The validation of the dual antiplatelet therapy score in East Asians receiving percutaneous coronary intervention with exclusively second generation drug-eluting stents.

OBJECTIVES: We investigated whether the dual antiplatelet therapy (DAPT) score (DS) predicts clinical outcome in an East-Asian population that received exclusively second generation drug-eluting stent (DES). BACKGROUNDS: It is uncertain whether the DS could adequately risk stratify patients exclusively receiving second generation DES. METHODS: From the Grand-DES registry, we evaluated patients who were treated with DAPT for at least 12 months and were event-free at 12 months after DES implantation. Patients were classified into two categories: high DS (≧2) (n = 3,157); and low DS (<2) (n = 5,226). The primary ischemic outcome was a composite of stent thrombosis and all myocardial infarction (MI), and the primary bleeding outcome was TIMI major or minor bleeding. A propensity score (PS)-matched analysis was done to correct for baseline differences between extended DAPT group and the conventional group. RESULTS: Among 8,383 subjects, the primary ischemic outcome occurred in 48 patients (0.6%) and the primary bleeding outcome in 49 patients (0.6%). High DS was associated with a higher incidence of ischemic events (ischemic outcome: 0.8% vs. 0.4%, for high vs. low DS, Log-rank p = .039), but not with any differences in bleeding events (Log-rank p = .734). In the PS-matched analysis, extended group was associated with lower risk of composite endpoint of MI, stent thrombosis, or cardiac death in only the high DS group (1.8% vs. 3.7%, Log-rank p = .004; hazard ratio 0.45, 95% confidence interval 0.27-0.76; p = .003 after adjustment). CONCLUSIONS: The DS was an adequate risk stratifier for future ischemic events in East Asians receiving exclusively second generation DES.

Safety and Efficacy of Second-Generation Drug-Eluting Stents in Real-World Practice: Insights from the Multicenter Grand-DES Registry.

OBJECTIVE: In this study, we sought to compare the efficacy and safety of the Xience Prime/Xience V/Promus EES and Biomatrix/Biomatrix Flex/Nobori BES with resolute integrity/resolute ZES using the grand drug-eluting stent (Grand-DES) registry. BACKGROUND: Currently, new-generation drug-eluting stents (DESs) are used as the standard of care in patients undergoing percutaneous coronary intervention. No study has simultaneously compared everolimus-eluting stent (EES), biolimus-eluting stent (BES), and zotarolimus-eluting stent (ZES). METHODS: Stent-related composite outcomes (target lesion failure) and patient-related composite outcomes were compared in crude and propensity score-matched analysis. RESULTS: Of the 17,286 patients in the Grand-DES group, 5,137, 2,970, and 4,990 patients in the EES, BES, and ZES groups completed a three-year follow-up. In the propensity score-matched cohort, the stent-related outcome (EES vs. BES vs. ZES; 5.9% vs. 6.7% vs. 7.1%, P = 0.226) and patient-related outcomes (12.7% vs. 13.5% vs. 14.3%, P = 0.226) and patient-related outcomes (12.7% vs. 13.5% vs. 14.3%, P = 0.226) and patient-related outcomes (12.7% vs. 13.5% vs. 14.3%, P = 0.226) and patient-related outcomes (12.7% vs. 13.5% vs. 14.3%. CONCLUSIONS: In this robust real-world registry with unrestricted use of EES, BES, and ZES, the three stent groups showed comparable safety and efficacy at the 3-year follow-up.

Long-Term Comparison of Platinum Chromium Everolimus-Eluting Stent vs. Cobalt Chromium Zotarolimus-Eluting Stent　- 3-Year Outcomes From the HOST-ASSURE Randomized Clinical Trial.

