Differential Effect of β-Blockers According to Heart Rate in Acute Myocardial Infarction Without Heart Failure or Left Ventricular Systolic Dysfunction: A Cohort Study

OBJECTIVE

To evaluate the effect of β-blockers according to heart rate in patients with acute myocardial infarction (AMI) without heart failure (HF) or left ventricular systolic dysfunction (LVSD).

PATIENTS AND METHODS

We enrolled patients with AMI without HF or LVSD between June 1, 2003, and February 28, 2015, from Seoul National University Hospital Acute Myocardial Infarction Registry. Patients were categorized according to discharge heart rate recorded on electrocardiographs and β-blocker use. Low heart rate was defined as less than 75 beats/min. The primary end point was 5-year all-cause mortality according to discharge heart rate and β-blocker use.

RESULTS

Of 2271 patients, 1696 (74.7%) received β-blockers and 1427 (62.8%) had low heart rates. At 5 years after discharge, 205 patients died. Overall, patients with low heart rates (P<.001) and those with β-blocker treatment had lower mortality (P<.001). After adjustment for covariates, β-blocker use was associated with 48% reduced risk for 5-year mortality in patients with high heart rates (hazard ratio, 0.52; 95% CI, 0.35-0.76), but not in those with low heart rates (P=.97). In an inverse-probability treatment-weighted cohort, β-blocker use was also associated with improved mortality in those with a high heart rate. Findings were similar for 5-year cardiovascular mortality.

CONCLUSION

Among survivors with AMI without HF or LVSD, β-blocker use was associated with reduced 5-year all-cause mortality in patients who have high heart rates, but not in those with low heart rates.

Association of Plasma Marker of Oxidized Lipid with Histologic Plaque Instability in Patients with Peripheral Artery Disease

BACKGROUND

The association between oxidized low-density lipoprotein (OxLDL) and plaque instability in coronary and carotid artery disease is well established. However, the association between OxLDL and the histologic changes of plaque in peripheral artery disease has not been clearly elucidated. This study aims to investigate the association between plasma OxLDL and histologic plaque instability in patients with peripheral artery disease.

METHODS

Prospectively obtained plaques from 48 patients who underwent endovascular atherectomy (n = 20), surgical endarterectomy (n = 9), or bypass surgery (n = 19) for treatment of atherosclerotic femoropopliteal artery disease were evaluated for histologic fibrosis, sclerosis, calcification, necrosis, cholesterol cleft, and foamy macrophages using hematoxylin and eosin, oil red O, and immunohistochemical staining. Unstable plaques were defined as plaques that were positive for foamy macrophages and with lipid content of more than 10% of the total plaque area. Plasma OxLDL levels were measured using an enzyme-linked immunosorbent assay (Mercodia AB, Uppsala, Sweden).

RESULTS

Of the 48 patients, 26 (54%) had unstable plaques. The unstable plaque group was younger, had fewer angiographic total occlusions, less calcification, and more CD68-positive and LOX-1-positive cells than the stable plaque group. Plasma OxLDL levels were significantly higher in the unstable plaque group than in the stable plaque group (57.4 ± 13.9 vs. 47.2 ± 13.6 U/L, P = 0.014). Multivariate analysis revealed that plasma OxLDL level, smoking, angiographic nontotal occlusion, and statin nonuse were independent predictors of unstable plaque.

CONCLUSIONS

Among patients with peripheral artery disease, the histologic instability of femoropopliteal plaque was independently associated with high plasma OxLDL, smoking, nontotal occlusion, and statin nonuse. Further large-scale studies are necessary to evaluate the role of noninvasive OxLDL measurement for predicting plaque instability and future adverse vascular event.

