Contemporary use and trends in percutaneous coronary intervention in Japan: an outline of the J-PCI registry

Determinants of In-hospital Death in Non-ST-segment Elevation Myocardial Infarction with Triple-vessel Disease

Objective Triple-vessel disease (TVD) is a well-established prognostic factor for patients with acute myocardial infarction. However, there is a paucity of literature regarding the risk factors for in-hospital death in patients with non-ST-segment elevation myocardial infarction (NSTEMI) and TVD. In this retrospective study, we examined the determinants of in-hospital death in patients with NSTEMI and TVD who underwent percutaneous coronary intervention (PCI) for culprit lesions. Methods The primary objective of this study was to identify the factors associated with in-hospital death using a multivariate analysis. We included 253 patients with NSTEMI and TVD and divided them into a survivor group (n=239) and an in-hospital death group (n=14). Results Systolic blood pressure (SBP) at admission was significantly higher in the survivor group than in the in-hospital death group. The estimated glomerular filtration rate (eGFR) was also higher in the survivor group than in the in-hospital death group. In the multivariate logistic regression analysis, in-hospital death was inversely associated with the SBP at admission [odds ratio (OR) 0.984, 95% confidence interval (CI) 0.970-0.999, p<0.035] and eGFR (OR 0.966, 95% CI 0.939-0.994, p=0.019) and was associated with cardiopulmonary arrest (CPA) before PCI (OR 8.448, 95% CI 1.863-38.309, p=0.006). Conclusion In-hospital death was associated with CPA before PCI and inversely associated with the SBP at admission and eGFR in patients with NSTEMI and TVD who underwent PCI for the culprit lesion. It may be important to recognize these high-risk features in order to improve the clinical outcomes of patients with NSTEMI and TVD.

Comparison of clinical outcomes between direct and indirect transfer in patients with ST-segment elevation myocardial infarction

Primary percutaneous coronary intervention (PCI) is the cornerstone of treatment for ST-segment elevation myocardial infarction (STEMI). Previous studies suggest that direct transport by ambulance to a primary PCI facility is associated with better clinical outcomes in patients with STEMI. However, those studies included seriously ill patients for whom direct transport is the only option. We included 462 patients with STEMI who were supposed to select either direct transport by ambulance or indirect transport via primary care doctor, and compared the clinical outcomes between the direct transfer group (n = 172) and the indirect transfer group (n = 290). The primary endpoint was major adverse cardiovascular events (MACE), which was defined as the composite of all-cause death, non-fatal myocardial infarction, re-admission for heart failure, and target vessel revascularization. The median follow-up duration was 540 days (86-1266 days). Age was significantly higher in the indirect transfer group [72.0 (64-80) years] than in the direct transfer group [69.5 (58.3-77) years] (p = 0.013). Onset to balloon time was significantly shorter in the direct transport group (p < 0.001). The Kaplan-Meier curves revealed that MACE were similarly observed between the two groups (31.4% vs. 27.2%; p = 0.330). After adjusting for potential confounders, indirect transfer was not associated with MACE (adjusted hazard ratio: 0.740, 95% confidence interval: 0.485-1.128, p = 0.161). In conclusion, indirect transfer was not associated with poor clinical outcomes in patients with STEMI who were supposed to select either direct transport or indirect transport.

Cumulative impact of procedural and anatomical factors on in-hospital bleeding complications in endovascular therapy for lower-extremity artery disease: A nationwide registry study in Japan

Background: Although bleeding is a common procedure-related adverse event following endovascular therapy (EVT), limited data exist regarding the procedural and anatomical factors associated with its complications in patients with lower-extremity artery disease (LEAD) undergoing EVT. Methods: Data were extracted from a nationwide Japanese EVT registry of 73,990 patients who underwent EVT for symptomatic LEAD between January 2021 and December 2022. The primary outcome measure was in-hospital bleeding complications, including access site bleeding, nonaccess site bleeding, and hemorrhagic stroke. Results: The mean age of the patients was 75 ± 9 years, and 69% were men. In-hospital bleeding complications were observed in 613 (0.8%) patients. Logistic regression analysis demonstrated significant associations between bleeding complications and the following procedural, anatomical, and pharmacological variables: emergent revascularization (odds ratio [OR]: 1.90, 95% CI: 1.29-2.79), multiple approach sites (OR: 2.46, 95% CI: 2.00-3.01), bilateral arterial calcification (OR: 1.46, 95% CI: 1.19-1.79), chronic occlusion (OR: 1.53, 95% CI: 1.28-1.83), dual antiplatelet therapy (OR: 1.70, 95% CI: 1.27-2.28), and oral anticoagulant (OR: 1.63, 95% CI: 1.31-2.03). The adjusted incidence of in-hospital bleeding was 0.59% (95% CI: 0.51-0.68%) in patients with one of the identified procedural and anatomical risk factors, 0.96% (95% CI: 0.82-1.13%) in patients with two factors, and 2.40% (95% CI: 1.88-3.05%) in patients with three or four factors. Conclusions: Procedural and anatomical factors as well as antithrombotic strategies were significantly associated with an increased risk of in-hospital bleeding in patients with LEAD who underwent EVT.

Routine intracoronary imaging-guided left main coronary intervention

Left main (LM) percutaneous coronary intervention (PCI) with routine intracoronary imaging guidance is recommended; however, its real-world effectiveness remains unclear. A total of 743 consecutive patients undergoing drug-eluting stent implantation for de novo unprotected LM lesions across 19 Japanese National Hospital Organization hospitals where routine imaging guidance was adopted were analyzed. The primary endpoint was 1-year major adverse cardiovascular and cerebrovascular events (MACCE), comprising all-cause death, cerebrovascular disorder, clinical-driven revascularization, and myocardial infarction. In this cohort, acute coronary syndrome was present in 31.2%, with 39.3% classified as Canadian Cardiovascular Society functional angina (CCS) class ≥ III. LM bifurcation lesions were observed in 78.0%, with two-stent implantation in 8.8%. MACCE occurred in 17.5%, with target lesion revascularization and cardiac death rates of 2.0% and 3.4%, respectively. Independent risk factors for MACCE included two-stent implantation (hazard ratio [HR], 2.49), mechanical cardiac support device use (HR, 2.17), CCS class ≥ III (HR, 2.07), 10% increase in left ventricular ejection fraction (HR, 0.72), and radial access (HR, 0.62). Routine imaging-guided LM-PCI is associated with favorable low rate of target lesion revascularization and cardiac death. However, severe left ventricular dysfunction and LM bifurcation treated with two-stent implantation increase risks, requiring more comprehensive management.

Impact of the Geriatric Nutritional Risk Index on In-hospital Thrombosis and Mortality in Patients Hospitalized with COVID-19

Objective To determine whether nutritional status is related to the incidence of thrombosis and mortality in patients with coronavirus disease 2019 (COVID-19). Methods A total of 496 consecutive patients who were admitted and diagnosed with COVID-19 between April 2020 and March 2023 were retrospectively analyzed. The geriatric nutritional risk index (GNRI) on admission was calculated as follows: 14.89×serum albumin (g/dL) +41.7×body mass index/22. Patients were divided into two groups according to the median GNRI values. The endpoint of this study was a composite of in-hospital thrombotic events and mortality. Results The median GNRI value was 99.3. Patients in the low GNRI (≤99.3) group were older (75±21 vs. 51±20 years, p<0.001) and more likely to be female (55.6% vs. 41.1%, p<0.05). In addition, patients with a low GNRI often exhibited hypertension (43.5% vs. 28.2%, p<0.001) and had a history of cardiovascular disease (34.3% vs. 14.5%, p<0.001). Under these conditions, the median D-dimer levels on admission were significantly higher in patients with a low GNRI (0.90 μg/mL; interquartile range (IQR), 0.49-1.64 μg/mL) than those with high GNRI (0.36 μg/mL; IQR, 0.26-0.51 μg/mL, p<0.001). During hospitalization, the composite endpoint was observed in 32 patients. In the logistic regression analysis, a low GNRI was significantly associated with the composite endpoint adjusted using inverse probability of treatment weighting (odds ratio, 3.24; 95% confidence interval: 1.51-6.93, p<0.05). Conclusion Assessment of the GNRI provides useful information for predicting in-hospital thrombosis and mortality in COVID-19 patients.

Association of door-to-balloon time and one-year outcomes in hospital survivors of ST-elevation myocardial infarction

In this study of 19,824 ST-elevated myocardial infarction (STEMI) patients from the J-PCI OUTCOME registry (January 1, 2017, to December 31, 2018), we investigated the association between door-to-balloon time (DTB) and 1-year post-discharge cardiovascular outcomes. Patients with DTB >90 min were older and had higher comorbidities. The incidence of 1-year major adverse cardiovascular events (MACE) showed an incremental increase: 3.7 %, 4.8 %, and 7.7 % for DTB ≤60, DTB 60-90, and DTB >90 groups, respectively. Adjusted hazard ratios (aHR) compared to the DTB 60-90 group were 0.83 (DTB ≤60, p = 0.03) and 1.25 (DTB >90, p = 0.005). Subgroup analysis revealed higher risk for MACE in DTB >90 group for patients aged <70, men, no history of coronary revascularization, and those with cardiac arrest or cardiogenic shock. Conversely, DTB ≤60 group without previous history had a lower MACE risk (aHR 0.80, p = 0.02). This study, the largest of its kind, demonstrates that a DTB below 90 min is associated with lower 1-year MACE risk, supporting current guidelines, and indicating additional benefits for specific patient subgroups, especially those experiencing their first acute coronary event. The findings suggest the importance of early intervention in primary prevention and emphasize the need for prompt detection of vulnerable plaque.

