Impact of hyperuricemia on 5-year clinical outcomes in patients with critical limb ischemia following percutaneous transluminal angioplasty.

BACKGROUND: A growing evidence on the correlation between hyperuricemia and cardiovascular disease (CVD) has been previously reported. However, there have been limited data on the impact of hyperuricemia on long-term clinical outcomes in patients with critical limb ischemia (CLI) who underwent percutaneous transluminal angioplasty (PTA). METHODS: A total of 425 peripheral artery disease patients who underwent PTA for CLI were enrolled. The patients were divided into the hyperuricemia group (n = 101) and the normal group (n = 324). The primary endpoint was major adverse cerebral and cardiovascular event (MACCE), including death, myocardial infarction, any coronary revascularization, and stroke, up to 5 years. The secondary endpoint was a major adverse limb event (MALE), including any repeated PTA, and target extremity surgery. Inverse probability weighting (IPTW) analysis, derived from the logistic regression model, was performed to adjust for potential confounders. RESULTS: After IPTW matching analysis, compared to the normal group, the hyperuricemia group was associated with a higher incidence of MACCE (20.7% vs. 13.6%, hazard ratio [HR], 1.65; 95% confidence interval [CI], 1.15-2.38, P  = 0.006) including non-cardiac death (11.7% vs. 6.3%, HR: 1.95, 95% CI: 1.19-3.19, P  = 0.006) and MALE (47.7% vs. 36.0%, HR: 1.62, 95% CI: 1.23-2.13, P  = 0.001) including non-target extremity revascularization (15.0% vs. 6.8%, HR: 2.42, 95% CI: 1.52-3.84, P  < 0.001). CONCLUSION: In the present study, hyperuricemia was associated with worse clinical outcomes in patients with CLI following PTA during 5-year clinical follow-up. Efficacy of controlling hyperuricemia in improving clinical outcomes should be evaluated in further studies.

Impact of hyperuricemia on 5-year clinical outcomes following percutaneous transluminal angioplasty.

BACKGROUND: Although the correlation between hyperuricemia and cardiovascular disease (CVD) is well known, there have been limited data regarding the impact of hyperuricemia on long-term clinical outcomes in patients with peripheral arterial disease (PAD) after percutaneous transluminal angioplasty (PTA). METHODS: A total of 718 patients who underwent PTA for PAD were enrolled. The patients were divided into the hyperuricemia group (N = 168) and the normal group (N = 550). Hyperuricemia was defined as a uric acid level ≥ 7.0 mg/dL in men, and ≥ 6.5 mg/dL in women. The primary endpoint was major adverse cerebral and cardiovascular event (MACCE), including death, myocardial infarction (MI), any coronary revascularization, and stroke, up to 5 years. The secondary endpoint was major adverse limb event (MALE), including any repeated PTA, and target extremity surgery (TES). Inverse probability weighting (IPTW) analysis, derived from the logistic regression model, was performed to adjust potential confounders. RESULTS: After IPTW matching analysis, compared to the normal group, the hyperuricemia group was not associated with increased MACCE but was associated with an increased incidence of MI (2.6 % vs. 0.5 %, p = 0.001), and coronary revascularization (6.7 % vs. 3.9 %, p = 0.018). Also, the hyperuricemia group was associated with a higher incidence of MALE (45.3 % vs. 28.9 %, p < 0.001), including target extremity revascularization (TER; 25.1 % vs. 15.9 %, p < 0.001), non-TER (11.5 % vs. 5.6 %, p < 0.001), and TES (22.8 % vs. 16.2 %, p = 0.002). CONCLUSIONS: In the present study, hyperuricemia was associated with worse clinical outcomes in PAD patients following PTA during 5-year clinical follow-up. Further investigations should be made regarding the clinical benefit of controlling hyperuricemia on clinical outcomes.

Impact of chronic outward force on arterial responses of proximal and distal of long superficial femoral artery stent.

