Resources for cardiovascular healthcare associated with 30-day mortality in acute myocardial infarction with cardiogenic shock

Aims

Although primary percutaneous coronary intervention (PCI) and mechanical circulatory support (MCS), such as extracorporeal membrane oxygenation (ECMO) or intra-aortic balloon pumping (IABP), have been widely used for acute myocardial infarction (AMI) patients with cardiogenic shock (AMICS), their in-hospital mortality remains high. This study aimed to investigate the association of cardiovascular healthcare resources with 30-day mortality in AMICS.

Methods and results

This was an observational study using a Japanese nationwide administrative data (JROAD-DPC) of 260 543 AMI patients between April 2012 and March 2018. Of these, 45 836 AMICS patients were divided into three categories based on MCS use: with MCS (ECMO with/without IABP), IABP only, or without MCS. Certified hospital density and number of board-certified cardiologists were used as a metric of cardiovascular healthcare resources. We estimated the association of MCS use, cardiovascular healthcare resources, and 30-day mortality. The 30-day mortality was 71.2% for the MCS, 23.9% for IABP only, and 37.8% for the group without MCS. The propensity score-matched and inverse probability-weighted Cox frailty models showed that primary PCI was associated with a low risk for mortality. Higher hospital density and larger number of cardiologists in the responsible hospitals were associated with a lower risk for mortality.

Conclusion

Although the 30-day mortality remained extremely high in AMICS, indication of primary PCI and improvement in providing cardiovascular healthcare resources associated with the short-term prognosis of AMICS.

Not Baseline Atrial Fibrillation but New-Onset Atrial Fibrillation and the Loss of Left Atrial Function Are Essential for Predicting Poor Outcomes in Non-ischemic Cardiomyopathy

Aims: The clinical impact of the type of atrial fibrillation (AF) has not been completely elucidated in non-ischemic cardiomyopathy (NICM). Although the structure and function of the left atrium (LA) provide prognostic information in patients with heart failure, the relationship of the AF type with LA structure and function in NICM is unclear. Methods: Consecutive patients with NICM who underwent cardiac magnetic resonance were evaluated and followed. Multivariable Cox regression models were used to estimate hazard ratios (HRs) for major adverse cardiovascular events (MACE) related to the AF type, such as paroxysmal AF, chronic AF, and new-onset AF (NOAF). Results: Among 625 patients with NICM (mean age, 64.4 ± 14.2 years; women, 39.7%), 133 had a history of AF at baseline; of these, 60 had paroxysmal AF. Each baseline AF type was associated with higher LA volume and lower LA emptying fraction but not with an increased incidence of MACE (p = 0.245). New-onset AF developed in 5.9% of patients with sinus rhythm over a median follow-up period of 609 days, and maximum LA volume was a strong and independent predictor [p < 0.001, area under the ROC curve (AUC): 0.795]. Maximum LA volume was superior to LA emptying fraction and B-type natriuretic peptide (AUC: 0.683 and 0.680, respectively). The use of β-blocker and the age of the patient were associated with the incidence of NOAF (HR: 0.37, 95% CI: 0.16-0.84 and HR: 1.05, 95% CI: 1.01-1.09, respectively). Kaplan-Meier analysis showed that patients with NOAF had a higher incidence of MACE than those with sinus rhythm or baseline AF (p = 0.002). NOAF and LA emptying fraction were independent predictors of MACE (HR: 2.28, 95% CI: 1.20-3.97 and HR: 0.98, 95% CI: 0.96-0.99, respectively) after adjusting for age, sex, body mass index, and diagnosis. Conclusions: Paroxysmal and chronic AF in patients with NICM were not associated with an increased incidence of MACE despite their association with LA volume and function. NOAF was independently associated with poor prognosis. Higher maximum LA volume predicted the onset and lower LA emptying fraction was independently associated with poor prognosis.

Clinical Significance of Atrial Fibrillation Status in Patients With Percutaneous Coronary Intervention

Background

Patients undergoing percutaneous coronary intervention (PCI) often develop atrial fibrillation (AF). We investigated the clinical effects of AF status on in-hospital mortality and complications in patients with PCI using a recent large-scale nationwide dataset.

Methods

Using a claims-based dataset from 1022 hospitals in Japan for the time period between 2012 and 2016, patients with PCI were identified and classified into 3 groups according to AF status: no AF, prevalent AF before admission, and incident AF after admission. In-hospital mortality, complications, and medical costs were compared in crude and propensity-matched cohorts.

Results

In 659,525 hospitalized patients undergoing PCI, prevalent AF and incident AF were observed in 6.0% and 1.3% patients, respectively; the AF rates increased over 5 years. A greater proportion of older patients and patients with comorbidities had both of these categories of AF; undergoing PCI for acute coronary syndrome was common in incident AF. Both prevalent AF and incident AF were associated with worse crude outcomes and complications during hospitalization. In propensity-matched cohorts, incident AF was associated with a higher in-hospital mortality rate, longer length of stay, higher direct costs, and higher rate of complications, including stroke and acute kidney injury, compared with prevalent AF. These outcomes, except length of in-hospital stay, did not change for either AF status over 5 years.

Conclusions

Prevalent AF and incident AF in patients undergoing PCI were both associated with deteriorating crude outcomes and complications; in particular, incident AF was associated with worse adjusted outcomes and complications. Further efforts are needed to improve patient outcomes in an aging society in which the incidence of AF is increasing.

