Combination of Lesion Stenosis and Myocardial Supply Area Assessed by Coronary Computed Tomography Angiography for Prediction of Myocardial Ischemia.

Recent clinical studies revealed that anatomical information assessed by coronary computed tomography angiography (CTA) may be used effectively to diagnose coronary artery disease (CAD). However, a physiological assessment, demonstrating myocardial ischemia, is required to justify a therapeutic strategy for CAD. This study aimed to investigate whether using CTA to assess myocardial supply area can improve the prediction of myocardial ischemia.We analyzed 201 vessels with moderate (luminal narrowing ≥ 50%, < 70%) and severe (luminal narrowing ≥ 70%, < 99%) stenosis on CTA from 174 patients, who were suspected of having stable angina and underwent measurement of fractional flow reserve (FFR). The myocardial area supplied by the coronary artery, distal to the stenosis, was evaluated with CTA, as reported previously (modified Alberta Provincial Project for Outcome Assessment in Coronary Heart score) and was classified into 3 groups (large, medium, and small).Both percentage area stenosis and myocardial supply area were significantly correlated with FFR (r = -0.46, P < 0.01, and r = -0.45, P < 0.01). Among patients who had coronary plaques, with moderate stenosis and a small myocardial supply area, only 3 of 42 lesions (7%) were identified as ischemic; deviation from the ischemic threshold (FFR = 0.80) was P < 0.01. The combined assessment of lesion stenosis and myocardial supply area, using CTA, improved the prediction of myocardial ischemia significantly compared to lesion stenosis alone (77% versus 59%, P < 0.01).Adding the assessment of myocardial supply area to standard CTA might help predict myocardial ischemia in patients with stable angina pectoris.

Retrospective Comparison of Long-Term Clinical Outcomes Between Percutaneous Coronary Intervention and Medical Therapy in Stable Coronary Artery Disease With Gray Zone Fractional Flow Reserve　- COMFORTABLE Retrospective Study.

BACKGROUND: A fractional flow reserve (FFR) between 0.75 and 0.80 constitutes a "gray zone" for clinical decision-making in coronary artery disease. We compared long-term outcomes of percutaneous coronary intervention (PCI) using drug-eluting stents vs. medical therapy for coronary stenosis with gray zone FFR. Methods and Results: We retrospectively investigated the clinical outcomes of 263 patients with gray zone FFR: 78 patients in the PCI group and 185 patients in the medical therapy group. During a median follow-up of 3.7 years, the frequency of target vessel failure (TVF, defined as a composite of cardiac death, myocardial infarction [MI], or ischemia-driven target vessel revascularization [TVR]) was significantly lower in the PCI group compared with the medical therapy group (6% vs. 19%, hazard ratio [HR]:0.33, 95% confidence interval [CI]: 0.13-0.84, P=0.008). The frequency of a composite of cardiac death or MI was not different between the 2 groups (1% vs. 2%, HR: 0.61, 95% CI: 0.07-5.49, P=0.645). The frequency of ischemia-driven TVR was significantly lower in the PCI group compared with the medical therapy group (5% vs. 18%, HR: 0.28, 95% CI: 0.10-0.79, P=0.005). CONCLUSIONS: In patients with gray zone FFR, compared with medical therapy, PCI decreased the frequency of TVF, which was mainly driven by a reduction in the frequency of angina or myocardial ischemia without any difference in the frequency of cardiac death or MI.

Altered coronary flow velocity reserve and left ventricular wall motion dynamics: a phenomenon in hypertensive patients with ECG strain.

