Profile and outcomes of patients with mediastinal hematoma after cardiac catheterization: A retrospective analysis.

OBJECTIVE: To provide a comprehensive introduction of mediastinal hematoma. BACKGROUND: Mediastinal hematoma is a rare complication that is usually not considered in the differential diagnosis of chest pain after cardiac catheterization. METHODS: From January 1, 2006, to December 31, 2013, at Fuwai Hospital, 126,265 patients underwent coronary angiography (CAG); 121,215 of them underwent CAG via the radial artery. Ultimately, 10 patients with mediastinal hematoma due to cardiac catheterization were included. Patients' clinical characteristics, diagnosis, treatment, and prognosis were retrospectively analyzed. RESULTS: The incidences of mediastinal hematoma in cardiac catheterization and transradial cardiac catheterization were 0.79‱ and 0.74‱, respectively. A super slide hydrophilic guidewire was used in all 10 patients with mediastinal hematoma. These patients felt chest pain and dyspnea during/after the procedure, and computed tomography (CT) was used to diagnose mediastinal hematoma. Among them, two patients had a neck hematoma. The post-procedural hemoglobin level decreased substantially in all patients. Antiplatelet therapy was discontinued for 8-20 days in three patients without stents implanted, and then only oral aspirin was prescribed. Aspirin was transiently discontinued for 2 days in one patient undergoing percutaneous coronary intervention. The others continued taking dual antiplatelet drugs. Two patients received blood transfusion. There was no case of stent thrombosis, and surgery was not indicated for any patient. No complication was observed after discharge during the 9.0 ± 2.5-year follow-up. CONCLUSION: CT should be performed as early as possible in patients with suspected mediastinal hematoma. The prognosis of mediastinal hematoma is usually good with early diagnosis and suitable therapy.

Long-term clinical outcomes in transradial versus transfemoral access for left main percutaneous coronary intervention.

OBJECTIVE: The present study compared 10-year clinical outcomes between transradial access (TRA) and transfemoral access (TFA) for left main (LM) percutaneous coronary intervention (PCI). BACKGROUND: There are limited data regarding the long-term safety and efficacy of TRA for LM PCI. METHODS: This retrospective study evaluated consecutive patients who underwent unprotected LM PCI between January 2004 and December 2008 at Fu Wai Hospital. The exclusion criteria were age of less than 18 years and presentation with acute myocardial infarction. The primary endpoint was major adverse cardiac or cerebrovascular events (MACCE), which was defined as a composite of all-cause death, myocardial infarction, stroke, and any revascularization at the 10-year follow-up. RESULTS: Among 913 eligible patients, TRA was used for 417 patients (45.7%) and TFA was used for 496 patients (54.3%). The 30-day clinical outcomes were similar between the two groups. Results from the 10-year follow-up revealed that MACCE occurred in 180 patients (46.7%) from the TRA group and in 239 patients (51.2%) from the TFA group (log-rank p = .3). The TRA and TFA groups also had low and comparable cumulative rates of all-cause death (14.6% vs. 17.3%, log-rank p = .56) and cardiac death (7.9% vs. 9.1%, log-rank p = .7). CONCLUSION: The present study revealed no significant differences in long-term clinical outcomes when TRA or TFA were used for LM PCI.

The relationship between ß1 -adrenergic and M2 -muscarinic receptor autoantibodies and hypertrophic cardiomyopathy.