Twenty-Year Change in Severity and Outcome of Ischemic and Hemorrhagic Strokes

Question

Did the initial neurological severity and functional outcomes of patients with stroke change throughout a 20-year period?

Findings

In this hospital-based, multicenter, prospective registry involving 183 080 patients with acute stroke, initial neurological severity showed a decrease over time in all stroke types. Functional outcome at hospital discharge improved in patients with ischemic stroke but no longer showed improvement after adjustment by reperfusion therapy and others; it did not clearly improve in patients with hemorrhagic stroke.

Meaning

Twenty-year changes in functional outcomes after ischemic and hemorrhagic strokes showed different trends presumably partly owing to differences in the development of acute therapeutic strategies.

Importance

Whether recent changes in demographic characteristics and therapeutic technologies have altered stroke outcomes remains unknown.

Objective

To determine secular changes in initial neurological severity and short-term functional outcomes of patients with acute stroke by sex using a large population.

Design, Setting, and Participants

This nationwide, hospital-based, multicenter, prospective registry cohort study used the Japan Stroke Data Bank and included patients who developed acute stroke from January 2000 through December 2019. Patients with stroke, including ischemic and hemorrhagic strokes, who registered within 7 days after symptom onset were studied. Modified Rankin Scale scores were assessed at hospital discharge for all patients.

Exposure

Time.

Main Outcomes and Measures

Initial severity was assessed by the National Institutes of Health Stroke Scale for ischemic stroke and intracerebral hemorrhage and by the World Federation of Neurological Surgeons grading for subarachnoid hemorrhage. Outcomes were judged as favorable if the modified Rankin Scale score was 0 to 2 and unfavorable if 5 to 6.

Results

Of 183 080 patients, 135 266 (53 800 women [39.8%]; median [IQR] age, 74 [66-82] years) developed ischemic stroke, 36 014 (15 365 women [42.7%]; median [IQR] age, 70 [59-79] years) developed intracerebral hemorrhage, and 11 800 (7924 women [67.2%]; median [IQR] age, 64 [53-75] years) developed subarachnoid hemorrhage. In all 3 stroke types, median ages at onset increased, and the National Institutes of Health Stroke Scale and World Federation of Neurological Surgeons scores decreased throughout the 20-year period on multivariable analysis. In ischemic stroke, the proportion of favorable outcomes showed an increase over time after age adjustment (odds ratio [OR], 1.020; 95% CI, 1.015-1.024 for women vs OR, 1.015; 95% CI, 1.011-1.018 for men) but then stagnated, or even decreased in men, on multivariate adjustment including reperfusion therapy (OR, 0.997; 95% CI, 0.991-1.003 for women vs OR, 0.990; 95% CI, 0.985-0.994 for men). Unfavorable outcomes and in-hospital deaths decreased in both sexes. In intracerebral hemorrhage, favorable outcomes decreased in both sexes, and unfavorable outcomes and deaths decreased only in women. In subarachnoid hemorrhage, the proportion of favorable outcomes was unchanged, and that of unfavorable outcomes and deaths decreased in both sexes.

Conclusions and Relevance

In this study, functional outcomes improved in patients with ischemic stroke during the past 20 years in both sexes presumably partly owing to the development of acute reperfusion therapy. The outcomes of patients with hemorrhagic stroke did not clearly improve in the same period.

The relationships among the pulse rate, use of beta-blockers, and prognosis in patients with ischemic heart disease in a real-world database using a storage system

Background

The use of β-blockers has the effect of improving the prognosis of patients with ischemic heart disease (IHD). One of the underlying mechanisms is a decrease in the cardiac load due to a reduction in the heart rate.

Purpose

To clarify the relationships among the pulse rate, the use of β-blockers, and the prognosis in patients with IHD in a multicenter study using a storage system.

Methods

The Clinical Deep Data Accumulation System (CLIDAS) collects (1) basic patient information, prescriptions, and laboratory data from electronic medical records from the Standardized Structured Medical Information eXchange (SS-MIX2) standard storage, and (2) the results of physiological tests, cardiac catheterization, and cardiac catheter intervention reports from the SS-MIX2 extended storage. 8540 cases who underwent cardiac catheterization from 6 university hospitals and the national cardiovascular center in Japan were registered (male: 77%, average age: 70.2 years). We evaluated these patients' pulse rate at admission and at the discharge of cardiac catheterization in 6,598 patients. We divided the pulse rates at discharge into quartiles (Q1: &lt;60, Q2: 60–66, Q3: 67–75, Q4: ≥76 bpm), and we analyzed the relationship between the pulse rate and the prognosis by dividing the patients into the stable angina group (n=2,631) and the acute coronary syndrome (ACS) group (n=2,394). Regarding the use of β-blockers, we compared the pulse rates of the patients taking carvedilol (n=1,728) and those taking bisoprolol (n=2,761) at admission and discharge. Major adverse cardiovascular events (MACE) were defined as cardiovascular death, non-fatal myocardial infarction, unstable angina, heart failure, stroke, and other hospitalized cardiovascular events.

Results

A total of 600 MACEs occurred during an average observation period of 890 days. The incidence of cardiovascular events was significantly higher in the Q4 patients in the stable angina group (hazard ratio 1.79, 95% confidence interval 1.32–2.41, but there was no significant difference among the four pulse rate subgroups in the ACS group. The bisoprolol-treated patients had lower pulse rates at discharge (67.4±12.2 vs. 68.8±11.8 bpm, p&lt;0.001) and a lower percentage of patients in the Q4 group (21.2 vs. 24.9%, p=0.005) compared to the carvedilol-treated patients. The pulse rate at admission was similar in the bisoprolol- and carvedilol-treated patients (74.3±19.3 vs. 73.2±29.5 bpm, p=0.328).

