Impacts of age on coronary atherosclerosis and vascular response to statin therapy

A novel nomogram for predicting the risk of coronary atherosclerosis in patients with gastroesophageal reflux disease

BACKGROUND AND STUDY AIMS

This study developed a novel nomogram to predict the incidence of coronary atherosclerosis (CA) in patients with gastroesophageal reflux disease (GERD) and evaluated its predictive value.

PATIENTS AND METHODS

In total, 13,658 patients with GERD from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database were analyzed. The patients were randomly divided into a training cohort (n = 9,560) and a validation cohort (n = 4,098) at a 7:3 ratio. Least absolute shrinkage and selection operator (LASSO) regression analyses were performed to identify associated risk variables. Then a nomogram was developed to predict the rate of CA in patients with GERD. The model's performance was evaluated using the concordance index, area under the receiver operating characteristic curve, calibration curve, and decision curve analysis.

RESULTS

LASSO regression identified nine potential predictors of CA. Multivariate logistic regression was used to evaluate these predictors and establish the final model. The concordance index was 0.750. The areas under the curve for the training and validation cohorts were 0.7500 and 0.7297, respectively.

CONCLUSION

Age, white blood cell count, hemoglobin, mean corpuscular hemoglobin, mean corpuscular volume, sodium, bicarbonate, creatinine, and chloride were identified as predictors of CA. The developed nomogram provides a reliable and convenient tool for predicting CA in patients with GERD.

Age and Computed Tomography and Invasive Coronary Angiography in Stable Chest Pain: A Prespecified Secondary Analysis of the DISCHARGE Randomized Clinical Trial

Importance

The effectiveness and safety of computed tomography (CT) and invasive coronary angiography (ICA) in different age groups is unknown.

Objective

To determine the association of age with outcomes of CT and ICA in patients with stable chest pain.

Design, Setting, and Participants

The assessor-blinded Diagnostic Imaging Strategies for Patients With Stable Chest Pain and Intermediate Risk of Coronary Artery Disease (DISCHARGE) randomized clinical trial was conducted between October 2015 and April 2019 in 26 European centers. Patients referred for ICA with stable chest pain and an intermediate probability of obstructive coronary artery disease were analyzed in an intention-to-treat analysis. Data were analyzed from July 2022 to January 2023.

Interventions

Patients were randomly assigned to a CT-first strategy or a direct-to-ICA strategy.

Main Outcomes and Measures

MACE (ie, cardiovascular death, nonfatal myocardial infarction, or stroke) and major procedure-related complications. The primary prespecified outcome of this secondary analysis of age was major adverse cardiovascular events (MACE) at a median follow-up of 3.5 years.

Results

Among 3561 patients (mean [SD] age, 60.1 [10.1] years; 2002 female [56.2%]), 2360 (66.3%) were younger than 65 years, 982 (27.6%) were between ages 65 to 75 years, and 219 (6.1%) were older than 75 years. The primary outcome was MACE at a median (IQR) follow-up of 3.5 (2.9-4.2) years for 3523 patients (99%). Modeling age as a continuous variable, age, and randomization group were not associated with MACE (hazard ratio, 1.02; 95% CI, 0.98-1.07; P for interaction = .31). Age and randomization group were associated with major procedure-related complications (odds ratio, 1.15; 95% CI, 1.05-1.27; P for interaction = .005), which were lower in younger patients.

Conclusions and Relevance

Age did not modify the effect of randomization group on the primary outcome of MACE but did modify the effect on major procedure-related complications. Results suggest that CT was associated with a lower risk of major procedure-related complications in younger patients.

Trial Registration

ClinicalTrials.gov Identifier: NCT02400229.

Surgical and demographic predictors of free flap salvage after takeback: A systematic review

BACKGROUND

Microsurgical free tissue transfer (FTT) is a widely employed surgical modality utilized for reconstruction of a broad range of defects, including head and neck, extremity, and breast. Flap survival is reported to be 90%-95%. When FTT fails, salvage procedures aim at establishing reperfusion while limiting ischemia time-with salvage rates between 22% and 67%. There are limited data-driven predictors of successful salvage present in the literature. This systematic review aims to identify predictors of flap salvage.