Effectiveness of the repeated 3-time-balloon-inflation method in reducing coronary stent edge dissection

The optimal procedural protocol for coronary stent deployment remains undetermined. Post-dilation with a high-pressure balloon is often performed to optimize the stent expansion. However, high-pressure dilation also carries the potential risk of coronary artery injury. A previous in vitro study reported that multiple-times balloon inflation at the same pressure resulted in better stent expansion compared to one-time balloon inflation. In our facility, we frequently perform the repeated 3-time-balloon-inflation method, wherein the stent delivery balloon was inflated 3 times at nominal pressure to deploy the stent, to improve stent expansion without high-pressure balloon inflation. Although this method seems effective in avoiding excessive high-pressure dilation, its clinical data are insufficient. In this study, we investigated the clinical outcomes of the repeated 3-time-balloon-inflation method. This retrospective study included 370 patients with 467 stented coronary lesions. These subjects were divided into two groups: one with standard balloon inflation and the other with repeated 3-time balloon inflation, and treatment outcomes were compared. The repeated 3-time-balloon-inflation group had 254 lesions, and the standard-balloon-inflation group had 213 lesions. Stent edge dissection occurred in 6 lesions (2.8%) in the standard-balloon-inflation group, whereas did not occur in the repeated 3-time-balloon-inflation group. A statistically significant difference remained even after propensity score matching (p = 0.040). The final minimum stent area and long-term clinical outcomes were not significantly different between the two groups. The repeated 3-time-balloon-inflation method may reduce stent edge dissection while demonstrating comparable minimal stent area and long-term outcomes to the standard-balloon-inflation method.

The Impact of the Coronary Artery Calcium Score on the Clinical Outcomes in Patients with Acute Myocardial Infarction

Background: It is essential to identify the risk factors for poor clinical outcomes in patients with acute myocardial infarction (AMI). The coronary artery calcium score (CACS) is gathering attention as a predictor for future cardiovascular events. This study aimed to (1) measure CACSs in patients with AMI by non-ECG-gated computed tomography (CT), (2) compare clinical outcomes between patients with a high CACS and a low-intermediate CACS and (3) to elucidate the association between high CACS and clinical outcomes. Methods: We defined the high CACS group as the highest quantile of CACS (Q4) and defined the low-intermediate CACS group as the other quantiles of CACS (Q1-Q3). The primary endpoint was major adverse cardiovascular events (MACE), which were defined as the composite of all-cause death, re-admission for heart failure, non-fatal MI and target vessel revascularization. We included 548 patients with AMI who underwent non-ECG-gated CT and divided them into the high CACS group (CACS ≥ 5346.5, n = 137) and the low-intermediate CACS group (CACS ≤ 5329.3, n = 411). Results: During the median follow-up duration of 535 days, 150 MACE were observed. The Kaplan-Meier curves showed that MACE occurred more frequently in the high CACS group than in the low-intermediate CACS group (p < 0.001). Multivariable Cox hazard analysis revealed that a high CACS was significantly associated with MACE (hazard ratio 1.597, 95% confidence interval 1.081-2.358, p = 0.019) after controlling for multiple confounding factors. Conclusions: Clinical outcomes were worse in AMI patients with a high CACS than in those with a low-intermediate CACS. A high CACS was significantly associated with MACE in multivariate analysis.

Effects of Transradial Access on In-Hospital Outcomes in Percutaneous Coronary Intervention for Coronary Artery Bypass Graft: Insights from the Japanese Nationwide Database

Because of its superior safety profile and improved outcomes, trans-radial percutaneous coronary intervention (TRI) has become the preferred access in percutaneous coronary intervention (PCI) of native coronary disease. This study investigated the impact of TRI on in-hospital outcomes after PCI for coronary artery bypass graft vessels (GV-PCI). We analyzed patients who underwent GV-PCI in 2019-2022 from the Japanese nationwide registry. Patients were categorized into the TRI and trans-femoral PCI (TFI) groups. We assessed the association between TRI and in-hospital outcomes. The primary outcome was a composite of in-hospital death and major bleeding. In this study, 2,295 patients were analyzed.. The primary outcomes occurred in 29 patients (1.3%), including 17 deaths (0.7%). Major bleeding occurred in 12 patients (0.5%), and access site bleeding in 7 patients (0.3%). The TRI group (n = 1,521) showed lower crude rates of the primary outcome (0.9% vs 1.9%, p = 0.039), major bleeding (0.3% vs 1.0%, p = 0.027), and access site bleeding (0.1% vs 0.6%, p = 0.047) compared with the TFI group (n = 774). Univariable logistic regression demonstrated a significant association of TRI with reduced primary outcome (odd ratio [OR] 0.47, 95% confidence interval [CI] 0.22 to 0.98), major bleeding (OR 0.25, 95% CI 0.07 to 0.80), and access site bleeding (OR 0.20, 95% CI 0.03 to 0.94). In the multivariable analysis, TRI was still significantly associated with a decrease in major bleeding events (OR 0.29, 95% CI 0.07 to 0.93). In conclusion, the use of TRI was associated with a reduction in bleeding events when referenced to TFI in the context of GV-PCI.

Gender Disparities in Japanese Interventional Cardiology: Outcomes of Female Operators in Percutaneous Coronary Interventions

Background

Gender disparity remains a significant global concern in interventional cardiology, and there is a lack of extensive research examining the outcomes of percutaneous coronary interventions (PCIs) performed by female interventionalists.

Objectives

The aim of this study was to examine the practice patterns and outcomes of PCIs conducted by female interventionalists in Japan.

Methods

This retrospective observational study analyzed data from the Japanese Percutaneous Coronary Intervention registry between January 2019 and December 2021. The primary endpoint was in-hospital mortality and the secondary endpoint was the success rate of PCIs.

Results

A total of 447 female operators (7.3% of all operators) performed 35,211 PCIs (5.3%) during the study period. Female doctors treated a higher percentage of patients with ST-segment elevation myocardial infarction compared with their male counterparts (20.2% vs 17.7%; P = 0.001), whereas male doctors were more likely to perform PCIs for left main disease (4.9% vs 5.9%; P < 0.001) and lesions treated with rotational atherectomy (3.5% vs 4.9%; P < 0.001). The success rate of PCIs was higher for female interventionalists (97.8% vs 97.2%; P < 0.001). After conducting a risk-adjusted analysis, we found no significant difference in in-hospital mortality (adjusted OR: 0.896; 95% CI: 0.78-1.03; P = 0.12), or procedural complications associated with the operator's gender.

Conclusions

Overall, female operators exhibited outcomes similar to their male counterparts in terms of adjusted procedural outcomes, and higher crude success rate in certain subgroups. These findings emphasize gender disparities and stress the need to increase gender diversity in interventional cardiology.

Determinants of serious in-hospital complications in patients with Killip class 1/2 ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention

Killip classification has been used to stratify the risk of patients with acute myocardial infarction (AMI). There were many reports that Killip class 3 or 4 is closely associated with poor clinical outcomes. In other words, Killip class 1 or 2 is associated with favorable clinical outcomes in patients with AMI, especially when patients received primary percutaneous coronary intervention (PCI). However, some patients with Killip class 1/2 suffer from serious in-hospital complications. This study aimed to identify factors associated with serious in-hospital complications of ST-segment elevation myocardial infarction (STEMI) in patients with Killip class 1/2. The primary endpoint was serious in-hospital complications defined as the composite of in-hospital death and mechanical complications. We included 809 patients with STEMI, and divided them into the non-complication group (n = 791) and the complication group (n = 18). In-hospital death was observed in 14 patients (1.7%), and mechanical complications were observed in 4 patients (0.5%). Final TIMI flow ≤ 2 was more frequently observed in the complication group (33.3%) than in the non-complication group (5.4%) (p < 0.001). Multivariate logistic regression analysis revealed that serious in-hospital complication was associated with final TIMI flow grade ≤ 2 (Odds ratio 6.040, 95% confidence interval 2.042-17.870, p = 0.001). In conclusion, serious in-hospital complication of STEMI was associated with insufficient final TIMI flow grade in patients with Killip class 1/2. If final TIMI flow grade is suboptimal after primary PCI, we may recognize the potential risk of serious complications even when patients presented as Killip class 1/2.

Impact of Sex Differences on Clinical Outcomes in Patients Following Primary Revascularization for Acute Myocardial Infarction - Insights From the Japanese Nationwide Registry

BACKGROUND

Women with acute myocardial infarction (AMI) often present a worse risk profile and experience a higher rate of in-hospital mortality than men. However, sex differences in post-discharge prognoses remain inadequately investigated. We examined the impact of sex on 1-year post-discharge outcomes in patients with AMI undergoing percutaneous coronary intervention.

METHODS AND RESULTS

We extracted patient-level data for the period January 2017-December 2018 from the J-PCI OUTCOME Registry, endorsed by the Japanese Association of Cardiovascular Intervention and Therapeutics. One-year all-cause and cardiovascular mortality and major adverse cardiovascular events were compared between men and women. In all, 29,856 AMI patients were studied, with 6,996 (23.4%) being women. Women were significantly older and had a higher prevalence of comorbidities than men. Crude all-cause mortality was significantly higher among women than men (7.5% vs. 5.4% [P<0.001] for ST-elevation myocardial infarction [STEMI]; 7.0% vs. 5.2% [P=0.006] for non-STEMI). These sex-related differences in post-discharge outcomes were attenuated after stratification by age. Multivariate analysis demonstrated an increase in all-cause mortality in both sexes with increasing age and advanced-stage chronic kidney disease (CKD).

CONCLUSIONS

Within this nationwide cohort, women had worse clinical outcomes following AMI than men. However, these sex-related differences in outcomes diminished after adjusting for age. In addition, CKD was significantly associated with all-cause mortality in both sexes.

Effect of Patient's Symptom Interpretation on In-Hospital Mortality in Acute Coronary Syndrome

BACKGROUND

The association between symptom interpretation and prognosis has not been investigated well among patients with acute coronary syndrome (ACS). As such, the present study evaluated the effect of heart disease awareness among patients with ACS on in-hospital mortality.

METHODS AND RESULTS

We performed a post hoc analysis of 1,979 consecutive patients with ASC with confirmed symptom interpretation on admission between 2014 and 2018, focusing on patient characteristics, recanalization time, and clinical outcomes. Upon admission, 1,264 patients interpreted their condition as cardiac disease, whereas 715 did not interpret their condition as cardiac disease. Although no significant difference was observed in door-to-balloon time between the 2 groups, onset-to-balloon time was significantly shorter among those who interpreted their condition as cardiac disease (254 vs. 345 min; P<0.001). Moreover, the hazard ratio (HR) for in-hospital mortality was significantly higher among those who did not interpret their condition as cardiac disease based on the Cox regression model adjusted for established risk factors (HR 1.73; 95% confidence interval 1.08-2.76; P=0.022).