Conclusion

In a real-world database using a storage system, a pulse rate of ≤75 bpm was associated with a good prognosis in patients with ACS. Compared to carvedilol, bisoprolol was associated with a decreased pulse rate at discharge.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Kowa Company, Ltd.

Clinical Deep Data Accumulation System (CLIDAS) reveals lipid paradox in guideline-defined high risk Japanese patients after PCI

Background

Japanese clinical guidelines recommend a stratification of the risks and LDL-cholesterol (LDL-C) treatment goals for patients with coronary artery disease after percutaneous coronary intervention (PCI), i.e. &lt;100 mg/dL for normal risk patients and &lt;70 mg/dL for high risk patients; however, less is known about the association between baseline LDL-C values and long-term prognosis.

Purpose

To investigate the association between LDL-C goals and baseline LDL-C levels in relation to major adverse cardiovascular events (MACE) among high-risk patients after PCI, using a real-world database.

Methods

We developed the Clinical Deep Data Accumulation System (CLIDAS) that acquires clinical data directly from hospital information system, and implemented the system in 6 university hospitals and the national cardiovascular center in Japan. The CLIDAS database accumulates data regarding patient background, laboratory data, prescriptions, electrocardiogram, echocardiogram, PCI report, and long-term prognosis. We retrospectively analyzed 8540 consecutive patients who underwent PCI during April 2014 and March 2020 in participating hospitals, and classified them into the normal risk group (n=3712, 43%) and the high risk group [n=4828, 57%, with any of acute coronary syndrome (ACS), familial hypercholesterolemia (FH), or diabetes with additional risk factor(s)], for which LDL-C goals are &lt;100 mg/dL and &lt;70 mg/dL, respectively, according to the Japanese Atherosclerosis Society guidelines or the diagnosis and prevention of atherosclerotic cardiovascular diseases. The primary outcome was the time to first occurrence of MACE, a composite of cardiovascular death, stroke, myocardial infarction, and coronary revascularization in associations with baseline LDL-C levels and patient background.

Results

Proportion of male (77% vs. 77%) and age (71±11 vs. 70±11) were similar between 2 groups. The prevalence of ACS at the index PCI (0% vs. 62%), FH (0% vs. 2%), hypertension (61% vs. 86%), diabetes (11% vs. 67%), dyslipidemia (73% vs. 84%), hemodialysis (4% vs. 9%), peripheral artery disease (5% vs. 9%), smoking (16% vs. 30%), and prescription of statins (79% vs. 86%) were significantly higher in the high risk group. Among patients in the high risk group, but not in the normal risk group, baseline LDL-C &lt;70 mg/dL was paradoxically associated with higher risk of MACE (P&lt;0.0001 by Log-rank test) (Figure). The Cox proportional hazard model confirmed that the high risk group (risk ratio 1.54, 95% CI [1.31–1.81]), baseline LDL-C &lt;70mg/dL (risk ratio 1.44, 95% CI [1.18–1.75]), baseline age (risk ratio 1.36, 95% CI [1.28–1.45] per 10 year), and prescription of statins (risk ratio 0.80, 95% CI [0.66–0.96]) were significantly associated with the risk of MACE in this population.

Conclusion

The CLIDAS real-world database revealed that baseline low LDL-C paradoxically associated with an increased risk of MACE among guideline-defined high risk patients after PCI.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Jichi Medical University, Tochigi, Japan, and Kowa

A novel method to demonstrate thrombus formation of the left atrial appendage in patients with persistent atrial fibrillation by cardiac computed tomography

•

We created a new algorism to detect a left atrial appendage (LAA) thrombus on CT.

•

We measured HU density at one proximal (ostium) and seven distal sites of LAA.

•

A distal/proximal ratio and a standard deviation of HU density were analyzed by ROC.

•

Combination of the two parameters demonstrated a high accuracy for LAA thrombus.

Background

Transesophageal echocardiography (TEE) is currently the gold standard technique for diagnosing left atrial appendage (LAA) thrombi. Cardiac computed tomography (CT) has been expected to become an alternative method to TEE; however, a reliable quantitative evaluation method has not been established.

Methods and results

We enrolled 177 patients with persistent atrial fibrillation who underwent both cardiac CT and TEE before catheter ablation. The patients were classified into two groups according to the TEE results: the thrombus group (13 patients) and non-thrombus group (164 patients). The Hounsfield unit (HU) density at the proximal LAA (LAAp) and distal LAA (LAAd) was measured on cardiac CT images. The LAAd/LAAp HU ratio and standard deviation of HU density (HU-SD) at the LAAd were evaluated. We created an algorithm by decision tree analysis to predict LAA thrombus formation using the HU ratio and HU-SD. Definite absence of LAA thrombus (Category-I) was diagnosed for 139 patients by combining the first and second branching of the decision tree (Category-Ia: HU ratio of ≥0.26, Category-Ib: HU ratio of <0.26, HD-SD of ≥26.94). Definite presence of LAA thrombus (Category-Ⅱ) was diagnosed for 3 patients using the third branching of the decision tree (Category-Ⅱ: HU ratio of <0.26 and HU-SD of <13.85). Highly possibility of LAA thrombus (Category-III), but not definite, was diagnosed for the remaining 35 patients; therefore, these patients required diagnostic TEE. The diagnostic accuracy of this algorithm was 0.95.