BACKGROUND: There are limited data on the long-term outcome of platinum chromium-based everolimus-eluting stents (PtCr-EES) vs. cobalt chromium-based zotarolimus-eluting stents (CoCr-ZES).Methods and Results:A total of 3,755 patients undergoing percutaneous coronary intervention (PCI) were randomized 2:1 to PtCr-EES or CoCr-ZES, and 96.0% of patients completed the 3-year clinical follow-up. The primary outcome was target lesion failure (TLF), defined as a composite of cardiac death, target vessel-related myocardial infarction (MI), and clinically-driven target lesion revascularization (TLR). At 3 years, TLF occurred in 5.3% and in 5.4% of the PtCr-EES and CoCr-ZES groups, respectively (hazard ratio 0.978; 95% confidence interval 0.730-1.310, P=0.919). There were no significant differences in the individual components of TLF. Routine angiographic follow-up was performed in 38.9% of the total patients. In a landmark analysis of the subgroup that had follow-up angiography, the clinically-driven TLR rate of CoCr-ZES was significantly higher than PtCr-EES group during the angiography follow-up period (P=0.009). Overall definite and probable stent thrombosis rates were very low in both groups (0.5% vs. 0.6%, P=0.677). CONCLUSIONS: PtCr-EES and CoCr-ZES had similar and excellent long-term outcomes in both efficacy and safety after PCI in an all-comer population.

Morphological characteristics of optical coherence tomography defined plaque fissure in patients with acute coronary syndrome.

We assessed the plaque disruption in 245 consecutive patients with acute coronary syndrome undergoing percutaneous coronary intervention. The plaque fissure was diagnosed with optical coherence tomography, and intravascular ultrasound was used to determine arterial remodeling. Of them, 26 fissures were found in this study. The definite fissure was seen in 17 (65.4%) and probable fissure was seen in 9 (34.6%) patients. In 18 (69.2%), plaque fissure component was lipidic or thin-capped fibroatheroma. Eighteen (69.2%) of fissured plaque were seen within 30 mm of coronary ostium. Combined plaque fissure with plaque rupture/erosion was seen in 21 (80.8%) cases. The isolated fissure was seen in 5 (19.2%). Compared to the maximal necrotic core site of the ruptured plaque, the fissure site showed a smaller %necrotic core (p = 0.012), however, greater in fissure site than minimal lumen area site (24.93 ± 11.50% vs 15.34 ± 10.40%, p < 0.0001). The remodeling index was higher at fissure site as compared to minimal lumen area site (1.02 ± 0.22 vs 0.94 ± 0.27; p = 0.047), but similar to the rupture plaque (p = 0.31). The frequency of positive remodeling was 34.6% (9/26) at the plaque fissure. Although the plaque fissure can be interchangeable with the rupture in acute coronary syndrome, the limited extension to the small lipid core might and less positive remodeling provoke a fissuring of the plaque. Further study is necessary to assess the plaque fissure.

Exploring Coronary Circulatory Response to Stenosis and Its Association With Invasive Physiologic Indexes Using Absolute Myocardial Blood Flow and Coronary Pressure.

BACKGROUND: Although invasive physiological assessment for coronary stenosis has become a standard practice to guide treatment strategy, coronary circulatory response and changes in invasive physiological indexes, according to different anatomic and hemodynamic lesion severity, have not been fully demonstrated in patients with coronary artery disease. METHODS: One hundred fifteen patients with left anterior descending artery stenosis who underwent both 13N-ammonia positron emission tomography and invasive physiological measurement were analyzed. Myocardial blood flow (MBF) measured with positron emission tomography and invasively measured coronary pressures were used to calculate microvascular resistance and stenosis resistance. RESULTS: With progressive worsening of angiographic stenosis severity, both resting and hyperemic transstenotic pressure gradient and stenosis resistance increased (P<0.001 for all) and hyperemic MBF (P<0.001) and resting microvascular resistance (P=0.012) decreased. Resting MBF (P=0.383) and hyperemic microvascular resistance (P=0.431) were not changed and maintained stable. Both fractional flow reserve and instantaneous wave-free ratio decreased as angiographic stenosis severity, stenosis resistance, and transstenotic pressure gradient increased and hyperemic MBF decreased (all P<0.001). When the presence of myocardial ischemia was defined by both low hyperemic MBF and low coronary flow reserve, the diagnostic accuracy of fractional flow reserve and instantaneous wave-free ratio did not differ, regardless of cutoff values of hyperemic MBF and coronary flow reserve. CONCLUSIONS: This study demonstrated how the coronary circulation changes in response to increasing coronary stenosis severity using 13N-ammonium positron emission tomography-derived MBF and invasively measured pressure data. Currently used resting and hyperemic pressure-derived invasive physiological indexes have similar patterns of relationships to the different anatomic and hemodynamic lesion severities. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01366404.