CONCLUSIONS

This study demonstrated that prehospital symptom interpretation was significantly associated with in-hospital clinical outcomes among patients with ACS. Moreover, the observed differences in clinical prognosis were not related to door-to-balloon time, but may be related to onset-to-balloon time.

Clinical outcomes of ST elevation myocardial infarction patients without standard modifiable risk factors

BACKGROUND

Standard modifiable cardiovascular risk factors (SMuRFs; hypertension, diabetes mellitus, dyslipidemia, and smoking) are widely recognized as risk factors for coronary artery disease. However, the associations between absence of SMuRFs and long-term clinical outcomes in ST-segment elevation myocardial infarction (STEMI) patients are unclear.

METHODS

Consecutive STEMI patients who underwent primary percutaneous coronary intervention (PCI) between 1999 and 2015 were retrospectively analyzed. The primary endpoint was up to 5-year all-cause mortality. Clinical characteristics and outcomes were compared between patients with at least one of the SMuRFs and those without any SMuRFs.

RESULTS

Of 1963 STEMI patients, 126 (6.4 %) did not have any SMuRFs. Patients without SMuRFs were significantly older, had lower body mass index, and were more likely to be female. During a median follow-up period of 4.9 years, the cumulative incidence of death was significantly higher in patients without SMuRFs than in those with SMuRFs (log-rank p < 0.0001). Landmark analysis showed that patients without SMuRFs had higher mortality within 30 days of STEMI onset (log-rank p = 0.0045) and >30 days after STEMI onset (log-rank p = 0.0004). Multivariable Cox hazards analysis showed that absence of SMuRFs was associated with a higher risk of mortality (hazard ratio, 1.59; 95 % confidence interval, 1.14-2.21; p = 0.006).

CONCLUSIONS

Of STEMI patients undergoing primary PCI, patients without any SMuRFs had higher mortality than those with at least one of the SMuRFs. Patients without any SMuRFs have a poor prognosis and require more attention.

Impact of controlled blood pressure and pulse rate at discharge on clinical outcomes in patients with ST-segment elevation myocardial infarction

BACKGROUND

Although major guidelines recommend the routine introduction of angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs) and beta-blockers for patients with ST-segment elevation myocardial infarction (STEMI), evidence regarding the target blood pressure (BP) or pulse rate (PR) at hospital discharge is sparse. This retrospective study aimed to compare the clinical outcomes in patients with STEMI between those with good BP and PR control and those with poor BP or PR control.

METHODS

We included 748 patients with STEMI who received both ACE inhibitors/ARBs and beta-blockers at hospital discharge, and divided them into a good control group (systolic BP ≤140 mmHg and PR ≤80 bpm, n = 564) and a poor control group (systolic BP >140 mmHg or PR >80 bpm, n = 184). The primary endpoint was major cardiovascular events (MACE) defined as the composite of all-cause death, non-fatal myocardial infarction, and re-admission for heart failure.

RESULTS

During the median follow-up duration of 568 days, a total of 119 MACE were observed. The Kaplan-Meier curves showed that MACE were more frequently observed in the poor control group (p = 0.009). In the multivariate Cox hazard analysis, the good control group was inversely associated with MACE (HR 0.656, 95 % CI: 0.444-0.968, p = 0.034) after controlling for multiple confounding factors.

CONCLUSIONS

The good control of systolic BP and PR at discharge was inversely associated with long-term adverse events in STEMI patients treated with both ACE inhibitors/ARBs and beta blockers. This study suggests the importance of titration of ACE inhibitors/ARBs and beta-blockers for better clinical outcomes in patients with STEMI.

Impact of the Japanese Version of High Bleeding Risk Criteria on Clinical Outcomes in Patients with ST-segment Elevation Myocardial Infarction

AIMS

Bleeding complications are often observed in patients with ST-segment elevation myocardial infarction (STEMI). Although the Japanese version of the high bleeding risk criteria (J-HBR) were established, it has not been sufficiently validated in patients with STEMI. This retrospective study aims to examine whether J-HBR is associated with cardiovascular and bleeding events in patients with STEMI.

METHODS

We included 897 patients with STEMI and divided them into the J-HBR group (n=567) and the non-J-HBR group (n=330). The primary endpoint was the major adverse cardiovascular events (MACE), defined as the composite of all-cause death, non-fatal myocardial infarction, ischemic stroke, and systemic embolism. Another primary endpoint was total bleeding events defined as type 3 or 5 bleeding events as defined by the Bleeding Academic Research Consortium .

RESULTS

During the median follow-up duration of 573 days, 187 MACE and 141 total bleeding events were observed. The Kaplan-Meier curves showed that MACE and total bleeding events were more frequently observed in the J-HBR group than in the non-J-HBR group (p＜0.001). Multivariate Cox hazard analysis revealed that after controlling for multiple confounding factors, the J-HBR group was significantly associated with MACE (hazard ratio [HR] 4.676, 95% confidence interval (CI) 2.936-7.448, p＜0.001) and total bleeding events (HR 6.325, 95% CI 3.376-11.851, p＜0.001).

CONCLUSIONS

J-HBR is significantly associated with MACE and total bleeding events in patients with STEMI. This study validated J-HBR as a risk marker for bleeding events and suggests J-HBR as a potential risk marker for MACE in patients with STEMI.

Cardiac arrest and post-discharge mortality in patients with myocardial infarction: A large-scale nationwide registry analysis

Background

Cardiac arrest is a serious complication of acute myocardial infarction. The implementation of contemporary approaches to acute myocardial infarction management, including urgent revascularization procedures, has led to significant improvements in short-term outcomes. However, the extent of post-discharge mortality in patients experiencing cardiac arrest during acute myocardial infarction remains uncertain. This study aimed to determine the post-discharge outcomes of patients with cardiac arrest.

Methods

We analysed data from the J-PCI OUTCOME registry, a Japanese prospectively planed, observational, multicentre, national registry of percutaneous coronary intervention involving consecutive patients from 172 institutions who underwent percutaneous coronary intervention and were discharged. Patients who underwent percutaneous coronary intervention for acute myocardial infarction between January 2017 and December 2018 and survived for 30 days were included. Mortality in patients with and without cardiac arrest from 30 days to 1 year after percutaneous coronary intervention for acute myocardial infarction was compared.

Results

Of the 26,909 patients who survived for 30 days after percutaneous coronary intervention for acute myocardial infarction, 1,567 (5.8%) had cardiac arrest at the onset of acute myocardial infarction. Patients with cardiac arrest were younger and more likely to be males than patients without cardiac arrest. The 1-year all-cause mortality was significantly higher in patients with cardiac arrest than in those without (11.9% vs. 2.8%, p < 0.001) for all age groups. Multivariable analysis showed that cardiac arrest was an independent predictor of all-cause long-term mortality (hazard ratio: 2.94; 95% confidence interval: 2.29-3.76).

Conclusions

Patients with acute myocardial infarction and concomitant cardiac arrest have a worse prognosis for up to 1 year after percutaneous coronary intervention than patients without cardiac arrest.

Association of Increased Inter-arm Blood Pressure Difference with Long-term Clinical Outcomes in Patients with Acute Myocardial Infarction Who Underwent Percutaneous Coronary Intervention

Objective Patients with acute myocardial infarction (AMI) often have peripheral artery disease (PAD). It is well known that the long-term clinical outcomes of AMI are worse in patients with a low ankle-brachial index (ABI) than in patients with a preserved ABI. Unlike ABI, the association between the inter-arm blood pressure difference (IABPD) and clinical outcomes in patients with AMI has not yet been established. This retrospective study examined whether or not the IABPD is associated with long-term clinical outcomes in patients with AMI. Methods We included 979 patients with AMI and divided them into a high-IABPD group (IABPD ≥10 mmHg, n=31) and a low-IABPD group (IABPD <10 mmHg, n=948) according to the IABPD measured during hospitalization for AMI. The primary endpoint was the all-cause mortality rate. Results During a median follow-up duration of 694 days (Q1, 296 days; Q3, 1,281 days), 82 all-cause deaths were observed. Kaplan-Meier curves showed that all-cause death was more frequently observed in the high-IABPD group than in the low-IABPD group (p<0.001). A multivariate Cox hazard analysis revealed that a high IABPD was significantly associated with all-cause death (hazard ratio 2.061, 95% confidence interval 1.012-4.197, p=0.046) after controlling for multiple confounding factors. Conclusion A high IABPD was significantly associated with long-term all-cause mortality in patients with AMI. Our results suggest the usefulness of the IABPD as a prognostic marker for patients with AMI.

Changing Trends in Mechanical Circulatory Support Use and Outcomes in Patients Undergoing Percutaneous Coronary Interventions for Acute Coronary Syndrome Complicated With Cardiogenic Shock: Insights From a Nationwide Registry in Japan

BACKGROUND

Temporal trends in the management of acute coronary syndrome complicated with cardiogenic shock after the revision of guideline recommendations for intra-aortic balloon pump (IABP) use and the approval of the Impella require further investigation, because their impact remains uncertain.

METHODS AND RESULTS

Using the Japanese Percutaneous Coronary Intervention (J-PCI) registry database from 2019 to 2021, we identified 12 171 patients undergoing percutaneous coronary intervention for acute coronary syndrome complicated with cardiogenic shock under mechanical circulatory support. The patients were stratified into 3 groups: (1) IABP alone, (2) Impella, and (3) venoarterial extracorporeal membrane oxygenation (VA-ECMO); the VA-ECMO group was further stratified into (3a) VA-ECMO alone, (3b) VA-ECMO in combination with IABP, and (3c) VA-ECMO in combination with Impella. The quarterly prevalence and outcomes were reported. The use of IABP alone decreased significantly from 63.5% in the first quarter of 2019 to 58.3% in the fourth quarter of 2021 (P for trend=0.01). Among 4245 patients requiring VA-ECMO, the use of VA-ECMO in combination with IABP decreased significantly from 78.7% to 67.3%, whereas the use of VA-ECMO in combination with Impella increased significantly from 4.2% to 17.0% (P for trend <0.001 for both). After adjusting for the confounders, the risk difference in the fourth quarter of 2021 relative to the first quarter of 2019 for in-hospital mortality was not significant (adjusted odds ratio, 0.84 [95% CI, 0.69-1.01]).

