A prospective double-blinded randomized study on drug-eluting stent implantation into nitrate-induced maximally dilated vessels in patients with coronary artery disease.

BACKGROUND: Percutaneous coronary intervention (PCI) has been developed using drug-eluting stents (DES); however, stent implantation is associated with concerns of stent thrombosis and target vessel revascularization (TVR). The stent diameter is a critical factor in TVR and clinical events. The nitrate administration in coronary angiography can dilate the reference vessel diameter, enabling accurate vessel size measurement and optimal stent implantation support. This study was designed to evaluate the effect of stent implantation in the maximally dilated coronary artery in patients with coronary artery disease (CAD). METHODS: This prospective double-blinded randomized (1:1) study is designed to compare the efficacy and safety between DES implantation into the nitrate-induced maximally dilated vessels and conventional DES implantation in patients with CAD. A total of 400 patients who underwent PCI with a sirolimus-eluting stent will be enrolled. The primary endpoint is the mean diameter of the deployed stents. Secondary endpoints include cardiac death, myocardial infarction, stent thrombosis, or ischemia-driven TVR 1 year after the procedure. DISCUSSION: This study will be the first randomized controlled trial to evaluate the effect of DES implantation on nitrate-induced maximally dilated vessels in patients with CAD. TRIAL REGISTRATION: The trial was registered on 18 June 2021 as Effect of Ultimaster Stents Treated to the Most Dilated Coronary Vessels (ClinicalTrials.gov Identifier: NCT04931784).

Prognostic Impact of Plasma Glucose on Patients With Cardiogenic Shock With or Without Diabetes Mellitus from the SMART RESCUE Trial.

Although the presence of hyperglycemia has been shown to affect the clinical outcome of patients with cardiogenic shock, the extent of hyperglycemia and its association with prognosis have not been fully addressed in a large population. A total of 1,177 consecutive patients with cardiogenic shock were enrolled from January 2014 to December 2018 at 12 hospitals in South Korea. The primary outcome was in-hospital mortality. Patients were divided into 4 groups according to their initial plasma glucose level in patients with diabetes mellitus (DM) (n = 752) and patients without DM (n=425); group 1 (≤8 mmol/L or 144 mg/100 ml), group 2 (8 to 12 mmol/L or 144 to 216 mg/100 ml), group 3 (12 to 16 mmol/L or 216 to 288 mg/100 ml), and group 4 (≥16 mmol/L or 288 mg/100 ml). The groups with higher admission plasma glucose were associated with lower systolic blood pressure and higher lactic acid levels in patients with and without DM. In-hospital mortality increased in groups with higher admission plasma glucose level in patients without DM (group 1:24.2%, group 2: 28.6%, group 3: 38.1%, group 4: 49.0%, p <0.01), whereas in patients with DM, mortality and admission plasma glucose level showed no significant association (group 1: 45%, group 2: 35.4%, group 3: 33.3%, group 4: 43.1%, p = 0.26). Even after multivariate analysis, high plasma glucose was an independent predictor of in-hospital mortality in patients without DM. In patients with cardiogenic shock, plasma glucose obtained at admission was associated with in-hospital mortality in patients without DM.

Correlation of heart rate recovery and heart rate variability with atrial fibrillation progression.

OBJECTIVE: To examine the combination of heart rate recovery (HRR) and heart rate variability (HRV) in predicting atrial fibrillation (AF) progression. METHODS: Data from patients with a first detected episode of AF who underwent treadmill exercise testing and 24-h Holter electrocardiography were retrospectively analysed. Autonomic dysfunction was verified using HRR values. Sympathetic and parasympathetic modulation was analysed by HRV. AF progression was defined as transition from the first detected paroxysmal episode to persistent/permanent AF. RESULTS: Of 306 patients, mean LF/HF ratio and HRR did not differ significantly by AF progression regardless of age (< or ≥65 years). However, when the LF/HF ratio was divided into tertiles, in patients aged <65 years, the mid LF/HF (1.60-2.40) ratio was significantly associated with lower AF progression rates and longer maintenance of normal sinus rhythm. For patients aged <65 years, less metabolic equivalents were related to higher AF progression rates. For patients aged ≥65 years, a low HRR was associated with high AF progression rates. CONCLUSION: In relatively younger age, high physical capacity and balanced autonomic nervous system regulation are important predictors of AF progression. Evaluation of autonomic function assessed by age could predict AF progression.

The Index of Microcirculatory Resistance after Primary Percutaneous Coronary Intervention Predicts Long-Term Clinical Outcomes in Patients with ST-Segment Elevation Myocardial Infarction.