Differential impact of smoking on cardiac or non-cardiac death according to age

Tobacco smoking causes cardiovascular diseases, lung disease, and various cancers. Understanding the population-based characteristics associated with smoking and the cause of death is important to improve survival. This study sought to evaluate the differential impact of smoking on cardiac or non-cardiac death according to age. Data from 514,866 healthy adults who underwent national health screening in South Korea were analyzed. The participants were divided into three groups: never-smoker, ex-smoker or current smoker according to the smoking status. The incidence rates and hazard ratios (HRs) of cardiac or non-cardiac deaths according to smoking status and age groups during the 10-year follow-up were calculated to evaluate the differential risk of smoking. Over the follow-up period, 6,192 and 24,443 cardiac and non-cardiac deaths had occurred, respectively. The estimated incidence rate of cardiac and non-cardiac death gradually increased in older age groups and was higher in current smokers and ex-smokers than that in never-smokers among all age groups. After adjustment of covariates, the HRs for cardiac death of current smokers compared to never-smokers were the highest in individuals in their 40’s (1.82; 95% CI, 1.45–2.28); this gradually decreased to 0.96 (95% CI, 0.67–1.38) in individuals >80 years. In contrast, the HRs for non-cardiac death peaked in individuals in their 50’s, (HR 1.69, 95% CI 1.57–1.82) and was sustained in those >80 years (HR 1.40, 95% CI 1.17–1.69). Ex-smokers did not show elevated risk of cardiac death compared to never-smokers in any age group, whereas they showed significantly higher risk of non-cardiac death in their 60’s and 70’s (HR, 1.29; 95% CI, 1.19–1.39; HR 1.22, 95% CI, 1.12–1.32, respectively). Acute myocardial infarction and lung cancer showed patterns similar to those of cardiac and non-cardiac death, respectively. Smoking was associated with higher relative risk of cardiac death in the middle-aged group and non-cardiac death in the older age group. Ex-smokers in the older age group had elevated risk of non-cardiac death. To prevent early cardiac death and late non-cardiac death, smoking cessation should be emphasized as early as possible.

1272Physical activity and mortality with and without cardiovascular disease

Background/Introduction

Physical activity has been shown to reduce mortality in a dose-response fashion. Current guidelines recommend 500 to 1,000 MET-min per week of regular physical activity. However, evidence is limited regarding the specific dose-response relationship in patients with cardiovascular disease.

Purpose

Our aim was to compare the impact of physical activity on mortality in primary versus secondary cardiovascular prevention.

Methods

We analyzed 441,798 individuals with complete information on physical activity levels between 2009 and 2015 were extracted from a population-based cohort (National Health Insurance Service-National Health Screening cohort). Physical activity measured by self-report questionnaires. A rating of 2.9, 4.0, and 7.0 METs were assigned for light-intensity, moderate-intensity, and vigorous-intensity activities, respectively. Physical activity-related energy expenditure (MET-min/week) was calculated by summing the product of frequency, intensity, and duration. The level of physical activity was classified into 0, 0 to 499, 500 to 999, 1,000 to 1,499, and ≥1,500 MET-min/week. Study participants were stratified by the presence of cardiovascular disease, defined as prior myocardial infarction, ischemic heart disease, prior stroke, and/or chronic heart failure. The main study outcome was all-cause mortality. The median follow-up duration was 5.9 years.

Results

Individuals with cardiovascular disease had lower physical activity levels and a higher risk of mortality than those without cardiovascular disease. There was an inverse relationship between the physical activity level and the mortality risk in both groups. The benefit in the secondary prevention group was shown to be greater than that in the primary prevention group: every 500 MET-min/week increase in physical activity resulted in a 14% and 7% risk reduction in mortality in the secondary and primary prevention groups, respectively (interaction P<0.001). In addition, while individuals without cardiovascular disease benefited the most between 0 and 500 MET-min/week of physical activity, the benefit in those with cardiovascular disease continued above 500 to 1,000 MET-min/week. The adjusted mortality risk of individuals with cardiovascular disease who performed a high level of physical activity (≥1,000 MET-min/week) was shown to be comparable to or lower than that of their counterparts without cardiovascular disease.

Adjusted risk of mortality

Conclusion

Individuals with cardiovascular disease may benefit from physical activity to a greater extent than do healthy subjects without cardiovascular disease. Clinicians should encourage patients with cardiovascular disease to maintain a physically active lifestyle as much as possible.