BACKGROUND: Self-expanding nitinol stent (SENS) implantation is commonly oversized in the superficial femoral artery (SFA), and leads to chronic outward force (COF) and in-stent restenosis (ISR). This study aimed to investigate the impact of COF of oversizing SENS on ISR of SFA. METHODS: In patients with implanted SENS in SFA, intimal hyperplasia especially between proximal segment and distal segment was evaluated by quantitative angiography, and the impact of COF on mid-term angiographic outcomes was investigated. In addition, porcine model with implanted SENS was used to evaluate the impact of COF on angiographic and histopathologic outcomes at 1 month. Excised stented arteries were evaluated by histopathologic analysis. RESULTS: We analyzed 65 SENS in 61 patients with follow-up angiography at 6 months to 1 year. The baseline diameter was 6.8 ± 0.71 mm and length were 97.0 ± 33.8 mm for the SENS. The ratio of the diameter of the stent to the reference vessel was 1.3 ± 0.24 at the proximal portion and 1.53 ± 0.27 at the distal portion (P < 0.001). In the long SFA stent, stent-to-vessel ratio was significantly higher in the distal stent than in the proximal stent (1.3 ± 0.2 vs. 1.55 ± 0.25, P = 0.001). ISR incidence was higher at the distal stent (37.3% vs 52.6%, P = 0.029). All 11 pigs survived for 4 weeks after SENS implantation. The vessel diameter was 4.04 ± 0.40 mm (control group) vs 4.45 ± 0.63 mm (oversized group), and the implanted stent diameter was 5.27 ± 0.46 mm vs. 7.18 ± 0.4 mm (P = 0.001). The stent-to-vessel diameter ratio was 1.31 ± 0.12 versus 1.63 ± 0.20 (P < 0.001). After 4 weeks, restenosis % was 29.5 ± 12.9% versus 46.8 ± 21.5% (P = 0.016). The neointimal area was 5.37 ± 1.15 mm2 vs. 8.53 ± 5.18 mm2 (P = 0.05). The restenosis % was 39.34 ± 8.53% versus 63.97 ± 17.1% (P = 0.001). CONCLUSIONS: COF is an important cause of restenosis in the distal portion of the SFA stent. Optimal sizing of the SFA stent is important to reduce the incidence of restenosis. Therefore, COF was an important factor of restenosis following distal SFA stenting.

A relationship between unrecognized anaemia and the development of type 2 diabetes mellitus in patient with cardiovascular risks.

Studies on anaemia in diabetic patients are well known. However, the data regarding association of anaemia on the development of diabetes mellitus (DM) are very limited. We aimed to evaluate the association of anaemia on the development of DM and major clinical outcomes in a series of the Korean population during 5-year clinical follow-up. The patients were retrospectively enrolled using the electronic database of Korea University Guro Hospital from January 2004 to February 2013. A total of 17 515 subjects without a history of DM were analysed. The World Health Organization definition of anaemia was used. Patients were divided into the anaemia group (n = 2907 patients) and the non-anaemia group (n = 14 608 patients). The primary endpoint was the development of DM. To adjust baseline potential confounders, a propensity score matching (PSM) analysis was performed. After PSM analysis, two matched groups (2731 pairs) were generated and their baselines characteristics were balanced. During 5-year follow-up, the anaemia group had a higher incidence of type 2 DM (10.7% vs 7.7%; hazard ratio [HR], 1.356; 95% confidence interval [CI], 1.021-1.802; P = .035), and total death (2.6% vs 1.2%; HR, 2.449; 95% CI, 1.337-4.486; P = .004) compared to the non-anaemia group. In the present study, anaemia was associated with higher rate of the development of DM and mortality during 5-year clinical follow-up. A randomized trial is needed to determine whether this results can be reproducible or not for the final conclusion.

Cilostazol-based triple versus potent P2Y12 inhibitor-based dual antiplatelet therapy in patients with acute myocardial infarction undergoing percutaneous coronary intervention.