The use of cardiac-CT alone to exclude left atrial thrombus before atrial fibrillation ablation: Efficiency, safety, and cost analysis.

BACKGROUND: Atrial fibrillation (AF) is a growing financial burden on the healthcare system. Cardiac computed tomographic angiography (CCTA) is needed for pulmonary vein mapping before AF ablation (AFA). CCTA has shown to be an alternative to transesophageal echocardiogram (TEE) to rule out left atrial appendage thrombus (LAAT) pre-AFA. We aim to examine the safety, cost-effectiveness, and time-efficiency of utilizing CCTA alone to rule out LAAT before AFA. METHODS: We prospectively screened patients with paroxysmal AF undergoing cryoablation. CCTA with delayed enhancement was performed within 72 hours of AFA. Once LAAT was ruled out, patients were enrolled and planned TEE was cancelled. A retrospective control cohort that had both CCTA and TEE prior to AFA was identified. Direct cost data, electrophysiology laboratory utilization time, and 30-day stroke outcomes were collected from the EMR, follow-up phone calls, or clinic visits, and comparative analyses were performed. RESULTS: Seventy patients met the inclusion criteria in the prospective CCTA-only cohort, and 71 for the retrospective CCTA+TEE cohort. Baseline characteristics were similar between the two groups. There was a nonsignificant reduction in overall cost ($15,870 ± 1,710 vs $16,557 ± 2,508, P = 0.06) in CCTA-only cohort, whereas the electrophysiology laboratory utilization time was significantly reduced (241.6 ± 41.7 vs 181.3 ±36.4 minutes, P < 0.001). There were no strokes reported on 30-day follow-up in the CCTA-only group. CONCLUSIONS: In low-to-intermediate stroke risk patients with paroxysmal AF undergoing cryoablation, eliminating TEE and employing CCTA-only strategy to rule-out LAAT improves electrophysiology laboratory efficiency without influencing periprocedural cost or increasing postprocedural stroke risk.

Gap junction remodelling by chronic pressure overload is related to the increased susceptibility to atrial fibrillation in rat heart.

AIMS: Left atrial (LA) fibrosis caused by various pathological stimuli is a common finding. However, the difference of atrial remodelling via haemodynamic change in diverse cardiomyopathy has not been elucidated. METHODS AND RESULTS: Male Sprague-Dawley rats (6-8 weeks, n = 180) were randomly assigned to three groups and corresponding sham control groups: (i) ischaemic cardiomyopathy, (ii) left ventricular hypertrophy (LVH), and (iii) dilated cardiomyopathy. At 12 weeks after operation, atrial fibrillation (AF) inducibility and duration were assessed by in vivo burst transoesophageal pacing. Using the Langendorff apparatus, left ventricular (LV) function and pressure were measured. The expression of connexin-43 (Cx43) and alpha-smooth muscle actin (α-SMA) in atrial tissues was assessed by quantitative real-time polymerase chain reaction and immunohistochemical staining. Fibrosis was analysed by Masson's trichrome staining. Compared with controls, the LA weight/heart weight ratio was increased in the LVH group alone, and was significantly correlated with AF duration (P < 0.001, R = 0.388). Atrial fibrillation inducibility and duration were higher and longer only in the LVH group (P = 0.002, 0.079, respectively), and isolated LV diastolic dysfunction and elevated LV pressure were observed. Although α-SMA expression and fibrosis were increased in all three cardiomyopathy models, down-regulation of Cx43 expression in the LA was observed in the LVH group alone. CONCLUSION: Chronic pressure overload in the absence of LV systolic dysfunction resulted in LA hypertrophy and increased susceptibility to AF, which might be related to conduction abnormality via decreased expression and lateral distribution of Cx43 as well as interstitial fibrosis.

Efficacy of dapagliflozin in improving arrhythmia-related outcomes after ablation for atrial fibrillation: a retrospective single-center study.