Prevalence, Awareness, Treatment, and Control of Hypertension in Korea

The purpose of the present study was to describe the temporal trends in prevalence and management status of hypertension in Korea between 1998 and 2015. Data of adults who were aged 30 years or older were extracted from the Korea National Health and Nutrition Examination Survey, a nationwide representative population-based survey. Hypertension was prevalent in 30.5% of Korean adults. The age and sex standardized prevalence showed little change between 1998 and 2015. The elderly population and men showed higher prevalence. The rates of awareness, treatment, and control showed substantial improvements among hypertensive subjects between 1998 and the time period of 2007‒2009 (awareness, from 23.5 to 66.3%; treatment, from 20.4 to 60.3%; and control, from 4.9 to 42.1%), after which the numbers reached a plateau and no significant changes were observed subsequently (67.3%, 63.6%, and 46.2%, respectively, between 2013 and 2015). The management status remained poor especially among the young population and in men. In conclusion, the hypertension prevalence remained stable at approximately 30% in Korea between 1998 and 2015. While awareness, treatment, and control of hypertension improved remarkably, the young population and particularly men showed a suboptimal management status.

Comparison of patency between two different peripheral self-expandable stents, absolute Pro® versus complete SE® in femoropopliteal occlusive disease

BACKGROUND

Self-expandable stents, Absolute Pro® (ABS) and Complete SE® (COM), demonstrated safety and efficacy in previous studies. We aimed to determine which stent is more effective for the endovascular treatment of femoropopliteal artery disease.

METHODS

We enrolled patients who underwent endovascular intervention from 2010 to 2015 in our hospital. The primary endpoint was clinical primary patency, which is a composite of freedom from restenosis or clinically driven target lesion revascularization (TLR).

RESULTS

A total of 197 patients and 210 limbs were analyzed, with 96 limbs of 88 patients assigned to the ABS group and 114 limbs of 109 patients assigned to the COM group. Baseline and lesion characteristics were similar between the two groups. The number of stents per limbs were 1.28±0.55 and 1.29±0.51 in the ABS and COM groups, respectively (P=0.92). The postprocedure ankle-brachial index was significantly improved in both groups compared with the preprocedural one (P<0.01), but there were no differences between the both groups at 6, 12, and 24 months after the index procedure. There were no significant differences in clinical primary patency rate (68.7% in ABS vs. 66.7% in COM, P=0.68) and TLR (9.4% in ABS vs. 14.0% in COM, P=0.41) between the two groups. There was no interaction of the clinical primary patency rate of the two stents and the patients' characteristics or lesion characteristics.

CONCLUSIONS

In this retrospective single-center study, ABS and COM showed no difference in clinical efficacy. Both stents can be effectively used for the endovascular intervention of femoropopliteal artery disease when it is necessary.

Different association between renal dysfunction and clinical outcomes according to the presence of diabetes in patients undergoing endovascular treatment for peripheral artery disease

OBJECTIVE

Although chronic kidney disease (CKD) and diabetes are important prognostic factors in patients with peripheral artery disease, there are limited data regarding the outcomes of endovascular treatment (EVT) according to the severity of CKD, especially in the presence of diabetes. This study sought to compare clinical outcomes of lower limb EVT between patients with and patients without CKD according to the presence of diabetes.

METHODS

Patients were enrolled from the Korean multicenter EVT registry and were divided according to the presence of diabetes, then further stratified by CKD (estimated glomerular filtration rate <60 mL/min/1.73 m²). The primary outcome was major adverse limb events (MALEs; a composite of reintervention for target limb, reintervention for target vessel, and unplanned major amputation) at 2 years.

RESULTS

A total of 3045 patients were eligible for analysis: 1277 nondiabetic patients (944 without CKD, 333 with CKD) and 1768 diabetic patients (951 without CKD, 817 with CKD). CKD was associated with a significantly increased risk of MALEs after EVT in diabetic patients (14.4% vs 9.9%; adjusted hazard ratio, 1.60; 95% confidence interval, 1.28-2.01; P < .001) but not in nondiabetic patients (7.6% vs 9.7%; adjusted hazard ratio, 0.78; 95% confidence interval, 0.53-1.14; P = .203; interaction P = .018). In analysis stratified by the severity of CKD among diabetic patients, end-stage renal disease was significantly associated with an increased risk of MALE.