Conclusion

We have proposed a reliable algorithm to diagnose LAA thrombus formation using the HU ratio and HU-SD.

Association of early administration of furosemide with improved oxygenation in patients with acute heart failure

Aims

Optimal pharmacological treatment for chronic heart failure has been established. However, treatments that can improve the prognosis of acute heart failure (AHF) are controversial. Although intravenous diuretics may be one optimal treatment option, little evidence has shown the effect of early administration of diuretics on clinical outcomes in patients with AHF. The aim of this study was to evaluate the association between door‐to‐furosemide (D2F) time, improved oxygenation, and in‐hospital mortality in patients hospitalized for AHF.

Methods and results

We screened 494 patients hospitalized for AHF in Miyazaki Prefectural Nobeoka Hospital. AHF patients who were treated with intravenous furosemide within 24 h of arrival at the hospital were included in this study. D2F time was defined as the time from patient arrival at the hospital to the first intravenous dose of furosemide. The early administration group was defined as those with D2F time ≤60 min, whereas the non‐early group was defined as those with D2F time >60 min. The primary outcome was the rate of improved oxygenation at Day 1. The secondary outcomes were in‐hospital mortality and cardiac death.

There were 219 patients treated with the first intravenous dose of furosemide within 24 h analysed after the exclusion of 275 patients. The median D2F time was 55 min (interquartile range: 30–120 min) in the final cohort. The early administration group included 121 patients (55.3%). The rate of improved oxygenation was higher in the early group than the non‐early group [median 16.7% (interquartile range: 0.0–40.0) vs. 0.0% (0.0–20.6), respectively, P < 0.001]. During the study period, there were six patients (5.0%) with in‐hospital mortality in the early group and nine patients (9.2%) in the non‐early group (P = 0.218). Cardiac death was observed less frequently in the early group than in the non‐early group, but without statistical significance (3.3% and 9.2%, respectively) (P = 0.067). The univariable logistic regression analyses showed that early administration of furosemide was associated with improved oxygenation [odds ratio (OR): 2.26; 95% confidence interval (CI): 1.31–3.91; P = 0.004], but not with in‐hospital mortality (OR: 0.52; 95% CI: 0.18–1.50; P = 0.225) or cardiac death (OR: 0.34; 95% CI: 0.10–1.13; P = 0.079). In multivariable analyses adjusted for risk score or relevant variables, early administration of furosemide was consistently associated with improvement of oxygenation.

Conclusions

The present study showed that in AHF patients, the early administration of furosemide was associated with improved oxygenation.

Incidence Rate of Acute Coronary Syndrome Including Acute Myocardial Infarction, Unstable Angina, and Sudden Cardiac Death in Nobeoka City for the Super-Aged Society of Japan

BACKGROUND

This study aimed to calculate incidence rates (IR) of acute coronary syndrome (ACS) including acute myocardial infarction (AMI), unstable angina (UAP), and sudden cardiac death (SCD) in Nobeoka city, Japan.Methods and Results:This was an observational study based on a city-wide comprehensive registration between 2015 and 2017 in Nobeoka city, Japan, using 2 databases: all patients with cardiogenic out-of-hospital cardiac arrest in Nobeoka city and hospitalized ACS patients from Miyazaki Prefectural Nobeoka Hospital in which all ACS patients in Nobeoka city were hospitalized except for possible rare cases of patients highly unlikely to be hospitalized elsewhere. The IRs of ACS based on the population size of Nobeoka city (125,000 persons), and their age-adjusted IRs by using the direct method and the 2015 model population of Japan were calculated. There were 260 eligible patients hospitalized with first-onset ACS (age [SD]=71.1 [12.4], 34.2% women) and 107 eligible SCD patients. Crude IRs of hospitalized ACS and SCD patients, and hospitalized AMI and SCD patients, respectively, were 130.2 (183.3 for men, 85.6 for women) and 107.5 (148.4 for men, 73.2 for women) per 100,000. Crude IRs of hospitalized ACS, AMI, and UAP patients, respectively, were 92.3 (132.8 for men, 58.1 for women), 69.6 (97.9 for men, 45.7 for women), and 22.7 (35.0 for men, 12.4 for women) per 100,000.

CONCLUSIONS

The calculated IRs can be useful in building a health strategy for treating ACS.

Validation of Acute Myocardial Infarction and Heart Failure Diagnoses in Hospitalized Patients With the Nationwide Claim-Based JROAD-DPC Database

Background: Big data systems such as diagnosis procedure combination (DPC) datasets have recently been used for research purposes. However, there have been few validation studies to determine the accuracy of diagnoses. The aim of this study was to validate and evaluate 2 diagnoses, namely acute myocardial infarction (AMI) and heart failure (HF), using International Classification of Diseases, 10th revision (ICD-10) codes in the Japanese Registry Of All cardiac and vascular Disease (JROAD)-DPC database.

Methods and Results: ICD-10 codes I21.0–I21.9 and I50.0–I50.9 were used to identify AMI and HF, respectively, in the JROAD-DPC database. Diagnoses of AMI and HF were validated in clinical datasets assessing sensitivity and positive predictive value (PPV). Over 1–2 years, 742 patients hospitalized for AMI and 1,368 patients hospitalized for HF were identified in the DPC dataset. Sensitivity and PPV for AMI were 78.9% and 78.8%, respectively. When emergency hospitalization was included as a criterion, PPV increased to 84.9%. For HF, sensitivity and PPV were 84.7% and 57.0%, respectively. When emergency hospitalization and acute HF were included as criteria, PPV increased to 83.0%.

