Calcium evaluation using coronary computed tomography in combination with optical coherence tomography.

Optical coherence tomography (OCT) can assess calcium thickness, a key factor for predicting good stent expansion; however, it underestimates coronary calcium severity due to its penetration limitation. This study aimed to evaluate computed tomography (CT) and OCT images to assess calcification. We investigated 25 left anterior descending arteries of 25 patients, using coronary CT and OCT, and assessed their calcification. Of the 25 vessels, 1811 pairs of CT and OCT cross-sectional images were co-registered. Of the 1811 cross-sectional CT images, calcification was not detectable in 256 (14.1%) of the corresponding OCT images due to limited penetration. In the 1555 OCT calcium-detectable images, the maximum calcium thickness was not detectable in 763 (49.1%) images compared to the CT images. In CT images of slices corresponding to undetected calcium in OCT images, the angle, thickness, and maximum density of calcium were significantly smaller compared to slices corresponding to detected calcium in OCT. Calcium with an undetectable maximum thickness in the corresponding OCT image had a significantly greater calcium angle, thickness, and density than calcium with a detectable maximum thickness. There was an excellent correlation between CT and OCT with respect to calcium angle ( R= 0.82, P < 0.001). The calcium thickness on the OCT image had a stronger correlation with the maximum density on the corresponding CT image (R = 0.73, P < 0.001) than with the calcium thickness on the CT image (R = 0.61, P < 0.001). Cross-sectional CT imaging allows for pre-procedural assessment of calcium morphology and severity and could complement the lack of information on calcium severity in OCT-guided percutaneous coronary intervention.

Women With Acute Aortic Dissection Have Higher Prehospital Mortality Than Men.

Background: Acute aortic dissection (AAD) often leads to out-of-hospital cardiac arrest (OHCA) and death before hospital arrival. Objectives: The purpose of this study was to investigate differences in AAD incidence by sex. Methods: A population-based study in a city with 121,180 residents was conducted using postmortem computed tomography data to identify patients with AAD who died before hospital arrival in 2008-2020. The incidence rate ratio and odds ratio were estimated using Poisson regression and univariable logistic regression, respectively. Results: A total of 266 patients with incident AAD were enrolled: 84 patients with OHCA, 137 women [n = 137], and 164 patients with type A AAD. The crude and age-adjusted incidence of AAD was 16.2 and 14.3/100,000 person-years, respectively. The incidence of AAD was comparable by sex (men, 16.7/100,000 person-years; women, 15.7/100,000 person-years; incidence rate ratio: 0.94; 95% CI: 0.74-1.20; P = 0.64). Compared with men with AAD, women with AAD were older (77 ± 11 years vs 70 ± 14 years; P < 0.001), and a higher proportion had type A AAD (76% vs 47%; P < 0.001). Women with AAD had higher prehospital mortality than men with AAD (37% vs 21%; P = 0.004; OR: 2.24; 95% CI: 1.30-3.87; P = 0.004). Among 1,373 patients with OHCA, the proportion of women with AAD was significantly higher than the proportion of men with AAD (11% vs 3.9%; P < 0.001; OR: 2.90; 95% CI: 1.86-4.53; P < 0.001). AAD was most common in women aged 60 to 69 years (16.4%). Conclusions: Women had a higher incidence of AAD presenting as prehospital death than men.

Relationship Between Heart Failure Hospitalization Costs and Left Ventricular Ejection Fraction in an Advanced Aging Society.