CONCLUSIONS

CKD was associated with a significantly higher risk of MALEs after EVT in diabetic patients but not in nondiabetic patients. The increased risk of MALEs was mainly driven by patients with end-stage renal disease.

Intravascular imaging analysis of a drug-eluting balloon followed by a bare metal stent compared to a drug-eluting stent for treatment of de novo lesions

BACKGROUND/AIMS

After a study comparing drug-eluting stents (DESs) to sequential treatment with drug-eluting balloons (DEBs) and bare metal stents (BMSs), we retrospectively analysed strut malapposition and neointimal hyperplasia in de novo coronary lesions using optical coherence tomography (OCT) or intravascular ultrasonography (IVUS).

METHODS

We obtained OCT data from 16 patients (eight per group) and IVUS data from 40 patients (20 per group). OCT or IVUS was performed after the index procedure and after 9 months. Parameters including obstruction volume due to neointimal hyperplasia (neointimal hyperplasia volume/stent volume, %), strut malapposition (% of malapposed struts), and intra-individual inhomogeneity of in-stent restenosis were compared.

RESULTS

Although obstruction volume due to neointimal hyperplasia was significantly higher in the DEB-BMS group (14.90 ± 15.36 vs. DES 7.03 ± 11.39, p = 0.025), there was no difference in strut malapposition between the two groups (DEB-BMS 1.99 ± 5.37 vs. DES 0.88 ± 2.22, p = 0.856). The DEB-BMS group showed greater intra-individual inhomogeneity of in-stent restenosis pattern than the DES group.

CONCLUSION

Treatment with DEB followed by BMS failed to improve strut malapposition despite higher in-stent neointimal growth, probably because of the inhomogeneous inhibition of in-stent neointimal hyperplasia by DEB. DEB technology should be improved to obtain even drug delivery to the vessel wall and homogeneous prevention of neointimal growth comparable to contemporary DES.

Long-Term Comparison of Platinum Chromium Everolimus-Eluting Stent vs. Cobalt Chromium Zotarolimus-Eluting Stent - 3-Year Outcomes From the HOST-ASSURE Randomized Clinical Trial

BACKGROUND

There are limited data on the long-term outcome of platinum chromium-based everolimus-eluting stents (PtCr-EES) vs. cobalt chromium-based zotarolimus-eluting stents (CoCr-ZES).Methods and Results:A total of 3,755 patients undergoing percutaneous coronary intervention (PCI) were randomized 2:1 to PtCr-EES or CoCr-ZES, and 96.0% of patients completed the 3-year clinical follow-up. The primary outcome was target lesion failure (TLF), defined as a composite of cardiac death, target vessel-related myocardial infarction (MI), and clinically-driven target lesion revascularization (TLR). At 3 years, TLF occurred in 5.3% and in 5.4% of the PtCr-EES and CoCr-ZES groups, respectively (hazard ratio 0.978; 95% confidence interval 0.730-1.310, P=0.919). There were no significant differences in the individual components of TLF. Routine angiographic follow-up was performed in 38.9% of the total patients. In a landmark analysis of the subgroup that had follow-up angiography, the clinically-driven TLR rate of CoCr-ZES was significantly higher than PtCr-EES group during the angiography follow-up period (P=0.009). Overall definite and probable stent thrombosis rates were very low in both groups (0.5% vs. 0.6%, P=0.677).

CONCLUSIONS

PtCr-EES and CoCr-ZES had similar and excellent long-term outcomes in both efficacy and safety after PCI in an all-comer population.