NEW FINDINGS: What is the central question of this study? The concentrations of ß1 -adrenergic receptor and M2 -muscarinic receptor autoantibodies in hypertrophic cardiomyopathy (HCM) patients and the relationship between the cardiac autoantibodies and clinical manifestations of HCM have rarely been reported. What is the main finding and its importance? We found that the concentrations of the two autoantibodies in HCM patients were significantly higher than those in control subjects. Furthermore, we found that the concentrations of the two autoantibodies could reflect myocardial injury and diastolic dysfunction in HCM patients to some extent and might be involved in the occurrence of arrhythmia. These findings might be valuable in exploration of the mechanisms of occurrence and progression of HCM. ABSTRACT: Increasing attention is being given to the role of immunological mechanisms in the development of heart failure. The purpose of this study was to investigate the concentration of serum ß1 -adrenergic receptor autoantibody (ß1 -AAb) and M2 -muscarinic receptor autoantibody (M2 -AAb) in patients with hypertrophic cardiomyopathy (HCM), and the relationship between ß1 -AAb, M2 -AAb and clinical indices. One hundred and thirty-four patients with HCM were recruited consecutively into the HCM group. Forty healthy subjects were assigned as the normal controls (NCs). Serum samples were collected to measure the concentrations of ß1 -AAb and M2 -AAb by enzyme-linked immunosorbent assay. The clinical data of HCM patients were collected. The serum concentrations of ß1 -AAb and M2 -AAb of HCM patients were significantly higher than those of NCs. In HCM patients, those with a left atrial diameter ≥50 mm or moderate-to-severe mitral regurgitation had significantly higher concentrations of the two autoantibodies. Patients with a history of syncope had higher concentrations of ß1 -AAb. Female patients and patients with a family history of sudden cardiac death or atrial fibrillation had higher concentrations of M2 -AAb. Maximal wall thickness, interventricular septum thickness and resting left ventricular outflow tract gradient were positively correlated with log ß1 -AAb or log M2 -AAb in HCM patients. In conclusion, the serum concentrations of ß1 -AAb and M2 -AAb of HCM patients were significantly higher than those of NCs. Being female, syncope, a family history of sudden death, atrial fibrillation, left atrial diameter ≥50 mm, moderate-to-severe mitral regurgitation, maximal wall thickness, interventricular septum thickness and resting left ventricular outflow tract gradient may affect the concentrations of the two autoantibodies.

Biodegradable polymer drug-eluting stents versus second-generation drug-eluting stents in patients with and without diabetes mellitus: a single-center study.

BACKGROUND: To improve outcomes in patients with diabetes mellitus (DM) undergoing percutaneous coronary intervention remain an unmet clinical need. The study aimed to evaluate the efficacy and safety of G2-DESs and BP-DESs in patients with and without DM in a single center in China. METHODS: A total of 7666 consecutive patients who exclusively had G2-DES or BP-DES implantation throughout 2013 in our center were studied. The primary efficacy endpoint was any target lesion revascularization (TLR), whereas the primary safety endpoint was a composite of death or myocardial infarction (MI) at 2-year follow-up. RESULTS: G2-DESs had a similar occurrence of death, non-fatal MI, TLR, stroke, and stent thrombosis compared with BP-DESs in patients with DM (all P > 0.05). The incidence of TVR and TLR was lower for G2-DESs than for BP-DESs in patients without DM (3.2% vs. 5.1%, P = 0.002; 2.2% vs. 4.5%, P < 0.001, respectively). Kaplan-Meier analysis also showed better TVR- and TLR-free survival rates for G2-DESs than for BP-DESs in patients without DM. Multivariate analysis showed that a BP-DES was an independent risk factor for TLR (hazard ratio 1.963, 95% confidence interval 1.390-2.772, P < 0.001) in patients without DM, which was not predictive of other components of major adverse cardiac events (P > 0.05). CONCLUSIONS: G2-DESs have better efficacy, represented by a reduced risk of TLR, and similar safety compared with BP-DESs in patients without DM. G2-DESs have similar efficacy and safety compared with BP-DESs in patients with DM at 2-year follow-up.

Dual antiplatelet therapy after coronary drug-eluting stent implantation in China: A large single center study.