METHODS

A systematic literature review was conducted per PRISMA guidelines. Articles included in the final analysis were limited to those investigating FTT salvage procedures and included factors impacting outcomes. Cohort and case series (>5 flaps) studies up until March 2021 were included. Chi-square tests and linear regression modeling was completed for analysis.

RESULTS

The patient-specific factors significantly associated with salvage included the absence of hypercoagulability (p < .00001) and no previous salvage attempts (p < .00001). Case-specific factors significantly associated with salvage included trunk/breast flaps (p < .00001), fasciocutaneous/osteocutaneous flaps (p = .006), venous compromise (p < .00001), and shorter time from index procedure to salvage attempt (R = .746). Radiation in the head and neck population was significantly associated with flap salvage failure.

CONCLUSIONS

Given the complexity and challenges surrounding free flap salvage procedures, the goal of this manuscript was to present data helping guide surgical decision-making. Based on our findings, patients without documented hypercoagulability, no previous salvage attempts, fasciocutaneous/osteocutaneous flaps, trunk/breast flaps, and a shorter time interval post-index operation are the best candidates for a salvage attempt.

Relationship between Different Degrees of Compression and Clinical Symptoms in Patients with Myocardial Bridge and the Risk Factors of Proximal Atherosclerosis

OBJECTIVE

To explore the relationship between different degrees of compression and clinical symptoms in patients with the myocardial bridge and the risk factors of proximal atherosclerosis.

METHODS

The clinical data of 156 patients with the myocardial bridge who underwent selective coronary angiography in our hospital from December 2010 to December 2015 were collected. The patients were divided into Noble grade I group (102 cases) and Noble grades II-III group (54 cases) according to the degree of mural coronary artery systolic stenosis. According to the results of coronary angiography, 156 patients with the myocardial bridge were divided into an atherosclerosis group (the myocardial bridge combined with atherosclerosis at the proximal end of the myocardial bridge of simple wall coronary artery), 91 cases, and a control group (isolated myocardial bridge), 65 cases. The relationship between different degrees of compression and clinical symptoms in patients with the myocardial bridge was observed, and the logistic regression model was used to analyze the risk factors of proximal atherosclerosis in patients with the myocardial bridge.

RESULTS

The incidence of atherosclerotic stenosis, angina pectoris, and myocardial infarction in the proximal part of the myocardial bridge in the Noble grades II-III group was higher than that in the Noble grade I group (P < 0.05). The differences in age, hypertension, and Noble classification between the two groups were statistically significant (P < 0.05). The differences of total cholesterol (TC) and C-reactive protein (CRP) between the two groups were statistically significant (P < 0.05). Multivariate analysis showed that age, hypertension, Noble grade, and CRP were all risk factors for proximal atherosclerosis in patients with the myocardial bridge (P < 0.05).

CONCLUSION

The more severe the compression of the myocardial bridge, the greater the risk of cardiovascular events for patients and the higher the incidence of atherosclerotic stenosis in the proximal part of the myocardial bridge. In addition, the occurrence of atherosclerosis in the proximal coronary artery of the myocardial bridge may be affected by age, hypertension, Noble grade, and CRP level.

Optical Coherence Tomography Predictors for a Favorable Vascular Response to Statin Therapy

Background

Specific plaque phenotypes that predict a favorable response to statin therapy have not been systematically studied. This study aimed to identify optical coherence tomography predictors for a favorable vascular response to statin therapy.

Methods and Results

Patients who had serial optical coherence tomography imaging at baseline and at 6 months were included. Thin‐cap area (defined as an area with fibrous cap thickness <200 μm) was measured using a 3‐dimensional computer‐aided algorithm, and changes in the thin‐cap area at 6 months were calculated. A favorable vascular response was defined as the highest tertile in the degree of reduction of the thin‐cap area. Macrophage index was defined as the product of the average macrophage arc and length of the lesion with macrophage infiltration. Layered plaque was defined as a plaque with 1 or more layers of different optical density. In 84 patients, 140 nonculprit lipid plaques were identified. In multivariable analysis, baseline thin‐cap area (odds ratio [OR] 1.442; 95% CI, 1.024–2.031, P=0.036), macrophage index (OR, 1.031; 95% CI, 1.002–1.061, P=0.036), and layered plaque (OR, 2.767; 95% CI, 1.024–7.479, P=0.045) were identified as the significant predictors for a favorable vascular response. Favorable vascular response was associated with a decrease in the macrophage index.