Although potent P2Y12 inhibitor-based dual antiplatelet therapy (DAPT) has replaced clopidogrel-based therapy as the standard treatment in patients with acute myocardial infarction (AMI), there is a concern about the risk of bleeding in East Asian patients. We compared the efficacy and safety of cilostazol-based triple antiplatelet therapy (TAT) with potent P2Y12 inhibitor-based DAPT in Korean patients. A total of 4152 AMI patients who underwent percutaneous coronary intervention (PCI) in the Korea Acute Myocardial Infarction Registry were analyzed retrospectively. Patients were divided into two groups: the TAT group (aspirin + clopidogrel + cilostazol, n = 3161) and the potent DAPT group (aspirin + potent P2Y12 inhibitors [ticagrelor or prasugrel], n = 991). Major clinical outcomes at 30 days and 2 years were compared between the two groups using propensity score matching (PSM) analysis. After PSM (869 pairs), there were no significant differences between the two groups in the incidence of total death, cardiac death, myocardial infarction (MI), target vessel revascularization, stent thrombosis, and stroke at 30 days and 2 years. However, the Thrombolysis in Myocardial Infarction (TIMI) major or minor bleeding rates were significantly lower in the TAT group compared with the potent DAPT group at 2 years (6.4% vs. 3.6%, p = 0.006). In Korean AMI patients undergoing PCI, TAT with cilostazol was associated with lower bleeding than the potent P2Y12 inhibitor-based DAPT without increased ischemic risk. These results could provide a rationale for the use of TAT in East Asian AMI patients.

Comparison of Two-Year Outcomes of Acute Myocardial Infarction Caused by Coronary Artery Spasm Versus that Caused by Coronary Atherosclerosis.

The study compared the 2-year outcomes of patients diagnosed with acute myocardial infarction (AMI) triggered by coronary artery atherosclerosis and AMI caused by coronary artery spasm. A total of 36,797 patients in the Korea AMI Registry were grouped into 2 categories-(1) AMI due to coronary artery spasm without stenotic lesion (CAS-AMI, n = 484); and (2) AMI induced by coronary artery atherosclerosis (CAA-AMI, n = 36,313). The major clinical outcomes of the 2 groups were compared over a 2-year clinical follow-up period. Major adverse cardiac events (MACE) were defined as the composite of total death, nonfatal myocardial infarction, and repeat revascularization. The incidence of MACE (7.1% vs 11.1%; p = 0.007) and repeat revascularization (0.4% vs 4.2%; p <0.001) in the CAS-AMI group were significantly lower than in the CAA-AMI group at 2 years. However, the incidence of total death and nonfatal myocardial infarction was similar in both the groups. Aborted cardiac arrest was strongly associated with 2-year mortality in the CAS-AMI group (hazard ratios 13.5, 95% confidence interval 5.34 to 34.15, p <0.001) The incidence of MACE in CAS-AMI patients was significantly lower than in the CAA-AMI group of patients up to 2 years due to the relatively lower rate of repeat revascularization in CAS-AMI patients. However, the incidence of total death or nonfatal myocardial infarction in CAS-AMI patients was not different from that of patients with CAA-AMI.

Impact of chronic total occlusion lesion length on six-month angiographic and 2-year clinical outcomes.

BACKGROUND: Successful management of chronic total occlusion (CTO)by percutaneous coronary intervention (PCI) is known to be associated with better clinical outcomes than failed PCI. However, whether angiographic and clinical outcomes following PCI for long CTO lesions differ from those following PCI for short CTO lesions in the drug eluting stent (DES) era remains unknown. We therefore investigated whether CTO lesion length can significantly influence6-month angiographic and 2-year clinical outcomes following successful CTO PCI. METHODS AND RESULTS: A total of 235 consecutive patients who underwent successful CTO intervention were allocated into either the long or short CTO group according to CTO lesion length. Six-month angiographic and 2-year clinical outcomes were then compared between the 2groups. We found that baseline clinical characteristics were generally similar between the 2 groups. Exceptions were prior PCI, which was more frequent in the long CTO group, and bifurcation lesions, which were more frequent in the short CTO group. Apart from intimal dissection, which was more frequent in the long than short CTO group, in-hospital complications were also similarly frequent between the 2groups. Furthermore, both groups had similar angiographic outcomes at 6 months and clinical outcomes at 2 years. However, the incidence of repeat PCI(predominantly target vessel revascularization),was higher in the long than short CTO group, with our multivariate analysis identifying long CTO as an important predictor of repeat PCI (odds ratio, 4.26;95% confidence interval, 1.53-11.9; p = 0.006). CONCLUSION: The safety profile, 6-month angiographic, and 2-year clinical outcomes of CTO PCI were similar between patients with long and short CTO. However, there was a higher incidence of repeat PCI in long CTO patients despite successful PCI with DESs.

Five-year major clinical outcomes between first-generation and second-generation drug-eluting stents in acute myocardial infarction patients underwent percutaneous coronary intervention.