CONCLUSIONS

Our study revealed substantial changes in the use of different mechanical circulatory support modalities in acute coronary syndrome complicated with cardiogenic shock, but they did not significantly improve the outcomes.

Age-Stratified Prevalence and Relative Prognostic Significance of Traditional Atherosclerotic Risk Factors: A Report from the Nationwide Registry of Percutaneous Coronary Interventions in Japan

Background The prevalence of traditional atherosclerotic risk factors (TARFs) and their association with clinical profiles or mortality in percutaneous coronary intervention remain unclear. Methods and Results The study analyzed 559 452 patients who underwent initial percutaneous coronary intervention between 2012 and 2019 in Japan. TARFs were defined as male sex, hypertension, dyslipidemia, diabetes, smoking, and chronic kidney disease. We calculated the relative importance according to R2 and machine learning models to assess the impact of TARFs on clinical profile and in-hospital mortality. The relative contribution (RC) of each TARF was defined as the average percentage of the relative importance calculated from these models. The age-specific prevalence of TARFs, except for chronic kidney disease, formed an inverted U-shape with significantly different peaks and percentages. In the logistic regression model and relative risk model, smoking was most strongly associated with acute myocardial infarction (adjusted odds ratio [OR], 1.62 [95% CI, 1.60-1.64]; RC, 47.1%) and premature coronary artery disease (adjusted unstandardized beta coefficient, 2.68 [95% CI, 2.65-2.71], RC, 42.2%). Diabetes was most strongly associated with multivessel disease (adjusted unstandardized beta coefficient, 0.068 [95% CI, 0.066-0.070], RC, 59.4%). The absence of dyslipidemia was most strongly associated with presentation of cardiogenic shock (adjusted OR, 0.62 [95% CI, 0.61-0.64], RC, 34.2%) and in-hospital mortality (adjusted OR, 0.44 [95% CI, 0.41-0.46], RC, 39.8%). These specific associations were consistently observed regardless of adjustment or stratification by age. Conclusions Our analysis showed a significant variation in the age-specific prevalence of TARFs. Further, their contribution to clinical profiles and mortality also varied widely.

Transradial intervention in dialysis patients undergoing percutaneous coronary intervention: a Japanese nationwide registry study

Aims

Transradial intervention (TRI) for percutaneous coronary intervention (PCI) is used to reduce periprocedural complications. However, its effectiveness and safety for patients on dialysis are not well established. We aimed to investigate the association of TRI with in-hospital complications in dialysis patients undergoing PCI.

Methods and results

We included 44 462 patients on dialysis who underwent PCI using Japanese nationwide PCI registry data (2019-21) regardless of acute or chronic coronary syndrome. Patients were categorized based on access site: TRI, transfemoral intervention (TFI). Periprocedural access site bleeding complication requiring transfusion was the primary outcome and in-hospital death, and other periprocedural complications were the secondary outcomes. Matched weighted analysis was performed for TRI and TFI. Here, 8267 (18.6%) underwent TRI, and 36 195 (81.4%) underwent TFI. Patients who received TRI were older and had lower rates of comorbidities than those who received TFI. Access site bleeding rate and in-hospital death were significantly lower in the TRI group (0.1% vs. 0.7%, P < 0.001; 1.8% vs. 3.2%, P < 0.001, respectively). After adjustment, TRI was associated with a lower risk of access site bleeding (odds ratio [OR] [95% confidence interval (CI)]: 0.19 [0.099-0.38]; P < 0.001) and in-hospital death (OR [95% CI]: 0.79 [0.65-0.96]; P = 0.02). Other periprocedural complications between TRI and TFI were not significantly different.

Conclusion

In patients undergoing dialysis and PCI, TRI had a lower risk of access site bleeding and in-hospital death than TFI. This suggests that TRI may be safer for this patient population.

The France PCI registry: Design, methodology and key findings

BACKGROUND

Obstructive coronary artery disease is the main cause of death worldwide. By tracking events and gaining feedback on patient management, the most relevant information is provided to public health services to further improve prognosis.

AIMS

To create an inclusive and accurate registry of all percutaneous coronary intervention (PCI) procedures performed in France, to assess and improve the quality of care and create research incentives. Also, to describe the methodology of this French national registry of interventional cardiology, and present early key findings.

METHODS

The France PCI registry is a multicentre observational registry that includes consecutive patients undergoing coronary angiography and/or PCI. The registry was set up to provide online data analysis and structured reports of PCI activity, including process of care measures and assessment of risk-adjusted outcomes in all French PCI centres that are willing to participate. More than 150 baseline data items, describing demographic status, PCI indications and techniques, and in-hospital and 1-year outcomes, are captured into local reporting software by medical doctors and local research technicians, with subsequent encryption and internet transfer to central data servers. Annual activity reports and scoring tools available on the France PCI website enable users to benchmark and improve clinical practices. External validation and consistency assessments are performed, with feedback of data completeness to centres.

RESULTS

Between 01 January 2014 and 31 December 2022, participating centres increased from six to 47, and collected 364,770 invasive coronary angiograms and 176,030 PCIs, including 54,049 non-ST-segment elevation myocardial infarction cases and 31,631 ST-segment elevation myocardial infarction cases. Fifteen studies stemming from the France PCI registry have already been published.

CONCLUSIONS

This fully electronic, daily updated, high-quality, low-cost, national registry is sustainable, and is now expanding. Merging with medicoeconomic databases and nested randomized scientific studies are ongoing steps to expand its scientific potential.

Volume-outcome relationship in complication-related mortality after percutaneous coronary interventions: an analysis on the failure-to-rescue rate in the Japanese Nationwide Registry

In-hospital mortality following percutaneous coronary intervention (PCI) varies across institutions with different annual PCI volumes. The failure to rescue (FTR) rate, defined as the mortality rate following PCI-related complications, may account for the volume-outcome relationship. The Japanese Nationwide PCI Registry, a consecutive, nationally mandated registry between 2019 and 2020, was queried. The FTR rate is defined as 'the number of patients who died following PCI-related complications' divided by 'the number of patients who experienced at least one PCI-related complication.' Multivariate analysis was used to calculate the risk-adjusted odds ratio (aOR) of the FTR rates among hospitals stratified into tertiles as low (≤ 236/year), medium (237-405/year), and high (≥ 406/year). A total of 465,716 PCIs and 1007 institutions were included. A volume-outcome relationship was observed for in-hospital mortality, and the medium-volume (aOR 0.90, 95% confidence interval [CI] 0.85-0.96), as well as high-volume (aOR 0.84, 95% CI 0.79-0.89) hospitals, had significantly lower in-hospital mortality than low-volume hospitals. Complication rates were lower at high-volume centers (1.9%, 2.2%, and 2.6% for high-, medium-, and low-volume centers, respectively; p < 0.001). The overall FTR rate was 19.0%. The FTR rates for the low-, medium-, and high-volume hospitals were 19.3%, 17.7%, and 20.6%, respectively. The medium-volume hospitals had a lower FTR rate (aOR 0.82, 95% [CI] 0.68-0.99), whereas the FTR rate was similar at the high-volume hospitals compared with that of the low-volume hospitals (aOR 1.02, 95% CI 0.83-1.26). In-hospital mortality was low after PCI in high-volume hospitals. However, the FTR rate in high-volume hospitals was not necessarily lower than that in low-volume hospitals. The FTR rate did not account for the volume-outcome relationship in PCI.

Angiographic Coronary Calcification: A Simple Predictor of Long-Term Clinical Outcomes in Patients with Acute Myocardial Infarction

AIMS

Coronary calcification detected by coronary angiography is a simple risk marker for long-term clinical outcomes in stable coronary artery disease. However, the significance of angiographic coronary calcification in the culprit lesion of acute myocardial infarction (AMI) has not been fully discussed. The purpose of this retrospective study was to assess the usefulness of angiographic coronary calcification as a risk marker for long-term clinical outcomes following percutaneous coronary intervention to the culprit lesions of AMI.

METHODS

We included 1209 patients with AMI and divided them into the none-mild calcification group (n=923) and the moderate-severe calcification group (n=286) according to angiographic coronary calcification in the culprit lesion of AMI. The primary endpoint was the occurrence of major adverse cardiac events (MACE), which was defined as a composite of all-cause death, nonfatal MI, readmission for heart failure, and ischemia-driven target vessel revascularization.

RESULTS

The median follow-up duration was 542 (Q1: 182, Q3: 990) days. A total of 345 MACE were observed during the study period. The occurrence of MACE was significantly greater in the moderate-severe calcification group than in the none-mild calcification group (43.4% vs. 23.9%, p＜0.001). In the multivariate Cox hazard model, moderate-severe calcification was significantly associated with MACE (hazard ratio 1.302, 95% confidence interval 1.011-1.677, p=0.041) after controlling multiple confounding factors.

CONCLUSIONS

Angiographically moderate to severe calcification in AMI culprit lesion was associated with long-term worse clinical outcomes. Angiographic coronary calcification can be a simple risk marker in patients after AMI.