Conclusions

Three optical coherence tomography predictors for a favorable vascular response to statin therapy have been identified: large thin‐cap area, high macrophage index, and layered plaque. Favorable vascular response to statin was correlated with signs of decreased inflammation.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT01110538.

Coronary plaque tissue characterization in patients with premature coronary artery disease

Premature coronary artery disease (CAD) studies rarely involve coronary plaque characterization. We characterize coronary plaque tissue by radiofrequency intravascular ultrasound (IVUS) in patients with premature CAD. From July 2015 to December 2017, 220 patients from the Department of Cardiology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine with first occurrence of angina or myocardial infarction within 3 months were enrolled. Patients with premature CAD (n = 47, males aged < 55 years, and females aged < 65 years) or later CAD (n = 155) were retrospectively compared for cardiovascular risk factors, laboratory examination findings, coronary angiography data, gray-scale IVUS, and iMap-IVUS. The mean age was 53.53 ± 7.24 vs. 70.48 ± 8.74 years (p < 0.001). The groups were similar for traditional coronary risk factors except homocysteine (18.60 ± 5.15 vs. 17.08 ± 4.27 µmol/L, p = 0.043). After matching for baseline characteristics, LDL cholesterol (LDL-C) was higher for premature CAD than later CAD (2.50 ± 0.96 vs. 2.17 ± 0.80 mmol/L, p = 0.019). Before the matching procedure, the premature CAD group had shorter target lesion length [18.50 (12.60–32.00) vs. 27.90 (18.70–37.40) mm, p = 0.002], less plaque volume [175.59 (96.60–240.50) vs. 214.73 (139.74–330.00) mm³, p = 0.013] than the later CAD group. After the matching procedure, the premature CAD group appeared to be less plaque burden (72.69 ± 9.99 vs. 74.85 ± 9.80%, p = 0.005), and positive remodeling (1.03 ± 0.12 vs. 0.94 ± 0.18, p = 0.034), and lower high risk feature incidence (p = 0.006) than the later CAD group. At the plaque’s minimum lumen, premature CAD had more fibrotic (p < 0.001), less necrotic (p = 0.001) and less calcified areas (p = 0.012). Coronary plaque tissue was more fibrotic with less necrotic and calcified components in premature than in later CAD, and the range and degree of atherosclerosis were significantly lower.

Legacy effects of statins on cardiovascular and all-cause mortality: a meta-analysis

OBJECTIVES

To assess evidence for 'legacy' (post-trial) effects on cardiovascular disease (CVD) mortality and all-cause mortality among adult participants of placebo-controlled randomised controlled trials (RCTs) of statins.

DESIGN

Meta-analysis of aggregate data.

SETTING/PARTICIPANTS

Placebo-controlled statin RCTS for primary and secondary CVD prevention.

METHODS

Data sources: PubMed, Embase from inception and forward citations of Cholesterol Treatment Trialists' Collaborators RCTs to 16 June 2016.

STUDY SELECTION

Two independent reviewers identified all statin RCT follow-up reports including ≥1000 participants, and cardiovascular and all-cause mortality.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

MAIN OUTCOMES

Post-trial CVD and all-cause mortality.

RESULTS

We included eight trials, with mean post-trial follow-up ranging from 1.6 to 15.1 years, and including 13 781 post-trial deaths (6685 CVD). Direct effects of statins within trials were greater than legacy effects post-trials. The pooled data from all eight studies showed no evidence overall of legacy effects on CVD mortality, but some evidence of legacy effects on all-cause mortality (p=0.01). Exploratory subgroup analysis found possible differences in legacy effect for primary prevention trials compared with secondary prevention trials for both CVD mortality (p=0.15) and all-cause mortality (p=0.02). Pooled post-trial HR for the three primary prevention studies demonstrated possible post-trial legacy effects on CVD mortality (HR=0.87; 95% CI 0.79 to 0.95) and on all-cause mortality (HR=0.90; 95% CI 0.85 to 0.96).