BACKGROUND: Atrial fibrillation (AF) is a widespread type of sustained arrhythmia that poses significant health risks. Catheter ablation is the preferred treatment; however, arrhythmia recurrence remains challenging. Sodium-glucose co-transporter 2 inhibitors, particularly dapagliflozin (DAPA), have exhibited cardiovascular benefits. However, to date, the influence of these inhibitors on AF post-ablation remains unclear. METHODS: We analyzed the records of 272 patients who underwent catheter ablation for AF from January 2018 to December 2022. Patients were divided into the control (n = 199) and DAPA (n = 73) groups based on DAPA prescription post-ablation. The primary outcome was total atrial arrhythmia recurrence after a 3-month blanking period. RESULTS: The mean age was 72.19 ± 5.45 years; 86.8% of the patients were men. At 18 months post-ablation, 36.2% and 9.5% of the patients in the control and DAPA groups, respectively, reported atrial arrhythmia. Multivariate analysis revealed that DAPA use was associated with a significantly reduced risk of arrhythmia recurrence (adjusted hazard ratio [aHR]: 0.15, 95% confidence interval [CI]: 0.07-0.32, p < 0.001). After propensity score-matching (PSM) in 65 pairs, arrhythmia recurrence was lower in the DAPA group compared with the control (8.3% versus 30.8%, aHR: 0.17, 95% CI: 0.06-0.51, p = 0.002). Freedom from total arrhythmia recurrence was significantly higher in the DAPA group compared with the control group in both the overall and PSM population (log-rank test p < 0.01). CONCLUSION: DAPA administration post-ablation was associated with significantly reduced atrial arrhythmia recurrence rates, indicating its potential as an adjunct therapy for enhancing the success of AF ablation.

A Case of Unintentional Release of the Watchman FLX Device During Implantation: A Cautionary Tale.

Atrial fibrillation (AF) is a common heart rhythm disorder that increases the risk of stroke and other cardiovascular complications. The Watchman FLX device is a percutaneous device used for the closure of the left atrial appendage in patients with atrial fibrillation and prevents blood clots from forming, thereby decreasing the risk of stroke. However, device dislodgement during the procedure can occur and compromise the effectiveness of the device. In this case report, we present the experience of an 86-year-old man with a history of atrial fibrillation, coronary artery disease, hypertension, and recent gastrointestinal bleeding due to diverticulosis. During the procedure, the device became dislodged prior to the planned release from the shaft due to the difficult anatomy of the appendage, which caused the operator to over-torque and kink the delivery sheath. The kinked sheath prevented the transmission of torque to the appropriate region of the sheath and caused the device to unscrew prematurely. Fortunately, the device was self-deployed in a satisfactory position, and no further intervention was required. The patient did not experience any complications prior to discharge and follow-up echocardiography showed proper positioning of the device. This case highlights the importance of careful technique during the Watchman FLX procedure and the need to replace the delivery sheath if kinking is noted to prevent unintentional dislodgement of the device. In addition, the case was written with the aid of the artificial intelligence-powered language model ChatGPT and demonstrates its benefits as well as calls for caution while using it for medical writing.

Rate of Change in 10-Year Atherosclerotic Cardiovascular Disease Risk and Its Implications for Primary Prevention.