OBJECTIVE: To investigate the actual dual antiplatelet therapy (DAPT) duration after drug-eluting stent (DES) treatment in China. BACKGROUND: Currently, less is known about actual DAPT duration after drug-eluting stent (DES) treatment in China. Here, we performed a study in the largest cardiovascular center in China to investigate DAPT duration and identify associated factors after DES implantation. METHODS: A total of 9,919 consecutive patients with DES implantation from January 2013 to December 2013 were enrolled. DAPT cessation was observed, and factors associated with different DAPT durations were analyzed. RESULTS: The median follow-up time was 882 days. The proportion of patients with DAPT coverage at 1-year of follow-up was 97.3%, and it decreased to 30.1% for 2 years. The distribution of DAPT duration was not significantly different among patients with acute myocardial infarction (AMI) versus non-AMI (P = 0.41) and with new-generation DES versus first-generation DES (P = 0.54). The multivariable analysis indicated some independent predictors prolonging DAPT duration, including target vessel revascularization (OR 2.50, 95% CI 2.04-3.06, P < 0.001), stent numbers (OR 1.10, 95% CI 1.05-1.15, P < 0.001), and previous coronary artery bypass grafting (OR 0.76, 95% CI 0.61-0.96, P = 0.02). Other clinical factors, such as the increased risk of bleeding and high ischemic risk, were not associated with DAPT duration. CONCLUSIONS: The 1-year DAPT after DES was applied to 97.3% of Chinese patients in the studied clinical center. However, the DAPT duration after 1 year was not adjusted according to the patients' bleeding situation and ischemic risks.

Sex-based differences in bleeding and long-term adverse events after percutaneous coronary intervention in older patients with coronary artery disease.

OBJECTIVES: Differences in outcomes for women and men after percutaneous coronary intervention (PCI) in older patients remain controversial. Herein, we compared 2-year outcomes by sex in Chinese older patients undergoing PCI. METHODS: A total of 4926 consecutive patients (33.6% women, age ≥60 years, mean age 67.4 ± 5.7 years) who underwent PCI at a single center in China from January 2013 to December 2013 were included in this study. The primary endpoint was 2-year risk of bleeding according to the Bleeding Academic Research Consortium definitions. The secondary endpoints included 2-year risk of major adverse cardiovascular and cerebrovascular events (MACCE). Hazard ratios were generated using multivariable Cox regression. RESULTS: Compared with men, women had significantly higher rates of in-hospital all-cause mortality (0.8% vs 0.2%, P = 0.001), cardiac death (0.5% vs 0.1%, P = 0.006), MACCE (2.4% vs 1.5%, P = 0.017), and bleeding (0.4% vs 0.1%, P = 0.015). At 2-year follow up, there were no differences between men and women for all-cause mortality (1.9% vs 1.8%, P = 0.839) and 2-year MACCE (13.1% vs 11.8%, P = 0.216). However, women had a higher risk of 2-year bleeding (9.2% vs 6.2%, P < 0.001), which persisted after adjusting for baseline differences and treatment characteristics (hazard ratio 1.35, 95% confidence interval 1.06-1.71; P = 0.014). CONCLUSION: We found that older women undergoing PCI were at increased risk of 2-year bleeding compared with men. Further dedicated studies are needed to confirm these findings.

Effect of sex difference in clinical presentation (stable coronary artery disease vs unstable angina pectoris or non-ST-elevation myocardial infarction vs ST-elevation myocardial infarction) on 2-year outcomes in patients undergoing percutaneous coronary intervention.

OBJECTIVE: To determine whether there is a difference in 2-year prognosis among patients across the spectrum of coronary artery disease undergoing percutaneous coronary intervention (PCI). METHODS: We analyzed all consecutive patients undergoing PCI at a single center from 1/1-12/31/2013. Clinical presentations were compared between sexes according to baseline clinical, angiographic, and procedural characteristics and 2-year (mean 730 ± 30-day) outcomes. RESULTS: We grouped 10 724 consecutive patients based on sex and clinical presentation. Among patients with ST-elevation myocardial infarction (STEMI), rates of all-cause death (6.7% vs 1.4%) and cardiac death (3.8% vs 1.1%) were significantly higher in women than in men (P < 0.05), but these rates did not differ between men and women with stable coronary artery disease (SCAD) and non-ST-elevation acute coronary syndrome ((NSTE-ACS). Incidence of major bleeding was greater than in men only in those women presenting with ACS. After multivariable adjustment, female sex was not an independent predictor of outcomes in STEMI (hazard ratio [HR] for all-cause death: 1.33, 95% confidence interval [CI]:0.52-3.38; P = 0.55; HR for cardiac death: 0.69, 95%CI: 0.23-2.09, P = 0.51], but was still an independent predictor of bleeding in STEMI (HR: 3.53, 95%CI: 1.26-9.91, P = 0.017). CONCLUSION: Among STEMI patients, women had worse 2-year mortality after PCI therapy, but female sex was not an independent predictor of mortality after adjustment for baseline characteristics. In STEMI patients, women were at higher bleeding risk than men after PCI, even after multivariable adjustment.