CONCLUSIONS

Possible post-trial statin legacy effects on all-cause mortality appear to be driven by the primary prevention studies. Although these relative benefits were smaller than those observed within the trial, the absolute benefits may be similar for the two time periods. Analysis of individual patient data from follow-up studies after placebo-controlled statin RCTs in lower-risk populations may provide more definitive evidence on whether early treatment of subclinical atherosclerosis is likely to be beneficial.

Is age an important factor for vascular response to statin therapy? A serial optical coherence tomography and intravascular ultrasound study

OBJECTIVE

Age-related structural and functional changes in vessel wall may affect the time course of vascular response to statin therapy. In this study, we sought to compare the response of lipid-rich plaque to statin therapy in elderly versus younger patients using optical coherence tomography and intravascular ultrasound.

PATIENTS AND METHODS

Sixty-nine patients who underwent serial optical coherence tomography and intravascular ultrasound at the time point of baseline, 6, and 12 months were divided into two groups according to median age: group A (age<57 years, n=35) and group B (age≥57 years, n=34). Patients were treated with intensive (atorvastatin 60 mg/day) or moderate (atorvastatin 20 mg/day or rosuvastatin 10 mg/day) statin therapy.

RESULTS

A continuous increase in fibrous-cap thickness (FCT) from baseline to 12 months was observed in both groups (P<0.001, <0.001, respectively). Intensive statin induced greater percent change in FCT at 12 months than moderate statin in group B (P=0.020), but not in group A (P=0.251). Mean lipid arc decreased significantly at 12 months in two groups (P<0.001, <0.001, respectively), and this response was delayed for 6 months (P=0.403) and began to decrease during the second 6 months (P<0.001) in group B. Normalized total atheroma volume decreased significantly in group A (P<0.001), but not in group B (P=0.349).

CONCLUSION

Statin therapy could stabilize lipid-rich plaque irrespective of age, and intensive statin therapy was more effective than a moderate dose of statin in increasing FCT, particularly in older patients. A delayed response of lipid content and unfavorable change in normalized total atheroma volume to statin were observed in elderly patients.

Spiromastixones Inhibit Foam Cell Formation via Regulation of Cholesterol Efflux and Uptake in RAW264.7 Macrophages

Bioassay-guided evaluation shows that a deep sea-derived fungus, Spiromastix sp. MCCC 3A00308, possesses lipid-lowering activity. Chromatographic separation of a culture broth resulted in the isolation of 15 known depsidone-based analogues, labeled spiromastixones A–O (1–15). Each of these compounds was tested for its ability to inhibit oxidized low-density lipoprotein (oxLDL)-induced foam cell formation in RAW264.7 macrophages. Spiromastixones 6–8 and 12–14 significantly decreased oxLDL-induced lipid over-accumulation, reduced cell surface area, and reduced intracellular cholesterol concentration. Of these compounds, spiromastixones 6 and 14 exerted the strongest inhibitory effects. Spiromastixones 6 and 14 dramatically inhibited cholesterol uptake and stimulated cholesterol efflux to apolipoprotein A1 (ApoA1) and high-density lipoprotein (HDL) in RAW264.7 macrophages. Mechanistic investigation indicated that spiromastixones 6, 7, 12 and 14 significantly up-regulated the mRNA levels of ATP-binding cassette sub-family A1 (ABCA1) and down-regulated those of scavenger receptor CD36, while the transcription of ATP-binding cassette sub-family A1 (ABCG1) and proliferator-activated receptor gamma (PPARγ) were selectively up-regulated by 6 and 14. A transactivation reporter assay revealed that spiromastixones 6 and 14 remarkably enhanced the transcriptional activity of PPARγ. These results suggest that spiromastixones inhibit foam cell formation through upregulation of PPARγ and ABCA1/G1 and downregulation of CD36, indicating that spiromastixones 6 and 14 are promising lead compounds for further development as anti-atherogenic agents.