BACKGROUND: The inner-half layer of the left ventricular (LV) wall is primarily affected by ischemia and increased LV afterload. We hypothesized that LV wall thickening of inner-half layer and coronary microvascular function are impaired in hypertensive patients, especially in those with electrocardiographic (ECG) strain, which is a marker of LV hypertrophy and adverse prognosis. Therefore, the aim of this study is to investigate the association of the ratio of inner- to outer-half layer of the LV myocardial deformation and coronary microvascular function with ECG strain in hypertensive patients. METHODS: We studied 98 hypertensive patients and 13 controls. Hypertensive patients were divided into 2 groups, with (S+) and without (S-) ECG strain. Coronary flow velocity reserve (CFVR) of the left anterior descending artery was evaluated using transthoracic echocardiography. Circumferential and radial strains of the LV wall were analyzed by two-dimensional echocardiographic speckle tracking method, and the inner- to outer-half layer ratio (in/out ratio) was assessed. RESULTS: Coronary flow velocity reserve of S+ (2.06 ± 0.65) was significantly smaller than those in S- and controls (3.03 ± 0.65 and 3.38 ± 0.51, respectively). In/out ratio in both circumferential and radial strains were decreased as well as in S+ patients. Furthermore, in/out ratio was directly proportional to CFVR. CONCLUSIONS: Hypertensive patients with ECG strain possessed severely impaired CFVR and inner-half myocardial deformation. Moreover, the more severe the LV hypertrophy progresses, the greater is the impairment of coronary microvascular and LV inner-half myocardial deformation. Thus, CFVR and in/out ratio are useful quantitative markers that can render sensitive assessment of physiological changes in hypertensive heart disease.

Usefulness of rescue ultrasound guidance for transradial cardiac catheterization.

INTRODUCTION AND OBJECTIVES: Transradial cardiac catheterization reduces access site complications and is more comfortable for patients than the transfemoral approach. However, failure of the transradial approach is more common than the transfemoral approach. This study aimed to investigate whether ultrasound-guided rescue could facilitate transradial cardiac catheterization. METHODS: We retrospectively analyzed 592 consecutive patients who underwent coronary angiography and/or percutaneous coronary intervention. Patients were divided into 2 groups: the palpation technique (PT) (n = 280) and the ultrasound guidance (UG) available group (n = 312). The application and the timing of introduction of ultrasound guidance in the UG group were at the discretion of the individual operators. RESULTS: Real-time ultrasound guidance was used in 98 patients (31.4%) in the UG group. No statistically significant intergroup differences were observed in the incidence of hematoma (6.8% vs. 5.8%, p = 0.62). Although the procedural time in the UG group was longer than that in the PT group (303 s vs. 357 s, p < 0.01), the success rate of sheath insertion was significantly higher in the UG group (97% vs. 92%, p < 0.01). Multivariate analysis revealed that the availability of UG was the only independent predictor of success of sheath insertion (odds ratio 2.79, 95% confidence interval 1.24-6.31, p = 0.01). CONCLUSIONS: Although UG maneuvers require additional procedural time for setting up systems, UG rescue was effective for successful transradial cardiac catheterization.

Safety and efficacy outcomes of second-generation everolimus-eluting stents in octogenarians compared to non-octogenarians.

BACKGROUND: In patients ≥80 years of age, the use of second-generation cobalt-chromium everolimus-eluting stents (CoCr-EES) versus bare-metal stents has been shown to reduce myocardial infarction (MI) and target vessel revascularization (TVR) rates, without an increase in bleeding. However, safety and efficacy of CoCr-EES in octogenarians compared to younger populations are less certain. We aimed to compare the clinical outcomes between octogenarian and non-octogenarian patients undergoing percutaneous coronary intervention (PCI) with CoCr-EES. METHODS: We retrospectively analyzed 186 patients treated with CoCr-EES; 54 octogenarians (63 lesions) and 132 non-octogenarians (152 lesions). The primary endpoint was a 1-year composite of all-cause death, MI, TVR, cerebrovascular accident (CVA), or major bleeding. Stent thrombosis (ST) was also evaluated. RESULTS: Radial approach was used in 70.4% of octogenarians versus 80.3% of non-octogenarians (p = 0.18). Rates of dual antiplatelet therapy at 1 year were 90.7% for octogenarians and 90.9% for non-octogenarians (p = 1.00). The primary endpoint occurred in 14.8% of octogenarians and 11.4% of non-octogenarians (p = 0.52). There were no significant differences with respect to the rates of 1-year all-cause death (7.4% vs. 3.8%, p = 0.30), MI (1.9% vs. 1.5%, p = 1.00), TVR (3.7% vs. 5.3%, p = 0.65), CVA (1.9% vs. 2.3%, p = 1.00), and definite/probable ST (1.9% vs. 1.5%, p = 1.00) between the 2 groups. Major bleeding was observed in only 1 of octogenarians. Multivariate analysis demonstrated that chronic kidney disease and intravascular ultrasound use were the only independent predictors of the primary endpoint. CONCLUSIONS: According to our series, 1-year safety and efficacy outcomes of CoCr-EES PCI in octogenarians were comparable to those in non-octogenarians. SUMMARY: We compared the clinical outcomes between octogenarian and non-octogenarian patients treated with second-generation cobalt-chromium everolimus-eluting stents (CoCr-EES). In our series, 1-year safety and efficacy outcomes of CoCr-EES percutaneous coronary intervention in octogenarians were similar to those in younger counterparts.