Prognostic Value of NT-proBNP in Stable Coronary Artery Disease in Chinese Patients after Percutaneous Coronary Intervention in the Drug-eluting Stent Era.

OBJECTIVE: The predictive value of N-terminal pro-brain natriuretic peptide (NT-proBNP) in patients with stable coronary artery disease (SCAD) in the drug-eluting stent era is not yet clear. We aimed to evaluate the prognostic value of NT-proBNP in SCAD patients after percutaneous coronary intervention (PCI). METHODS: We examined 4,293 consecutive SCAD patients who underwent PCI between January 2013 and December 2013 in Fuwai Hospital, China. The primary endpoint was all-cause death. NT-proBNP levels were measured before PCI using Elisa kits (Biomedica, Austria). The indication for PCI was based on the degree of coronary stenosis and evidence of ischemia. RESULTS: Among 3,187 SCAD patients with NT-proBNP data, after a 2-year follow-up, NT-proBNP levels were predictive for all-cause death in the SCAD population [area under the receiver operating characteristic curve, 0.768; 95% confidence interval (CI), 0.687-0.849; P < 0.001]. At the optimum cutoff point of 732 pg/mL, the sensitivity and specificity of death was 75.0% and 72.3%, respectively. In a multivariable Cox regression model, the death hazard ratio was 6.43 (95% CI, 2.99-13.82; P < 0.001) for patients with NT-proBNP levels ⪖ 732 pg/mL, compared with < 732 pg/mL. CONCLUSION: NT-proBNP is a strong predictor of 2-year death with SCAD after PCI in the drug-eluting stent era.

Transradial Versus Transfemoral Approach for Percutaneous Coronary Intervention in Elderly Patients in China: A Retrospective Analysis.

Objective To compare hospital costs and clinical outcomes between transradial intervention (TRI) and transfemoral intervention (TFI) in elderly patients aged over 65 years. Methods We identified 1229 patients aged over 65 years who underwent percutaneous coronary intervention (PCI) in Fuwai Hospital, Beijing, China, between January 1 and December 31, 2010. Total hospital costs and in-hospital outcomes were compared between TRI and TFI. An inverse probability weighting (IPW) model was introduced to control potential biases. Results Patients who underwent TRI were younger, less often female, more likely to receive PCI for single-vessel lesions, and less likely to undergo the procedure for ostial lesions. TRI was associated with a cost saving of CNY7495 (95%CI: CNY4419-10 420). Such differences were mainly driven by lower PCI-related costs. TRI patients had shorter length of stay (1.9 days, 95%CI: 1.1-2.7 days), shorter post-procedural stay (0.7 days, 95%CI: 0.3-1.1 days), and fewer major adverse cardiac events (adjusted odds ratio = 0.47, 95%CI: 0.31-0.73). There was no statistical significance in the incidence of post-PCI bleeding between TRI and TFI (P>0.05). Such differences remained consistent in clinically relevant subgroups of acute myocardial infarction, acute coronary syndrome, and stable angina. Conclusion The use of TRI in patients aged over 65 years was associated with significantly reduced hospital costs and more favorable clinical outcomes.

Effectiveness of Alcohol Septal Ablation Versus Transaortic Extended Myectomy in Hypertrophic Cardiomyopathy with Midventricular Obstruction.