Comparison of Minimally Invasive Direct Coronary Artery Bypass and Percutaneous Coronary Intervention Using Second-Generation Drug-Eluting Stents for Coronary Artery Disease - Propensity Score-Matched Analysis

BACKGROUND

Some studies comparing minimally invasive direct coronary artery bypass (MIDCAB) and percutaneous coronary intervention (PCI) have reported MIDCAB's superiority, but they did not investigate contemporary PCI with newer generation drug-eluting stents (DES). We compared clinical outcomes after MIDCAB with previously reported outcomes after PCI with second-generation DES.Methods and Results:We retrospectively reviewed the records of patients treated with MIDCAB. Baseline characteristics and clinical outcomes after MIDCAB were compared with those for left anterior descending artery disease treated via PCI. The primary outcomes were major adverse cardiovascular and cerebrovascular events (MACCE), a composite of cardiovascular death, non-fatal myocardial infarction, ischemic stroke, and target vessel revascularization (TVR). A propensity score-matching (PSM) analysis was conducted to adjust for between-group differences in baseline characteristics. We analyzed 77 patients treated with MIDCAB and 2,206 treated with PCI. The MIDCAB group was older and had more severe coronary disease and a higher incidence of left ventricular dysfunction. Over a 3-year follow-up, the PCI group had favorable MACCE outcomes. After PSM, there were no between-group differences in MACCE (MIDCAB, 15.6% vs. PCI, 23.4%; hazard ratio [HR], 0.80; 95% CI: 0.38-1.68, P=0.548) or TVR (MIDCAB, 2.6% vs. PCI, 5.2%; HR, 0.51; 95% CI: 0.10-3.09, P=0.509).

CONCLUSIONS

Clinical outcomes were similar between MIDCAB and PCI using second-generation DES over 3 years of follow-up.

Long-term safety of bioresorbable scaffolds: insights from a network meta-analysis including 91 trials

AIMS

The aim of this study was to investigate the long-term safety and efficacy of biodegradable scaffolds and metallic stents.

METHODS AND RESULTS

We analysed a total of 91 randomised controlled trials with a mean follow-up of 3.7 years in 105,842 patients which compared two or more coronary metallic stents or biodegradable scaffolds and reported the long-term clinical outcomes (≥2 years). Network meta-analysis showed that patients treated with the Absorb bioresorbable vascular scaffold (BVS) had a significantly higher risk of definite or probable scaffold thrombosis (ScT) compared to those treated with metallic DES. The risk of very late ScT was highest with the Absorb BVS among comparators. Pairwise conventional meta-analysis demonstrated that the elevated risk of ScT with Absorb BVS compared to cobalt-chromium everolimus-eluting stents was consistent across the time points of ≤30 days (early), 31 days - 1 year (late) and >1 year (very late) ScT. In addition, target lesion failure rates were significantly higher in the Absorb BVS cohort, driven by both increased risk of target vessel myocardial infarction and ischaemia-driven target lesion revascularisation.

CONCLUSIONS

Absorb BVS implantation was associated with increased risk of long-term and very late ScT compared to current-generation metallic DES. The risk of ScT occurred with a rising trend beyond one year.

Efficacy of IntraCoronary Erythropoietin Delivery BEfore Reperfusion-Gauging Infarct Size in Patients with Acute ST-segment Elevation Myocardial Infarction (ICEBERG)

Previous clinical studies have shown inconsistent results regarding the effect of erythropoietin in ST-segment elevation myocardial infarction (STEMI). This study investigated whether directed intracoronary infusion of darbepoetin-α into ischemic myocardium before reperfusion would reduce infarct size or post-infarct remodeling in STEMI patients.Eighty STEMI patients received one of the following treatments simultaneously with the first balloon inflation: intracoronary darbepoetin-α 300 μg (n = 40) or saline (n = 40), administered via the over-the-wire balloon system. The primary endpoint was infarct size estimated by serial cardiac enzyme levels after procedure. The secondary endpoints were (1) infarct size and proportion of salvaged myocardium measured with cardiac magnetic resonance (CMR) at baseline; (2) post-infarct remodeling (PIR), defined as an increase in left ventricular end-diastolic volume more than 20% at 4 months compared to the baseline on CMR; and (3) composite cardiovascular endpoints assessed at 4 months.The peak CK-MB [median 270.0 (interquartile range 139.8-356.3) versus 231.5 (131.0-408.5) ng/mL, P = 0.55] and troponin-I [128.5 (63.5-227.8) versus 109.0 (43.8-220.0) ng/mL, P = 0.52) ] did not differ between the darbepoetin-α and control group. Fifty-seven patients completed the baseline and 4-month follow-up CMR. There were no differences in infarct size [30.6 (18.1-49.8) versus 31.5 (22.5-47.3) cm³, P = 0.91), proportion of salvaged myocardium [26.7% (15.9-42.6%) versus 35.8% (22.4-48.8%), P = 0.12) or PIR (8.0% versus 6.7%, P = 0.62) between the two groups. Composite cardiovascular outcomes did not differ between the two groups.In conclusion, administration of intracoronary darbepoetin-α before reperfusion did not reduce infarct size or post-infarct remodeling in STEMI patients.