BACKGROUND: Contemporary cardiovascular primary prevention is based on the assessment of the 10-year risk of atherosclerotic cardiovascular disease (ASCVD). However, the clinical implications of temporal change in the 10-year ASCVD risk estimate (∆10-year ASCVD risk/year) are unknown. METHODS: A total of 211 077 participants without established ASCVD and with repetitive 10-year ASCVD risk assessment at an interval of 4 to 5 years were selected from the Korean National Health Insurance Service data. The primary end point was a composite of myocardial infarction, stroke, coronary revascularization, and all-cause death. RESULTS: ASCVD event rates were proportional to the ∆10-year ASCVD risk/year regardless of the baseline 10-year ASCVD risk. Adjusted hazard ratio for ASCVD events per 1% increase in ∆10-year ASCVD risk/year was 1.53 (95% CI, 1.44-1.63), 1.24 (95% CI, 1.15-1.32), 1.18 (95% CI, 1.13-1.23), and 1.05 (95% CI, 1.00-1.10) in those with a baseline 10-year ASCVD risk of <5%, 5% to 7.5%, 7.5% to 20%, and ≥20%, respectively. Appropriate control of risk factors, including low-density lipoprotein cholesterol, blood pressure, body mass index, exercise habits, and smoking status, was associated with lower ASCVD event rates, whereas failure to control these risk factors resulted in higher ASCVD event rates. CONCLUSIONS: The temporal change in 10-year ASCVD risk over a period of 4 to 5 years reflects success or failure in controlling major cardiovascular risk factors and indicates the risk of future ASCVD events. The ∆10-year ASCVD risk/year can be used as an indicator of primary prevention and guide the application of preventive measures.

Sex Differences in Fractional Flow Reserve- or Intravascular Ultrasound-Guided Percutaneous Coronary Intervention.

BACKGROUND: A recent randomized trial reported fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) strategy was noninferior to the intracoronary ultrasound (IVUS)-guided PCI strategy with respect to clinical outcomes with fewer revascularizations. OBJECTIVES: This study sought to investigate the sex differences in treatment and clinical outcomes according to physiology- or imaging-guided PCI strategies. METHODS: In this secondary analysis of the FLAVOUR (Fractional Flow Reserve or Intravascular Ultrasonography to Guide PCI) trial, the impact of sex on procedural characteristics, PCI rate, and outcomes according to different strategies and treatment types (PCI vs deferral of PCI) was analyzed. The primary outcome was target vessel failure (TVF) at 24 months, defined as a composite of cardiac death, target vessel myocardial infarction, and target vessel revascularization. RESULTS: Of 1,619 patients, 30% were women. Compared with men, women had a smaller minimal lumen area, smaller plaque burden, and higher FFR. They had a lower PCI rate (40.8% vs 47.9%; P = 0.008), which was mainly contributed by FFR guidance. Overall, women showed a lower TVF rate (2.4% vs 4.5%). According to the treatment type, the cumulative incidence of TVF was lower in women than in men among those with the deferral of PCI (1.7% vs 5.2%). However, this trend was not observed in patients who underwent PCI. In both women and men, there were no differences in clinical outcomes between the FFR- and IVUS-guided strategies. CONCLUSIONS: In cases of intermediate stenosis, despite receiving fewer interventions, women had more favorable outcomes than men. The use of FFR led to a lower PCI rate but had a similar prognostic value compared with IVUS in both women and men.

Practical Application of Coronary Physiologic Assessment: Asia-Pacific Expert Consensus Document: Part 2.

Coronary physiologic assessment is performed to measure coronary pressure, flow, and resistance or their surrogates to enable the selection of appropriate management strategy and its optimization for patients with coronary artery disease. The value of physiologic assessment is supported by a large body of clinical data that has led to major recommendations in all practice guidelines. This expert consensus document aims to convey practical and balanced recommendations and future perspectives for coronary physiologic assessment for physicians and patients in the Asia-Pacific region, based on updated information in the field that includes both wire- and image-based physiologic assessment. This is Part 2 of the whole consensus document, which provides theoretical and practical information on physiologic indexes for specific clinical conditions and patient statuses.

Differential cardiovascular and renal benefits of SGLT2 inhibitors and GLP1 receptor agonists in patients with type 2 diabetes mellitus.

BACKGROUND: The differential benefits of sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP1RA) in cardiovascular or renal outcomes have not been fully investigated. METHODS: Patients with diabetes prescribed SGLT2i or GLP1RA were retrospectively identified. Patients treated with antihyperglycemic medications other than SGLT2i or GLP1RA were used as a control group. Primary outcomes were composite ischemic events (acute coronary syndrome, coronary revascularization, and stroke) and a composite of heart failure and renal events (hospitalization for heart failure, renal death, initiation of renal replacement therapy, and renal admission). RESULTS: During a median 38.7 months of follow-up, the incidence of composite ischemic events tended to be lower in the GLP1RA group (annualized rate 0.82% per person-year) than in the other groups (1.68% per person-year in the SGLT2i group and 1.36% per person-year in the control group). The risk of a composite of heart failure and renal outcomes was significantly lower in the SGLT2i group than in the GLP1RA and control groups (0.86% per person-year, 2.33% per person-year, and 1.48% per person-year, respectively). The SGLT2i group had a slower decline in renal function over time compared to that in other groups. CONCLUSIONS: SGLT2i showed more benefits in heart failure and renal outcomes, whereas GLP1RA tended to have more favorable ischemic outcomes.