The Effect of Statin Therapy on Coronary Plaque Composition Using Virtual Histology Intravascular Ultrasound: A Meta-Analysis

OBJECTIVE

Previous studies have indicated that statin therapy may promote plaque regression. However, the impact of statin therapy on plaque composition has not been clearly elucidated. We performed a meta-analysis to investigate the effect of statin therapy on coronary plaque composition as assessed by virtual histology intravascular ultrasound (VH-IVUS).

METHODS

Online databases were searched from inception to March 1, 2015. Studies providing VH-IVUS volumetric analyses of coronary plaque composition at baseline and follow-up in patients receiving statin therapy were included. Weighted mean difference (WMD) using a random-effects model was used.

RESULTS

Ten studies involving 682 patients were included. There was a substantial reduction in fibrous volume between baseline and follow-up (WMD: -2.37 mm3, 95% confidence interval (CI) -4.01 to -0.74 mm3, P=0.004), and a significant increase in dense calcium (DC) volume (WMD: 0.89 mm3, 95% CI 0.70 to 1.08 mm3, P<0.00001). No significant change was seen in fibro-fatty and necrotic core (NC) volumes. In stratified analyses, the fibrous volume was decreased significantly (WMD: -3.39 mm3, 95% CI -6.56 to -0.21 mm3, P=0.04) and the absolute DC volume (WMD: 0.99 mm3, 95% CI 0.23 to 1.76 mm3, P=0.01) was increased in the subgroup with ≥12 months follow-up, whereas no significant change was observed in the subgroup with < 12 months follow-up. Similarly, a substantial decrease in fibrous volume (WMD: -2.01 mm3, 95% CI -3.05 to -0.96 mm3, P< 0.0002) and an increase in DC volume (WMD: 0.90 mm3, 95% CI 0.70 to 1.10 mm3, P< 0.00001) were observed in the subgroup with high-intensive statin therapy, while the change in fibrous and DC volumes approached statistical significance (P=0.05 and P=0.05, respectively) in the subgroup with low-intensive statin therapy.

CONCLUSIONS

Statin treatment, particularly of high-intensity and long-term duration, induced a marked modification in coronary plaque composition including a decrease in fibrous tissue and an increase in DC.

Effects of the Peroxisome Proliferator-Activated Receptor-γ Agonist Pioglitazone on Peripheral Vessel Function and Clinical Parameters in Nondiabetic Patients: A Double-Center, Randomized Controlled Pilot Trial

Objective: Despite the advanced therapy with statins, antithrombotics, and antihypertensive agents, the medical treatment of atherosclerotic disease is less than optimal. Therefore, additional therapeutic antiatherosclerotic options are desirable. This pilot study was performed to assess the potential antiatherogenic effect of the peroxisome proliferator-activated receptor-γ agonist pioglitazone in nondiabetic patients. Methods: A total of 54 nondiabetic patients were observed in a prospective, double-blind, placebo-controlled study. Patients were randomized to pioglitazone or placebo. The following efficacy parameters were determined by serial analyses: artery pulse wave analysis and carotid-femoral pulse wave velocity (PWV), static and dynamic retinal vessel function, and the common carotid intima-media thickness (IMT). The main secondary endpoint was the change in different biochemical markers. Results: After 9 months, no relevant differences could be determined in the two treatment groups in PWV (pioglitazone 14.3 ± 4.4 m/s vs. placebo 14.2 ± 4.2 m/s), retinal arterial diameter (pioglitazone 112.1 ± 23.3 µm vs. placebo 117.9 ± 21.5 µm) or IMT (pioglitazone 0.85 ± 0.30 mm vs. placebo 0.79 ± 0.15 mm). Additionally, there were no differences in the change in biochemical markers like cholesteryl ester transfer protein, low-density lipoprotein cholesterol, high-sensitivity C-reactive protein or white blood cell count. Conclusions: Treatment with a peroxisome proliferator-activated receptor-γ agonist in nondiabetic patients did not improve the function of large and small peripheral vessels (PPP Trial, clinicaltrialsregister.eu: 2006-000186-11).

