction. RESULTS: During a median follow-up period of 1568 days, 56 cardiac events occurred. Using Kaplan-Meier analysis, the 4-year event-free rates were found to be 79% for GNRI <92, 90% for GNRI 92 to ≤98, and 97% for GNRI >98 (log-rank test p<0.001). GNRI <92 and GNRI 92 to ≤98 showed 6.76-fold [95% confidence interval (CI) 3.13-14.56, p<0.001] and 3.03-fold (HR 3.03, 95%CI 1.36-6.78, p=0.007) increase in the incidences of cardiac death or non-fatal myocardial infarction compared with GNRI >98 after adjusting for confounding factors. CONCLUSION: GNRI significantly associated with cardiac events after elective PCI. Further studies should be performed to establish appropriate therapeutic strategies for this vulnerable patient group.