Sex difference in 5-year relative survival following percutaneous coronary intervention

Background

Sex-specific survival following percutaneous coronary intervention (PCI) varies among studies. This might be clarified using relative survival, which adjusts observed survival in relation to that seen in sex- and age-matched general population. We investigated sex-specific relative survival after PCI.

Methods

A total of 48,783 patients were enrolled in the year 2011 Korean nationwide PCI cohort. Primary outcome was all-cause death. Observed and relative survival at 5 years conditional on surviving 0 days, 30 days, 1 year, and 2 years were assessed. Sex-specific differences in cardiovascular risk factors were adjusted via age-group stratified propensity score matching.

Results

In the unadjusted analyses, 15,710 female patients had a higher frequency of cardiovascular risk factors compared with 33,073 male patients. Both observed survival (hazard ratio [HR]=1.28, 95% confidence interval [CI]=1.22–1.34) and relative survival (HR=1.21, 95% CI: 1.16–1.27) were worse in female compared with male (p<0.001, all). In analyses of propensity score-matched 14,454 pairs, female showed a higher observed survival (HR=0.78, 95% CI: 0.74–0.82) but a lower relative survival (HR=1.19, 95% CI: 1.13–1.26) compared with male (p<0.001, all). Neither observed nor relative survival differed between female of age≤50s and age-matched male, but they were lower in female of age≥60s than age-matched male. These findings were consistent in further analyses conditional on surviving 30 days, 1 year, and 2 years.

Conclusions

The 5-year relative survival of female aged≥60 years adjusted by clinical risk factors was lower than that of age-matched male, which mandates the need for the excessive risk reduction in older female undergoing PCI.

Funding Acknowledgement

Type of funding sources: None.

Hyperaemic and non-hyperaemic pressure indices of coronary stenosis severity in patients with chronic kidney disease

Background

Evidence regarding the use of pressure indices for the assessment of coronary stenoses in patients with chronic kidney disease (CKD) is scarce.

Methods

We assessed the relation between eGFR, FFR and resting Pd/Pa in 1147 consecutive patients (1316 vessels) included in the International Collaboration of Comprehensive Physiologic Assessment Study. We also compared FFR and Pd/Pa against a standardized cut-off of coronary flow reserve (CFR<2.0). Finally, we examined the occurrence of vessel-oriented composite outcome (VOCO: cardiac death, vessel-specific revascularization, vessel-specific myocardial infarction) across negative/positive results of both FFR and CFR in patients with and without CKD.

Results

FFR increases as renal function worsens (beta −10.5, 95% CI −20.0 to −11.03, p=0.030), a relation that was not seen with resting Pd/Pa (beta −6.14, 95% CI −19.9 to 6.78, p=0.351). Both indices had similar diagnostic accuracies for the detection of a CFR<2.0 in the presence of CKD (AUC 0.629 for FFR vs 0.663 for resting Pd/Pa, p=0.192). However, CKD patients showed a higher proportion of vessels with negative FFR but low CFR (24.5% vs 13.4%, p=0.015).

CFR decreased linearly with deteriorating eGFR, and this was mainly driven by higher resting coronary flow in CKD patients (p=0.026), while hyperaemic coronary flow remained similar (p=0.403). IMR did not change significantly with eGFR (beta −0.02, 95% −0.09 to 0.05, p=0.557).

The incidence of VOCO was higher in patients with CKD and FFR>0.80 when compared to non-CKD patients and FFR>0.80 (12.7% vs 6.90%, p=0.062). Prognosis was worse for those with CKD, negative FFR and CFR<2.0 (20.59% vs. 8.44% in non-CKD, p=0.038).

Conclusions

The assessment of a given coronary stenosis in patients with CKD with either FFR or resting Pd/Pa is equivalent when compared to underlying coronary flow. In CKD, impaired CFR is caused by a state of increased resting flow. The assessment of CFR on top of standard pressure wire examination significantly improves prognostic stratification in CKD patients.

Funding Acknowledgement

Type of funding sources: None.