Effect of exercise-based cardiac rehabilitation on non-culprit mild coronary plaques in the culprit coronary artery of patients with acute coronary syndrome

Approximately, 70 % of acute myocardial infarctions are known to develop from mild atherosclerotic lesions. Therefore, it is important to evaluate mild coronary plaques to prevent acute coronary syndrome (ACS). The aim of the present study was to investigate the effects of exercise-based cardiac rehabilitation (CR) on mild coronary atherosclerosis in non-culprit lesions in patients with ACS. Forty-one men with ACS who underwent emergency percutaneous coronary interventions and completed a 6-month follow-up were divided into CR and non-CR groups. Quantitative coronary angiography (QCA) was performed using the automatic edge detection program. The target lesion was a mild stenotic segment (10-50 % stenosis) at the distal site of the culprit lesion, and the segment to be analyzed was determined at a segment length ranging from 10 to 15 mm. The plaque area was significantly decreased in the CR group after 6 months, but was significantly increased in the non-CR group (P < 0.05). The low-density lipoprotein (LDL) cholesterol, LDL/high-density lipoprotein (HDL) ratio and high-sensitivity C-reactive protein (Hs-CRP) levels were significantly reduced in both groups (P < 0.01). Peak VO2 in the CR group was significantly increased (P < 0.01). Changes in the plaque area correlated with those in Hs-CRP in both groups, while that association with those in HDL-C was observed in only CR group. Stepwise regression analysis revealed the decrease in Hs-CRP as an independent predictor of plaque area regression in the CR group. CR prevented the progression of mild coronary atherosclerosis in patients with ACS.

Comparison of the effects of two low-density lipoprotein cholesterol goals for secondary prevention after acute myocardial infarction in real-world practice: ≥ 50% reduction from baseline versus <70 mg/dL

BACKGROUND

The present study compared the effects of two low-density lipoprotein cholesterol (LDL-C) goals for secondary prevention after acute myocardial infarction (AMI) in real-world practice.

METHODS AND RESULTS

Of 3091 consecutive patients with AMI who had baseline LDL-C levels ≥ 70 mg/dL and underwent successful percutaneous coronary intervention, 1305 eligible patients who received discharge statin prescriptions were analyzed. Patients were categorized into 2 groups according to the values of LDL-C at 1 year in two different manners using percent reduction from baseline (≥ 50% reduction, n=428 versus <50% reduction, n=877) and fixed levels (< 70 mg/dL, n=625 versus ≥ 70 mg/dL, n=680). The primary outcome was defined by the composite of 2-year major cardiac events including cardiac death, non-fatal myocardial infarction, percutaneous coronary intervention, and coronary artery bypass grafting after hospital discharge. At 2 years, major cardiac events occurred in 139 patients (10.7%). Compared with <50% LDL-C reduction from baseline, patients with ≥ 50% LDL-C reduction had a 47% risk reduction in major cardiac events (adjusted hazard ratio, 0.53; 95% confidence interval, 0.36 to 0.79; P=0.002). But, compared with LDL-C levels ≥ 70 mg/dL at 1 year, patients with LDL-C levels < 70 mg/dL at 1 year had a similar risk of major cardiac events (adjusted hazard ratio, 0.96; 95% confidence interval, 0.68 to 1.34; P=0.793).

CONCLUSIONS

Obtaining a ≥ 50% reduction in LDL-C was associated with better clinical outcomes after AMI in real-world practice, whereas achieving a < 70 mg/dL was not.

