Long-Term Impact of Renin-Angiotensin System Inhibitors for Secondary Prevention in Patients with Chronic Kidney Disease Who Underwent Percutaneous Coronary Intervention

Introduction

The long-term impact of renin-angiotensin system (RAS) inhibitors for secondary prevention in patients with chronic kidney disease (CKD) and coexisting coronary artery disease remains unclear.

Methods

Altogether, 1,160 consecutive patients with CKD (mean age, 70 ± 9 years; 78% men) who underwent their first percutaneous coronary intervention (PCI) between 2000 and 2018 were included and analyzed. Based on their RAS inhibitor use, 674 patients (58%) were allocated to the RAS inhibitor group, and 486 patients (42%) were allocated to the non-RAS inhibitor group. This study evaluated the incidence of 3-point major adverse cardiovascular events (3P-MACE), including cardiovascular death, nonfatal acute coronary syndrome and nonfatal stroke, admission for heart failure (HF), target vessel revascularization (TVR), and all-cause death.

Results

During a median follow-up duration of 7.8 years, 280 patients (24.1%) developed 3P-MACE, 134 patients (11.6%) were hospitalized for HF, 171 patients (14.7%) underwent TVR, and 348 patients (30.0%) died of any causes. The cumulative incidence rate of 3P-MACE in the RAS inhibitor group was significantly lower than in the non-RAS inhibitor group (31.7% vs. 39.0%, log-rank test, p = 0.034); however, that of admission for HF in the RAS inhibitor group was significantly higher than in the non-RAS inhibitor group (28.1% vs. 13.3%, log-rank test, p < 0.001). The subgroup of preserved ejection fraction, non-acute myocardial infarction, and non-proteinuria tended to promote the onset of HF rather than cardiovascular prevention by RAS inhibitors.

Conclusion

The long-term RAS inhibitor use for patients with CKD after PCI might prevent cardiovascular events but increase the risk of HF.

Erdafitinib in BCG-treated high-risk non-muscle-invasive bladder cancer

BACKGROUND

Treatment options are limited for patients with high-risk non-muscle-invasive bladder cancer (NMIBC) with disease recurrence after bacillus Calmette-Guérin (BCG) treatment and who are ineligible for/refuse radical cystectomy. FGFR alterations are commonly detected in NMIBC. We evaluated the activity of oral erdafitinib, a selective pan-fibroblast growth factor receptor (FGFR) tyrosine kinase inhibitor, versus intravesical chemotherapy in patients with high-risk NMIBC and select FGFR3/2 alterations following recurrence after BCG treatment.

PATIENTS AND METHODS

Patients aged ≥18 years with recurrent, BCG-treated, papillary-only high-risk NMIBC (high-grade Ta/T1) and select FGFR alterations refusing or ineligible for radical cystectomy were randomized to 6 mg daily oral erdafitinib or investigator's choice of intravesical chemotherapy (mitomycin C or gemcitabine). The primary endpoint was recurrence-free survival (RFS). The key secondary endpoint was safety.

RESULTS

Study enrollment was discontinued due to slow accrual. Seventy-three patients were randomized 2 : 1 to erdafitinib (n = 49) and chemotherapy (n = 24). Median follow-up for RFS was 13.4 months for both groups. Median RFS was not reached for erdafitinib [95% confidence interval (CI) 16.9 months-not estimable] and was 11.6 months (95% CI 6.4-20.1 months) for chemotherapy, with an estimated hazard ratio of 0.28 (95% CI 0.1-0.6; nominal P value = 0.0008). In this population, safety results were generally consistent with known profiles for erdafitinib and chemotherapy.

CONCLUSIONS

Erdafitinib prolonged RFS compared with intravesical chemotherapy in patients with papillary-only, high-risk NMIBC harboring FGFR alterations who had disease recurrence after BCG therapy and refused or were ineligible for radical cystectomy.

Successful Rituximab Therapy for Skin Sclerosis and Myositis in a Patient With Systemic Sclerosis, Myositis and Sjögren's Syndrome Associated With Autoimmune Polyendocrine Syndrome Type 2

Autoimmune polyendocrine (or polyglandular) syndrome (APS) is a relatively rare clinical condition characterized by functional impairment of multiple endocrine glands due to loss of immune tolerance. APS is broadly categorized as rare monogenic forms, such as autoimmune polyendocrine syndrome type 1 (APS-1), and a more common polygenic variety, autoimmune polyendocrine syndrome type 2 (APS-2). Although many autoimmune conditions including autoimmune rheumatic diseases can develop in APS-2, systemic sclerosis or myositis as a complication is quite rare and no treatment strategy has yet been established. A 25-year-old man who had been diagnosed as having type 1 diabetes developed finger stiffness. Although the subjective symptoms were relatively mild, extensive examinations including various autoantibodies, hormones and biopsy of the skin and minor salivary glands revealed that he had APS-2 (type 1 diabetes and autoimmune thyroid disease) accompanied by systemic sclerosis, myositis and Sjögren's syndrome. Rituximab therapy was initiated for the progressive skin sclerosis, and this resulted in significant alleviation of both the sclerosis and the myositis. In APS, early diagnosis and immunomodulatory therapy may arrest the autoimmune process before irreversible organ damage has occurred. This case report suggests that rituximab may be a promising therapy for autoimmune rheumatic diseases associated with APS-2.