Effect of tailored use of tirofiban in patients with Non-ST-elevation acute coronary syndrome undergoing percutaneous coronary intervention: a randomized controlled trial

Background

We conducted a randomized controlled trial to investigate whether an additional platelet inhibition with tirofiban would reduce the extent of myocardial damage and prevent periprocedural myonecrosis in patients with Non-ST-elevation acute coronary syndrome (NSTE-ACS) with a high residual platelet activity (HPR).

Methods

Patients with an HPR, defined as P₂Y₁₂ reaction unit (PRU) > 230, were randomly assigned to group A (tirofiban treatment, n = 30) or C1 (n = 30) and patients without an HPR to C2 (n = 78). Periprocedural myocardial damage was assessed using the area under the curve (AUC) of serial cardiac enzyme levels from the time of the procedure to post-36 h. Periprocedural myonecrosis incidence was evaluated.

Results

The troponin I AUC was not different between the groups (197.2 [41.5395.7], 37.9 [8.9313.9], 121.3 [43.7481.8] h∙ng/mL; p = 0.088). The results did not change when the baseline levels were adjusted (365.3 [279.5, 451.1], 293.0 [207.1, 379.0], and 298.0 [244.7, 351.3] h∙ng/mL; p = 0.487). The rate of periprocedural myonecrosis was also not different between the groups (53.0% vs. 50.0% vs. 33.3%, p = 0.092). The CK-MB isoenzyme analysis showed similar results. No difference in complications was noted.

Conclusion

Additional tirofiban administration was not beneficial to patients with NSTE-ACS even with an HPR.

Trial registration

Clinical trial no. NCT03114995, registered 11 April, 2017, retrospectively.

Electronic supplementary material

The online version of this article (10.1186/s12872-018-0938-6) contains supplementary material, which is available to authorized users.

Blood Pressure Control and Cardiovascular Outcomes: Real-world Implications of the 2017 ACC/AHA Hypertension Guideline

The 2017 American College of Cardiology/American Heart Association (ACC/AHA) hypertension guideline lowered the threshold defining hypertension and treatment target from 140/90 mmHg to 130/80 mmHg. We compared the 2017 ACC/AHA guideline and the Eighth Joint National Committee (JNC8) report with regard to the current status of hypertension using the Korean National Health and Nutrition Examination Survey. The association between blood pressure (BP) control and long-term major cardiovascular outcomes (MACEs) was analyzed using the Korea National Health Insurance Service cohort. In the cross-sectional study with 15,784 adults, the prevalence of hypertension was expected to be 49.2 ± 0.6% based on the definition suggested by the 2017 ACC/AHA guideline versus 30.4 ± 0.6% based on the JNC8 report. In a longitudinal analysis with 373,800 hypertensive adults for the median follow-up periods of 11.0 years, the adults meeting the target goal BP goal of 2017 ACC/AHA guideline were associated with 21% reduced risk of MACEs compared with adults, not meeting 2017 ACC/AHA BP goal but meeting JNC8 target goal. In conclusion, substantial increase of prevalence of hypertension is expected by the 2017 ACC/AHA guideline. This study also suggests endorsing the aggressive approach would lead to an improvement in cardiovascular care.