The index of microcirculatory resistance (IMR) is a simple method that can measure microvascular function after primary percutaneous coronary intervention (PCI) in patients with ST-segment Elevation Myocardial Infarction (STEMI). This study is to find out whether IMR predicts clinical long-term outcomes in STEMI patients. A total of 316 patients with STEMI who underwent primary PCI from 2005 to 2015 were enrolled. The IMR was measured using pressure sensor/thermistor-tipped guidewire after primary PCI. The primary endpoint was the rate of death or hospitalization for heart failure (HF) over a mean follow-up period of 65 months. The mean corrected IMR was 29.4 ± 20.0. Patients with an IMR > 29 had a higher rate of the primary endpoint compared to patients with an IMR ≤ 29 (10.3% vs. 2.1%, p = 0.001). During the follow-up period, 13 patients (4.1%) died and 6 patients (1.9%) were hospitalized for HF. An IMR > 29 was associated with an increased risk of death or hospitalization for HF (OR 5.378, p = 0.004). On multivariable analysis, IMR > 29 (OR 3.962, p = 0.022) remained an independent predictor of death or hospitalization for HF with age (OR 1.048, p = 0.049) and symptom-to-balloon time (OR 1.002, p = 0.049). High IMR was an independent predictor for poor long-term clinical outcomes in STEMI patients after primary PCI.

mHealth Interventions for Lifestyle and Risk Factor Modification in Coronary Heart Disease: Randomized Controlled Trial.

BACKGROUND: Self-management of lifestyle and cardiovascular disease risk factors is challenging in older patients with coronary heart disease (CHD). SMS text messaging could be a potential support tool for self-management and the most affordable and accessible method through a mobile phone. High-quality evidence had been lacking, and previous studies evaluated the effects of SMS text messaging on the subjective measures of short-term outcomes. Recently, a large-sized randomized controlled trial in Australia reported promising findings on the objective measures upon 6-month follow-up. However, an examination of the effectiveness of such interventions in an Asian population with unique demographic characteristics would be worthwhile. OBJECTIVE: This study examined the effectiveness of a 1-way SMS text messaging program to modify the lifestyle and cardiovascular disease risk factors of patients who underwent the first percutaneous coronary intervention (PCI). METHODS: A parallel, single-blinded, 1:1 random allocation clinical trial was conducted with 879 patients treated through PCI. They were recruited during hospital admission from April 2017 to May 2020 at 2 university hospitals in the Republic of Korea. In addition to standard care, the intervention group received access to a supporting website and 4 SMS text messages per week for 6 months regarding a healthy diet, physical activity, smoking cessation, and cardiovascular health. Random allocation upon study enrollment and SMS text messaging after hospital discharge were performed automatically using a computer program. The coprimary outcomes were low-density-lipoprotein cholesterol (LDL-C), systolic blood pressure (SBP), and BMI. The secondary outcomes were change in lifestyle and adherence to the recommended health behaviors. RESULTS: Of the eligible population, 440 and 439 patients who underwent PCI were assigned to the intervention and control groups, respectively. The 1-way SMS text messaging program significantly enhanced physical activity (P=.02), healthy diet (P<.01), and medication adherence (P<.04) among patients with CHD. Hence, more people were likely to control their cardiovascular disease risk factors per the recommendations. The intervention group was more likely to control all 5 risk factors by 62% (relative risk 1.62, 95% CI 1.05-2.50) per the recommendations. On the other hand, physiological measures of the primary outcomes, including LDL-C levels, SBP, and BMI, were not significant. Most participants found the SMS text messaging program useful and helpful in motivating lifestyle changes. CONCLUSIONS: Lifestyle-focused SMS text messages were effective in the self-management of a healthy diet, exercise, and medication adherence, but their influence on the physiological measures was not significant. One-way SMS text messages can be used as an affordable adjuvant method for lifestyle modification to help prevent the recurrence of cardiovascular disease. TRIAL REGISTRATION: Clinical Research Information Service (CRiS) KCT0005087; https://cris.nih.go.kr/cris/search/detailSearch.do/19282.

Prognosis of Atrial Fibrillation Patients Undergoing PCI According to Anticoagulants and Antiplatelet Agents.

There are limited data evaluating conformation of antithrombotic therapy usage to the guideline recommendations. We investigated clinical trends and prognoses of patients with atrial fibrillation (AF) according to anticoagulants and antiplatelet agents beyond 1 year after percutaneous coronary intervention (PCI). We analyzed the records of patients with AF who underwent PCI using the Korean National Health Insurance Service database. The primary endpoint was a composite of major adverse cardiac events (MACE). The safety outcome was bleeding complications. Of 4193 participants, 81.6% received antiplatelet therapy, whereas 27.3% had oral anticoagulant (OAC)-based therapy at 18 months after PCI. The dominant therapy was dual antiplatelet therapy (37.2%), and only 3.3% of participants had OAC monotherapy. At the 1-year follow-up, the incidence of MACE was significantly lower among those receiving a combination of OAC and single antiplatelet therapy (SAPT) than among those receiving OAC monotherapy (4.78% vs. 9.42%, p = 0.017). Bleeding complication events (5.01% vs. 5.80%, p = 0.587) did not differ between the groups. In clinical practice, most patients with AF who underwent PCI continued to receive antiplatelet agents beyond 1-year post-PCI. OAC with SAPT seemed to be more effective than OAC monotherapy, without a difference in safety.