Artificial intelligence versus physicians on interpretation of printed ECG images: Diagnostic performance of ST-elevation myocardial infarction on electrocardiography.

BACKGROUND: Smartphone-based ECG analyzer using camera input can be useful as everyone have it. The purpose of this study was to evaluate whether such a system can outperform clinicians in detecting ST-elevation myocardial infarction (STEMI) regardless of image acquisition conditions. METHODS: We retrospectively enrolled suspected STEMI patients in an emergency department from January to October 2021. A multifaceted cardiovascular assessment system (Quantitative ECG, QCG™) using ECG images to produce a quantitative score (QCG score, ranging from 0 to 100) was compared to human experts of 7 emergency physicians and 3 cardiologists. Voting scores (number of participants answering "yes" for STEMI) were calculated for comparison. The system's robustness was evaluated using an equivalence test where we prove its performance metric (area under the curve of the receiver operating characteristic curve, AUC-ROC) changes within a predetermined equivalence range (-0.01 to 0.01) in 6 different environments (A combination of three different smartphones and two image sources including computer screen and paper). RESULTS: 187 patients (96 STEMI, 51.3%) were analyzed. AUC-ROC of QCG score was 0.919 (0.880-0.957). AUC-ROCs of voting scores, 0.856 (0.799-0.913) for all clinicians, 0.843 (0.786-0.900) for emergency physicians, 0.817 (0.756-0.877) for cardiologists, and 0.848 (0.790-0.905) for high-performance group were significantly lower compared to that of QCG score. The change in AUC-ROC by image acquisition condition was negligible with a narrow confidence interval within -0.01 to 0.01 confirming the equivalence. CONCLUSIONS: Image-based AI system can outperform clinicians in STEMI diagnosis and its performance was robust to change in image acquisition conditions.

Differences in Plaque Characteristics and Myocardial Mass: Implications for Physiological Significance.

Background: The mechanism of the fractional flow reserve (FFR) difference according to sex has not been clearly understood. Objectives: This study sought to evaluate sex differences in coronary stenosis, plaque characteristics, and left ventricular (LV) mass and their implications for physiological significance. Methods: This was a post hoc analysis of a pooled population of multicenter, international prospective cohorts. Patients (166 women and 489 men) underwent coronary computed tomography angiography (CCTA) within 90 days before invasive FFR measurements were included. The minimal lumen area, percent of plaque burden, whole vessel plaque volume by composition, high-risk plaque characteristics, and LV mass were analyzed from CCTA images. Results: Among 1,188 vessels analyzed, the FFR value was higher in women than that in men (0.85 ± 0.13 vs 0.82 ± 0.14; P = 0.001) despite a similar percentage of diameter stenosis between the sexes (45.9% ± 18.9% vs 46.1% ± 17.7%; P = 0.920). The composition of fibrofatty plaque + necrotic core (13.1% ± 16.9% vs 21.2% ± 19.9%; P < 0.001) and frequencies of low attenuation plaque (12.7% vs 24.5%; P < 0.001) and positive remodeling (33.8% vs 45.5%; P = 0.001) were lower in women than in men. Vessel, plaque, and lumen volumes were significantly smaller in women than that in men (all P < 0.001); however, no sex difference was observed in any of these parameters after adjustment for LV mass (all P > 0.10). Sex was not an independent predictor of the FFR value after adjustment for stenosis severity, plaque characteristics, and LV mass. Conclusions: Higher FFR values for the same stenosis severity in women can be explained by fewer high-risk plaque characteristics and smaller myocardial mass in women than that in men. (CCTA-FFR Registry for Risk Prediction; NCT04037163).