BACKGROUND: There were limited data comparing the major clinical outcomes between first-generation (1G)-drug eluting stents (DES) and second-generation (2G)-DES in patients with acute myocardial infarction (AMI) after percutaneous coronary intervention (PCI) during very long follow-up periods. We thought to investigate the comparative efficacy and safety of 2G-DES compared with 1G-DES in AMI patients during 5-year follow-up periods. METHOD: A total of 1016 eligible AMI patients who underwent PCI with 1G-DES [paclitaxel-, sirolimus-, 1G-zotarolimus-eluting stent (endeavor® or endeavor sprint®), n = 554] or 2G-DES [2G-zotarolimus (endeavor resolute®)- or everolimus-eluting stent, n = 462] were enrolled. The primary endpoint was the occurrence of major adverse cardiac events (MACE) defined as total death, non-fatal myocardial infarction (MI), target lesion revascularization (TLR), target vessel revascularization (TVR), non-target vessel revascularization (Non-TVR) and the secondary endpoint was stent thrombosis (ST) at 5 years. RESULTS: Two propensity score-matched (PSM) groups (232 pairs, n = 464, C-statistic = 0.802) were generated. During the 5-year follow-up period, the cumulative incidence of TLR [hazard ratio (HR): 3.133; 95% confidence interval (CI): 1.539-6.376; P = 0.002], TVR (HR: 3.144; 95% CI: 1.596-6.192; P = 0.001) and total revascularization rate (HR: 1.874; 95% CI: 1.086-3.140; P = 0.023) were significantly higher in 1G-DES compared with 2G-DES after PSM. However, the incidence of total death, non-fatal MI and ST were similar between the two groups. CONCLUSION: In this single-center and all-comers registry, 2G-DES's superiorities for TLR, TVR and total revascularization in AMI patients suggested during 5-year clinical follow-up periods.

Clinical characteristics and satisfaction with the fimasartan in Korean hypertensive patients: a prospective, cross-sectional and open-label, 8-week switching study (Kanarb-hypertension epidemiology medication satisfaction study; K-HEMS study).

BACKGROUND: Fimasartan (Kanarb; Boryung Pharmaceutical Co., Ltd., Seoul, Republic of Korea) is a non-protein angiotensin II receptor blocker that selectively blocks the AT1 receptor. No prior large-scale study has investigated the impact of demographics, disease, treatment, and clinical characteristics on medication satisfaction and quality of life in Korean hypertensive patients. Additionally, it is unclear whether increased medication compliance affects the achievement of hypertension treatment objectives. METHODS: This was a multicenter, non-interventional, open-label and 8-week switching study. This study was divided into 2 steps. STEP I was a cross-sectional study composed entirely of hypertensive patients undergoing treatment and STEP II was a prospective observational study of hypertensive patients switching to fimasartan. A total of 12,244 and 2023 patients were analyzed in the STEP I and STEP II groups, respectively. In STEP I, we investigated demographics, clinical, disease, and treatment characteristics at the registration point and then analyzed medication satisfaction, patient compliance, and quality of life. In STEP II, the patients who switched to fimasartan were followed up for 8 weeks, and the data analyzed included changes in medication effects, satisfaction, compliance, and adverse events. RESULTS: Some baseline characteristics, such as sex, body mass index, region of residence, educational level, and income level, affected the quality of life and medication duration in hypertensive patients. At 4 and 8 weeks, 62.5 and 69.9% of patients, respectively, reached their target blood pressure. The medication satisfaction scores were increased 4.0 ± 1.2, 5.1 ± 1.1, and 5.4 ± 1.0 at baseline, 4 weeks, and 8 weeks, respectively, and the difference was statistically significant (p < 0.0001). Most patients (76.4%) who changed from prior antihypertensive drug to fimasartan were not satisfied with conventional antihypertensive drugs (e.g., lack of efficacy). Among 2183 patients, 234 adverse events occurred in 151 (6.9%) and 50 adverse drug reactions occurred in 39 (1.8%). CONCLUSION: The demographic, clinical, disease, and treatment characteristics of hypertensive patients were investigated in this study. After switching to fimasartan, blood pressure was significantly decreased and patient satisfaction was improved. Fimasartan treatment was well tolerated and safe in hypertensive patients in Korea.Trial registration. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: (NCT02394392).

Five-Year Outcomes of Successful Percutaneous Coronary Intervention with Drug-Eluting Stents versus Medical Therapy for Chronic Total Occlusions.