OBJECTIVES: Investigate the effectiveness of alcohol septal ablation (ASA) and transaortic extended myectomy (TEM) in hypertrophic cardiomyopathy (HCM) with midventricular obstruction (MVO). BACKGROUND: MVO is less common than subaortic obstruction. Data on the effectiveness of ASA and TEM in MVO are lacking. METHODS: The clinical profiles of 22 patients undergoing ASA and 37 patients undergoing TEM were compared. No patient had apical aneurysm, abnormal chordae, mitral valve replacement or repair. RESULTS: Baseline midventricular pressure gradient and symptoms were comparable between the ASA and TEM groups. During follow-up, both groups demonstrated substantial reduction in pressure gradient (the ASA group: 79.7 ± 21.2 mm Hg to 43.7 ± 28.9 mm Hg, P < 0.001; the TEM group: 69.0 ± 23.9 mm Hg to 15.0 ± 16.9 mm Hg, P < 0.001). The reduction in pressure gradient was greater (78.9 ± 18.6% vs. 46.4 ± 33.4%, P < 0.001) and the residual pressure gradient was lower after TEM versus ASA (P < 0.001). Patients with New York Heart Association class III/IV dyspnea decreased from 59.1 to 18.2% (P = 0.022) in the ASA group and from 56.8 to 5.6% (P < 0.001) in the TEM group. Patients with Canadian Cardiovascular Society class III/IV angina decreased from 40.9 to 9.1% (P = 0.016) in the ASA group and from 32.4 to 0% (P < 0.001) in the TEM group. CONCLUSIONS: While ASA and TEM both improve gradients and symptoms, TEM may provide a more reliable reduction in gradients compared to ASA.

Effects of alcohol septal ablation on left ventricular diastolic filling patterns in obstructive hypertrophic cardiomyopathy.

Alcohol septal ablation (ASA) has been shown to improve left ventricular (LV) diastolic function in patients with obstructive hypertrophic cardiomyopathy (HCM). However, its beneficial effect on diastolic function assessed by cardiac magnetic resonance (CMR) has not been reported. We investigated the mid-term changes of diastolic function by CMR combined with echocardiography in HCM patients after ASA at a median of 14-month follow-up. CMR parameters of diastolic function including peak filling rate (PFR), and time to peak filling rate (TPFR) were evaluated in 43 patients (aged 48 ± 9 years). LV diastolic function improved significantly measured by echocardiography with the decrease in ratio of transmitral early LV filling velocity (E) to early diastolic mitral lateral annular velocity (E') (14.20 ± 1.17 to 11.58 ± 1.16, p < 0.001) and E-wave deceleration time (194.04 ± 19.30 to 168.45 ± 12.58 ms, p < 0.001). PFR increased significantly with associated decrease in TPFR after ASA (both p < 0.001) at follow-up. Furthermore, patients with larger decrease in LVOT gradients had a greater improvement of LV diastolic function, as measured by the reduction of E/E' (p < 0.001) and increase of PFR (p < 0.001). In conclusion, this study demonstrated that successful ASA results in both echocardiographic and CMR indices of diastolic function improvement after ASA at 14-month follow-up. ASA therapy can significantly reduce LVOT gradient and mitral regurgitation, both of which may contribute to the improvement of diastolic function.

Factors associated with coronary artery disease in young population (age ≤ 40): analysis with 217 cases.