Differential Prognostic Implications of Pre- and Post-Stent Fractional Flow Reserve in Patients Undergoing Percutaneous Coronary Intervention.

BACKGROUND AND OBJECTIVES: The influence of pre-intervention coronary physiologic status on outcomes post percutaneous coronary intervention (PCI) is not well known. We sought to investigate the prognostic implications of pre-PCI fractional flow reserve (FFR) combined with post-PCI FFR. METHODS: A total of 1,479 PCI patients with pre-and post-PCI FFR data were analyzed. The patients were classified according to the median values of pre-PCI FFR (0.71) and post-PCI FFR (0.88). The primary outcome was target vessel failure (TVF) at 2 years. RESULTS: The risk of TVF was higher in the low pre-PCI FFR group than in the high pre-PCI FFR group (hazard ratio, 1.82; 95% confidence interval, 1.15-2.87; p=0.011). In 4 group comparisons, the cumulative incidences of TVF at 2 years were 3.8%, 4.1%, 4.8%, and 10.2% in the high pre-/high post-, low pre-/high post-, high pre-/low post-, and low pre-/low post-PCI FFR groups, respectively. The risk of TVF was the highest in the low pre-/low post-PCI FFR group among the groups (p values for comparisons <0.05). In addition, the high pre-/low post-PCI FFR group presented a comparable risk of TVF with the high post-PCI FFR groups (p values for comparison >0.05). When the prognostic value of the post-PCI FFR was evaluated according to the pre-PCI FFR, the risk of TVF significantly decreased with an increase in post-PCI FFR in the low pre-PCI FFR group, but not in the high pre-PCI FFR group. CONCLUSIONS: Pre-PCI FFR was associated with clinical outcomes after PCI, and the prognostic value of post-PCI FFR differed according to the pre-PCI FFR. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04012281.

The effect of aspirin on C-reactive protein in hypertensive patients.

High level of C-reactive protein (CRP), most popular inflammatory marker, increases the risk of thrombotic cardiovascular events. Aspirin, which has both anti-inflammatory and anti-thrombotic effects, has the potential to influence CRP release. Several studies have been reported investigating clinical effects of aspirin on CRP levels. Some studies have reported aspirin reduced CRP levels, but other studies did not. This study was designed to assess the effect of low-dose aspirin on CRP levels in controlled hypertensive patients who had low inflammatory burden. Two hundred twenty-five patients with controlled hypertension were randomly divided into two groups; aspirin group (n = 122, 100 mg of aspirin) and the control group (n = 134). Patients with a CRP level >1 mg/dL (10 mg/L) were excluded because these high levels suggest infection. C-reactive protein level and lipid profiles were measured before therapy and 3 months after therapy. There were no differences in baseline clinical characteristics between the two groups. Low-dose aspirin showed no significant influence on CRP levels over 3 months (from 0.10 ± 0.0099 to 0.12 ± 0.0097 mg/dL, p = 0.12). Statin therapy did not influence CRP levels. Aspirin-resistance also had no influence on CRP levels. We conclude that low-dose aspirin has no significant effect on decreasing CRP levels in the patients with controlled hypertension which had low inflammatory burden. The anti-inflammatory mechanism may not play an important role in the cardioprotective effect of aspirin in the population with low inflammatory burden such as controlled hypertensive patients.

Sepsis with multiple abscesses after massive autologous fat grafting for augmentation mammoplasty: a case report.