Factors associated with intensive care unit delirium in patients with acute myocardial infarction

Some patients admitted to intensive care units (ICU) would develop delirium, which is associated with poor prognosis. The purpose of this retrospective study was to identify factors associated with ICU delirium in patients with acute myocardial infarction (AMI). We included 753 AMI and divided those into the ICU-delirium group (n = 110) and the non-ICU-delirium group (n = 643) according to the presence of ICU delirium. The ICU delirium was evaluated by confusion assessment method for the intensive care unit. Patient characteristics and clinical outcomes were compared between the 2 groups, and factors associated with ICU delirium were sought by multivariate analysis. The prevalence of female sex was significantly higher in the ICU-delirium group (43.6%) than in the non-ICU-delirium group (20.2%) (p < 0.001). The incidence of in-hospital death was significantly higher in the ICU-delirium group (17.3%) than in the non-ICU-delirium group (0.5%) (p < 0.001). The multivariate logistic regression analysis revealed that age [every 10 years increase: odds ratio (OR) 1.439, 95% confidence interval (CI) 1.127-1.837, p = 0.004], female sex (OR 2.237, 95%CI 1.300-3.849, p = 0.004), triple vessel disease (OR 2.317, 95%CI 1.365-3.932, p = 0.002), body mass index < 18.5 kg/m² (OR 2.910, 95%CI 1.410-6.008, p = 0.004), use of mechanical support (OR 2.812, 95%CI 1.500-5.270, p = 0.001), respiratory failure (OR 5.342, 95%CI 3.080-9.265, p < 0.001), and use of continuous renal replacement therapy (OR 5.901, 95%CI 2.520-13.819, p < 0.001) were significantly associated with ICU delirium. In conclusion, ICU delirium was associated with in-hospital death. Older age, female sex, triple vessel disease, leanness, use of mechanical support, respiratory failure, and continuous renal replacement therapy were significantly associated with the occurrence of ICU delirium.

Volume-Outcome Relations of Percutaneous Coronary Intervention in Patients Presenting With Acute Myocardial Infarction (from the J-PCI Registry)

A lower institutional primary percutaneous coronary intervention (PCI) volume is associated with a higher risk of postprocedural poor outcomes, particularly in urgent or emergent settings (e.g., PCI for acute myocardial infarction [MI]). However, the individual prognostic impact of PCI volume stratified by indication and the relative ratio remains unclear. Using the Japanese nationwide PCI database, we investigated 450,607 patients from 937 institutions who underwent either primary PCI for acute MI or elective PCI. The primary end point was the observed/predicted in-hospital mortality ratio. The predicted mortality per patient was calculated using the baseline variables and averaged for each institution. The relation between the annual primary, elective, and total PCI volumes and institutional in-hospital mortality after acute MI was evaluated. The association between the primary-to-total PCI volume per hospital and mortality was also investigated. Of the 450,607 patients, 117,430 (26.1%) underwent primary PCI for acute MI, of whom 7,047 (6.0%) died during hospitalization. The median total PCI volume and primary-to-total PCI volume ratio were 198 (interquartile range 115 to 311) and 0.27 (0.20 to 0.36). Overall, the observed in-hospital mortality and observed/predicted mortality ratio in patients with acute MI were higher in institutions with lower primary, elective, and total PCI volumes. The observed/predicted mortality ratio was also higher in institutions with lower primary-to-total PCI volume ratios, even in high-PCI volume hospitals. In conclusion, in this nationwide registry-based analysis, lower institutional PCI volumes, regardless of setting, were associated with higher in-hospital mortality after acute MI. The primary-to-total PCI volume ratio provided independent prognostic information.

Characteristics and outcomes of patients with no standard modifiable risk factors undergoing primary revascularization for acute myocardial infarction: Insights from the nationwide Japanese percutaneous coronary intervention registry

BACKGROUND

Identification of and therapeutic approaches to standard modifiable risk factors (SMuRFs), including hypertension, diabetes, dyslipidemia, and smoking, have led to improved survival of patients at risk for coronary events. However, recent studies have indicated that a significant proportion of patients with acute myocardial infarction (AMI) have no SMuRFs. We aimed to assess in-hospital outcomes and the prevalence of these patients using the Japanese nationwide percutaneous coronary intervention (J-PCI) registry.

METHODS

The J-PCI is a procedure-based registration program in Japan. A total of 115,437 PCI procedures were performed on patients with AMI between January 2019 and December 2020. The participants were divided into 2 groups: those with at least 1 SMuRF and those without any SMuRFs. The primary outcome was in-hospital mortality.

RESULTS

Of the 115,437 patients with AMI, 1,777 (1.6%) had no SMuRFs. Patients without SMuRFs were older; more likely to have left main disease; and more likely to present with heart failure, cardiogenic shock, and cardiac arrest than those with SMuRFs, resulting in higher rates of mechanical circulatory support use and impaired post-PCI coronary blood flow. In-hospital mortality was significantly higher in patients without SMuRFs than in those with SMuRFs (18.3% vs 5.3%, P < .001), irrespective of the presence or absence of ST-segment elevation.

CONCLUSIONS

In Japan, where annual health checks are mandated under universal health care coverage, the vast majority of patients with AMI undergoing PCI have SMuRFs. However, although small in number, patients without SMuRFs are more likely to present with life-threatening conditions and have worse in-hospital survival.

Clinical expert consensus document on drug-coated balloon for coronary artery disease from the Japanese Association of Cardiovascular Intervention and Therapeutics

Drug-coated balloon (DCB) technology was developed to deliver the antiproliferative drugs to the vessel wall without leaving any permanent prosthesis or durable polymers. The absence of foreign material can reduce the risk of very late stent failure, improve the ability to perform bypass-graft surgery, and reduce the need for long-term dual antiplatelet therapy, potentially reducing associated bleeding complications. The DCB technology, like the bioresorbable scaffolds, is expected to be a therapeutic approach that facilitates the "leave nothing behind" strategy. Although newer generation drug-eluting stents are the most common therapeutic strategy in modern percutaneous coronary interventions, the use of DCB is steadily increasing in Japan. Currently, the DCB is only indicated for treatment of in-stent restenosis or small vessel lesions (< 3.0 mm), but potential expansion for larger vessels (≥ 3.0 mm) may hasten its use in a wider range of lesions or patients with obstructive coronary artery disease. The task force of the Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT) was convened to describe the expert consensus on DCBs. This document aims to summarize its concept, current clinical evidence, possible indications, technical considerations, and future perspectives.

Ischemic and Bleeding Outcomes in Patients Who Underwent Percutaneous Coronary Intervention With Chronic Kidney Disease or Dialysis (from a Japanese Nationwide Registry)

The relation between chronic kidney disease (CKD) and outcomes in patients receiving percutaneous coronary intervention (PCI) is thought to be bidirectional; these patients are at a higher risk of ischemic and bleeding events. From a Japanese nationwide PCI registry, ischemic (cardiovascular death, nonfatal myocardial infarction, or nonfatal ischemic stroke) and bleeding events (fatal or nonfatal major bleeding) 1 year after discharge among patients who had second- or newer-generation drug-eluting stent implantation were analyzed. Patients on oral anticoagulants were excluded. Patients were stratified according to their preprocedural renal function: CKD stages 1 to 2 (estimated glomerular filtration rate [eGFR] ≥60 ml/min/1.73 m²), 3 (eGFR 30 to 59), or 4 to 5 (eGFR <30), or those receiving dialysis. Overall, 23,349 patients, including 2,798 patients with CKD 3 to 5 (12.0%) and 1,464 patients on dialysis (6.3%), were investigated. One-year ischemic events were observed in 1.5%, 5.2%, 9.7%, and 5.3% in the CKD stages 1-to-2, 3, 4-to-5, and dialysis groups, respectively; patients with CKD stages 3 or 4 to 5 and those receiving dialysis were associated with higher risks of ischemic events after adjustment of covariates than were patients without CKD. Compared with ischemic events, 1-year bleeding events were low, with incidence rates of 1.5%, 2.0%, 3.4%, and 2.3%, respectively. Furthermore, the presence of CKD or dialysis was not associated with a higher risk of bleeding events after adjustment of covariates. In conclusion, in the contemporary nationwide PCI registry, the presence of CKD and dialysis was independently associated with a higher risk of ischemic events but not with bleeding events, and this suggests a need to alter the models of care delivery in these patients.

Intracardiac Echocardiography Guidance for Percutaneous Transcatheter Closure of Atrial Septal Defects - Nationwide Registry Data Analysis

BACKGROUND

Transesophageal echocardiography (TEE) has been used for percutaneous atrial septal defect (ASD) closure, with intracardiac echocardiography (ICE) guidance recently being introduced.

METHODS AND RESULTS

The Japanese Structural Heart Disease Registry was established by the Japanese Association of Cardiovascular Intervention and Therapeutics. This study analyzed data from the Registry for 2,859 consecutive cases undergoing percutaneous ASD closure between January 2015 and December 2020. ASD closure was performed under ICE guidance (n=519; 18.2%), TEE guidance (n=1,428; 49.9%), or TEE plus ICE guidance ("Both"; n=900 cases; 31.5%). The success rates were similar in the TEE, ICE, and both groups (99.0%, 99.2%, vs. 98.0%, respectively; P=0.054), as were complication rates (1.2%, 0.5%, vs. 2.1%, respectively; P=0.24). In the TEE and Both groups, 92.4% and 79.6% of patients required general anesthesia, compared with only 2.9% of patients in the ICE group (P<0.001). Fluoroscopic time was longer in the ICE and Both groups than in the TEE group (median [interquartile range] 19 [14-28] and 21 [13-30] vs. 12 [8-19] min, respectively; P<0.001). Rim deficiency and larger defect diameter were inversely related, whereas hospital volume was positively related to ICE guidance.

CONCLUSIONS

Percutaneous transcatheter ASD closure was as feasible under ICE as under TEE guidance. ICE guidance is used for less challenging cases in high-volume centers in Japan.