OBJECTIVE: To investigate the relevant factors of coronary artery disease (CAD) in young people under 40 years of age. METHODS: The study population was 292 young patients accepting coronary angiography in Fuwai Hospital from July to December 2006, including 272 men and 20 women, with the mean age being 36.7 ± 3.7 years. The diagnosis of CAD was made in the cases presenting ≥ 50% stenosis in coronary lumen in coronary angiography. Based on the diagnosis, 217 patients (204 men, 13 women) were assigned to CAD group, and 75 (68 men, 7 women) to non-CAD group. Clinical data and metabolic characteristics of the patients were collected and analyzed using t-test, χ² test, and multinomial logistic regression with SPSS 8.0 software. RESULTS: Most study subjects were current smokers (209/292, 71.6%), and more than half had body mass index (BMI)>24 kg/m² (230/292, 78.8%) and usually took high-fat diet (162/292, 55.5%). The proportion of heavy smokers (smoking history ≥ 10 years and ≥ 20 cigarettes per day) were significantly higher in the CAD group than in the non-CAD group [20.7% (45/217) vs. 9.3% (7/75), P=0.015)]. Heavy smoking [odds ratio (OR), 1.89; 95% confidence interval (CI), 1.74-2.05], hypertension (OR, 1.56; 95% CI, 1.48-1.65), alcohol (OR, 1.37; 95% CI, 1.30-1.46), type 2 diabetes mellitus (OR, 1.37; 95% CI, 1.25-1.50), high-fat diet (OR, 1.35; 95% CI, 1.28-1.43), and BMI>24 kg/m² (OR, 1.09; 95% CI, 1.03-1.17) were factors related to CAD in the young patients (all P<0.05). Total cholesterol (4.56 ± 1.46 mmol/L vs. 4.09 ± 1.00 mmol/L), low-density lipoprotein cholesterol (2.38 ± 1.11 mmol/L vs. 2.14 ± 0.63 mmol/L), lipoprotein a (134.97 ± 109.70 mg/L vs. 101.58 ± 58.39 mg/L), uric acid (359.89 ± 100.09 µmol/L vs. 336.75 ± 94.36 µmol/L), erythrocyte sedimentation rate (9.98 ± 12.19 mm/hour vs. 4.89 ± 4.92 mm/hour), high-sensitivity C-reactive protein (3.42 ± 4.39 mg/L vs. 2.80 ± 3.77 mg/L) and Big endothelin-1 (1.41 ± 1.50 fmol/mL vs. 0.77 ± 1.13 fmol/mL) in plasma were significantly increased in the CAD group compared with the non-CAD group (all P<0.05). CONCLUSIONS: Heavy smoking, hypertension, alcohol consumption, type 2 diabetes mellitus, high-fat diet and BMI>24 kg/m² were significantly related to CAD in patients aged ≤ 40, with heavy smoking presenting the highest OR. Metabolic syndrome and inflammation were also more common in young CAD patients than in non-CAD patients.

The prognostic value of collateral circulation in coronary chronic total occlusion underwent percutaneous coronary intervention.

BACKGROUND: The prognostic value of coronary collateral circulation (CC) in patients undergoing chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is underdetermined. The purpose of the study was to assess the prognostic value of current two CC grading systems and their association with long-term outcomes in patients with CTO underwent PCI. METHODS: We consecutively enrolled patients with single-vessel CTO underwent PCI between January 2010 and December 2013. All patients were categorized into well-developed or poor-developed collaterals group according to angiographic Werner's CC (grade 2 vs. grade 0-1) or Rentrop (grade 3 vs. grade 0-2) grading system. The primary endpoint was 5-year cardiac death. RESULTS: Of 2452 enrolled patients, the overall technical success rate was 74.1%. Well-developed collaterals were present in 686 patients (28.0%) defined by Werner's CC grade 2, and in 1145 patients (46.7%) by Rentrop grade 3. According to Werner's CC grading system, patients with well-developed collaterals had a lower rate of 5-year cardiac death compared with those with poor-developed collaterals (1.6% vs. 3.3%, P = 0.02), those with suboptimal recanalization was associated with higher rate of 5-year cardiac death compared with optimal recanalization (4.7% vs. 0.8%, P = 0.01) and failure patients (4.7% vs. 1.6%, P = 0.12). However, the similar effect was not shown in Rentrop grading system. CONCLUSIONS: In patients with the single-vessel CTO underwent PCI, well-developed collaterals by Werner's CC definition were associated with lower rate of 5-year cardiac death. Werner's CC grading system had a greater prognostic value than Rentrop grading system in patients with CTO underwent PCI.

Diagnostic performance of intravascular ultrasound-based fractional flow reserve in evaluating of intermediate left main stenosis.