Background: Left ventricular ejection fraction (LVEF) is a basic clinical index that determines the heart failure (HF) treatment strategy. We aimed to evaluate the association between hospitalization costs for HF patient and LVEF in an advanced aging society in a region in Japan. Methods and Results: Consecutive HF patients admitted to Miyazaki Prefectural Nobeoka Hospital between January 2015 and March 2018 were included in the study. The 346 HF patients (mean age 78 years) were divided into 2 groups: HF with reduced ejection fraction (HFrEF; LVEF <40%; n=129) and HF with preserved ejection fraction (HFpEF; LVEF ≥40%; n=217). Median hospitalization costs (in 2017 US dollars) were higher in the HFrEF than HFpEF group, but the difference was not statistically significant ($7,128 vs. $6,580; P=0.189). However, in older adults (age ≥75 years; n=252), median hospitalization costs were significantly higher in the HFrEF than HFpEF group ($7,240 vs. $6,471; P=0.014), and LVEF was an independent factor of hospitalization costs (ß=-0.0301, P=0.006). Median hospitalization costs were significantly lower in the older than younger HFpEF group ($6,471 vs. $7,250; P=0.011), but there was no significant difference in costs between the older and younger HFrEF groups ($7,240 vs. $6,760; P=0.351). Conclusions: The relationship between LVEF and hospitalization costs became more pronounced with age, and LVEF was a negative independent factor for hospitalization costs in the older population.

Optical coherence tomography-versus intravascular ultrasound-guided stent expansion in calcified lesions.

Optical coherence tomography (OCT) has a higher resolution than intravascular ultrasound (IVUS) and enables a more precise evaluation of calcium severity. We investigated the impact of the imaging method (OCT versus IVUS) on stent expansion during intravascular imaging-guided percutaneous coronary intervention (PCI) in calcified lesions. In this single-center, retrospective, observational study, 145 lesions with moderate to severe calcification were divided into four groups: 40 IVUS-guided rotational atherectomy (RA), 38 IVUS-guided non-RA, 35 OCT-guided RA, and 32 OCT-guided non-RA. Lesions without pre-procedural intravascular imaging were excluded. OCT-guided RA was associated with greater stent expansion at the target calcium compared with IVUS-guided RA (median 88.0%, interquartile range [78.0-96.0] vs. 76.5% [71.0-84.3], P = 0.008). Furthermore, stent expansion in OCT-guided non-RA was similar to OCT-guided RA. OCT-guided RA used a larger burr compared to IVUS-guided RA (1.75 mm [1.50-2.0] vs. 1.50 mm [1.50-1.75], P = 0.004). In OCT-guided RA, the median minimum calcium thickness was significantly reduced from 800 (640-980) µm to 550 (350-680) µm (P < 0.001). There was no significant difference in the incidence of ischemia driven target lesion revascularization between the four groups (P = 0.37). By determining the indication and endpoint of lesion modification by RA based on the thickness of calcium, OCT-guided PCI was associated with significantly greater stent expansion compared with IVUS-guided PCI.

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

AIMS: Optimal pharmacological treatment for chronic heart failure has been established. However, treatments that can improve the prognosis of acute heart failure (AHF) are controversial. Although intravenous diuretics may be one optimal treatment option, little evidence has shown the effect of early administration of diuretics on clinical outcomes in patients with AHF. The aim of this study was to evaluate the association between door-to-furosemide (D2F) time, improved oxygenation, and in-hospital mortality in patients hospitalized for AHF. METHODS AND RESULTS: We screened 494 patients hospitalized for AHF in Miyazaki Prefectural Nobeoka Hospital. AHF patients who were treated with intravenous furosemide within 24 h of arrival at the hospital were included in this study. D2F time was defined as the time from patient arrival at the hospital to the first intravenous dose of furosemide. The early administration group was defined as those with D2F time ≤60 min, whereas the non-early group was defined as those with D2F time >60 min. The primary outcome was the rate of improved oxygenation at Day 1. The secondary outcomes were in-hospital mortality and cardiac death. There were 219 patients treated with the first intravenous dose of furosemide within 24 h analysed after the exclusion of 275 patients. The median D2F time was 55 min (interquartile range: 30-120 min) in the final cohort. The early administration group included 121 patients (55.3%). The rate of improved oxygenation was higher in the early group than the non-early group [median 16.7% (interquartile range: 0.0-40.0) vs. 0.0% (0.0-20.6), respectively, P < 0.001]. During the study period, there were six patients (5.0%) with in-hospital mortality in the early group and nine patients (9.2%) in the non-early group (P = 0.218). Cardiac death was observed less frequently in the early group than in the non-early group, but without statistical significance (3.3% and 9.2%, respectively) (P = 0.067). The univariable logistic regression analyses showed that early administration of furosemide was associated with improved oxygenation [odds ratio (OR): 2.26; 95% confidence interval (CI): 1.31-3.91; P = 0.004], but not with in-hospital mortality (OR: 0.52; 95% CI: 0.18-1.50; P = 0.225) or cardiac death (OR: 0.34; 95% CI: 0.10-1.13; P = 0.079). In multivariable analyses adjusted for risk score or relevant variables, early administration of furosemide was consistently associated with improvement of oxygenation. CONCLUSIONS: The present study showed that in AHF patients, the early administration of furosemide was associated with improved oxygenation.