PURPOSE: Many recent studies have reported that successful percutaneous coronary intervention (PCI) with drug-eluting stents (DESs) for chronic total occlusion (CTO) has more beneficial effects than failed CTO-PCI; however, there are only limited data available from comparisons of successful CTO-PCI with medical therapy (MT) in the Korean population. MATERIALS AND METHODS: A total of 840 consecutive CTO patients who underwent diagnostic coronary angiography, receiving either PCI with DESs or MT, were enrolled. Patients were divided into two groups according to the treatment assigned. To adjust for potential confounders, propensity score matching (PSM) analysis was performed using logistic regression. Individual major clinical outcomes and major adverse cardiac events, a composite of total death, myocardial infarction (MI), stroke, and revascularization, were compared between the two groups up to 5 years. RESULTS: After PSM, two propensity-matched groups (265 pairs, n=530) were generated, and the baseline characteristics were balanced. Although the PCI group showed a higher incidence of target lesion and vessel revascularization on CTO, the incidence of MI tended to be lower [hazard ratio (HR): 0.339, 95% confidence interval (CI): 0.110 to 1.043, p=0.059] and the composite of total death or MI was lower (HR: 0.454, 95% CI: 0.224 to 0.919, p=0.028), compared with the MT group up to 5 years. CONCLUSION: In this study, successful CTO PCI with DESs was associated with a higher risk of repeat PCI for the target vessel, but showed a reduced incidence of death or MI.

The impact of myocardial bridge on coronary artery spasm and long-term clinical outcomes in patients without significant atherosclerotic stenosis.

BACKGROUND AND AIMS: Myocardial bridge (MB) and coronary artery spasm (CAS) can induce a sustained chest pain, acute coronary syndrome (ACS) and even sudden cardiac death. The aim of this study is to evaluate the relationship between MB and CAS and its impact on long-term clinical outcomes. METHODS: A total of 812 patients with MB without significant coronary artery disease (CAD), who underwent acetylcholine (ACH) provocation test, were enrolled. Significant CAS was defined as ≥70% temporary narrowing by ACH test, and MB was defined as the characteristic phasic systolic compression of the coronary artery with a decrease of more than 30% in diameter on the angiogram after intracoronary nitroglycerin infusion. To adjust baseline confounders, logistic regression analysis was performed. The primary endpoint was incidence of CAS, and secondary endpoints were major adverse cardiac events (MACE) and recurrent angina requiring repeat coronary angiography (CAG) at 5 years. RESULTS: MB is closely implicated in a high incidence of CAS, spontaneous spasm, ischemic ECG change and chest pain during ACH provocation test. In addition, MB of various severity and reference vessel size was substantially implicated in CAS incidence, and severe MB was a strong risk factor of CAS. MB patients with CAS were shown to have a higher rate of recurrent angina compared with MB patients without CAS, up to a 5-year follow-up. However, there were no differences regarding the incidence of MACE. CONCLUSIONS: Severe MB was associated with high incidence of CAS, and MB patients with CAS were likely to have a higher incidence of recurrent angina. Intensive medical therapy and close clinical follow-up are needed for better clinical outcomes in MB patients with CAS.

Therapeutic Effects of Targeted PPARÉ£ Activation on Inflamed High-Risk Plaques Assessed by Serial Optical Imaging In Vivo.

Rationale: Atherosclerotic plaque is a chronic inflammatory disorder involving lipid accumulation within arterial walls. In particular, macrophages mediate plaque progression and rupture. While PPARγ agonist is known to have favorable pleiotropic effects on atherogenesis, its clinical application has been very limited due to undesirable systemic effects. We hypothesized that the specific delivery of a PPARγ agonist to inflamed plaques could reduce plaque burden and inflammation without systemic adverse effects. Methods: Herein, we newly developed a macrophage mannose receptor (MMR)-targeted biocompatible nanocarrier loaded with lobeglitazone (MMR-Lobe), which is able to specifically activate PPARγ pathways within inflamed high-risk plaques, and investigated its anti-atherogenic and anti-inflammatory effects both in in vitro and in vivo experiments. Results: MMR-Lobe had a high affinity to macrophage foam cells, and it could efficiently promote cholesterol efflux via LXRα-, ABCA1, and ABCG1 dependent pathways, and inhibit plaque protease expression. Using in vivo serial optical imaging of carotid artery, MMR-Lobe markedly reduced both plaque burden and inflammation in atherogenic mice without undesirable systemic effects. Comprehensive analysis of en face aorta by ex vivo imaging and immunostaining well corroborated the in vivo findings. Conclusion: MMR-Lobe was able to activate PPARγ pathways within high-risk plaques and effectively reduce both plaque burden and inflammation. This novel targetable PPARγ activation in macrophages could be a promising therapeutic strategy for high-risk plaques.

