Inferior and precordial ST-segment elevation myocardial infarction due to large wrap-around left anterior descending artery occlusion.

Left anterior descending artery (LAD) occlusion normally develops into precordial ST-segment elevation; however, we describe a case of a 50-year-old man with inferior and precordial ST-segment elevation myocardial infarction that resulted from proximal occlusion of the wrap-around LAD perfusing the anterior and inferior wall. We performed early and prompt reperfusion and were able to save the patient without any complications. A wrap-around LAD perfuses a large myocardial area; therefore, this type of coronary occlusion causes severe myocardial damage and has a poor prognosis. The rates of new-onset heart failure and heart failure rehospitalization are also high. Simultaneous inferior and precordial ST-segment elevations on electrocardiography suggest acute myocardial infarction with a wrap-around LAD lesion, which requires prompt revascularization. More careful medications for heart failure and follow-up should be also required even after discharge in such case.

In vivo optical coherence tomography of very late drug-eluting stent thrombosis compared with late in-stent restenosis.

BACKGROUND: Autopsy findings have suggested delayed arterial healing as a primary cause of very late stent thrombosis (VLST) after drug-eluting stent (DES) implantation. METHODS AND RESULTS: Optical coherence tomography of DES-treated lesions that developed VLST (n = 6) was compared with that of DES-treated lesions that developed late in-stent restenosis (L-ISR: n = 32) among patients with recurrent ischemia >1 year after DES implantation (mean, 37 ± 17 months), and with the stented segment without any evidence of VLST or L-ISR (no-event: n = 20; mean, 38 ± 19 months). The proportion of uncovered and malapposed struts in each stented segment was evaluated. A total of 961 frames, 9,763 struts were analyzed. The proportion of uncovered struts was higher in the VLST group than in the L-ISR group and the no-event group (29.2 ± 22.8%, 7.9 ± 9.7%, and 7.6 ± 8.0%, respectively; P = 0.0002). The proportion of malapposed struts was higher in the VLST group than in the no-event group (7.3 ± 8.7% vs 1.1 ± 2.4%, P = 0.01). Two patients in the VLST group had lower rates of uncovered and malapposed struts, but this involved lipid-laden-like neointima with disruptions. CONCLUSIONS: Delayed neointimal coverage and incomplete stent apposition were frequently observed in the DES-treated lesions that developed very late thrombosis. Lipid-laden-like neointima with disruption within the DES may be another possible mechanism for very late thrombosis.

The potential benefits and risks of the use of dual antiplatelet therapy beyond 6 months following sirolimus-eluting stent implantation for low-risk patients.

BACKGROUND: The optimal duration of dual antiplatelet therapy (DAT) in patients undergoing intracoronary sirolimus-eluting stent implantation remains controversial. OBJECTIVE: To evaluate the clinical effects of long duration DAT in patients undergoing intracoronary sirolimus-eluting stent implantation in daily practice. In addition, to attempt to identify the optimal duration of DAT after implantation of a sirolimus-eluting stent. METHODS: We retrospectively report on 1293 consecutive patients who underwent successful intracoronary sirolimus-eluting stent implantation. We analyzed the cumulative incidence of stent thrombosis, non-fatal myocardial infarction (MI), death from cardiac causes, and the cumulative incidence of bleeding complications. RESULTS: We compared the study end point in patients who received DAT for <6 months (n=1136) with that for patients who received DAT for >6 months (n=157). The median follow-up period was 1260 ± 462 days. Major bleeding occurred in 35 patients and intracranial hemorrhage in 8. In patients on DAT for >6 months, the incidence of any bleedings, major bleedings, and intracranial hemorrhage was significantly increased. On the other hand, there was no significant difference between the two groups in the risk of the primary end points (stent thrombosis, non-fatal MI, death from cardiac causes, death or MI). CONCLUSIONS: Prolonged DAT for more than 6 months was not significantly more beneficial than aspirin monotherapy in reducing the risk of the occurrence of acute MI, stent thrombosis, and death, although it was associated with an increase in bleeding complications for low-risk patients.

Waist circumference reduction is more strongly correlated with the improvement in endothelial function after acute coronary syndrome than body mass index reduction.

BACKGROUND: Endothelial function predicts recurrence of adverse cardiac events in patients with acute coronary syndromes (ACS). Moreover, the recovery of endothelial function correlates with cardiac event-free survival. OBJECTIVES: The aim of this study was to determine which clinical factors correlate with the improvement in endothelial function after ACS. METHODS: Vascular endothelial function was assessed in 98 patients with ACS by flow-mediated dilation (FMD) of the brachial artery using high-resolution ultrasound at 2 weeks and 6 months after ACS. We measured several risk parameters including plasma markers of glucose homeostasis, lipids, and blood pressure at baseline and at 6 months after ACS. Body mass index (BMI) and waist circumference (WC) were also measured as anthropometric assessments. RESULTS: At baseline, FMD was significantly correlated with BMI, WC, high-density lipoprotein cholesterol, the homeostasis model assessment of insulin resistance, and brachial artery diameter (r=-0.32, p=0.001; r=-0.44, p<0.0001; r=0.34, p=0.0006; r=-0.21, p=0.04; r=-0.47, p<0.0001, respectively). In a stepwise multivariate regression analysis at baseline, larger WC and brachial artery diameter were independently correlated with lower brachial artery FMD (R(2)=0.319, p<0.0001). At 6 months, the change in FMD was significantly correlated with the change in WC and BMI (r=-0.59, p<0.0001; r=-0.33, p=0.001, respectively). In a stepwise multivariate regression analysis, WC reduction was independently correlated with improved FMD (R(2)=0.349, p<0.0001). CONCLUSIONS: WC reduction is more strongly correlated with the improvement of endothelial function after ACS than BMI reduction.