BACKGROUND: The recently introduced ultrasonic flow ratio (UFR), is a novel fast computational method to derive fractional flow reserve (FFR) from intravascular ultrasound (IVUS) images. In the present study, we evaluate the diagnostic performance of UFR in patients with intermediate left main (LM) stenosis. METHODS: This is a prospective, single center study enrolling consecutive patients with presence of intermediated LM lesions (diameter stenosis of 30%-80% by visual estimation) underwent IVUS and FFR measurement. An independent core laboratory assessed offline UFR and IVUS-derived minimal lumen area (MLA) in a blinded fashion. RESULTS: Both UFR and FFR were successfully achieved in 41 LM patients (mean age, 62.0 ± 9.9 years, 46.3% diabetes). An acceptable correlation between UFR and FFR was identified (r = 0.688, P < 0.0001), with an absolute numerical difference of 0.03 (standard difference: 0.01). The area under the curve (AUC) in diagnosis of physiologically significant coronary stenosis for UFR was 0.94 (95% CI: 0.87-1.01), which was significantly higher than angiographic identified stenosis > 50% (AUC = 0.66, P < 0.001) and numerically higher than IVUS-derived MLA (AUC = 0.82; P = 0.09). Patient level diagnostic accuracy, sensitivity and specificity for UFR to identify FFR ≤ 0.80 was 82.9% (95% CI: 70.2-95.7), 93.1% (95% CI: 82.2-100.0), 58.3% (95% CI: 26.3-90.4), respectively. CONCLUSION: In patients with intermediate LM diseases, UFR was proved to be associated with acceptable correlation and high accuracy with pressure wire-based FFR as standard reference. The present study supports the use of UFR for functional evaluation of intermediate LM stenosis.

Long-term outcomes of complete versus incomplete revascularization after drug-eluting stent implantation in patients with multivessel coronary disease.

BACKGROUND: A limited number of studies on the impact of complete revascularization (CR) vs. incomplete revascularization (IR) on long-term outcomes in patients with multivessel coronary disease (MVD) in current percutaneous coronary intervention (PCI) practice have yielded inconsistent results. METHODS: Between April 2004 and November 2010, 7,376 consecutive patients with MVD underwent PCI at the Fuwai Hospital in Beijing, China. Patients who underwent prior CABG and those who had an acute myocardial infarction (MI) within 24 hr before revascularization or presented with cardiogenic shock were excluded. Angiographic CR was defined as successful angioplasty of all diseased lesions in the major epicardial coronary vessels and their first degree side branches (diameter ≥2.5 mm), and proximal CR was defined as successful angioplasty of all diseased proximal arteries. RESULTS: Among 7,065 patients with MVD undergoing PCI treatment, angiographic CR was performed in 1,188 patients (16.8%), and proximal CR in 2,053 patients (29.1%). The study found that either angiographic or proximal IR were associated with significantly higher estimated 3-year rate of cardiac death (2.55% vs. 1.13%, log-rank P = 0.016; and 2.70% vs. 1.43%, log-rank P = 0.024, respectively). After adjustment for differences in baseline characteristics between IR and CR patients, angiographic IR was associated with a significantly higher rate of cardiac death (adjusted hazards ratio [HR]: 2.56, 95% confidence interval [CI]: 1.03-6.41) while proximal IR was associated with a numerically higher rate of cardiac death (adjusted HR: 1.72, 95% CI: 0.93-3.17). For the subgroup of ≥2-vessel IR with total occlusion, either angiographic or proximal IR patients had significantly higher rate of cardiac death (adjusted HR: 4.25, 95% CI: 1.50-12.09; and adjusted HR: 3.02, 95% CI: 1.40-6.52, respectively). CONCLUSION: Compared with IR, patients with CR had better clinical outcomes, supporting CR as first choice for patients with MVD.

Outcomes of overlapping heterogeneous drug-eluting stents versus homogeneous drug-eluting stents for diffuse lesions in small coronary arteries.