Aspirin vs. Clopidogrel as a Chronic maintenance monotherapy after PCI in patients with high ischemic risk and high bleeding risk: Subgroup analysis of the HOST-EXAM trial

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

on behalf of the HOST-EXAM investigators

Background

The HOST-EXAM randomized clinical trial recently performed a comparison of clopidogrel monotherapy vs. aspirin monotherapy in patients requiring indefinite antiplatelet monotherapy after percutaneous coronary intervention (PCI). This study randomized 5,438 patients who maintained dual antiplatelet therapy without clinical events for 6–18 months after PCI with drug-eluting stents (DES) to receive a monotherapy agent of clopidogrel 75 mg once daily or aspirin 100 mg once daily for 24 months. During the 24-month follow-up, the primary outcome (a composite of all-cause death, non-fatal myocardial infarction, stroke, readmission due to acute coronary syndrome, and Bleeding Academic Research Consortium (BARC) bleeding type 3 or greater) rate was significantly lower in the clopidogrel group (hazard ratio [HR] 0.73 [95% CI 0.59–0.90]; p = 0.0035). However, it is uncertain whether the beneficial effect of clopidogrel will be consistent in patients with high ischemic risk or those with high bleeding risk.

Methods

This is a post-hoc analysis of the HOST-EXAM trial. A high ischemic risk was defined as those who had at least 1 of the following procedural features: 3 vessels treated, ≥3 stents implanted, ≥3 lesions treated, bifurcation PCI, total stent length >60 mm, or left main PCI. Patients with high bleeding risk were defined according to the Academic Research Consortium for High Bleeding Risk (ARC-HBR) criteria. The co-primary outcome were thrombotic endpoints (a composite of cardiac death, non-fatal myocardial infarction, ischemic stroke, readmission due to acute coronary syndrome, and definite or probable stent thrombosis) and bleeding endpoints (BARC type ≥2 bleeding events) at 24-month follow-up.

Results

 Among the total population, 22.1% had high ischemic risk and 21.4% had high bleeding risk. Complex PCI was not associated with a higher risk of thrombotic endpoints, nor bleeding endpoints. For patients with a high bleeding risk, these patients had a higher risk of both thrombotic endpoints (HR 1.545, 95% CI 0.141-2.092, p = 0.005) and bleeding endpoints (HR 3.418, 95% CI 2.413-4.840, p < 0.001). The primary results focusing on the interaction between high ischemic risk, high bleeding and the antiplatelet regimen will be presented.

Conclusion

The current post-hoc analysis of the HOST-EXAM trial will evaluate the efficacy of clopidogrel monotherapy vs. aspirin monotherapy during the chronic maintenance period after PCI, in patients with high ischemic risk or those with high bleeding risk.

STAT1-mediated Bim expression promotes the apoptosis of retinal pericytes under high glucose conditions

Hyperglycemia impacts different vascular cell functions and promotes the development and progression of various vasculopathies including diabetic retinopathy. Although the increased rate of apoptosis in pericytes (PCs) has been linked to increased oxidative stress and activation of protein kinase C-δ (PKC-δ) and SHP-1 (Src homology region 2 domain-containing phosphatase-1) tyrosine phosphatase during diabetes, the detailed mechanisms require further elucidation. Here we show that the rate of apoptosis and expression of proapoptotic protein Bim were increased in the retinal PCs of diabetic Akita/+ mice and mouse retinal PCs cultured under high glucose conditions. Increased Bim expression in retinal PCs under high glucose conditions required the sustained activation of signal transducer and activator of transcription 1 (STAT1) through production of inflammatory cytokines. PCs cultured under high glucose conditions also exhibited increased oxidative stress and diminished migration. Inhibition of oxidative stress, PKC-δ or Rho-associated protein kinase I/II was sufficient to protect PCs against apoptosis under high glucose conditions. Furthermore, PCs deficient in Bim expression were protected from high glucose-mediated increased oxidative stress and apoptosis. However, only inhibition of PKC-δ lowered Bim levels. N-acetylcysteine did not affect STAT1 levels, suggesting that oxidative stress is downstream of Bim. PCs cultured under high glucose conditions disrupted capillary morphogenesis of retinal endothelial cells (ECs) in coculture experiments. In addition, conditioned medium prepared from PCs under high glucose conditions attenuated EC migration. Taken together, our results indicate that Bim has a pivotal role in the dysfunction of retinal PCs under high glucose conditions by increasing oxidative stress and death of PCs.