Electrocardiographic strain and endomyocardial radial strain in hypertensive patients.

BACKGROUND: Electrocardiographic strain pattern (ECGS) is a well-recognized marker of the presence and severity of anatomic left ventricular hypertrophy (LVH) and also has been associated with adverse prognosis in hypertensive patients. Left ventricular (LV) endomyocardial radial strain (Endo-RS) is predominant in systolic LV wall thickening compared with epimyocardial radial strain (Epi-RS) in a normal heart. However, it remains unclear whether the ratio of Endo-RS to Epi-RS alters in hypertensive patients, especially in those with ECGS. METHODS: Endo-RS and Epi-RS in 9 non-hypertensive subjects (Group A), 26 hypertensive subjects without ECGS (Group B), and 16 hypertensive subjects with ECGS (Group C) were assessed by a tissue tracking system. RESULTS: Relative wall thickness, LV mass index, and voltage of SV1+RV5 were significantly greater in Group C than in both Groups A and B. Although no significant difference was seen in Epi-RS among the 3 groups, Endo-RS and the ratio of Endo-RS to Epi-RS (Endo/Epi-RS) in Group C were significantly lower than those in the other two groups. Multiple logistic regression analysis revealed that the only factor which significantly correlated with Endo/Epi-RS in the first tertile (<1.6) was the presence of ECGS (OR=9.28, p=0.01). CONCLUSIONS: The appearance of ECGS significantly correlated with not only the development of LV hypertrophy but also with the attenuation of Endo-RS.

Impact of heterogeneity of human peripheral blood monocyte subsets on myocardial salvage in patients with primary acute myocardial infarction.

OBJECTIVES: We examined whether distinct monocyte subsets contribute in specific ways to myocardial salvage in patients with acute myocardial infarction (AMI). BACKGROUND: Recent studies have shown that monocytes in human peripheral blood are heterogeneous. METHODS: We studied 36 patients with primary AMI. Peripheral blood sampling was performed 1, 2, 3, 4, 5, 8, and 12 days after AMI onset. Two monocyte subsets (CD14(+)CD16(-) and CD14(+)CD16(+)) were measured by flow cytometry. The extent of myocardial salvage 7 days after AMI was evaluated by cardiovascular magnetic resonance imaging as the difference between myocardium at risk (T2-weighted hyperintense lesion) and myocardial necrosis (delayed gadolinium enhancement). Cardiovascular magnetic resonance imaging was also performed 6 months after AMI. RESULTS: Circulating CD14(+)CD16(-) and CD14(+)CD16(+) monocytes increased in AMI patients, peaking on days 3 and 5 after onset, respectively. Importantly, the peak levels of CD14(+)CD16(-) monocytes, but not those of CD14(+)CD16(+) monocytes, were significantly negatively associated with the extent of myocardial salvage. We also found that the peak levels of CD14(+)CD16(-) monocytes, but not those of CD14(+)CD16(+) monocytes, were negatively correlated with recovery of left ventricular ejection fraction 6 months after infarction. CONCLUSIONS: The peak levels of CD14(+)CD16(-) monocytes affect both the extent of myocardial salvage and the recovery of left ventricular function after AMI, indicating that the manipulation of monocyte heterogeneity could be a novel therapeutic target for salvaging ischemic damage.