Starting primary prevention earlier with statins

The 2013 American College of Cardiology/American Heart Association Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults was based on a systematic review of randomized trials with atherosclerotic cardiovascular disease (ASCVD) outcomes and meta-analyses of these trials published through 2011. With evidence of an ASCVD risk reduction benefit greatly outweighing the potential for adverse effects, the guideline recommends statin therapy for primary prevention in those with ≥7.5% 10-year ASCVD risk and consideration of statin therapy in those with 5% to <7.5% 10-year ASCVD risk. Subsequent meta-analyses of the statin trials support these recommendations and have additionally found a reduction in total mortality in lower-risk subjects. Additional evidence from imaging trials and epidemiologic studies suggests that initiation of statin therapy earlier in the course of ASCVD could have the potential to more effectively prevent age-related progression of atherosclerosis. Given the high levels of suboptimal risk factors in adults and the safety and availability of low-cost generic statins, a consideration of all the available evidence strongly supports earlier intervention for the primary prevention of ASCVD. In conclusion, earlier initiation of statin therapy has the potential to have a large long-term impact on the heavy burden of cardiovascular disease in the aging populations.

Effect of novel modified bipolar radiofrequency ablation for preoperative atrial fibrillation combined with off-pump coronary artery bypass grafting surgery

We described a novel modified bipolar radiofrequency (RF) ablation for preoperative atrial fibrillation (AF) combined with off-pump coronary artery bypass grafting (OPCABG) for patients with AF and coronary artery disease (CAD). The aim of this study was to assess the effect of this novel procedure and to determine whether it can eliminate AF for CAD patients. From January 2007 to June 2013, 45 patients (26 male patients) with AF (9 paroxysmal, 17 persistent, and 19 long-standing persistent) and CAD underwent the novel modified bipolar RF ablation combined with OPCABG in our department. After median sternotomy, the modified bipolar RF ablation and OPCABG were performed on beating heart without cardiopulmonary bypass. Pulmonary vein isolation and left atrium ablation were achieved using a bipolar RF champ. Mitral annular lesion and ganglionic plexus were ablated with a bipolar RF pen. The left atrial appendage was excluded using a surgical stapler. 24 h holter monitoring and echocardiography were performed at discharge and 3, 6, 12 months postoperatively as well as every year thereafter. The modified bipolar RF ablation and OPCABG were performed successfully in all patients. Mean AF ablation time was 33.6 ± 4.2 min, and mean OPCABG time was 87.6 ± 13.3 min. Mean postoperative hospital stay was 12.6 ± 5.5 days. The maintenance of sinus rhythm was 95.6 % (43/45) at discharge. There was no early death and permanent pacemaker implantation in perioperation. At a mean follow-up of 29.8 ± 10.2 months, 38 of 45 (84.4 %) patients were in sinus rhythm. Follow-up TTE at 6 months postoperatively showed that left atrial diameter was significantly reduced and left ventricular ejection fraction was significantly increased. The novel modified bipolar RF ablation procedure was safe, feasible and effective. It may be useful in selecting the best ablation approaches for patients with AF and CAD.

Effects of the PPARγ agonist pioglitazone on coronary atherosclerotic plaque composition and plaque progression in non-diabetic patients: a double-center, randomized controlled VH-IVUS pilot-trial

Despite the advanced therapy with statins, antithrombotics and antihypertensive agents, the medical treatment of coronary artery disease is less than optimal. Therefore, additional therapeutic anti-atherosclerotic options are desirable. This VH-IVUS study (intravascular ultrasonography with virtual histology) was performed to assess the potential anti-atherogenic effect of the PPARγ agonist pioglitazone in non-diabetic patients. A total of 86 non-culprit atherosclerotic lesions in 54 patients with acute coronary syndrome were observed in a 9-month prospective, double-blind, and placebo-controlled IVUS study. Patients were randomized to receive either 30 mg pioglitazone (Pio) or placebo (Plac). As primary efficacy parameter, the change of relative plaque content of necrotic core was determined by serial VH-IVUS analyses. Main secondary endpoint was the change of total plaque volume. In contrast to placebo, in the pioglitazone-treated group, the relative plaque content of necrotic core decreased significantly (Pio -1.3 ± 6.9% vs. Plac +2.6 ± 6.5%, p < 0.01). In comparison to the placebo group, the plaques in pioglitazone-treated patients showed significantly greater reduction of the total plaque volume (Pio -16.1 ± 26.4 mm3 vs. Plac -1.8 ± 30.9 mm3, p = 0.02). Treatment with a PPARγ agonist in non-diabetic patients results in a coronary artery plaque stabilization on top of usual medical care.

