Ratio of eicosapentaenoic acid to arachidonic acid is a critical risk factor for acute coronary syndrome in middle-aged older patients as well as younger adult patients.

BACKGROUND: Coronary risk factors for the onset of acute coronary syndrome (ACS), including polyunsaturated fatty acids (PUFAs), in younger adult patients may be different from those in older patients. METHODS AND RESULTS: We enrolled 578 patients who underwent coronary angiography at Fukuoka Saiseikai Hospital, and divided them into a younger adult group (YG) (<50 years, n=47) and a middle-aged older group (OG) (≥50 years, n=531). In a multivariate analysis, lower levels of high-density lipoprotein cholesterol and the ratio of eicosapentaenoic acid (EPA) to arachidonic acid (AA) (EPA/AA), and less aspirin, oral hypoglycemic agent, and calcium channel blocker (CCB) use were independent risk factors for ACS in all patients. In YG, lower levels of EPA/AA and less angiotensin II receptor blocker/angiotensin-converting enzyme inhibitor use were the independent risk factors. In OG, smoking, lower levels of EPA/AA, less aspirin and CCB use were the risk factors. While lower levels of EPA/AA was the only risk factor for ACS that was common to all patients, YG and OG, docosahexaenoic acid/AA was not associated with ACS in YG and OG. CONCLUSIONS: Lower level of EPA/AA is a common critical risk factor for ACS in middle-aged older patients as well as younger adult patients. Some of the risk factors for the onset of ACS in younger patients were different from those in older patients.

Impact of glycemic control on the clinical outcome in diabetic patients with percutaneous coronary intervention--from the FU-registry.

BACKGROUND: It is not yet clear whether glycemic control affects the clinical outcome of percutaneous coronary intervention (PCI) in diabetic patients. METHODS AND RESULTS: This study compared the effects of glycemic control on the clinical outcome in 2 groups of patients with diabetes mellitus (DM) who underwent PCI: a poor-glycemic-control group, who showed greater than 6.9% HbA(1c) at the time of PCI (Pre-HbA(1c)) (`≥6.9 group', n=334 patients) and a good-glycemic-control group, who showed less than <6.9% at Pre-HbA(1c) (`<6.9 group', n=212 patients). The patients in the ≥6.9 group were further divided into 2 groups for further comparisons: a `DM control group' and a `Poor control group'. At follow-up (300 days), the incidence of major adverse cardiac event (MACE) was significantly (P<0.05) lower in the <6.9 group (18.4% vs. 26.2%). However, there was no difference in MACE between the DM control group and the Poor control group. In a multivariate analysis, there was no relationship between the incidence of MACE and Pre-HbA(1c), Pre-HbA(1c)≥6.9% or the HbA(1c) difference (Pre-HbA(1c)-HbA(1c) at follow-up). CONCLUSIONS: Clinical outcomes in the <6.9 group were superior to those in the ≥6.9 group as pre-PCI glycemic control affected the baseline characteristics. The results suggested that glycemic control started at PCI was not associated with an improvement in the clinical outcome at follow-up.

Angiographic late lumen loss at the site of overlap of multiple Cypher™ sirolimus-eluting stents: ALSOCE study.

OBJECTIVES: It has been reported that the overlap of sirolimus-eluting stents (SESs) is associated with greater in-stent late lumen loss and more angiographic restenosis. The purpose of this study was to evaluate whether the site of such overlap shows increased or decreased late lumen loss as assessed by quantitative coronary angiogram. METHODS AND RESULTS: We compared 7-month angiographic late lumen loss at the site of overlap in patients with multiple overlapping stents (overlap SES group, n=48) to that in patients with single stents (single SES group, n=144). With regard to baseline angiographic characteristics and procedural results, there were significant differences between the overlap SES group and the single SES group in lesion complexity, lesion length and reference diameter, minimal lumen diameter, and mean stent length. In-stent late lumen loss at the 7-month follow-up did not differ significantly between the two groups (overlap SES 0.25 ± 0.61 mm vs. single SES 0.10 ± 0.55 mm, p=0.11). Furthermore, the site of overlap in the overlap SES group did not show greater late lumen loss compared to the stented area in the single SES group (0.17 ± 0.55 mm vs. 0.10 ± 0.55 mm, p=0.43). The overlap SES group tended to be associated with an increase in binary restenosis compared with the single SES group (22.8% vs. 12.8%, p=0.08), while this value was 4.2% at the site of overlap. There were no significant differences in death, myocardial infarction, target lesion revascularization, or stent thrombosis between the two groups. In addition, stent length was the most independent factor of late lumen loss in the overlap SES group by multivariate logistic analysis, whereas it was not an independent factor of late lumen loss of the SES overlap segment. CONCLUSIONS: The site of overlap of overlapping SES dose not associate with greater late lumen loss or a higher in-stent binary restenosis rate compared to single SES implantation. The overlapping of SES by itself did not increase in-stent late lumen loss.

Impact of angulated lesions on angiographic late loss in patients with drug-eluting stent implantation.