Clinical Outcomes of Subintimal vs. Intraluminal Revascularization Approaches for Long Femoropopliteal Occlusions in a Korean Multicenter Retrospective Registry Cohort

BACKGROUND

There are limited data comparing the outcomes of subintimal vs. intraluminal approach in the treatment of long femoropopliteal artery occlusions. The objective of this study was to investigate the efficacy and safety of the subintimal approach for long femoropopliteal artery occlusions.Methods and Results:From a multicenter retrospective registry cohort, we included a total of 461 patients with 487 femoropopliteal artery occlusions classified as Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) II C/D for this analysis. We compared the immediate and mid-term outcomes of subintimal vs. intraluminal approaches. There were 228 patients with 243 limbs in the subintimal group, and 233 patients with 244 limbs in the intraluminal group. Baseline clinical and lesion characteristics were comparable between the 2 groups. The technical success rate was significantly higher in the subintimal group than in the intraluminal group (95.1% vs. 89.8%, P=0.041). The clinical primary patency (67.5% vs. 73.4% at 12 months, 54.0% vs. 61.3% at 24 months; P=0.086) and target lesion revascularization (TLR)-free survival (89.5% vs. 86.3% at 12 months, 77.6% vs. 76.0% at 24 months; P=0.710) did not differ significantly between the subintimal and the intraluminal groups.

CONCLUSIONS

In long femoropopliteal occlusions, the subintimal approach achieved a higher technical success rate and similar mid-term primary patency and TLR-free survival compared with intraluminal approach.

Third-Generation P2Y12 Inhibitors in East Asian Acute Myocardial Infarction Patients: A Nationwide Prospective Multicentre Study

Third-generation P2Y₁₂ inhibitors (prasugrel, ticagrelor) are recommended in acute myocardial infarction (AMI). We aimed to evaluate the efficacy and safety of third-generation P2Y₁₂ inhibitors in East Asian AMI patients. From the Korean AMI Registry, 9,355 patients who received dual antiplatelet agent (aspirin with clopidogrel [AC], 6,444 [70.5%] patients; aspirin with prasugrel [AP], 1,100 [11.8%] patients; or aspirin with ticagrelor [AT], 1,811 [19.4%] patients) were analysed. In-hospital endpoints were all-cause mortality or bleeding events during admission and 1-year endpoints were major adverse cardiac and cerebrovascular events (MACCE) and major bleeding events. Regarding in-hospital events, AP and AT showed similar all-cause mortality rates but higher bleeding event rates compared with AC. This trend was extended to 1-year endpoints; Cox regression analysis showed that third-generation P2Y₁₂ inhibitors had significantly higher bleeding risk (AP vs. AC: hazard ratio [HR], 2.14; 95% confidence interval [CI], 1.53-2.99; p < 0.001; AT vs. AC: HR, 2.26; 95% CI, 1.73-2.95; p < 0.001). A propensity score matched triplet of 572 patients showed similar 1-year MACCE and higher bleeding events with third-generation P2Y₁₂ inhibitors (2.1 vs. 2.6 vs. 2.1%, p = 0.790 for MACCE and 3.1 vs. 8.0 vs. 8.0%, p < 0.001 for bleeding events, in AC, AP and AT groups, respectively). Inverse probability weighted regression analysis and pooled analysis after randomly imputing missing variables showed consistent results. Collectively, prasugrel and ticagrelor showed similar rates of 1-year MACCE, but a higher rate of bleeding events, compared with clopidogrel in Korean AMI patients. Further studies are warranted to adapt Western guidelines on third-generation P2Y₁₂ inhibitors for East Asians.

Effect of β-Blockers Beyond 3 Years After Acute Myocardial Infarction

Background

The optimal duration of β‐blocker therapy in patients with acute myocardial infarction (AMI) is unknown. We aimed to evaluate the late effect of β‐blockers in patients with AMI.