Conclusions: Using ICD-10 codes for AMI and HF diagnoses among hospitalized patients, the DPC dataset showed acceptable concordance with clinical datasets. PPV increased when any conditions of hospitalization were included, especially in HF.

Sex difference in pulmonary hypertension in the evaluation by exercise echocardiography

Male patients with pulmonary hypertension have poor survival than their female counterparts. Poor right ventricular function in men may be one of the major determinants of poor prognosis. This study aimed to investigate the difference in hemodynamics during exercise between men and women by exercise echocardiography. Consecutive patients with pulmonary hypertension who underwent right heart catheterization were enrolled, and survival was analyzed. In patients who underwent exercise echocardiography, the change in tricuspid regurgitation pressure gradient during exercise was calculated at multiple stages (low-, moderate-, and high-load exercise), and the mortality was also recorded. In a total of 93 patients, although there were no differences in pulmonary artery pressure and vascular resistance between sexes, male patients showed poor survival. In patients with exercise echocardiography, change in tricuspid regurgitation pressure gradient at low-load (25 W) exercise was significantly lower in men, although that at maximum-load exercise was not different between men and women. In the Kaplan-Meier analysis, in a median follow-up duration of 1760 days, male patients and those with lower change in tricuspid regurgitation pressure gradient at low-load exercise showed poorer survival (P = 0.002 and 0.026, respectively). In the Cox proportional hazards analysis, the change in tricuspid regurgitation pressure gradient at low-load exercise was independently associated with poor survival after adjustment for age and sex. In conclusion, a lower change in tricuspid regurgitation pressure gradient at low-load exercise was observed in male patients and was a prognostic marker, which may be associated, at least in part, with poorer prognosis in male patients with pulmonary hypertension.

Long-term effects of non-retrieved inferior vena cava filters on recurrences of venous thromboembolism in cancer and non-cancer patients: From the COMMAND VTE registry

BACKGROUND

There is a paucity of data comparing the long-term outcomes after inferior vena cava (IVC) filters placement for patients with acute venous thromboembolism (VTE) between those with and without active cancer.

METHODS

In the COMMAND VTE Registry, we evaluated the effects of IVC filter use on the long-term clinical outcomes stratified by the presence and absence of active cancer.

RESULTS

Among 2,626 patients with acute symptomatic VTE, there were 604 patients with active cancer, and 2022 patients without active cancer. IVC filters were placed and not retrieved in 455 patients (17%) in the entire cohort, in 150 patients (24.8%) in the active cancer stratum, and in 305 patients (15.1%) in the non-cancer stratum. In the entire cohort, non-retrieved IVC filter placement was not associated with a lower adjusted risk for PE recurrence (HR 0.59, 95% CI 0.30-1.15, P = 0.122), but with an increased adjusted risk for DVT recurrence (HR 2.27, 95% CI 1.43-3.60, P<0.001). In the non-cancer stratum, the non-retrieved IVC filter placement was associated with a decreased risk for PE (HR 0.29, 95% CI 0.09-0.93, P = 0.037), but not with an increased risk for DVT (HR 1.73, 95% CI 0.89-3.38, P = 0.108), while in the active cancer stratum, it was associated with an increased risk for DVT (HR 2.47, 95% CI 1.24-4.91, P = 0.010), but not with a decreased risk for PE (HR 0.82, 95% CI 0.34--1.96, P = 0.650).

CONCLUSIONS

There were some differences in the risk-benefit balance between VTE patients with and without active cancer.

Impact of Neointimal Condition and Platelet Reactivity on Intrastent Thrombus at Long-Term Follow-up After 2nd- and 3rd-Generation Drug-Eluting Stent Implantation - Insights From a Coronary Angioscopy and Pharmacodynamic Study

BACKGROUND

Although the incidence of very late stent failure (VLSF) is reduced with newer generation drug-eluting stent (DES), the mechanism of VLSF has not been fully explored.Methods and Results:This study evaluated both local vascular healing using coronary angioscopy and systemic factors determined by platelet reactivity at long-term follow-up after 2nd- and 3rd-generation DES implantation in patients with acute coronary syndrome. Coronary angioscopy was performed to assess neointimal coverage (NIC), yellow color (YC) grade and presence of thrombus. The obtained findings were compared with 2nd- and 3rd-DES. Platelet aggregation was assessed by light transmittance aggregometry. 100 consecutive patients were prospectively enrolled: 2nd- (n=50) and 3rd-DES (n=50). 3rd-DES patients had significantly higher NIC grade and lower YC grade compared with 2nd-DES. The presence of thrombus was tended to be lower with 3rd-DES than with 2nd-DES (8% vs. 18%, P=0.11). Patients with thrombus had significantly higher maximum platelet aggregation and higher prevalence of high on-treatment platelet reactivity (HPR) than those without thrombus. Multivariable analysis showed stent strut exposure and HPR as independent predictors of thrombus.

CONCLUSIONS

Newer generation DES contribute to better vascular healing depending on the degree of neointimal coverage. In addition to local factors at the stented lesion, systemic factors such as degree of platelet reactivity might also contribute to VLSF.