OBJECTIVE: To investigate the outcomes of overlapping drug-eluting stenting (DES) in small and diffuse lesions. BACKGROUND: Clinical outcomes of overlapping heterogeneous versus homogeneous DES of diffuse lesions (requiring ≥ 30 mm of length) in small coronary arteries (requiring ≤ 2.75 mm of diameter) are unknown. METHODS: From January 2005 to December 2009, there were 99 patients with diffuse lesions in small coronary arteries receiving overlapping heterogeneous DES, and 558 patients receiving overlapping homogeneous DES at our institution. The clinical end-point of the study included in-hospital and 12-month major adverse cardiac events (death, nonfatal myocardial infarction, and target vessel revascularization (TVR). RESULTS: There were no statistically significant differences between overlapping heterogeneous and homogeneous DES groups in-hospital (2.0% vs. 1.4%, respectively; P = 0.66) and 12-month (9.1% vs. 9.3%, respectively; P = 0.94) major adverse cardiac events. After adjustment, no significant differences for major adverse cardiac events were noted, but the rate of nonfatal myocardial infarction was lower in overlapping homogeneous DES group (odds ratio: 4.20, P = 0.03). CONCLUSION: In this analysis, there were no significant differences in major adverse cardiac events between the 2 types of overlapping DES for diffuse lesions in small coronary arteries, except for higher nonfatal myocardial infarction in overlapping heterogeneous DES.

Long-term outcomes of drug-eluting stent therapy for in-stent restenosis versus de novo lesions.

BACKGROUND: Drug-eluting stents (DES) are currently the most popular treatment modality for restenosis in bare metal stents and DES. This study compares risks of adverse cardiovascular events between DES-treated in-stent restenosis (ISR) and de novo lesions, an area that has not been systematically studied thus far. METHODS AND RESULTS: One thousand three hundred consecutive ISR patients were compared with 27,211 patients with de novo lesions who underwent DES treatment during the same period at the Fu Wai Hospital in Beijing. Angiographic success rate was similar between the ISR and de novo groups (98.0% vs. 98.2%; P = 0.61). Using logistic regression to derive the propensity score model, 1,266 matched patient pairs were compared. In this adjusted model, the rate of target lesion revascularization (TLR) was significantly higher in the ISR group (19.19% vs. 2.37%; P < 0.01) during an average 17-month follow-up, while rates of cardiac death and myocardial infarction (MI) were similar (0.71% vs. 0.79%; P = 0.93 and 3.48% vs. 1.26%; P = 0.13, respectively) between groups. In multivariate regression analysis, ISR was predictive of TLR, but not of cardiac death and MI. CONCLUSION: Compared with those with de novo lesions, patients with ISR had a higher revascularization rate after DES treatment but no significant difference in rates of cardiac death and MI.

Effect of the CYP2C19 2 and 3 genotypes, ABCB1 C3435T and PON1 Q192R alleles on the pharmacodynamics and adverse clinical events of clopidogrel in Chinese people after percutaneous coronary intervention.

PURPOSE: Chinese people are more frequent carriers of cytochrome P450 2C19 (CYP2C19) loss-of-function alleles than Caucasians. The effect of the ATP-binding cassette, sub-family B, member 1 (ABCB1), and paraoxonase 1 (PON1) variants on platelet reactivity and clinical outcomes of clopidogrel treatment has not yet been reported in Chinese patients after percutaneous coronary intervention. The aim of this study was to investigate the effect of the CYP2C19, ABCB1, and PON1 variants on clopidogrel pharmacodynamics and clinical outcomes in these patients. METHODS: Six hundred and seventy patients after percutaneous coronary intervention were enrolled in a single-center registry. The antiplatelet effect of clopidogrel was assessed by thromboelastography, and the CYP2C19, ABCB1, and PON1 genotypes were detected by the ligase detection reaction. Primary clinical endpoints included cardiovascular death, nonfatal myocardial infarction, target vessel revascularization, and stent thrombosis. The secondary clinical endpoints were thrombolysis in myocardial infarction bleeding. The follow-up period was 12 months. RESULTS: The frequency of the CYP2C19 loss-of-function alleles was relatively high (57.3 %). The risk of a low response to clopidogrel and composite ischemic events increased with the number of CYP2C19 loss-of-function alleles. However, there were not significant differences in clopidogrel pharmacodynamics and clinical outcomes across the ABCB1 and PON1 genotype groups; bleeding was not significantly different across the CYP2C19, ABCB1, and PON1 genotype groups. CONCLUSIONS: The CYP2C19 loss-of-function alleles had a gene dose effect on the pharmacodynamics and composite ischemic events of clopidogrel in our study population. Neither the ABCB1 nor the PON1 genotype significantly influenced the antiplatelet effect and clinical outcomes of clopidogrel in these patients.