BACKGROUND: Autologous fat grafting to the breast for breast reconstruction and cosmetic breast augmentation has gained much attention recently. However, its efficacy and the severities of its associated complications are of concern. The authors experienced one case of multiple breast abscesses after augmentation mammoplasty by autologous fat grafting. METHODS: A 42-year-old woman presented to the authors' emergency department reporting tenderness, swelling, and a sensation of heat in both breasts. The patient had undergone augmentation mammoplasty by autologous fat grafting 7 days previously. Abscess formation was suspected based on the patient's history, physical examination, laboratory findings, and image study. RESULTS: Incision and drainage were performed immediately with the patient under general anesthesia, and 500 ml of a foul, brown, turbid, purulent fluid containing necrotic fat debris was drained from each breast. Empiric antibiotics were started on the first hospital day, and betadine and saline-irrigation were administered daily for 2 weeks. Incisions were closed on hospital day 19 when laboratory data and local infection signs had improved. At the patient's 9-month follow-up assessment, breast contours were found to be well preserved, and scarring was minimal. CONCLUSION: Immediate complications such as edema, hematoma, and infection require serious consideration after autologous fat grafting in the breast. In particular, infection probably is the most serious complication because the volume of the fat injected is large and can induce systemic infections such as sepsis and distort the contours of the breast. To avoid such infections, systemic and multicenter studies are required to determine how fat grafting should be performed to minimize the risks of fat necrosis and infection.

Prevalence and characteristics of isolated nocturnal hypertension in the general population.

BACKGROUND/AIMS: Ascertaining the prevalence of isolated nocturnal hypertension (INHT) in the general population and identifying the characteristics of patients with INHT may be important to determine patients who should receive 24- hour ambulatory blood pressure (BP) measurements. This study aimed to evaluate the prevalence and characteristics of INHT in the general population. METHODS: Of 1,128 participants (aged 20 to 70 years), we analyzed 823 who had valid 24-hour ambulatory BP measurements and were not on antihypertensive drug treatment. RESULTS: The prevalence of INHT in the study was 22.8%. Individuals with INHT had a higher office, 24-hour, and daytime and nighttime ambulatory systolic and diastolic BPs compared to individuals with sustained day-night normotension. INHT was more prevalent in individuals with masked hypertension (MH) than in those with sustained hypertension (59.8% vs. 15.6%, p < 0.001). Among individuals with INHT, 92.6% had MH. Among individuals with office BP-based prehypertension, 34.5% had both INHT and MH. The prevalence of INHT was highest in individuals with office BP-based prehypertension. INHT was an independent determinant of MH after adjustment for age, sex, body mass index, diabetes, low-density-lipoprotein cholesterol, 24-hour systolic and diastolic BP, systolic and diastolic BP dipping, and systolic and diastolic BP non-dipping. CONCLUSION: The present study showed that INHT is not uncommon and is a major determinant of MH. Our findings strongly suggest the use of 24-hour ambulatory BP measurement for individuals within the prehypertension range of office BP owing to the high prevalence of INHT and MH in this population.

Algorithm for diagnosing hypertension using out-of-office blood pressure measurements.

The authors developed and validated a diagnostic algorithm using the optimal upper and lower cut-off values of office and home BP at which ambulatory BP measurements need to be applied. Patients presenting with high BP (≥140/90 mm Hg) at the outpatient clinic were referred to measure office, home, and ambulatory BP. Office and home BP were divided into hypertension, intermediate (requiring diagnosis using ambulatory BP), and normotension zones. The upper and lower BP cut-off levels of intermediate zone were determined corresponding to a level of 95% specificity and 95% sensitivity for detecting daytime ambulatory hypertension by using the receiver operator characteristic curve. A diagnostic algorithm using three methods, OBP-ABP: office BP measurement and subsequent ambulatory BP measurements if office BP is intermediate zone; OBP-HBP-ABP: office BP, subsequent home BP measurement if office BP is within intermediate zone and subsequent ambulatory BP measurement if home BP is within intermediate zone; and HBP-ABP: home BP measurement and subsequent ambulatory BP measurements if home BP is within intermediate zone, were developed and validated. In the development population (n = 256), the developed algorithm yielded better diagnostic accuracies than 75.8% (95%CI 70.1-80.9) for office BP alone and 76.2% (95%CI 70.5-81.3) for home BP alone as follows: 96.5% (95%CI: 93.4-98.4) for OBP-ABP, 93.4% (95%CI: 89.6-96.1) for OBP-HBP-ABP, and 94.9% (95%CI: 91.5-97.3%) for HBP-ABP.  In the validation population (n = 399), the developed algorithm showed similarly improved diagnostic accuracy. The developed algorithm applying ambulatory BP measurement to the intermediate zone of office and home BP improves the diagnostic accuracy for hypertension.