Angulated lesion was classified in moderate risk lesion subset in PTCA guidelines 2000, because angulated lesion has been associated with abrupt closure or myocardial injury. We compared angiographic late loss at 6-9 months in bending lesions to that in non-bending lesion. This study included 227 lesions (de nowo) who were implanted Cypher Sirolimus-eluting stent (SES). There were 52 bending lesions (22.9%) and 175 non-bending lesions (77.1%). There were no significant differences in age and complicated disease between the two groups except the higher prevalence of prior cerebral infarction in the bending lesion group. There were more eccentric lesions in the bending group than in the non-bending group (43.7% vs. 63.5%, p=0.01). Follow-up MLD (in stent) was not significantly different between the two groups (p=NS) and the angiographic restenosis rate was 23.6% in bending lesions and 17.8% in non-bending lesions (p=NS). In-stent and in-segment late loss were similar between the two groups (0.09+/-0.58 vs. 0.18+/-0.64, p=NS, 0.06+/-0.50 vs. 0.09+/-0.65, p=NS). No stent fracture was observed by angiography and IVUS in this study. Follow-up MLD (in stent) was not significantly different between the two groups (p=NS) and the angiographic restenosis rate was 23.6% in bending lesions and 17.8% in non-bending lesions (p=NS). Lesion bending is not associated with long-term angiographic late loss after DES implantation. DES may reduce clinical events in patients with bending lesion.

Left ventricular oozing rupture following acute myocardial infarction.

We describe the case of an 85-year-old woman in whom pericardiocentesis, prolonged bed rest and blood pressure control were performed without surgery to successfully treat an oozing-type myocardial rupture due to myocardial infarction.

Results of provisional stenting with a Sirolimus-eluting stent for bifurcation lesion: multicenter study in Japan.

BACKGROUND: Treatment of bifurcation lesion with a drug-eluting stent (DES) remains problematic. The purpose of this study was to investigate an appropriate treatment strategy for bifurcation lesion with a Sirolimus-eluting stent (SES). METHOD: One-hundred-forty-one patients with 169 bifurcation lesions were treated at three centers in Japan using a Sirolimus-eluting stent. Forty-six lesions (39 patients) were treated on side branches, and provisional stenting was performed in these cases. We evaluated the angiographic results and clinical outcomes with this strategy. Patients with acute myocardial infarction were excluded. RESULT: After a follow-up period of 184 +/- 65 days, there were no deaths or myocardial infarction (MI), and only one (2.0%) target lesion revascularization (TLR). The strategies used for side-branch treatment were balloon only (83.7%) and T or Modified T stent (16.3%). The final kissing balloon technique was performed on 53.4% overall. In patients with a 6-month follow-up angiogram who had 25 bifurcation lesions (including 5 LMT bifurcation Lesions, 6 LCX-OM Lesions, 13 LAD-Dx lesions, and 1 RCA lesion) that were treated with balloon only, the percent diameter stenosis (%DS) of the side branch at follow-up was similar to that after the procedure (47.2 +/- 34.4% vs. 46.4 +/- 24.1%). CONCLUSIONS: In the treatment of bifurcation lesions using a SES, the results of provisional stenting for the side branch are acceptable. Percent DS of the side branch remained unchanged over time after PCI.

Reduction of charge-modified LDL by statin therapy in patients with CHD or CHD risk factors and elevated LDL-C levels: the SPECIAL Study.

Various forms of atherogenic modified low-density lipoprotein (LDL) including oxidized LDL and small, dense LDL have increased negative charge as compared to normal LDL. Charge-modified LDL (electronegative LDL) and normal LDL subfractions in plasma are analyzed by capillary isotachophoresis (cITP) as fast-migrating LDL (fLDL) and slow-migrating LDL (sLDL). We examined the effects of pravastatin and simvastatin on charge-based LDL subfractions as determined by cITP in patients with hypercholesterolemia. Patients (n=72) with CHD or CHD risk factors and elevated LDL cholesterol (LDL-C) levels were randomly assigned to receive pravastatin or simvastatin. After treatment with statins for 3 and 6 months, both cITP fLDL and sLDL were reduced (p<0.05) from the baseline, but the effects did not differ between treatment with pravastatin and simvastatin. At baseline and after treatment for 3 months, cITP sLDL was correlated with LDL-C, but fLDL was correlated with inflammatory markers, high-sensitive C-reactive protein and LDL-associated platelet-activating factor acetylhydrolase, and atherogenic lipoproteins, remnant-like particle cholesterol and small, dense LDL cholesterol. In conclusion, cITP fLDL was related to inflammatory markers and atherogenic lipoproteins and was reduced by treatment with statins. Charge-modified LDL subfraction could be a potential marker for atherosclerosis and a target for therapy.

Possible predictors of target lesion revascularization after drug-eluting stent implantation.

BACKGROUND: A small number of patients still need target lesion revascularization (TLR) after drug-eluting stent (DES) implantation. It is important for the management of coronary artery disease to assess the predictors of TLR after DES implantation. METHODS AND RESULTS: Two hundred ninety-seven patients (325 lesions) were treated with Cypher sirolimus-eluting and/or TAXUS paclitaxel-eluting stent implantation at four centers in Japan and Brazil. Among these centers, 20 patients (24 lesions) needed clinically driven TLR. The clinical and angiographic characteristics of TLR patients were compared to those of non-TLR patients. Hemodialysis, prior myocardial infarction (MI) and prior coronary artery bypass grafting (CABG) were more frequent in TLR patients than in non-TLR patients. An ostial stenosis was more frequent in the TLR group than in the non-TLR group (41.7% vs 19.9%, p=0.012). In addition, post-procedure in-stent percentage diameter stenosis (%DS) was higher in TLR patients (21.9% vs 13.3%, p = 0.002). Stepwise logistic regression analysis indicated that all of these variables were independent predictors of TLR after DES implantation. CONCLUSIONS: Hemodialysis, prior MI, prior CABG, ostial lesion location and high in-stent %DS may be independent predictors of TLR after DES implantation.