The association of chronic air pollutants with coronary artery spasm, vasospastic angina, and endothelial dysfunction.

BACKGROUND: We evaluated the effect of chronic exposure to air pollutants (APs) on coronary endothelial function and significant coronary artery spasm (CAS) as assessed by intracoronary acetylcholine (ACH) provocation test. PATIENTS AND METHODS: A total of 6430 patients with typical or atypical chest pain who underwent intracoronary ACH provocation test were enrolled. We obtained data on APs from the Korean National Institute of Environmental Research (http://www.nier.go.kr/). APs are largely divided into two types: particulate matter with aerodynamic diameter of less than or equal to 10 µm in size (PM10) and gaseous pollutants such as nitrogen dioxide, sulfur dioxide, carbon monoxide, and ozone. The primary endpoint is the incidence of significant CAS and its associated parameters during ACH provocation test. RESULTS: The incidence of CAS was positively correlated with an exposure duration of PM10, whereas nitrogen dioxide, sulfur dioxide, carbon monoxide, and ozone were shown to be unrelated to CAS. During the ACH provocation test, as PM10 increased, the frequency of CAS was increased, and the incidence of transient ST-segment elevation was also increased. There was a trend toward higher incidence of spontaneous spasm as PM10 increased. The mean exposure level of PM10 was 51.3±25.4 µg/m. The CAS risk increased by 4% when the level of PM10 increased by 20 µg/m by an adjusted Cox regression analysis. CONCLUSION: CAS incidence is closely related to exposure to PMs but not to gaseous pollutants. Particularly, higher exposure concentrations and longer exposure duration of PM10 increased the risk of CAS. These important findings provide a plausible mechanism that links air pollution to vasospastic angina and provide new insights into environmental factors.

Comparison of prasugrel versus clopidogrel in Korean patients with acute myocardial infarction undergoing successful revascularization.

BACKGROUND: Although there have been several reports that prasugrel can improve clinical outcomes, the efficacy and safety of prasugrel is unknown in Korean patients with acute myocardial infarction (AMI) undergoing successful revascularization. METHODS: A total of 4421 patients [637 patients were prescribed prasugrel (60/10 or 5mg, loading/maintenance dose) and 3784 patients clopidogrel (600 or 300/75mg)] with AMI undergoing successful revascularization were enrolled from the core clinical cohort of Korea Acute Myocardial Infarction Registry-National Institute of Health. RESULTS: After propensity score matching (637 pairs), there were no significant differences in baseline clinical and procedural characteristics and in-hospital medications between the two groups. The primary efficacy endpoint, defined as the composite of cardiac death, MI, stroke, or target vessel revascularization at 6 months showed no significant difference between prasugrel and clopidogrel (2.4% vs. 2.9%, p=0.593). Also, no difference was observed in the composite of cardiac death, MI, or stroke during hospitalization between two groups (0.8% vs. 0.9%, p=0.762). However, the incidence of in-hospital Thrombolysis in Myocardial Infarction (TIMI) major or minor bleeding was significantly higher in prasugrel compared with clopidogrel (5.3% vs. 2.7%, p=0.015). In multivariate linear regression analysis, trans-femoral intervention, use of glycoprotein IIb/IIIa inhibitors, use of calcium channel blocker, and use of prasugrel were independent predictors of in-hospital TIMI major or minor bleeding [odds ratio (OR)=6.918; 95% confidence interval (CI)=2.453-19.510, OR=2.577; 95% CI=1.406-4.724, OR=4.016; 95% CI=1.382-11.668, OR=2.022; 95% CI=1.101-3.714]. CONCLUSIONS: Our study shows that the recommended dose of prasugrel had significantly higher in-hospital bleeding complications without reducing ischemic events compared with clopidogrel. However, further large-scale, long-term, randomized clinical trials are required to accurately assess the efficacy and safety of prasgurel and to find out the optimal dose for Korean AMI patients.