Impact of Low-Dose Prasugrel on Platelet Reactivity in Chronic Phase of Post-Percutaneous Coronary Intervention (CHAPERON): a Prospective Cohort Study

PURPOSE

Asians often face the problems of clopidogrel resistance and East Asian paradox. This study aimed to evaluate the effects of P2Y₁₂ inhibitors, including low-dose prasugrel 2.5 mg, on the P2Y₁₂ reaction unit (PRU) in the chronic phase after percutaneous coronary intervention (PCI).

METHODS

A total of 348 patients were studied. PRU was measured 6-12 months after PCI and subsequently, 6 months later using a P2Y₁₂ assay, respectively. This study evaluated the proportion of bleeding risk (PRU ≤ 85) and ischemic risk (PRU ≥ 239) as primary endpoints, and the prediction of bleeding risk and ischemic risk using multivariable logistic regression analysis.

RESULTS

At baseline, 136 patients (39%) received prasugrel 3.75 mg, 48 patients (14%) received prasugrel 2.5 mg, and 164 patients (47%) received clopidogrel 75 mg. Clopidogrel 75 mg had a significantly higher proportion of ischemic risk within one year after PCI than the other groups, and was an independent predictor for ischemic risk with reference of prasugrel 3.75 mg. In addition, switching from clopidogrel 75 mg to prasugrel 2.5 mg significantly lowered and aggregated the PRU value. Whereas, dose reduction of prasugrel had a significantly lower proportion of bleeding risk over one year after PCI than the continuation of prasugrel 3.75 mg, and was an independent predictor for bleeding risk with reference of continuation of prasugrel 3.75 mg.

CONCLUSIONS

Prasugrel 2.5 mg has a lower ischemic risk and a more stable PRU value compared with clopidogrel treatment. Prasugrel also contributes to a decline in bleeding risk with concomitant dose reduction.

TRIAL REGISTRATION

University Hospital Medical Information Network (UMIN), ID: UMIN000029541, Date: October 16, 2017 ( https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000033395 ).

9,9-Bis[4-(N-aryl)phenyl]methylidene-xanthylidene Derivatives Displaying Mechano-, Crystallo-, and Thermochromism

Tetraphenylethylene (TPE) derivatives bearing a xanthene moiety are of interest because they have novel optical properties. 9,9-Bis[4-(N,N-diphenylamino)phenyl] and 9,9-bis[4-(9-carbazolyl)-phenyl]methylidene-xanthylidenes 3 and 4 were synthesized using Suzuki-Miyaura coupling of 9,9-dibromomethylidene-xanthylidene with the corresponding boronic acids. Diphenylamino derivative 3 exhibits mechanochromism and mechanofluorochromism (MC and MFC) reflected in absorption and fluorescence color changes. In contrast, carbazolyl derivative 4 displays thermo- and crystallo-chromism in addition to MC and MFC in the solid state. Powder X-ray diffraction and single crystal X-ray crystallographic analysis reveal that the solid state photophysical properties of these substances are governed by conformational changes rather by the creation of planar π-conjugation extended geometries.

Relationship between coronary high-intensity plaques on T1-weighted imaging by cardiovascular magnetic resonance and vulnerable plaque features by near-infrared spectroscopy and intravascular ultrasound: a prospective cohort study

BACKGROUND

This study aimed to compare the coronary plaque characterization by cardiovascular magnetic resonance (CMR) and near-infrared spectroscopy (NIRS)-intravascular ultrasound (IVUS) (NIRS-IVUS), and to determine whether pre-percutaneous coronary intervention (PCI) evaluation using CMR identifies high-intensity plaques (HIPs) at risk of peri-procedural myocardial infarction (pMI). Although there is little evidence in comparison with NIRS-IVUS findings, which have recently been shown to identify vulnerable plaques, we inferred that CMR-derived HIPs would be associated with vulnerable plaque features identified on NIRS-IVUS.

METHODS

52 patients with stable coronary artery disease who underwent CMR with non-contrast T1-weighted imaging and PCI using NIRS-IVUS were studied. HIP was defined as a signal intensity of the coronary plaque-to-myocardial signal intensity ratio (PMR) ≥ 1.4, which was measured from the data of CMR images. We evaluated whether HIPs were associated with the NIRS-derived maximum 4-mm lipid-core burden index (maxLCBI4mm) and plaque morphology on IVUS, and assessed the incidence and predictor of pMI defined by the current Universal Definition using high-sensitive cardiac troponin-T.