Retrograde-angioscopy guided wiring technique in chronic total occlusion lead to successful revascularization

Endovascular therapy (EVT) was performed in two cases with chronic total occlusion (CTO) of superficial femoral artery. In these cases, angioscopy was deployed in the backyard of the CTO lesion from popliteal artery retrogradely, then the guidewire was advanced from antegrade. When the wire crossed the distal of the CTO lesion, the wire penetration was clearly visualized by the retrograde-angioscopy. Therefore, wire crossing of CTO into the distal true lumen was certainly confirmed, and EVT was successful. <Learning objective: Angioscopy-guided endovascular therapy for chronic total occlusion was useful not only to evaluate thrombus and plaque in situ visually, but also to successfully perform guidewire crossing.>.

Predictive value of the coronary artery calcium score and advanced plaque characteristics: Post hoc analysis of the PREDICT registry

BACKGROUND

Whether coronary plaque characteristics assessed in coronary computed tomography angiography (CCTA) in association with the coronary artery calcium score (CACS) have predictive value for coronary events is unclear. We aimed to examine the predictive value of the CACS and plaque characteristics for the occurrence of coronary events.

METHODS

Among 2802 patients who were analyzed in the PREDICT registry, 2083 with suspected coronary artery disease (CAD) were studied using post hoc analysis. High-risk plaques were defined as having ≥2 adverse characteristics, such as low computed tomographic attenuation, positive remodeling, spotty calcification, and napkin-ring sign. An adjudicative composite of coronary events (cardiac death, nonfatal acute coronary syndrome, and coronary revascularization ≥3 months after indexed CCTA) were analyzed.

RESULTS

Seventy-three (3.5%) patients had coronary events and 313 (15.0%) had high-risk plaques. Multivariate Cox proportional hazard analysis showed that high-risk plaques remained an independent predictor of coronary events (adjusted hazard ratio [HR] 1.95, 95% confidence interval [CI] 1.13-3.34, P ​= ​0.0154), as well as the log-transformed CACS (adjusted HR 1.24, 95% CI 1.11-1.39, P ​= ​0.0002) and the presence of obstructive stenosis (adjusted HR 5.63, 95% CI 3.22-10.12, P 0.0001). In subgroup analyses, high-risk plaques were independently predictive only in the low CACS class (<100).

CONCLUSION

This study shows that assessment of adverse features by coronary plaque imaging independently predicts coronary events in patients with suspected CAD and a low CACS. Our findings suggest that the clinical value of high-risk plaques to CACS and stenosis assessment appears marginal.

Determinants and prognostic implications of instantaneous wave-free ratio in patients with mild to intermediate coronary stenosis: Comparison with those of fractional flow reserve

The instantaneous wave-free ratio (iFR) is used for assessing the hemodynamic severity of a lesion, as an alternative to the fractional flow reserve (FFR). We evaluated the relationship between iFR and FFR in detail and the clinical significance of iFR in patients with mild to intermediate coronary artery stenosis. We recruited consecutive 323 patients (421 lesions) with lesions exhibiting 30% to 80% diameter stenosis on angiography in whom FFR and iFR were measured. In the total lesions, mean diameter stenosis was 48.6% ± 9.0%, and physiological significance, defined by FFR of 0.80 or less or by iFR of 0.92 or less, was observed in 32.5% or 33.5%, respectively. Mismatch between iFR and FFR was observed in 18.1% of the lesions. Clinical factors did not predict FFR value; however, gender, diabetes mellitus, aortic stenosis, anemia, high-sensitivity CRP value, and renal function predicted iFR value. In multivariate logistic analysis after adjustment for FFR value, gender (p < 0.001), diabetes mellitus (p = 0.005), aortic stenosis (p = 0.016), high-sensitivity CRP (p < 0.001), and renal function (p = 0.003) were all independent predictors of iFR value. In Kaplan-Meier analysis, the baseline iFR predicted the subsequent major cardiovascular events (MACE) (hazard ratio, 2.40; 95% CI, 1.16–4.93; p = 0.018) and the results of the iFR-guided strategy for predicting rates of MACE and myocardial infarction/revascularization were superior to those of the FFR-guided strategy. In conclusion, significant clinical factors predicted iFR value, which affected the prognostic capacity. The iFR-guided strategy may be superior in patients with mild to intermediate stenosis.

P3389Angioscopic differences in quality and quantity of neointima in patients experiencing an acute coronary syndrome treated with bare metal, first-, second-, and third generation drug-eluting stents

Background

Although drug-eluting stents (DES) have substantially reduced the need for early target lesion revascularization (TLR) compared with bare-metal stents (BMS) by inhibiting neointima hyperplasia, early generation DES have been associated with an increased risk of very late stent failure (VLSF) due to stent thrombosis and TLR after 1 year. Although the incidence of VLSF is reduced with newer generation DES, VLSF remains an unresolved problem and its mechanisms are not fully explored.

Purpose

The purpose of this study was to evaluate quality and quantity of neointima and presence of thrombus by using coronary angioscopy at long-term follow-up in patients who experienced an acute coronary syndrome (ACS) treated with BMS and DES on dual antiplatelet therapy.

Methods

Coronary angioscopy was performed at 6 and 10 months after BMS and DES implantation, respectively, in ACS patients. We assessed neointimal coverage (NC) of the stent struts, yellow color grade (YG) of stented segment and the existence of thrombus. Angioscopic NC was defined as follows: grade 0= fully visible struts; grade 1= visible struts through thin neointima; grade 2= no visible struts. We determined maximum (Max-NC) and minimum coverage (Min-NC) grades and the dominant NC grades. YG was classified into 4 grades (0= white; 1= slight yellow; 2= yellow; 3= intensive yellow). The obtained findings were compared with BMS, first-generation (1st-) DES, second-generation (2nd-) DES and third-generation (3rd-) DES.