Factors Associated with Impaired Resistive Reserve Ratio and Microvascular Resistance Reserve

Coronary microvascular dysfunction (CMD) is described as an important subset of ischemia with no obstructive coronary artery disease. Resistive reserve ratio (RRR) and microvascular resistance reserve (MRR) have been proposed as novel physiological indices evaluating coronary microvascular dilation function. The aim of this study was to explore factors associated with impaired RRR and MRR. Coronary physiological indices were invasively evaluated in the left anterior descending coronary artery using the thermodilution method in patients suspected of CMD. CMD was defined as a coronary flow reserve <2.0 and/or index of microcirculatory resistance ≥25. Of 117 patients, 26 (24.1%) had CMD. RRR (3.1 ± 1.9 vs. 6.2 ± 3.2, p < 0.001) and MRR (3.4 ± 1.9 vs. 6.9 ± 3.5, p < 0.001) were lower in the CMD group. In the receiver operating characteristic curve analysis, RRR (area under the curve 0.84, p < 0.001) and MRR (area under the curve 0.85, p < 0.001) were both predictive of the presence of CMD. In the multivariable analysis, previous myocardial infarction, lower hemoglobin, higher brain natriuretic peptide levels, and intracoronary nicorandil were identified as factors associated with lower RRR and MRR. In conclusion, the presence of previous myocardial infarction, anemia, and heart failure was associated with impaired coronary microvascular dilation function. RRR and MRR may be useful to identify patients with CMD.

Current status of real-world big data research in the cardiovascular field in Japan

Real-world data (RWD) are observational data obtained by collecting, structuring, and accumulating patient information among the medical big data. RWD are derived from a variety of patient medical care and health information outside of conventional research data, and include electronic health records, claims data, registry data of disease, drug and device, health check-up data, and more recently, patient information data from wearable devices. They are currently being utilized in various forms for optimal medical care and real-world evidence (RWE) is constructed through a process of hypothesis generation and verification based on the RWD research. Together with classic clinical research and pragmatic trials, RWE shapes the learning healthcare system and contributes to the improvement of medical care. In the cardiovascular medical care of the current super-aged society, the need for a variety of RWE and the research is increasing, since the guidelines established over time and the medical care based on it cannot necessarily be the best in accordance with the current medical situation. In this review, we focus on the RWD and RWE studies in the cardiovascular medical field and outlines their current status in Japan. Furthermore, we discuss the potential for extending the studies and issues related to the use of medical big data and RWD.

Association of peak C-reactive protein with long-term clinical outcomes in patients with ST-segment elevation myocardial infarction

Peak C-reactive protein (CRP) levels following ST-segment elevation myocardial infarction (STEMI) are associated with left ventricular thrombus formation or cardiac rupture. However, the impact of peak CRP on long-term outcomes in patients with STEMI is not completely understood. The purpose of this retrospective study was to compare the long-term all-cause death after STEMI between patients with and without high peak CRP levels. We included 594 patients with STEMI, and divided them into the high CRP group (n = 119) and the low-moderate CRP group (n = 475) according to the quintile of peak CRP levels. The primary endpoint was all-cause death after the discharge of the index admission. The mean peak CRP level was 19.66 ± 5.14 mg/dL in the high CRP group, whereas that was 6.43 ± 3.86 mg/dL in the low-moderate CRP group (p < 0.001). During the median follow-up duration of 1045 days (Q1 284 days, Q3 1603 days), a total of 45 all-cause deaths were observed. The Kaplan-Meier curves showed that all-cause death was more frequently observed in the high CRP group than in the low-moderate CRP group (p = 0.002). The multivariate Cox hazard analysis revealed that high CRP was significantly associated with all-cause death (hazard ratio 2.325, 95% confidence interval 1.246-4.341, p = 0.008) after controlling for confounding factors. In conclusion, high peak CRP was significantly associated with all-cause death in patients with STEMI. Our results suggest that peak CRP may be useful to stratify patients with STEMI for the risk of future death.

Comparison of in-hospital outcomes of acute myocardial infarction between patients with cardiogenic shock and with cardiac arrest

In-hospital mortality of acute myocardial infarction (AMI) complicated with cardiogenic shock (CS) remains high. Also, in-hospital mortality of AMI complicated with cardiac arrest (CA) has been reported to be highest among any AMI. However, there were few reports that compared in-hospital mortality directly between AMI complicated with CS and complicated with CA. The purpose of this study was to compare in-hospital outcomes between AMI complicated with CS and complicated with CA. We retrospectively included 195 AMI patients complicated by CS or CA, and divided those into the CA group (n = 109) and the CS group (n = 86). We also subdivided the CA group into CA with persistent CS (n = 83) and CA without persistent CS (n = 26). One-third of the study population died during the index admission. In-hospital death was more frequently observed in the CA group (45.0%) than in the CS group (20.9%) (p < 0.001). In-hospital mortality was highest in the CA with persistent CS group (68.7%), followed by the CS group (20.9%), and least in the CA without persistent CS group (11.5%) (p < 0.001). Favorable neurological function was more frequently observed in the CA without persistent CS group (76.9%) and the CS group (74.4%) than in the CA with persistent CS group (27.7%) (p < 0.001). In conclusion, in-hospital mortality was higher in AMI patients with CA than in those with CS. However, when we divided AMI patients with CA into those with and without persistent CS, in-hospital mortality was lowest in CA without persistent CS, followed by CS, and highest in CA with persistent CS.

Impact of lipoprotein(a) levels on primary patency after endovascular therapy for femoropopliteal lesions

Lipoprotein(a) [Lp(a)] is a risk factor for peripheral artery disease (PAD). However, the relationship between Lp(a) levels and clinical events after endovascular therapy (EVT) for the femoropopliteal artery in PAD patients remains unclear. Thus, this study aimed to assess the impact of Lp(a) levels on primary patency after EVT for de novo femoropopliteal lesions in PAD patients. A retrospective analysis was conducted on 109 patients who underwent EVT for de novo femoropopliteal lesions, and Lp(a) levels were measured before EVT between June 2016 and December 2019. Patients were divided into low Lp(a) [Lp(a) < 30 mg/dL; 78 patients] and high Lp(a) [Lp(a) ≥ 30 mg/dL; 31 patients] groups. The main outcome was primary patency following EVT. Loss of primary patency was defined as a peak systolic velocity ratio > 2.4 on a duplex scan or > 50% stenosis on angiography. Cox proportional hazards analysis was performed to determine whether high Lp(a) levels were independently associated with loss of primary patency. The mean follow-up duration was 28 months. The rates of primary patency were 83 and 76% at 1 year and 75 and 58% at 2 years in the low and high Lp(a) groups, respectively (P = 0.02). After multivariate analysis, High Lp(a)[Lp(a) ≥ 30 mg/dL] (hazard ratio 2.44; 95% CI 1.10-5.44; P = 0.03) and female sex (hazard ratio 2.65; 95% CI 1.27-5.51; P < 0.01) were independent predictors of loss of primary patency. Lp(a) levels might be associated with primary patency after EVT for de novo femoropopliteal lesions.

Periprocedural and 30-day outcomes of robotic-assisted percutaneous coronary intervention used in the intravascular imaging guidance

In recent years, there have been several reports on robotic-assisted percutaneous coronary intervention (R-PCI), but few studies have been conducted on R-PCI performed under intravascular imaging guidance. To elucidate the periprocedural and postoperative 30-day outcomes of intravascular imaging-guided R-PCI, we performed a retrospective observational study on all patients in 102 consecutive cases who underwent R-PCI under intravascular imaging guidance at a single center in Japan from June 12, 2019 to February 18, 2021. The primary end point was 30-day survival, and the secondary end point was the incidence of complications. Intravascular imaging-guided R-PCI was performed 110 times in total on 125 lesions. The medians of procedural time, fluoroscopy time, contrast volume, patient entrance skin dose, and radiation exposure to the main operator were 49 min, 16 min, 67 mL, 0.62 Gy, and 0 μSv, respectively. Furthermore, 60.0% of target lesion branches were American College of Cardiology Foundation/American Heart Association classification type B2 or type C. However, in all cases, lesion dilatation was successful, and the final Thrombolysis in Myocardial Infarction flow grade was 3. The combination of manual operation was required in 12.7% of all cases, but 30-day survival was confirmed in all cases. There were two problems at the puncture site. One small distal branch artery dissection occurred due to manual operation, but no cardiovascular events (myocardial infarction, stroke) occurred and no target lesion restenosis was observed within 30 days of R-PCI. Hence, R-PCI using intravascular imaging demonstrated highly satisfactory treatment outcomes, and no complication caused by robotic operation was observed.

Safety of clinical engineer-assisted percutaneous coronary intervention

Percutaneous coronary intervention (PCI) requires multiple staff members, including interventional cardiologists, with the physical burden of heavy protective measures to minimize radiation exposure. Here, we aimed to investigate the safety of task sharing with clinical engineers (CEs) working as 1st assistant during ad hoc PCI. We retrospectively included 286 patients who underwent ad hoc PCI following diagnostic catheterization for coronary artery disease between April 2019 and March 2021. Procedural complications including coronary perforation or rupture, myocardial infarction, cerebral embolism, cardiovascular death, decreased kidney function, and radiation parameters were compared between the two clinical settings [CE group, CEs as the 1st assistant from the beginning of diagnostic coronary angiography to the end of PCI vs. doctor (DR) group, others]. There was no increase in the ratio of procedural complications in the CE group (1.7%) versus the DR group (1.2%). Fluorescence time and radiation exposure dose were significantly reduced in the CE group {25 min [interquartile range (IQR), 19-35 min] vs. 28 min (IQR, 20-39 min), P = 0.036; 908 mGy (IQR, 654-1326 mGy) vs. 1062 mGy (IQR, 732-1594 mGy), P = 0.049}. The median amount of contrast medium was significantly reduced in the CE group [100 mL (IQR, 80-119 mL) vs. 110 mL (IQR 90-140 mL), P < 0.001]. After propensity matching, fluorescence time, radiation exposure dose, and contrast medium amount were similar between groups. Task sharing with CEs as the 1st assistant during ad hoc PCI could contribute to clinical safety in patients with coronary artery disease.

Impact of Chronic Kidney Disease on Outcomes of Percutaneous Coronary Intervention in Patients With Diabetes Mellitus: A Systematic Review and Meta-Analysis

BACKGROUND

The impact of chronic kidney disease (CKD) on adverse cardiovascular outcomes after percutaneous coronary intervention in patients with diabetes mellitus (DM) is still unclear. This study aimed to systematically assess evidence on this topic.

METHODS

The PubMed, Embase, and CENTRAL databases were searched for studies comparing mortality, myocardial infarction (MI), or revascularization outcomes between patients with DM with and without CKD.