RESULTS

Of 62 lesions, HIPs were observed in 30 lesions (48%). The HIP group had a significantly higher remodeling index, plaque burden, and proportion of echo-lucent plaque and maxLCBI4mm ≥ 400 (known as large lipid-rich plaque [LRP]) than the non-HIP group. The correlation between the maxLCBI4mm and PMR was significantly positive (r = 0.51). In multivariable logistic regression analysis for prediction of HIP, NIRS-derived large LRP (odds ratio [OR] = 5.41; 95% confidence intervals [CIs] 1.65-17.8, p = 0.005) and IVUS-derived echo-lucent plaque (OR = 5.12; 95% CIs 1.11-23.6, p = 0.036) were strong independent predictors. Furthermore, pMI occurred in 14 of 30 lesions (47%) with HIP, compared to only 5 of 32 lesions (16%) without HIP (p = 0.005). In multivariable logistic regression analysis for prediction of incidence of pMI, CMR-derived HIP (OR = 5.68; 95% CIs 1.53-21.1, p = 0.009) was a strong independent predictor, but not NIRS-derived large LRP and IVUS-derived echo-lucent plaque.

CONCLUSIONS

There is an important relationship between CMR-derived HIP and NIRS-derived large LRP. We also confirmed that non-contrast T1-weighted CMR imaging is useful for characterization of vulnerable plaque features as well as for pre-PCI risk stratification. Trial registration The ethics committee of Juntendo Clinical Research and Trial Center approved this study on January 26, 2021 (Reference Number 20-313).

Relationship Between Optical Coherence Tomography-Derived In-Stent Neoatherosclerosis and the Extent of Lipid-Rich Neointima by Near-Infrared Spectroscopy and Intravascular Ultrasound: A Multimodal Imaging Study

Background In-stent restenosis, especially for neoatherosclerosis, is a major concern following percutaneous coronary intervention. This study aimed to elucidate the association of features of in-stent restenosis lesions revealed by optical coherence tomography (OCT)/optical frequency domain imaging (OFDI) and the extent of lipid-rich neointima (LRN) assessed by near-infrared spectroscopy (NIRS) and intravascular ultrasound, especially for neoatherosclerosis. Methods and Results We analyzed patients undergoing percutaneous coronary intervention for in-stent restenosis lesions using both OCT/OFDI and NIRS-intravascular ultrasound. OCT/OFDI-derived neoatherosclerosis was defined as lipid neointima. The existence of large LRN (defined as a long segment with 4-mm maximum lipid core burden index ≥400) was evaluated by NIRS. In 59 patients with 64 lesions, neoatherosclerosis and large LRN were observed in 17 (26.6%) and 21 lesions (32.8%), respectively. Naturally, large LRN showed higher 4-mm maximum lipid core burden index (median [interquartile range], 623 [518-805] versus 176 [0-524]; P<0.001). In OCT/OFDI findings, large LRN displayed lower minimal lumen area (0.9±0.4 versus 1.3±0.6 mm²; P=0.02) and greater max lipid arc (median [interquartile range], 272° [220°-360°] versus 193° [132°-247°]; P=0.004). In the receiver operating characteristic curve analysis, 4-mm maximum lipid core burden index was the best predictor for neoatherosclerosis, with a cutoff value of 405 (area under curve, 0.92 [95% CI, 0.83-1.00]). In multivariable logistic analysis, only low-density lipoprotein cholesterol (odds ratio, 1.52 [95% CI, 1.11-2.08]) was an independent predictor for large LRNs. Conclusions NIRS-derived large LRN was significantly associated with neoatherosclerosis by OCT/OFDI. The neointimal characterization by NIRS-intravascular ultrasound has potential as an alternative method of OCT/OFDI for in-stent restenosis lesions.

Paradoxical Long-Term Impact Between Serum Apolipoprotein E and High-Density Lipoprotein Cholesterol in Patients Undergoing Percutaneous Coronary Intervention

AIM

Apolipoprotein E (ApoE) strongly affects arteriosclerosis but has atheroprotective effects in combination with high-density lipoprotein cholesterol (HDL-C). The impact of the quantitative relationship between serum ApoE and HDL-C levels in patients with coronary artery disease (CAD) remains unclear.