Impact of diabetes mellitus on 5-year clinical outcomes in patients with chronic total occlusion lesions.

BACKGROUND: Diabetes mellitus (DM) is a major predictor of cardiovascular morbidity and mortality. However, there are limited data on the impact of DM in patients who have chronic total occlusion (CTO) lesion on long-term outcomes. PATIENTS AND METHODS: A total of 822 CTO patients who underwent coronary angiography, treated by either percutaneous coronary intervention or optimal medical therapy, were enrolled and divided into two groups: (i) diabetic group (n=363) and (ii) nondiabetic group (n=459). Individual and composite major clinical outcomes were compared up to 5 years. RESULTS: Propensity score matching analysis was carried out generating two groups (298 pairs, n=596, C-statistic=0.655) with balanced baseline characteristics. Up to 5 years, the DM group showed a higher trend toward revascularization (19.5 vs. 13.5%, P=0.051) and major adverse cardiovascular events (MACE) (24.7 vs. 19.1%, P=0.097) compared with the nondiabetic group. However, there was no difference in the incidence of death and myocardial infarction between the two groups. Subgroup analysis showed that the chronic kidney disease (CKD) subgroup was associated with a higher incidence of all-cause death, cardiac death, myocardial infarction, revascularization, and MACE in comparison with diabetic patients without CKD and nondiabetic patients, respectively (total MACE: 39 vs. 20.5 vs. 19.2% , P=0.001). Insulin-dependent diabetic patients had a significantly higher incidence of MACE (hazard ratio=1.58; 95% confidence interval: 1.04-2.40; P=0.03) compared with the nondiabetic patients. CONCLUSION: Diabetic patients with CTO were associated with a trend toward a higher incidence of revascularization and total MACE up to 5 years. Insulin-dependent and diabetic patients with CKD subgroups had a significantly higher incidence of total MACE.

Clinical characteristics and outcomes of patients with coronary artery spasm who initially presented with acute myocardial infarction.

BACKGROUND: The long-term clinical outcomes of coronary artery spasm (CAS) patients presented with acute myocardial infarction (AMI) compared to those who did not present with AMI has rarely been investigated. METHODS: From November 2004 to May 2014, a total of 3360 patients who were confirmed as CAS by the acetylcholine (Ach) provocation test and without significant coronary lesion were retrospectively analyzed. AMI was an initial presentation in 34 patients [CAS-myocardial infarction (MI) group], and not in other 3326 patients (CAS group). The clinical outcomes up to 5 years were compared between the two groups. RESULTS: Baseline characteristics and cardiovascular risk factors did not differ between the two groups, except the higher smoking rate in CAS-MI group (38.2 vs. 23.5%, P=0.046). During a mean follow-up period of 1211±583 days, the cumulative incidence of recurrent angina [hazard ratio (HR): 2.71; 95% confidence interval (CI): 1.20-6.13; P=0.016], MI (HR: 33.89; 95% CI: 8.76-131.1; P<0.001) and major adverse cardiovascular events (MACE; HR: 10.94; 95% CI: 3.83-31.22; P<0.001) were significantly higher in the CAS-MI group. After propensity score matched analysis (1 : 5 matching; n=186, C-statistic=0.834), the incidences of recurrent angina (HR; 4.68; 95% CI: 1.62-13.5; P=0.004) and MACE (HR: 12.2; 95% CI: 2.23-67.3; P=0.003) remained higher in the CAS-MI group. CONCLUSION: The CAS-MI group patients were associated with higher incidence of recurrent angina, MI, and MACE compared to CAS group patients. More intensive antispastic medication might be needed for these patients, and further study will be necessary to determine which treatment can improve the prognosis of CAS-MI patients.

Transradial versus transfemoral intervention in ST-segment elevation myocardial infarction patients in Korean population.