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

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

Risk Prediction Score for Cancer Development in Patients With Acute Coronary Syndrome.

BACKGROUND: Cancer is a known prognostic factor in patients with acute coronary syndrome (ACS), but few risk assessments of cancer development after ACS have been established.Methods and Results:Of the 573 consecutive ACS admissions between January 2015 and March 2018 in Nobeoka City, Japan, 552 were analyzed. Prevalent cancer was defined as a treatment history of cancer, and incident cancer as post-discharge cancer incidence. The primary endpoint was post-discharge cancer incidence, and the secondary endpoint was all-cause death during follow-up. All-cause death occurred in 9 (23.1%) patients with prevalent cancer, and in 17 (3.5%) without cancer. In the multivariable analysis, prevalent cancer was associated with all-cause death. To develop the prediction model for cancer incidence, 21 patients with incident cancer and 492 without cancer were analyzed. We compared the performance of D-dimer with that of the prediction model, which added age (≥65 years), smoking history, and high red blood cell distribution width to albumin ratio (RAR) to D-dimer. The areas under the receiver-operating characteristics curves of D-dimer and the prediction model were 0.619 (95% confidence interval: 0.512-0.725) and 0.774 (0.676-0.873), respectively. Decision curve analysis showed superior net benefits of the prediction model. CONCLUSIONS: By adding elderly, smoking, and high RAR to D-dimer to the prediction model it became clinically useful for predicting cancer incidence after ACS.

Association between coronary artery calcium score and stent expansion in percutaneous coronary intervention.

BACKGROUND: Measurement of the coronary artery calcification score using multidetector computed tomography (MDCT) is a useful noninvasive test for the diagnosis of coronary artery disease. However, whether pre-intervention assessment of the target vessel coronary artery calcification (TV-CAC) score is associated with stent expansion failure and future target lesion revascularization (TLR), remains unknown. This study aimed to determine the association between the TV-CAC score measured by MDCT and stent expansion rate in patients who underwent IVUS-guided PCI for stable angina. METHODS: We conducted a retrospective observational study including 135 consecutive patients (186 target lesions) who underwent MDCT and were scheduled for the first PCI. The patients were divided into 2 groups based on the median value of the TV-CAC score. The primary outcome was the stent expansion rate measured by IVUS after stent implantation. The secondary outcome was TLR within 1 year. RESULTS: Stent expansion rate was associated with the TV-CAC score (p < 0.001). According to the ROC curve analysis, the TV-CAC score had the largest area under the curve (AUC) for the stent expansion area of 0.90 (AUC = 0.893, p < 0.001). The TV-CAC score was a positive predictor for stent expansion rate of <90% (odds ratio: 7.54, p < 0.001). Mediation analysis showed that stent under-expansion was a mediator of the association between high TV-CAC and TLR. CONCLUSIONS: Our study demonstrates that pre-intervention assessment of TV-CAC using MDCT is a predictor of stent expansion. The TV-CAC score might predict the complexity and help in the PCI operative strategy.