METHODS

A total of 3632 consecutive patients who underwent their first intervention between 2000 and 2016 were included. They were categorized into normal and abnormal HDL-C groups based on the normal HDL-C value, and each group was subdivided into high and low ApoE subgroups based on the group-specific median ApoE value. We evaluated the incidence of major adverse cardiac and cerebrovascular events (MACCE), including cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, and all-cause death Results: During a 6.4-year follow-up, 419 patients developed MACCE and 570 patients died. The interaction term between ApoE levels and HDL-C status in MACCE and all-cause death proved to be statistically significant. Kaplan-Meier analysis revealed that the cumulative incidence of MACCE was significantly higher for elevated pre-procedural ApoE levels than for reduced preprocedural ApoE levels in the normal HDL-C group. Conversely, the cumulative incidence of MACCE was significantly higher for reduced pre-procedural ApoE levels than for elevated pre-procedural ApoE levels in the abnormal HDL-C group. After adjustment for important covariates, multivariable Cox hazard analysis revealed that the serum ApoE level was a strongly independent predictor of MACCE; this was inversely related in both groups.

CONCLUSIONS

Serum ApoE levels may have a paradoxical impact on the future cardiovascular risk depending on the HDL-C status in patients with CAD.

Long-term impact of β-blocker in elderly patients without myocardial infarction after percutaneous coronary intervention

AIMS

Little is known about the long-term outcomes of β-blockers use in patients with coronary artery disease (CAD) without myocardial infarction (MI) and reduced ejection fraction (rEF). However, more attention should be paid to the oral administration of β-blockers in elderly patients who are susceptible to heart failure (HF), sinus node dysfunction, or rate response insufficiency. We aimed to evaluate the long-term impact of β-blockers in elderly patients with CAD without MI or systolic HF who have undergone percutaneous coronary intervention.

METHODS AND RESULTS

A total of 1018 consecutive elderly patients with CAD (mean age, 72 ± 7 years; 77% men) who underwent their first intervention between 2010 and 2018 were included in this study. According to the presence or absence of the use of β-blockers, 514 patients (50.5%) were allocated to the β-blocker group, and 504 (49.5%) to the non-β-blocker group. We evaluated the incidence of 4-point major adverse cardiovascular events (4P-MACE), including cardiovascular death, non-fatal MI, non-fatal stroke, admission for HF, target vessel revascularization (TVR), and all-cause death. We focused on the association between chronotropic incompetence of β-blockers and incidence of a new HF and analysed the results using an exercise electrocardiogram regularly performed in the outpatient department after percutaneous coronary intervention. During a median follow-up duration of 5.1 years, 83 patients (8.3%) developed 4P-MACE, including cardiovascular death in 17, non-fatal MI in 13, non-fatal stroke in 25, and admission for HF in 39 patients. Additionally, 124 patients (12.2%) had a TVR and 104 (10.2%) died of other causes. Kaplan-Meier analysis showed that the cumulative incidence rate of 4P-MACE in the β-blocker group was significantly higher than that in the non-β-blocker group (15.4% vs. 10.0%, log-rank test, P = 0.015). Above all, the cumulative incidence rate of admission for HF in the β-blocker group was significantly higher (8.8% vs. 3.2%, log-rank test, P < 0.001). The β-blocker group had significantly lower resting heart rate, stress heart rate, and stress-rest Δ heart rate on exercise electrocardiogram. Multivariate Cox hazard analysis revealed that EF, β-blocker use, stress-rest Δ heart rate, and CKD were strong independent predictors of admission for HF.

CONCLUSIONS

Long-term β-blocker use was significantly associated with an increased risk of adverse cardiovascular events in elderly patients with CAD without MI or systolic HF. In particular, the chronotropic incompetence action of β-blockers could increase the risk of admission for HF in elderly patients with CAD without MI and systolic HF, and the present findings warrant further investigation.

Serum apolipoprotein E levels predict residual cardiovascular risk in patients with chronic coronary syndrome undergoing first percutaneous coronary intervention and on-statin treatment

BACKGROUND AND AIMS

Little is known about the long-term impact of apolipoprotein E (apoE) on residual cardiovascular risk in patients with chronic coronary syndrome (CCS) receiving statin treatment.

METHODS

A total of 1109 consecutive patients (mean age, 67 ± 10 years; 83% men) with CCS who underwent their first intervention between 2000 and 2016 were included in this study. All patients had achieved low-density lipoprotein cholesterol (LDL-C) <100 mg/dL on statin treatment and were divided into two groups based on median serum apoE values. We evaluated the incidence of major adverse cardiovascular events (MACEs), including cardiovascular death, non-fatal acute coronary syndrome, and target vessel revascularization.

RESULTS

A total of 552 and 557 patients were categorized to the higher and lower apoE groups, respectively. There were significant relationships between apoE levels and total cholesterol levels, triglyceride levels, high-density lipoprotein cholesterol levels, and estimated remnant cholesterol, except for LDL-C levels. During the median follow-up period of 5.1 years, 195 patients (17.6%) developed MACEs. Kaplan-Meier analysis revealed that the cumulative incidence of MACEs in the higher apoE group was significantly higher than in the lower apoE group (29.5% vs.23.8% log-rank test, p = 0.019). Using multivariable Cox hazard analysis, serum apoE level (1-mg/dL increase) (hazard ratio 1.15; 95% confidence interval 1.03-1.29, p = 0.013) was the strongest independent predictor of MACEs.