RESULTS

In 11 studies, the presence of CKD was associated with significantly increased risk of early all-cause mortality (risk ratio [RR], 3.45; 95% CI, 3.07-3.87; I2 = 0%; P < .001), late all-cause mortality (RR, 2.78; 95% CI, 1.92-4.02; I2 = 83%; P < .001), cardiac mortality (RR, 2.90; 95% CI, 1.99-4.22; I2 = 29%; P < .001), and MI (RR, 1.40; 95% CI, 1.06-1.85; I2 = 13%; P = .02) compared with no CKD. There was no difference in the risk of any revascularization between those with and without CKD. Analysis of adjusted hazard ratios (HRs) indicated significantly increased risk of mortality (HR, 2.64; 95% CI, 1.91-3.64; I2 = 0%; P < .001) in the CKD group but only a nonsignificant tendency of increased MI (HR, 1.59; 95% CI, 0.99-2.54; I2 = 0%; P = .05) and revascularization (HR, 1.24; 95% CI, 0.94-1.63; I2 = 2%; P = .12) in the CKD group.

CONCLUSION

The presence of CKD in patients with DM significantly increases the risk of mortality and MI. However, CKD had no impact on revascularization rates.

Influence of daily temperature on the occurrence of ST-elevation myocardial infarction

BACKGROUND

Epidemiological studies reported that acute myocardial infarction (AMI) occurs more often in winter season or days with low temperatures. However, most of these studies did not distinguish ST-elevation myocardial infarction (STEMI) from AMI. The purpose of this study was to investigate the relationship between temperature and the occurrence of STEMI.

METHODS

We reviewed all daily temperature in Saitama City between January 2015 and December 2021 (2557 days) and divided them into days in which our institution received STEMI (days with STEMI) and days in which our institution did not receive STEMI (days without STEMI).

RESULTS

The daily maximum temperature was significantly lower in days with STEMI than in days without STEMI [20.0 °C (68.0 °F) versus 21.2 °C (70.2 °F), p = 0.001]. The maximum temperature was significantly lower in days with STEMI than in days without STEMI in the elderly [19.9 °C (67.8 °F) versus 21.1 °C (70.0 °F), p = 0.003], whereas this trend was weaker in the non-elderly [20.2 °C (68.4 °F) versus 20.9 °C (69.6 °F), p = 0.171]. Furthermore, the maximum temperature was significantly lower in days with STEMI than in days without STEMI in male [20.0 °C (68.0 °F) versus 21.1 °C (70.0 °F), p = 0.002], whereas this trend was weaker in females [20.0 °C (68.0 °F) versus 20.9 °C (69.6 °F), p = 0.169].

CONCLUSIONS

The daily temperatures were significantly lower in days with STEMI than in days without STEMI, and this relationship was pronounced in elderly or male patients.

Validation of pressure-bounded coronary flow reserve using invasive coronary physiologic assessment

Coronary flow reserve (CFR) represents entire coronary compensatory capacity. While CFR assessment is recommended to identify patients at an increased risk of cardiovascular events and coronary microvascular dysfunction, invasive CFR measurement is often technically challenging. Although not well validated yet, pressure-bounded CFR (pbCFR) has been proposed as a simple surrogate to estimate impaired CFR. In this study, we evaluated coronary physiological characteristics of low pbCFR using detailed invasive assessment. Invasive physiological assessment including resting ratio of distal coronary pressure to aortic pressure (Pd/Pa), fractional flow reserve (FFR), resting and hyperemic mean transit time, index of microcirculatory resistance (IMR), CFR, resistive reserve ratio, and microvascular resistance reserve (MRR) was performed in 107 patients in the left anterior descending coronary artery. pbCFR was calculated only with resting Pd/Pa and FFR. Patients were divided into low pbCFR and non-low pbCFR groups. Of 107 patients, 50 (46.7%) had low pbCFR. FFR (0.90 ± 0.05 vs. 0.83 ± 0.05, p < 0.001), hyperemic mean transit time (0.27 ± 0.17 vs. 0.21 ± 0.12, p = 0.04), and IMR (20.4 ± 13.2 vs. 15.0 ± 9.1, p = 0.01) were significantly higher in the low pbCFR group than their counterpart. While directly measured CFR did not differ significantly (4.4 ± 2.3 vs. 5.1 ± 2.8, p = 0.18), MRR was lower in the low pbCFR group (5.4 ± 3.0 vs. 6.8 ± 3.8, p = 0.047). The rates of CFR < 2.0 and IMR ≥ 25 were not significantly different between the 2 groups. In conclusion, although CFR did not differ significantly, IMR and MRR were impaired in patients with low pbCFR, suggesting pbCFR as a potential surrogate of coronary microvascular function in clinical practice.

Advances in Cellular Reprogramming-Based Approaches for Heart Regenerative Repair

Continuous loss of cardiomyocytes (CMs) is one of the fundamental characteristics of many heart diseases, which eventually can lead to heart failure. Due to the limited proliferation ability of human adult CMs, treatment efficacy has been limited in terms of fully repairing damaged hearts. It has been shown that cell lineage conversion can be achieved by using cell reprogramming approaches, including human induced pluripotent stem cells (hiPSCs), providing a promising therapeutic for regenerative heart medicine. Recent studies using advanced cellular reprogramming-based techniques have also contributed some new strategies for regenerative heart repair. In this review, hiPSC-derived cell therapeutic methods are introduced, and the clinical setting challenges (maturation, engraftment, immune response, scalability, and tumorigenicity), with potential solutions, are discussed. Inspired by the iPSC reprogramming, the approaches of direct cell lineage conversion are merging, such as induced cardiomyocyte-like cells (iCMs) and induced cardiac progenitor cells (iCPCs) derived from fibroblasts, without induction of pluripotency. The studies of cellular and molecular pathways also reveal that epigenetic resetting is the essential mechanism of reprogramming and lineage conversion. Therefore, CRISPR techniques that can be repurposed for genomic or epigenetic editing become attractive approaches for cellular reprogramming. In addition, viral and non-viral delivery strategies that are utilized to achieve CM reprogramming will be introduced, and the therapeutic effects of iCMs or iCPCs on myocardial infarction will be compared. After the improvement of reprogramming efficiency by developing new techniques, reprogrammed iCPCs or iCMs will provide an alternative to hiPSC-based approaches for regenerative heart therapies, heart disease modeling, and new drug screening.

Cost reduction associated with transradial access in percutaneous coronary intervention: A report from a Japanese nationwide registry

Background

Percutaneous coronary intervention (PCI) is increasingly performed via transradial access (TRA). This study aimed to investigate the clinical and economic benefits of TRA compared with transfemoral access (TFA) under universal healthcare coverage system in Japan.

Methods

A total of 36,153 patients (acute coronary syndrome [ACS], 15,266; stable ischemic heart disease [SIHD], 20,052) across 714 institutions in the Japanese nationwide PCI registry (J-PCI) in 2015 were analyzed (mean age 69.9 ± 11.1 years and 23.6% female). Cost was defined as the total amount of healthcare resources used to care for the patient during hospitalization. Propensity score matching analysis was conducted to balance the baseline characteristics of patients undergoing TRA and TFA.

Findings

The median total cost of PCI was JPY 1,341,176 (interquartile range, 959,052), with higher expenses for ACS (JPY 1,772,116 [1,117,107]) compared with SIHD (JPY 1,119,153 [540,440]) patients. Most patients underwent PCI via TRA (73.8%), and after propensity score matching, TRA was associated with a reduced risk of in-hospital death and bleeding (0.88% vs. 1.91% [P < 0.0001] and 2.18% vs. 4.53% [P < 0.0001] in ACS, and 0.10% vs. 0.28% [P = 0.070] and 0.53% vs. 1.72% [P < 0.0001] in SIHD, respectively), which led to lower costs in both ACS (JPY 1,699,279 [1,164,554] for TRA vs. JPY 1,931,255 [1,070,222] for TFA; P < 0.0001), and SIHD (JPY 1,102,352 [505,904] for TRA vs. JPY 1,311,525 [706,450] for TFA; P < 0.0001) patients.

Interpretation

In this direct cost analysis of a nationwide registry, the use of TRA was associated with cost saving for both ACS and SIHD patients.

Funding

This study was funded by the Japan Society for the Promotion of Science (grant nos. 20H03915, 16H05215, 16KK0186, 20K22883, and 21K08064), Japan Agency for Medical Research and Development [AMED] (grant number 16lk1010004h0002), and the National Clinical Database. The J-PCI registry is led and supported by the Japanese Association of Cardiovascular Intervention and Therapeutics.

Prognostic Factors of In-Hospital Mortality in Patients with Acute Myocardial Infarction Complicated by Cardiogenic Shock

Among patients with acute myocardial infarction (MI) complicated by cardiogenic shock (CS), in-hospital mortality remains high. In the present study, we aimed to identify factors associated with clinical outcomes of acute MI patients with CS in a contemporary setting. A total of 1102 patients with acute MI undergoing primary percutaneous coronary intervention were included, among whom 196 (17.8%) were complicated by CS. The primary outcome was all-cause death during hospitalization, and factors associated with in-hospital mortality were explored in patients with acute MI and CS. Of the 196 patients with acute MI complicated by CS, 77 (39.3%) died during hospitalization. The rates of non-ST-segment elevation MI (NSTEMI) (33.8% vs. 19.3%, p = 0.02) and culprit lesion in the left main or left anterior descending coronary artery (68.8% vs. 47.9%, p = 0.004) were higher, while left ventricular ejection fraction (LVEF) was lower (24.4 ± 11.7% vs. 39.7 ± 13.8%, p < 0.001) in non-survivors than in survivors. Multivariable analysis identified NSTEMI presentation and lower LVEF as independent predictors of in-hospital death. In conclusion, NSTEMI and low LVEF were identified as factors associated with higher in-hospital mortality. The identification of even higher-risk subsets and targeted therapeutic strategies may be warranted to improve survival of patients with acute MI and CS.