Results

A total of 212 patients were enrolled: BMS (n=127), 1st DES (n=26, sirolimus-eluting stent), 2nd-DES (n=38, permanent polymer everolimus-eluting stent), and 3rd-DES (n=21, bioresorbable polymer everolimus-eluting stent). Max-NC and Min-NC grade were significantly lower with 1st- and 2nd-DES than with BMS and 3rd-DES (Figure). The same trend was also observed in the dominant NC grades. There was a lower trend of YG in BMS and 3rd-DES than in 1st or 2nd-DES (Figure). The presence of thrombus was significantly lower in 3rd-DES in comparison with BMS, 1st-, and 2nd-DES (3rd-DES 0%, BMS 20.5%, 1st-DES 24%, 2nd-DES 13.5%, P=0.01).

Figure 1

Conclusion

Patients treated with 3rd-DES have higher NC grade, lower incidence of intrastent thrombus, and lower YG than in 1st and 2nd-DES. These findings may explain the lower incidence of VLSF associated with these newer generation stent platforms.

Increased Left Ventricular Trabeculation Is Associated With Increased B-Type Natriuretic Peptide Levels and Impaired Outcomes in Nonischemic Cardiomyopathy

BACKGROUND

The clinical significance of left ventricular (LV) trabeculation remains unknown in cardiomyopathies. B-Type natriuretic peptide (BNP) strongly reflects LV end-diastolic wall stress and is a useful prognostic marker of cardiovascular diseases. The enhanced identification of LV trabeculae (T) with the use of cardiac magnetic resonance and the evaluation of its relationship with BNP may elucidate the biologic significance and clinical impact of trabeculation in patients with nonischemic cardiomyopathy (NICM).

METHODS

The LV volume and mass of 515 patients with NICM and 36 control subjects were analyzed with the use of a steady-state free precession sequence, and individual T mass was planimetred. Major adverse cardiac events (MACE) were assessed.

RESULTS

T mass index correlated with LV end-diastolic volume index (EDVI), LV mass index, and papillary muscle mass index (all P < 0.001). Also, T mass index was positively correlated with BNP level (R = 0.381; P < 0.001) and was an independent determinant of BNP after adjusting for age, sex, body mass index (BMI), etiology, LV ejection fraction, and LV EDVI (P < 0.001). Kaplan-Meier analysis during a median follow-up of 17.3 months showed that higher T mass index and increased BNP level correlated with MACE. On multivariate analysis, T mass index (P = 0.031) and BNP (P < 0.001) remained associated with poor outcomes when combined with age, sex, BMI, and etiology.

CONCLUSIONS

Increased LV trabeculation was associated with LV dysfunction/remodelling and impaired outcomes in NICM of various etiologies. This may support the biologic significance of LV trabeculation and could be attributed to its association with BNP through LV wall stress.

Clinical Significance of Increased Cardiac Troponin T in Patients with Chronic Hemodialysis and Cardiovascular Disease: Comparison to B-Type Natriuretic Peptide and A-Type Natriuretic Peptide Increase

BACKGROUND

An increased cardiac troponin T (cTnT) level identifies a high-risk group in patients with end-stage renal disease; however, the mechanism of cTnT elevation remains unclear in such patients without acute coronary syndrome (ACS). Therefore, we explored the relationship between cTnT levels and the hemodynamic parameters and the prognostic potential of cTnT in stable patients with chronic hemodialysis (HD).

METHODS

We included consecutive 174 patients with HD who were referred for coronary angiography due to stable coronary artery disease (CAD), peripheral artery disease (PAD), or heart failure (HF). Hemodynamic measurement was performed, and plasma cTnT, B-type natriuretic peptide (BNP), and A-type natriuretic peptide (ANP) were measured at the same time. The potential of 3 biomarkers to predict all-cause mortality, cardiac death or hospitalized HF, and vascular event was assessed.

RESULTS

Increased log cTnT levels were correlated with increased log BNP and log ANP levels (r = 0.531, p < 0.001 and r = 0.411, p < 0.001, respectively). Not increased log cTnT, but increased log BNP and log ANP were associated with the presence of CAD and the extent of CAD. In contrast, they were all associated with the New York Heart Association functional classification and the presence of PAD and significantly correlated with left ventricular end-diastolic pressure (LVEDP) in an independent manner. Increased cTnT and BNP levels were associated with the mortality and hospitalized HF. However, increased cTnT was not associated with vascular events, unlike increased BNP.

CONCLUSIONS

In patients with chronic HD without ACS, increased cTnT reflected increased LVEDP and the presence of HF or PAD independently, and it did not reflect the presence of CAD in contrast to increased BNP. cTnT and BNP were significant prognostic predictors; however, increased cTnT was associated with HF-related events, not with arteriosclerotic events.

Cardiac Magnetic Resonance Identified the Fibrotic Lesion Associated with Syncope Attack Due to Complete Atrioventricular Block in a Patient with Hypertrophic Cardiomyopathy and Aortic Stenosis

An 84-year-old man presented with syncope. Prior to admission, ambulatory electrocardiogram had demonstrated non-sustained ventricular tachycardia. Echocardiography showed severe aortic stenosis. He was also diagnosed with hypertrophic cardiomyopathy (HCM) by cardiac magnetic resonance (CMR) showing remarkable inhomogeneous left ventricular hypertrophy and extensive late gadolinium enhancement (LGE) in the lesions at the upper border and right-ventricular side of the basal-mid septal wall. Finally, he showed complete atrioventricular (AV) block followed by a long pause and syncope several times after admission. In this case with several possible causes of syncope, the CMR findings suggested a clue concerning the etiology of his syncope: complete AV block in HCM.