CONCLUSIONS

Serum apoE level could be a strong predictor of residual cardiovascular risk in patients with CCS long-term, even if LDL-C levels are controlled with statin treatment.

Comparison of 6-month vascular healing response after bioresorbable polymer versus durable polymer drug-eluting stent implantation in patients with acute coronary syndromes: A randomized serial optical coherence tomography study

Objectives

This study was conducted to use optical coherence tomography (OCT) to compare vascular healing between bioresorbable polymer (BP) and durable polymer (DP) everolimus‐eluting stents (EES) in patients with acute coronary syndromes (ACS).

Background

Whether BP‐EES induce better vascular healing compared to contemporary DP‐EES remains controversial, especially for ACS.

Methods

In this prospective, randomized, non‐inferiority trial, we used OCT to compare 6‐month vascular healing in patients with ACS randomized to BP versus DP‐EES: percent strut coverage (primary endpoint, non‐inferiority margin of 2.0%) and neointimal thickness and percent neointimal hyperplasia (NIH) volume. As an exploratory analysis, morphological factors related to the endpoints and the effect of underlying lipidic plaque on stent healing were evaluated.

Results

A total of 104 patients with ACS were randomly assigned to BP‐EES (n = 52) versus DP‐EES (n = 52). Of these, 86 patients (40 BP‐EES and 46 DP‐EES) were included in the final OCT analyses. Six‐month percent strut coverage of BP‐EES (83.6 ± 11.4%) was not non‐inferior compared to those of DP‐EES (81.6 ± 13.9%), difference 2.0% (lower 95% confidence interval‐2.6%), p_{non‐inferiority} = 0.07. There were no differences in neointimal thickness 70.0 ± 33.9 μm versus 67.2 ± 33.9 μm, p = 0.71; and percent NIH volume 7.5 ± 4.7% versus 7.3 ± 5.3%, p = 0.85. By multivariable linear regression analysis, stent type was not associated with percent strut coverage or percent NIH volume; however, percent baseline embedded struts or stent expansion was positively associated with percent NIH volume. Greater NIH volume was observed in lipidic compared with non‐lipidic segments (8.7 ± 5.6% vs. 6.1 ± 5.2%, p = 0.005).

Conclusions

Six‐month strut coverage of BP‐EES was not non‐inferior compared to those of DP‐EES in ACS patients. Good stent apposition and expansion were independently associated with better vascular healing.

High Apolipoprotein E Levels Predict Adverse Limb Events in Patients with Peripheral Artery Disease Due to Peripheral Artery Disease Undergoing Endovascular Treatment and On-Statin Treatment

Little is known about the association between limb prognosis in peripheral artery disease and apolipoprotein E (apoE). We evaluated the long-term impact of apoE on adverse limb events in patients with intermittent claudication receiving statin treatment.A total of 218 consecutive patients (mean age, 73 ± 8 years; 81% men) with intermittent claudication who underwent their first intervention between 2009 and 2020 were included in this study. All patients had achieved LDL-C < 100 mg/dL on statin treatment and were divided into two groups based on the apoE value (≥ 4.7 or < 4.7 mg/dL). We evaluated the incidence of major adverse limb events (MALEs), including vessel revascularization and limb ischemia development.A total of 39 and 179 patients were allocated to the higher and lower apoE groups, respectively. Compared to the lower apoE group, the higher apoE group had a significantly higher total cholesterol level, triglyceride level, and non-high-density lipoprotein cholesterol level. During the median follow-up period of 3.6 years, 30 patients (13.8%) developed MALEs. Kaplan-Meier analysis revealed that the cumulative incidence of MALEs in the higher apoE group was significantly higher than that in the lower apoE group (44.0% versus 21.6%, log-rank test, P = 0.002). During multivariable Cox hazard analysis, higher apoE level (≥ 4.7 mg/dL) (hazard ratio, 2.61; 95% confidence interval, 1.18-5.70, P = 0.019) was the only strong independent predictor of MALEs.ApoE levels could be a strong predictor and residual risk for long-term limb prognosis in patients with intermittent claudication and achieving LDL-C < 100 mg/dL with statin treatment.