Comparison of Long-Term Clinical Outcomes in Patients Stratified by a Novel Acute Myocardial Infarction Risk Stratification (nARS) System

BACKGROUND

As severity of acute myocardial infarction (AMI) varies widely, several risk stratifications for AMI have been reported. We have introduced a novel AMI risk stratification system linked to a rehabilitation program (novel AMI risk stratification; nARS), which stratified AMI patients into low (L)-, intermediate (I)-, and high (H)-risk groups. The purpose of this retrospective study was to compare the long-term clinical outcomes in patients with AMI among L-, I-, H-risk groups.

METHODS AND RESULTS

This study included 773 AMI patients, and assigned them into the L-risk group (n=332), the I-risk group (n=164), and the H-risk group (n=277). The primary endpoint was major cardiovascular events (MACE), defined as the composite of all-cause death, readmission for heart failure, non-fatal myocardial infarction, and target vessel revascularization after the discharge of index admission. The median follow-up duration was 686 days. MACE was most frequently observed in the H-risk group (39.4%), followed by the I-risk group (23.2%), and least in the L-risk group (19.9%) (P<0.001). The multivariate Cox hazard analysis revealed that the H-risk was significantly associated with MACE (HR 2.166, 95% CI 1.543-3.041, P<0.001) after controlling for multiple confounding factors.

CONCLUSIONS

H-risk according to nARS was significantly associated with long-term adverse events after hospital discharge for patients with AMI. These results support the validity of nARS as a risk marker for long-term outcomes.

Association of collateral flow with clinical outcomes in patients with acute myocardial infarction

Coronary collateral flow is an important prognostic marker in percutaneous coronary intervention (PCI) for chronic total occlusion. However, the role of collateral flow to the culprit lesion of acute myocardial infarction (AMI) has not been fully established yet. The purpose of this retrospective study was to examine the association between collateral flow and long-term clinical outcomes in patients with AMI. We included 937 patients with AMI, and divided those into the no-collateral group (n = 704) and the collateral group (n = 233) according to the presence or absence of collateral flow to the culprit lesion of AMI. The primary endpoint was the incidence of major adverse cardiac events (MACE), which was defined as a composite of all-cause death, non-fatal MI, re-admission for heart failure, and ischemia driven target vessel revascularization. The median follow-up duration was 473 days (Q1: 184 days- Q3: 1027 days), and a total of 263 MACE was observed during the study period. The incidence of MACE was significantly greater in the no-collateral group than in the collateral group (29.8% vs. 22.3%, p = 0.027). In the multivariate COX hazard model, the presence of collateral flow was inversely associated with MACE (HR 0.636, 95% CI 0.461-0.878, p = 0.006) after controlling multiple confounding factors. In conclusion, the presence of collateral flow to the culprit lesion of AMI was inversely associated with long-term adverse outcomes. Careful observation of collateral flow may be important in emergent coronary angiography to stratify a high-risk group among various patients with AMI.

Use of a Cutting Balloon Reduces the Incidence of Distal Embolism in Acute Coronary Syndrome Requiring Predilatation Before Stenting

Background: Acute coronary syndrome (ACS) patients with solid lesions often require predilatation before stenting. Predilatation with high pressure may increase the risk of distal embolism, whereas direct stenting increases the risk of stent underexpansion. We recently reported that, in severely calcified lesions, using a cutting balloon (CB) can provide greater acute gain compared with other scoring balloons. Therefore, we hypothesized that predilatation with CB may reduce the incidence of distal embolism in ACS patients with solid lesions. Methods and Results: This study retrospectively analyzed data for 175 ACS patients who required predilatation, either with a conventional balloon (n=136) or CB (n=39). The occurrence of distal embolism was significantly lower in the CB than conventional balloon group (10.3% vs 32.4%, respectively; P=0.007). Multivariate analysis showed that the occurrence of distal embolism was positively associated with Thrombolysis in Myocardial Infarction (TIMI) grade and the presence of attenuated plaque, but negatively associated with the use of a CB. To support this clinical observation, we compared thrombus dispersal using a CB and non-compliant balloon in an ex vivo experimental model using a pseudo-thrombus. In this model, pseudo-thrombus dispersal was significantly smaller when a CB rather than non-compliant balloon was used (1.8±1.0% vs 2.6±1.2%, respectively; n=20, for each; P=0.002). Conclusions: In ACS patients with solid lesions that require predilatation, predilatation with a CB may reduce the incidence of distal embolism.

Use of Thrombus Aspiration for Patients With Acute Coronary Syndrome: Insights From the Nationwide J-PCI Registry

Background

There is significant regional or institutional variation in the use of thrombus aspiration (TA) in patients undergoing percutaneous coronary intervention (PCI). We investigated the temporal trend in TA use and its association with clinical outcomes in acute coronary syndrome using the nationwide J‐PCI (Japanese PCI) registry.

Methods and Results

Between 2016 and 2018, patients with acute coronary syndrome undergoing PCI (n=282 606; median age, 71.0 years; interquartile range, 62.0–79.0 years; women, 24.7%) at 1124 hospitals were stratified on the basis of whether TA was performed (TA and non‐TA). The patients were subdivided according to clinical presentation (ST‐segment–elevation myocardial infarction, non–ST‐segment–elevation myocardial infarction, and unstable angina). Successful PCI, defined as the achievement of TIMI (Thrombolysis in Myocardial Infarction) 3 flow, and in‐hospital mortality were assessed. During the study period, 83 422 patients (29.5%) underwent TA (52.9%, 23.5%, and 5.2% for ST‐segment–elevation myocardial infarction, non–ST‐segment–elevation myocardial infarction, and unstable angina, respectively), and the TA implementation rate remained relatively stable throughout. Patients treated with TA had higher rate of successful PCI than non‐TA (98.7% versus 97.8%; P<0.001). TA was not associated with in‐hospital death among patients with ST‐segment–elevation myocardial infarction (adjusted odds ratio [aOR], 1.02 [95% CI, 0.94–1.12]). However, TA use was associated with higher rates of in‐hospital death in patients with non–ST‐segment–elevation myocardial infarction ( aOR, 1.51 [95% CI, 1.23–1.86]) or unstable angina ( aOR, 1.95 [95% CI, 1.37–2.79]).

Conclusions

In our retrospective analysis of the nationwide PCI registry, TA use was associated with a higher achievement of successful PCI without impairing in‐hospital mortality among patients with ST‐segment–elevation myocardial infarction. Nevertheless, its use should be cautioned in less‐established indications (eg, non–ST‐segment–elevation myocardial infarction and unstable angina).

Relationship of body mass index to clinical outcomes after percutaneous coronary intervention

BACKGROUND

Elevated body mass index (BMI) demonstrates lower all-cause and cardiovascular mortalities compared with normal-weight or lean patients in chronic diseases. This study investigated relationships between BMI and clinical outcomes following percutaneous coronary intervention (PCI) in coronary artery disease (CAD) patients, together with the sex-specific impacts of BMI on mortality.

METHODS

We reviewed 1104 CAD patients who underwent PCI between 2006 and 2015. Patients were divided by BMI into three groups: lean, <18.5 kg/m² ; normal, 18.5-24.9 kg/m² ; and overweight/obese, ≥25 kg/m² . The primary endpoint was all-cause mortality, and the secondary endpoint was 3-point major adverse cardiovascular events (MACE).

RESULTS

Kaplan-Meier survival analysis demonstrated risks of all-cause death, and 3-point MACE were higher in lean patients compared with normal-weight and overweight/obese subjects (log-rank p < .001). Cox proportional hazard modelling showed overweight/obese was significantly associated with all-cause death (hazard ratio (HR) 0.68, 95% confidence interval (CI) 0.48-0.95; p = .03), and lean was significantly associated with 3-point MACE (HR 2.02, 95% CI 1.15-3.53; p = .01). Cox proportional hazard analysis with restricted cubic spline showed non-linear associations between BMI and both all-cause mortality and 3-point MACE (p for effect = .002 and = .003, respectively). No significant interaction was evident between sex and BMI for all-cause mortality (p for interaction = .104) or 3-point MACE (p for interaction =0.122).

CONCLUSIONS

Lean category was associated with adverse outcomes among CAD patients. An obesity paradox regarding the independent association of elevated BMI with reduced mortality after PCI is evident in both males and females.

Relation of hyperemic response during fractional flow reserve measurement to coronary flow reserve

BACKGROUND

Coronary flow reserve (CFR) represents entire coronary compensatory capacity, while fractional flow reserve (FFR) is a standard to evaluate functional severity of epicardial coronary artery disease (CAD). ΔFFR, a decrease in a ratio of mean distal coronary pressure to aortic pressure (Pd/Pa) at rest to FFR, is conceptually associated with coronary microvascular function. This study aimed to evaluate the relation of ΔFFR to CFR in patients with stable CAD.

METHODS

We performed resting Pd/Pa and FFR measurements in a total of 309 vessels with intermediate coronary artery stenosis in 242 patients. ΔFFR was defined as (resting Pd/Pa - FFR), and pressure bounded-CFR was calculated to estimate low CFR. Vessels were divided as the low CFR and non-low CFR groups.

RESULTS

Of 309 vessels, low CFR was observed in 101 (32.7 %). While FFR values were similar (0.78 ± 0.11 vs. 0.78 ± 0.09, p = 0.84), resting Pd/Pa (0.85 ± 0.08 vs. 0.93 ± 0.04, p < 0.001) and ΔFFR (0.07 ± 0.06 vs. 0.15 ± 0.06, p < 0.001) were significantly lower in the low CFR group than in the non-low CFR group. The receiver operating characteristic curve analysis indicated that ΔFFR was predictive for low CFR (area under the curve 0.84, best cut-off value 0.08, p < 0.001). Multivariable analysis identified lower ΔFFR, the left anterior descending coronary artery, and lower hemoglobin and higher brain natriuretic peptide levels as factors associated with low CFR.

CONCLUSIONS

In patients with stable CAD, lower ΔFFR was significantly associated with low CFR in intermediate coronary stenosis in patients with stable CAD. ΔFFR may be a simple, practical, and useful surrogate to identify patients with impaired CFR.