Beam Energy and Centrality Dependence of Direct-Photon Emission from Ultrarelativistic Heavy-Ion Collisions

The PHENIX collaboration presents first measurements of low-momentum (0.4<p_{T}<3  GeV/c) direct-photon yields from Au+Au collisions at sqrt[s_{NN}]=39 and 62.4 GeV. For both beam energies the direct-photon yields are substantially enhanced with respect to expectations from prompt processes, similar to the yields observed in Au+Au collisions at sqrt[s_{NN}]=200. Analyzing the photon yield as a function of the experimental observable dN_{ch}/dη reveals that the low-momentum (>1  GeV/c) direct-photon yield dN_{γ}^{dir}/dη is a smooth function of dN_{ch}/dη and can be well described as proportional to (dN_{ch}/dη)^{α} with α≈1.25. This scaling behavior holds for a wide range of beam energies at the Relativistic Heavy Ion Collider and the Large Hadron Collider, for centrality selected samples, as well as for different A+A collision systems. At a given beam energy, the scaling also holds for high p_{T} (>5  GeV/c), but when results from different collision energies are compared, an additional sqrt[s_{NN}]-dependent multiplicative factor is needed to describe the integrated-direct-photon yield.

Acute effects of intravenous carvedilol versus metoprolol on baroreflex-mediated sympathetic circulatory regulation in rats

AIMS

To compare the effects of metoprolol and carvedilol on baroreflex-mediated sympathetic circulatory regulation.

METHODS

In anesthetized Wistar-Kyoto rats, carotid sinus baroreceptor regions were isolated. Changes in sympathetic nerve activity (SNA), arterial pressure (AP), heart rate (HR), and aortic flow (AoF) in response to a staircase-wise pressure input were examined before (control) and after intravenous injection of low-dose metoprolol (2 mg/kg), high-dose metoprolol (10 mg/kg), or carvedilol (0.67 mg/kg) (n = 6 each). Peripheral vascular resistance (PVR) was calculated from mean AP divided by mean AoF.

RESULTS

Low-dose metoprolol had limited effect on sympathetic AP regulation compared to control [operating-point AP (drug vs. control): 88.7 ± 7.1 vs. 98.3 ± 3.3 mm Hg, not significant] despite a significant bradycardic effect. Although high-dose metoprolol showed central sympathoinhibition, it increased PVR at a given SNA as a peripheral effect. Consequently, high-dose metoprolol decreased the operating-point AP slightly (96.1 ± 2.7 vs. 101.9 ± 2.7 mm Hg, P < 0.01). Carvedilol showed no significant central sympathoinhibition at the dose examined in this study, but significantly reduced PVR at a given SNA, leading to a marked reduction in the operating-point AP (71.9 ± 8.2 vs. 112.6 ± 7.6 mm Hg, P < 0.05).

CONCLUSION

Low-dose metoprolol has limited hypotensive effect despite blockade of sympathetic HR regulation. Although high-dose metoprolol induces central sympathoinhibition, it also induces peripheral vasoconstriction that antagonizes the hypotensive effect. In contrast, carvedilol exhibits hypotensive effect mainly through peripheral vasodilation. Although carvedilol is frequently classified as a β-blocker, its vasodilatory effect via α₁-adrenergic blockade plays an important role in AP reduction or heart failure treatment.

Modulation of Sympathetic Activity and Innervation With Chronic Ivabradine and β-Blocker Therapies: Analysis of Hypertensive Rats With Heart Failure

BACKGROUND

Whether the reduction of heart rate with ivabradine (IVA) could affect sympathetic activation and cardiac innervation in heart failure (HF) remains unknown.

PURPOSE

The present study assessed the chronic effects of IVA and β-blocker on the systemic and local sympathetic nervous systems of hypertensive animals with HF.

METHODS AND RESULTS

The Dahl salt-sensitive rats received chronic IVA, bisoprolol (BIS), or placebo (CTL) therapy. The survival of the animal models with IVA and BIS significantly improved (median; 19.7 in IVA and 19.7 in BIS vs 17.0 weeks in CTL, P < .001). A similar decrease in 24-hour heart rate (mean; 305 in IVA and 329 in BIS vs 388 beats/min in CTL, P < .001) without effect on blood pressure, and an improvement in the left ventricular dysfunction (mean fractional shortening; 56.7% in IVA and 47.8% in BIS vs 39.0% in CTL, P < .001) were observed in the animals with IVA and BIS. However, a negative inotropic effect was only observed in the animals with BIS. Excessive urinary noradrenaline excretion in animals with CTL was only suppressed with the use of IVA (mean; 1.35 μg/d in IVA and 1.95 μg/d in BIS vs 2.27 μg/d in CTL, P = .002). In contrast, atrial noradrenaline and acetylcholine depletion in the animals with CTL improved and the tyrosine hydroxylase expression in the both atria were restored with the use of both IVA and BIS.

CONCLUSIONS

IVA therapy improved the survival of hypertensive animals with HF. Furthermore, it was associated with the amelioration of systemic sympathetic activation and cardiac sympathetic and parasympathetic nerve innervations. Chronic β-blocker therapy with negative inotropic effects had beneficial effects only on cardiac innervations.