Integrative analysis of gut microbiome and host transcriptomes reveals associations between treatment outcomes and immunotherapy-induced colitis

Immune checkpoint inhibitors (ICIs) are widely used to treat various malignancies. Although the gut microbiome is known to influence the efficacy of ICIs on epithelial tumors, the functional interactions between gut taxa and colonic mucosa remain poorly understood. Here we performed transcriptomic profiling and 16S rRNA sequencing to investigate the relationships between mucosal gene expression and microbial composition with ICI responses and gastrointestinal immune-related adverse events (GI irAEs). In responders, genes related to DNA repair and cell cycle signatures were enriched in responders whereas signatures related to innate immune response, NFAT and IFN-γ signaling pathways were enriched in nonresponders. Gut microbial composition revealed an association between moderate GI irAE and favorable response to ICI therapy. Favorable therapeutic responses to ICI and GI irAE treatments were associated with taxa classified as Enterobacteriaceae and were related to ribonucleoprotein complex biogenesis, cytokine-mediated signaling pathway, tRNA metabolic process, and ribonucleoprotein complex assembly in the colon. These findings open new perspectives for improving the efficacy and safety of cancer immunotherapy.

Long-term impact of high-sensitivity C-reactive protein in patients with intermittent claudication due to peripheral artery disease following endovascular treatment

Little is known about the prognostic impact of high-sensitivity C-reactive protein (hs-CRP) levels on causes of death during long-term follow-up. We, therefore, investigated the associations between hs-CRP and clinical outcomes in the patients with intermittent claudication. Three hundred thirty-five consecutive patients (mean age, 72 ± 8 years, 82% men) undergoing first intervention for de novo iliac and/or femoropopliteal artery lesions from 2009 to 2020 were studied. Patients were divided into 2 groups based on the optimal cutoff value of hs-CRP (> or ≤ 0.15 mg/dL). The median follow-up duration was 3.6 years (interquartile range, 1.0-6.2 years). Although the cumulative incidence rate of major adverse cardiovascular limb events was not significantly different between the higher and lower hs-CRP groups (29.0 and 22.1%, respectively; log-rank test, p = 0.410), that of all-cause death was significantly higher in the higher hs-CRP group than in the lower hs-CRP group (18.7 vs. 5.8%, log-rank test, p = 0.007), even in cardiovascular-related death and malignancy-related death (log-rank test, p = 0.030 and 0.046, respectively). Higher hs-CRP levels at the time of intervention were significantly associated with higher frequency of all-cause death, even after adjusting for other risk factors (hazard ratio 2.79; 95% confidence interval 1.66-7.17, p = 0.024). In addition, malignancy-related death was most frequent as high as 60% (21/35 deaths), and elevated hs-CRP levels and the Brinkman index were strongly independent predictors of malignancy-related death. In conclusion, elevated hs-CRP levels were significantly associated with cardiovascular-related and malignancy-related deaths in patients with intermittent claudication. Furthermore, the result that cancer mortality exceeds cardiovascular mortality is different from previous reports, so the present findings warrant further investigation.

Predictors of discordance between fractional flow reserve and resting full-cycle ratio in patients with coronary artery disease: Evidence from clinical practice

BACKGROUND

Fractional flow reserve (FFR) is an established method for assessing functional myocardial ischemia. Recently, the resting full-cycle ratio (RFR) has been introduced as a non-hyperemic index of functional coronary stenosis. However, the effects of clinical characteristics on discordance between RFR and FFR have not been fully evaluated. We aimed to identify clinical characteristics that influence FFR-RFR concordance.

METHODS

We included 410 patients with 573 intermediate coronary lesions who underwent clinically indicated invasive coronary angiography, as well as assessments of FFR and RFR. Receiver-operating characteristic (ROC) curves were created to assess the optimal cut-off values of RFR for predicting FFR ≤0.80.

RESULTS

RFR exhibited a strong correlation with FFR (r = 0.66, p < 0.0001). ROC analysis identified an optimal RFR cut-off value of 0.92 for categorization based on an FFR cut-off value of 0.8. The discordance of FFR >0.8 and RFR ≤0.92 (high FFR/low RFR) was observed in 112 lesions (20.9%), whereas the discordance of FFR ≤0.8 and RFR >0.92 (low FFR/high RFR) was observed in 35 lesions (6.5%). Higher rate of hemodialysis and lower hemoglobin levels were observed in the high FFR/low RFR group. Multivariate analyses identified female sex, left anterior descending artery (LAD) lesions, and hemodialysis as significant predictors of high FFR/low RFR. Conversely, body surface area and non-LAD lesions were significantly associated with low FFR/high RFR. Hemodialysis [odds ratio (OR): 2.41, 95% confidence interval (CI) 1.31-4.41; p = 0.005] and LAD lesions (OR: 1.86, 95% CI: 1.25-2.79; p = 0.002) were identified as independent predictors of overall FFR-RFR discordance.

CONCLUSIONS

RFR exhibited good diagnostic performance in the identification of functionally significant stenosis. However, RFR may overestimate functional severity in patients undergoing hemodialysis or in those with LAD lesions. Further prospective trials are required to demonstrate the non-inferiority of RFR to FFR.