Remodeling pattern is related to the degree of coronary plaque regression induced by pitavastatin: a sub-analysis of the TOGETHAR trial with intravascular ultrasound and coronary angioscopy

This study aimed to clarify the relationships between arterial remodeling patterns and plaque volume regression or stabilization. The TOGETHAR trial is a prospective open-label trial designed to assess coronary plaque regression and stabilization with multiple plaque imaging modalities following 52 weeks of pitavastatin treatment (2 mg/day). Coronary plaques were observed in 46 patients with both angioscopy and intravascular ultrasound at baseline and after 52 weeks of drug treatment. We divided these patients into three groups according to their remodeling indices (RI). Group P consisted of patients with a baseline RI >1.05, Group M of patients with a baseline RI of 0.95-1.05, and Group N of patients with a baseline RI <0.95 and then evaluated differences in coronary plaque volume changes and yellow grade among the three groups. In the positive remodeling group, whose remodeling index (RI) exceeded 1.05 at baseline, RI and percent atheroma volume (PAV) were significantly reduced (RI 1.14 ± 0.07 to 1.05 ± 0.10, p = 0.010, PAV 47.3 ± 8.3 to 45.3 ± 7.3 mm(3), p = 0.048). There was no relationship between baseline RI and the change in yellow grade of plaque. RI increased without significant change of PAV or a decrease in lumen volume in group N, with RI below 0.95 at baseline. Plaques with positive remodeling were more likely to have plaque volume regression by pitavastatin than those without in patients with coronary artery disease. Moreover, plaques with positive and negative remodeling were changed into those with intermediate remodeling by pitavastatin. Pitavastatin might induce not only plaque regression or stabilization, but also conformational normalization of vessel structure.

Impact of tissue characteristics on luminal narrowing of mild angiographic coronary stenosis: assessment of integrated backscatter intravascular ultrasound

Integrated backscatter intravascular ultrasound (IB-IVUS) is a useful method for analyzing coronary plaque tissue. We evaluated whether tissue composition determined using IB-IVUS is associated with the progression of stenosis in coronary angiography. Sixty-three nontarget coronary lesions in 63 patients with stable angina were evaluated using conventional IVUS and IB-IVUS. IB-IVUS images were analyzed at 1-mm intervals for a length of 10 mm. After calculating the relative areas of the tissue components using the IB-IVUS system, fibrous volume (FV) and lipid volume (LV) were calculated through integration of the slices, after which percentages of per-plaque volume (%FV/PV, %LV/PV) and per-vessel volume (%FV/VV, %LV/VV) were calculated. Progression of coronary stenosis was interpreted from the increase in percent diameter stenosis (%DS) from baseline to the follow-up period (6-9 months) using quantitative coronary angiography. %DS was 24.1 ± 12.8 % at baseline and 23.2 ± 13.7 % at follow-up. Using IB-IVUS, LV was 31.7 ± 10.5 mm(3), and %LV/PV and %LV/VV were 45.6 ± 10.3 % and 20.2 ± 6.0 %, respectively. FV, %FV/PV, and %FV/VV were 35.5 ± 12.1 mm(3), 52.1 ± 9.5 %, and 23.4 ± 7.1 %, respectively. The change in %DS was -0.88 ± 7.25 % and correlated closely with %LV/VV (r = 0.27, P = 0.03) on simple regression. Multivariate regression after adjustment for potentially confounding risk factors showed %LV/VV to be correlated independently with changes in %DS (r = 0.42, P = 0.02). Logistic regression analysis after adjusting for confounding coronary risk factors showed LV (odds ratio 1.08; 95 % confidence interval 1.01-1.16; P = 0.03) and %LV/VV (odds ratio 1.13; 95 % confidence interval 1.01-1.28; P = 0.03) to be independent predictors of the progression of angiographic coronary stenosis. Our findings suggest that angiographic luminal narrowing of the coronary artery is likely associated with tissue characteristics. IB-IVUS may provide information about the natural progression of luminal narrowing in coronary stenosis.