Background/Aims: Transradial intervention (TRI) is becoming the preferred method over transfemoral intervention (TFI) because TRI is associated with lower incidence of major bleeding and vascular complications. However, there has been limited published data regarding the clinical outcomes of TRI versus TFI in Korean patients with ST-elevation myocardial infarction (STEMI). METHODS: A total of 689 consecutive STEMI patients who underwent primary percutaneous coronary intervention (PCI) with drug-eluting stents (DESs) from January to December of 2009 at nine university hospitals were enrolled in this study. Mid-term angiographic and 12-month cumulative clinical outcomes of the TRI group (n = 220, 31.9%) were compared to those of the TFI group (n = 469, 28.1%). RESULTS: After propensity score matching, in-hospital complications and the 12-month major clinical outcomes during follow-up in the two groups were similar to each other. However, the incidence rates of repeat revascularization (6.4% vs. 0.5%, p = 0.003), target vessel revascularization (6.4% vs. 0.5%, p = 0.003), and major adverse cardiac events (MACE; 11.6% vs. 4.6%, p = 0.018) in the TFI group were higher than those in the TRI group during the 12-month of follow-up. Conclusions: In our study, TRI in STEMI patients undergoing primary PCI with DESs was associated with lower incidence of access site hematoma, 12-month repeat revascularization, and MACE compared to TFI. Therefore, TRI might play an important role in reducing bleeding complications while improving major clinical outcomes in STEMI patients undergoing primary PCI with DESs.

Five-year major clinical outcomes according to severity of coronary artery spasm as assessed by intracoronary acetylcholine provocation test.

BACKGROUND: Long-term clinical outcome data according to severity of coronary artery spasm (CAS) as assessed by an intracoronary acetylcholine provocation test are limited in series of Asian patients. AIM: To investigate 5-year clinical outcomes in patients with CAS according to CAS severity. METHODS: In total, 5873 consecutive patients with insignificant coronary artery disease (<70% fixed stenosis) who underwent an acetylcholine provocation test were enrolled and divided into four groups according to CAS severity during the acetylcholine provocation test: negative, borderline positive, moderately positive and severely positive. CAS severity was assessed by quantitative coronary angiography. We investigated 5-year clinical outcomes according to CAS severity. RESULTS: Over a follow-up period of up to 5 years, before adjustment, the severely-positive CAS group showed a significantly higher incidence of major adverse cardiac events (MACE; composite of death, myocardial infarction and de novo revascularization) (hazard ratio [HR]: 1.834, 95% confidence interval [CI]: 1.047-3.211; P=0.033), total death (HR: 3.124, 95% CI: 1.047-9.322; P=0.041), myocardial infarction (HR: 3.190, 95% CI: 1.069-9.519; P=0.037) and recurrent angina (HR: 1.762, 95% CI: 1.363-2.278; P<0.001) compared with the negative group. However, after adjustment for baseline confounders, only the incidence of recurrent angina (HR: 1.323, 95% CI: 1.014-1.726; P=0.039) was significantly higher in the severely-positive CAS group compared with the negative group. CONCLUSIONS: The severity of CAS in the positive group was not associated with an increased incidence of MACE after adjustment for covariates compared with the negative group, but the severely-positive CAS group was associated with a higher incidence of recurrent angina compared with the negative group.

Impact of Trimetazidine Treatment on 5-year Clinical Outcomes in Patients with Significant Coronary Artery Spasm: A Propensity Score Matching Study.

OBJECTIVE: We aimed to evaluate the additive benefit of trimetazidine with well-known antispasmodic agents such as calcium channel blockers and nitrate in patients with significant coronary artery spasm (CAS) as assessed by acetylcholine provocation test up to 5 years. METHODS: A total 1727 patients with significant CAS were enrolled. They were divided into two groups: a trimetazidine group (trimetazidine, diltiazem, and nitrate, n = 695), and control group (diltiazem and nitrate, n = 473). After propensity score matching analysis, two matched groups (441 pairs, n = 882, C-statistic = 0.673) were generated. The individual and composite clinical end points [mortality, myocardial infarction (MI), revascularization, cerebrovascular accident (CVA), major adverse cardiac events (MACE), major adverse cardiac or cerebrovascular events (MACCE), and recurrent angina] were assessed up to 5 years for the two groups. RESULTS: At 5 years, there were similar incidences of individual and composite hard endpoints including mortality, MI, revascularization, CVA, MACE, MACCE, and recurrent angina in the two groups. CONCLUSIONS: Additional long-term (5-year) treatment with trimetazidine in combination with diltiazem and nitrate in patients with significant CAS was not associated with improved clinical outcomes compared with combination therapy with diltiazem and nitrate only (without trimetazidine).