Long-term clinical outcomes and cause of death after endovascular treatment for femoropopliteal artery lesions

BACKGROUND

Endovascular treatment (EVT) for femoropopliteal artery disease is common in clinical practice. However, little is known about its prognostic factors, causes of death, and long-term clinical outcomes.

METHODS

Two hundred eighty-five consecutive patients (mean age, 72±8 years, 73% men) undergoing their first EVT for de-novo femoropopliteal artery disease from 2009 to 2018 were studied. Patients were divided in two groups according to the presence of critical limb ischemia (CLI). We evaluated the incidence of major adverse limb events (MALE) including clinically driven target vessel revascularization and target limb major amputation, and all-cause death.

RESULTS

The procedure was successful in 97.9% of cases. The non-CLI group comprised 205 patients (72%), and the CLI group comprised 80 patients (28%). The CLI group exhibited higher high-sensitivity C-reactive protein (hs-CRP) levels and a higher rate of hemodialysis than the non-CLI group. During the median follow-up period of 3.5 years, there were 62 deaths (21.8%) including cardiovascular (32.3%), infection (32,3%), and malignancy-related (22.6%) deaths. Kaplan-Meier analysis revealed that the CLI group had a significantly higher incidence of MALE and all-cause death (log-rank, both p<0.001, respectively). The leading causes of death in the CLI group were cardiovascular- and infection-related death; the leading cause of death in the non-CLI group was malignancy-related. On multivariate Cox hazard analysis, hemodialysis, TASC II classification C/D lesions, and CLI were significant predictors of MALE (p<0.001, p=0.005, and p=0.012, respectively). Hemodialysis, age, higher hs-CRP levels, and CLI were significant predictors of all-cause death (p<0.001, p=0.003, p=0.009, and p=0.021, respectively).

CONCLUSIONS

Although EVT for femoropopliteal artery disease appears feasible with a high rate of procedural success, a high incidence of MALE and all-cause death was observed. Further studies are needed to improve the outcomes in patients with CLI.

Fluoride-Ion-Catalyzed Synthesis of Ladder-type Conjugated Benzobisbenzofurans via Intramolecular Nucleophilic Aromatic Substitution Reaction under Metal-free and Mild Conditions

The fluoride-ion-catalyzed synthesis of benzobisbenzofuran derivatives is described. Fluorine-containing aryl silyl ethers were reacted with 5 mol % of Bu₄NF to give desired compounds in high yield under mild conditions. Syn-selective cyclization reaction was discovered for a particular compound as a kinetic product. Computational analysis revealed that the fluorine substituents in the anti-type benzobisbenzofurans affect the order of the molecular orbitals.

Postfunctionalization of a Perfluoroarene-Containing π-Conjugated Polymer via Nucleophilic Aromatic Substitution Reaction

Postfunctionalization is a useful strategy to tune the properties of conjugated polymers, while polymer reactions in the main chain of a conjugated backbone are still underexplored. Here we report the postfunctionalization of the main chain of a conjugated polymer via nucleophilic aromatic substitution reaction. Poly(9,9-dioctylfluorene-alt-tetrafluoro-p-phenylene) is used as a precursor to react with thiophenol derivatives in the presence of a base to enable multiple introduction of arylthio groups into the polymer main chain in high yield with preserving the backbone and the dispersity of the precursor polymer. The main chain structure and optoelectronic properties of the resulting polymers were significantly changed, evidenced by spectroscopic analysis of both model compounds and polymers as well as a computational simulation.

Deficiency of Gankyrin in the small intestine is associated with augmented colitis accompanied by altered bacterial composition of intestinal microbiota

Background

Gankyrin (GK) is an oncoprotein which regulates inflammatory responses and its inhibition is considered as a possible anti-inflammatory therapy for inflammatory bowel disease (IBD).

Methods

In this study, we investigated the role of GK in epithelial cells using mice with intestinal epithelial cell-specific GK deletion in (i) the entire small intestine and colon (Villin-Cre;Gankyrin^f/f) and (ii) the distal intestine and colon (Cdx2-Cre;Gankyrin^f/f).

Result

Unexpectedly, GK-deficiency in the upper small bowel augmented inflammatory activity compared with control mice when colitis was induced with dextran sodium sulfate. Biochemical analyses have revealed GK-deficiency to have caused reduction in the expression of antimicrobial peptides, α-Defensin-5 and -6, in the upper small bowel. Examination of human samples have further confirmed that the reduction of GK expression in the small bowel is associated with colonic involvement in human Crohn’s disease. Through the sequencing of bacterial 16S rRNA gene amplicons, bacteria potentially deleterious to intestinal homeostasis such as Helicobacter japonicum and Bilophila were found to be over-represented in colitis induced Villin-Cre;Gankyrin^f/f mice when compared to Gankyrin^f/f control mice under the same condition.