Methods and Results

We enrolled all consecutive patients who presented with AMI at Seoul National University Bundang Hospital, between June 3, 2003 and February 24, 2015. The primary end point was 5‐year all‐cause mortality, depending on the use of β‐blockers at discharge, 1 year after AMI, and 3 years after AMI. Of 2592 patients, the prescription rates of β‐blockers were 72%, 69%, 63%, and 60% at discharge and 1, 3, and 5 years after AMI, respectively. The patients who were receiving β‐blocker therapy had more favorable clinical characteristics, such as younger age (62 versus 65 years; P<0.001). They received reperfusion therapy more often (92% versus 80%; P<0.001) than those without β‐blocker prescription. In the univariate analysis, the patients with β‐blocker prescription had lower 5‐year mortality at all time points. In the Cox model after adjustment for significant covariates, β‐blocker prescription at discharge was associated with a 29% reduced mortality risk (hazard ratio, 0.71; 95% confidence interval, 0.55–0.90; P=0.006); however, β‐blocker prescriptions at 1 and 3 years after AMI were not associated with reduced mortality.

Conclusions

The beneficial effect of β‐blocker therapy after AMI may be limited until 1 year after AMI. Whether late β‐blocker therapy beyond 1 year after AMI offers clinical benefits should be confirmed in further clinical trials.

Multimodality Imaging in Patients with Secondary Hypertension: With a Focus on Appropriate Imaging Approaches Depending on the Etiologies

Although the causes of hypertension are usually unknown, about 10% of the cases occur secondary to specific etiologies, which are often treatable. Common categories of secondary hypertension include renal parenchymal disease, renovascular stenosis, vascular and endocrinologic disorders. For diseases involving the renal parenchyma and adrenal glands, ultrasonography (US), computed tomography (CT) or magnetic resonance (MR) imaging is recommended. For renovascular stenosis and vascular disorders, Doppler US, conventional or noninvasive (CT or MR) angiography is an appropriate modality. Nuclear imaging can be useful in the differential diagnosis of endocrine causes. Radiologists should understand the role of each imaging modality and its typical findings in various causes of secondary hypertension. This article focuses on appropriate imaging approaches in accordance with the categorized etiologies leading to hypertension.

Increased epicardial adipose tissue thickness is a predictor of new-onset diabetes mellitus in patients with coronary artery disease treated with high-intensity statins

Background

Statins are widely used for lipid lowering in patients with coronary artery disease (CAD), but increasing evidence indicates an association between statin use and new-onset of diabetes mellitus (NODM). Epicardial adipose tissue (EAT) refers to the visceral fat surrounding the heart, which is associated with metabolic diseases. We sought to determine the association between EAT thickness and NODM in CAD patients treated with high-intensity statins.

Methods

We conducted a retrospective medical record review of CAD patients treated with high-intensity statins for at least 6 months after percutaneous coronary intervention performed between January 2009 and June 2013 at Seoul National University Bundang Hospital. EAT thickness was measured by echocardiography using standardized methods.

Results

A total of 321 patients were enrolled, who received high-intensity statins for a mean of 952 days; atorvastatin 40 mg in 204 patients (63.6%), atorvastatin 80 mg in 57 patients (17.8%), and rosuvastatin 20 mg in 60 patients (18.7%). During the follow-up period of 3.9 ± 1.7 years, NODM occurred in 40 patients (12.5%). On Cox proportional-hazard regression analysis, EAT thickness at systole [for each 1 mm: hazard ratio (HR) 1.580; 95% confidence interval (CI) 1.346–1.854; P < 0.001] and prediabetes at baseline (HR 4.321; 95% CI 1.998–9.349; P < 0.001) were the only independent predictors of NODM. Using binary cutoff values derived from the receiver operating characteristic curve analysis, EAT thickness at systole larger than 5.0 mm had an HR of 3.402 (95% CI 1.751–6.611, P < 0.001), sensitivity of 52.5%, and specificity of 80.8% for predicting NODM. Also, patients with EAT thickness ≥ 5 mm and prediabetes at baseline had a 12.0-times higher risk of developing NODM compared to the risk noted in patients with EAT thickness < 5 mm and normal glucose tolerance at baseline.

Conclusion

Epicardial adipose tissue thickness at systole is a consistent independent predictor of NODM in patients with CAD treated with high-intensity statins. Such predictors may help physicians plan adequate surveillance for early detection of NODM.

Electronic supplementary material

The online version of this article (10.1186/s12933-017-0650-3) contains supplementary material, which is available to authorized users.