Neutrophil-to-Lymphocyte Ratio at Emergency Room Predicts Mechanical Complications of ST-segment Elevation Myocardial Infarction.

BACKGROUND: The neutrophil-to-lymphocyte ratio (NLR) has been proven to be a reliable inflammatory marker. A recent study reported that elevated NLR is associated with adverse cardiovascular events in patients with ST-segment elevation myocardial infarction (STEMI). We investigated whether NLR at emergency room (ER) is associated with mechanical complications of STEMI undergoing primary percutaneous coronary intervention (PCI). METHODS: A total of 744 patients with STEMI who underwent successful primary PCI from 2009 to 2018 were enrolled in this study. Total and differential leukocyte counts were measured at ER. The NLR was calculated as the ratio of neutrophil count to lymphocyte count. Patients were divided into tertiles according to NLR. Mechanical complications of STEMI were defined by STEMI combined with sudden cardiac arrest, stent thrombosis, pericardial effusion, post myocardial infarction (MI) pericarditis, and post MI ventricular septal rupture, free-wall rupture, left ventricular thrombus, and acute mitral regurgitation during hospitalization. RESULTS: Patients in the high NLR group (> 4.90) had higher risk of mechanical complications of STEMI (P = 0.001) compared with those in the low and intermediate groups (13% vs. 13% vs. 23%). On multivariable analysis, NLR remained an independent predictor for mechanical complications of STEMI (RR = 1.947, 95% CI = 1.136-3.339, P = 0.015) along with symptom-to balloon time (P = 0.002) and left ventricular dysfunction (P < 0.001). CONCLUSION: NLR at ER is an independent predictor of mechanical complications of STEMI undergoing primary PCI. STEMI patients with high NLR are at increased risk for complications during hospitalization, therefore, needs more intensive treatment after PCI.

Ivabradine-Induced Torsade de Pointes in Patients with Heart Failure Reduced Ejection Fraction.

Ivabradine is a selective inhibitor of the sinoatrial node "funny" current, prolonging the slow diastolic depolarization. As it has the ability to block the heart rate selectively, it is more effective at a faster heart rate. It is recommended for the treatment of heart failure reduced ejection fraction in the presence of beta-blocker therapy for the further reduction of the heart rate. However, previous reports have shown the association of Torsade de pointes (TdP) with concurrent use of ivabradine and drugs resulting in QT prolongation or blockage of the metabolic breakdown of ivabradine. In this article, we report two cases of patients with heart failure reduced ejection fraction who developed TdP after ivabradine use. Our report highlights the need to exercise caution with the administration of ivabradine in the presence of a reduced repolarization reserve, such as QT prolongation or metabolic insufficiency.

Anomalous origin of the left circumflex artery from the right sinus of valsalva: non-ST-segment elevation myocardial infarction.

An anomalous origin of the left coronary artery from the right sinus of Valsalva (RSV) is rare. We herein report the case of an 80-year-old woman who presented to the emergency department with chest pain. Emergent coronary angiography was performed following a diagnosis of non-ST segment elevation myocardial infarction. A right coronary angiogram showed that the common trunk originating from the RSV branched into the left anterior descending and right coronary arteries. Although the initial angiogram failed to show the left circumflex artery (LCx), considered to be the culprit vessel, computed tomographic angiography demonstrated that the LCx was located immediately below the common trunk and exhibited a retroaortic course. We successfully treated the patient and obtained optimal angiography results.

Thrombus aspiration during primary percutaneous coronary intervention for preserving the index of microcirculatory resistance: a randomised study.

AIMS: We aimed to investigate whether thrombus aspiration could preserve the index of microcirculatory resistance (IMR) after primary percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI). METHODS AND RESULTS: Sixty-three patients with STEMI were randomised into two groups: primary PCI after thrombus aspiration (aspiration group, n=33) and primary PCI without thrombus aspiration (non-aspiration group, n=30). IMR was measured using a pressure-temperature sensor-tipped coronary wire. Echocardiography was performed at baseline and at six-month follow-up. No significant differences in baseline ejection fraction (EF, 47.3±8.5% vs. 49.5±7.8%, p=0.281) and baseline wall motion score index (WMSI, 1.45±0.31 vs. 1.37±0.27, p=0.299) were observed between the two groups. However, significant differences in IMR (23.5±10.2 U vs. 34.2±21.7 U, p=0.018), %E2%88%86EF (follow-up EF - baseline EF; 3.33±4.6% vs. 0.73±1.9%, p=0.005), and %E2%88%86WMSI (follow-up WMSI - baseline WMSI; -0.121±0.16 vs. -0.004±0.07, p=0.001) were observed between the two groups. CONCLUSIONS: Thrombus aspiration as an adjunctive method to primary PCI for STEMI may preserve microvascular integrity and have beneficial effects on myocardial microcirculation.