Positive regulation of hepatic carnitine palmitoyl transferase 1A (CPT1A) activities by soy isoflavones and L-carnitine

BACKGROUND

Genistein increases CPT1A, a rate-limiting enzyme in the beta-oxidation pathway, enzyme activity by increasing CPT1A transcription in HepG2 cells and, consequently, suppresses high fat induced obesity in C57BL/6J mice. Genistein and daidzein are the most abundant isoflavones in soy.

AIM OF STUDY

To investigate the effect of co-treatment of genistein and L-carnitine on CPT1A enzyme activity and to determine whether daidzein also increases CPT1A activity and to establish a cell line that can be used to screen chemicals to regulate CPT1A transcription.

METHODS

The enzyme activities of CPT1A were determined after HepG2 cells were incubated with 10 microM genistein or 10 microM daidzein or 1 mM L-carnitine or in combination with 10 microM genistein and 1 mM L-carnitine or in combination with 10 microM daidzein and 1 mM L-carnitine. The mRNA expression levels of CPT1A were determined by real time PCR method after HepG2 cells were incubated with 10 microM genistein or 10 microM daidzein. A suggested CPT1A promoter region was cloned from human genomic DNA and the CPT1A promoter-luciferase reporter gene construct was made, and the promoter-reporter gene construct was transfected into human hepatoma cell line Huh7.

RESULTS

The enzyme activity of CPT1A was at least 2.3- fold higher in L-carnitine and genistein co-treated HepG2 cells than either single-agent treated cells. Daidzein also significantly increased the mRNA expression of CPT1A as well as the enzyme activity of CPT1A. A stable Huh7 cell line, which was selected after Huh7 cells were transfected with CPT1A promoter luciferase reporter gene construct, was characterized by confirming that luciferase activity of the cell line can be regulated by genistein and daidzein as well as clofibrate, a well-known CPT1A mRNA up-regulating drug.

CONCLUSIONS

Genistein and daidzein can up-regulate CPT1A enzyme activity through up-regulation of CPT1A transcription. Co-treatment of L-carnitine and genistein additively increases CPT1A enzyme activity in HepG2 cells. A stable Huh7 cell line transfected with the CPT1A promoter luciferase reporter gene was established and characterized.

Transjugular intrahepatic portosystemic shunt placement in the setting of polycystic liver disease: questioning the contraindication

Although polycystic liver disease has long been listed as a contraindication to transjugular intrahepatic portosystemic shunt (TIPS) creation, two cases of TIPS placement in that particular clinical setting have been reported. Another case is reported in this article and the clinical course over 21 months of follow-up is examined. The discussion reviews the mechanics of TIPS creation in a polycystic liver and the vague premise of the polycystic liver as a contraindication to TIPS.

Effect of weight control on hepatic abnormalities in obese patients with fatty liver

This study was aimed at finding out whether weight reduction alone can improve liver function in obese patients with fatty liver. We did a longitudinal, clinical intervention study on weight reduction by behavior modification, diet and exercise. The study subjects were 25 patients referred to an obesity clinic in whom obesity is the sole factor causing abnormal liver function and fatty liver. Patients were weighed about one year later. We compared the degree of improvement in hepatic function between Group I that showed weight reduction and Group II that showed no-weight reduction. Group I (13) showed dramatic improvement in aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels, nearly all down to within normal levels. AST showed statistically significant improvement from 74 +/- 36 IU/l to 25 +/- 7 IU/l. ALT also showed statistically significant improvement from 109 +/- 67 IU/l to 30 +/- 14 IU/l. Group II (12) showed higher AST and ALT levels on follow-up visit than initial visit. AST showed statistically significant elevation from 43 +/- 11 IU/l to 59 +/- 23 IU/l. ALT also showed statistically significant elevation from 64 +/- 21 IU/l to 97 +/- 33 IU/l. If we can rule the other causes of hepatic abnormalities in obese patients with fatty liver, we suggest these patients would benefit by weight reduction.