Relationship between coronary arterial remodeling, fibrous cap thickness and high-sensitivity C-reactive protein levels in patients with acute coronary syndrome.

BACKGROUND: Thin-capped fibroatheroma (TCFA) is a recognized precursor lesion for acute coronary syndrome (ACS). Positive remodeling (PR) is the predominant pattern of arterial remodeling in patients with ACS. The aim of this study was to evaluate the relationship between coronary arterial remodeling, fibrous cap thickness and high-sensitivity C-reactive protein (hs-CRP) concentration in patients with ACS. METHODS AND RESULTS: The 47 consecutive ACS patients were enrolled in this study. Arterial remodeling of culprit plaque was assessed by intravascular ultrasound, and fibrous cap thickness was measured by optical coherence tomography. The remodeling index (RI) was calculated as lesion divided by the reference external elastic membrane cross-sectional area, and PR was defined as RI >1.05 (PR group). TCFA were observed more frequently in the PR group than in the intermediate and negative remodeling (IR/NR) groups (59% vs 17%, P<0.01). RI was inversely correlated with fibrous cap thickness (r=0.47, P=0.02). hs-CRP levels were higher in the PR group than in the IR/NR groups (0.32 +/-0.26 vs 0.18 +/-0.14 mg/dl, P=0.02). CONCLUSIONS: Coronary arterial remodeling, fibrous cap thickness and hs-CRP level in patients with ACS are associated with each other. This result suggests that inflammation simultaneously contributes to both plaque growth and plaque instability.

Coronary microvascular resistance index immediately after primary percutaneous coronary intervention as a predictor of the transmural extent of infarction in patients with ST-segment elevation anterior acute myocardial infarction.

OBJECTIVES: The purpose of this study was to investigate whether microvascular resistance index (MVRI) immediately after primary percutaneous coronary intervention (PCI) can predict the transmural extent of infarction (TEI) defined by contrast-enhanced cardiac magnetic resonance (ce-CMR) in patients with anterior acute myocardial infarction (MI). BACKGROUND: The degree of microvascular damage is an important determinant of myocardial viability and clinical outcomes in acute MI. A novel dual-sensor (pressure and Doppler velocity) guidewire has the ability to evaluate microvascular damage. ce-CMR can accurately discriminate transmural from nontransmural MI, and the TEI by ce-CMR can predict future improvement in contractile function. METHODS: In 27 patients immediately after primary PCI for a first anterior acute MI, MVRI, coronary flow reserve (CFR), deceleration time of diastolic velocity (DDT), and zero flow pressure (Pzf) were measured with a dual-sensor guidewire. TEI was graded from 1 to 4 based on the transmural extent of hyperenhanced tissue (1 = 0% to 25% of left ventricular wall thickness, 2 = 26% to 50%, 3 = 51% to 75%, and 4 = 76% to 100%). Infarct size by ce-CMR was also calculated. RESULTS: Peak creatine kinase-myocardial band values were significantly correlated with MVRI (r = 0.77, p < 0.0001), CFR (r = -0.69, p < 0.0001), DDT (r = -0.75, p = 0.0001), and Pzf (r = 0.75, p < 0.0001). Also, infarct size by ce-CMR was significantly correlated with MVRI (r = 0.78, p < 0.0001), CFR (r = -0.67, p < 0.0001), DDT (r = -0.70, p < 0.0001), and Pzf (r = 0.72, p = 0.0002). Receiver-operating characteristic curve analyses of MVRI, CFR, DDT, and Pzf for predicting transmural MI (TEI-grade 4) demonstrated that the area under the curve tended to be higher for MVRI (0.885) than those for CFR (0.848), DDT (0.862), and Pzf (0.853). The best cut-off value for MVRI was 3.25 mm Hg x cm(-1) x s (sensitivity 75%, specificity 89%). Moreover, increased MVRI was significantly related to increased TEI-grade (p < 0.0001). CONCLUSIONS: MVRI measured immediately after primary PCI is a useful predictor for the TEI in patients with anterior acute MI.