Conclusion

These results highlight the distinct site dependence of the pro- and anti-inflammatory functions of GK and provide important insights into the pathogenesis of IBD.

Tellurophene-containing π-conjugated polymers with unique heteroatom–heteroatom interactions by post-element-transformation of an organotitanium polymer

A unique π-conjugated tellurophene-containing polymer that possesses fully coplanar ring units through a tellurium–oxygen interaction, was prepared by the post-element-transformation of a titanacyclopentadiene-containing reactive precursor.

Redox chemistry of π-extended tellurophenes

In the past decade, the incorporation of tellurophene motifs into organic devices has been a promising strategy for the design of advanced materials. However, fundamental redox behavior of tellurophene-containing materials have never been comprehensively explored. Here, we report unique redox behavior of π-extended tellurophenes. The facile coordination of solvent molecules and/or anions becomes evident, in addition to the attachment of nucleophilic halides. This indicates that the tellurium center in oxidized 2,5-diphenyltellurophene is highly electron-deficient and easily yields coordinated structures. This coordination appears to trap the positive charge on the tellurium center rather than delocalizing it over the π-system. When no coordinating counter ion is present, however, oxidation appears to be delocalized over the entire π-system. Additionally, by using more delocalized structures, we show that coordination and charge-delocalization can co-exist. These results provide important insights to understand the properties of tellurophene-containing molecules and materials with extended π-systems.

Te-Li Exchange Reaction of Tellurophene-Containing π-Conjugated Polymer as Potential Synthetic Tool for Functional π-Conjugated Polymers

On the basis of the facts that tellurophene-containing π-conjugated polymers are obtainable from organotitanium polymers and that the tellurium atoms in the tellurophene derivatives can be transformed into lithium atoms, the synthesis of reactive lithiated polymer precursor and its transformations into some functionalized π-conjugated polymers are described. A regioregular organometallic polymer having 1,4-dilithio-1,3-butadiene and 9,9-dioctylfluorene-2,7-diyl units is generated by the reaction of a tellurophene-containing polymer having the number-average molecular weight (M_n ) and molecular weight distribution (M_w /M_n ) of 5890 and 1.9, respectively, with n-butyllithium (2.4 equiv.) at -78 °C to -60 °C for 3 h. The lithiated polymer thus prepared is subjected to reactions with electrophiles to produce functionalized π-conjugated polymers. For example, a π-conjugated polymer possessing 1,4-bis(tri-n-butylstannyl)-1,3-butadiene-1,4-diyl unit is obtained in 67% yield by the reaction with tri-n-butyltin chloride (2.4 equiv.) at -60 °C to ambient temperature for 12 h in tetrahydrofuran, whose M_n and M_w /M_n are estimated as 7320 and 2.5, respectively, by size exclusion chromatography. The absorption maximum and onset of the obtained polymer are observed at 380 and 465 nm, respectively, in the UV-vis spectrum, from which the optical band gap of the polymer is estimated as 2.67 eV.

Synthesis of Stannole-Containing π-Conjugated Polymers by Post-Element Transformation of Organotitanium Polymer

The synthesis of stannole-2,5-diyl-containing π-conjugated polymers by the post-element transformation of a regioregular organotitanium polymer is described. For example, a 1,1-diphenylstannole-containing polymer is obtained in 83% yield by the reaction of a regioregular organotitanium polymer, which is prepared from 1,4-bis(2-ethylhexyloxy)-2,5-diethynylbenzene and a low-valent titanium complex with diphenyltin dichloride at -50 °C to ambient temperature. The number-average molecular weight and molecular weight distribution (M_n and M_w /M_n ) of the stannole-containing polymer are estimated as 4800 and 1.8, respectively. The obtained polymer is found to have the extended π-conjugated backbone and relatively low-lying lowest unoccupied molecular orbital (LUMO) energy level (-3.12 eV), which is supported by its UV-vis absorption spectrum and cyclic voltammetric (CV) analysis. In addition, the stannole-containing polymer is found to be applicable to a chemosensor for fluoride anion where the color and photoluminescence intensity of the polymer solution exhibits a distinct change in the presence of a fluoride anion.

Successful Coronary Flow Restoration by Stent-Free Strategy Using the Pull-Back Method of Cutting Balloon in Spontaneous Coronary Artery Dissection

This report describes a 46-year-old woman with ST-elevation myocardial infarction due to spontaneous coronary artery dissection. Because continuous chest pain and ST-segment elevation in electrocardiography indicated ongoing cardiac ischemia, the urgent revascularization strategy was used using a novel method of cutting balloon angioplasty, “the pull-back of inflated cutting balloon,” which led to the successful coronary flow restoration and complete healing of dissected coronary artery in 1 year. The pull-back of the inflated cutting balloon method is a useful therapeutic option in the treatment of patients with spontaneous coronary artery dissection with ongoing cardiac ischemia.