Non-Fasting Hypertriglyceridemia as an Independent Risk Factor for Coronary In-Stent Restenosis after Primary Bare Metal Stent Implantation in Patients with Coronary Artery Disease.

After a percutaneous coronary intervention (PCI) in patients with coronary artery disease (CAD), in-stent neoatherosclerosis may pose a risk of in-stent restenosis (ISR). To clarify whether non-fasting hypertriglyceridemia contributes to ISR, we examined the relationship between non-fasting hypertriglyceridemia (i.e., triglyceride (TG) level ≥ 200 mg/dL) and ISR after stenting with a bare metal stent (BMS) post-primary PCI in patients with CAD by means of a single-site retrospective analysis. A total of 1,039 patients with CAD were enrolled, and 86 patients (112 lesions) were evaluated for BMS-ISR 3-6 months post-primary PCI. The percentage of patients with non-fasting hypertriglyceridemia was significantly higher in the ISR (+) group than in the ISR (-) group (P < 0.009). The follow-up period and number of patients in the ISR (+) group were significantly smaller than those in the ISR (-) group (P < 0.001). There were no significant between-group differences in the other baseline patient characteristics before the primary PCI or at the time of the follow-up coronary angiography. However, at the follow-up period, the ISR (+) group had significantly lower diastolic blood pressure and high-density lipoprotein cholesterol levels (P = 0.015) and significantly higher TG levels (P = 0.012) than the ISR (-) group. A multiple logistic regression analysis demonstrated that non-fasting hypertriglyceridemia and a follow-up period of ≥ 6 months were independent risk factors for ISR after primary PCI in patients with BMS implantation for stenotic CAD (P = 0.006), with an adjusted odds ratio of 8.232 (1.201-56.410) and 0.006 (95% confidence interval < 0.001-0.045), respectively. Non-fasting hypertriglyceridemia may be an additional independent risk factor for BMS-ISR after primary PCI in patients with CAD.

Factors limiting habitual exercise in patients with chronic heart failure: a multicenter prospective cohort study.

Physical activity (PA) in the daily life is strongly related to prognosis in patients with or at high risk of heart failure (HF). However, factors limiting habitual exercise and their prognostic impacts remain unknown in HF patients. We sent questionnaires asking factors limiting habitual exercise in the daily life to 8370 patients with Stage A/B/C/D HF in our nationwide registry and received valid responses from 4935 patients (mean age 71.8 years, 71.0% male). Among the 5 components consisting of "busyness", "weak will", "dislike, "socioeconomic reasons" and "diseases" in the questionnaires, "busyness" (34.5%) and "diseases" (34.7%) were the most frequently reported factors limiting habitual exercise, while "socioeconomic reasons" were the least (15.3%). Multiple Cox proportional hazard models indicated that "busyness"and "diseases" were associated with better (hazard ratio (HR) 0.53, 95% confidence interval (CI) 0.39-0.72, P < 0.001) and worse prognosis (HR 1.57, 95% CI 1.21-1.98, P < 0.001), respectively, while other components were not. Furthermore, it was noted that, while prognostic relevance of "busyness" limiting exercise did not differ by age or sex, negative impact of "diseases" was particularly evident in patients with age < 75 years (P for interaction < 0.01). Factors limiting habitual exercise were associated with "busyness" and "diseases", but not with "weak will", "dislike, or "socioeconomic reasons". While "busyness" was associated with better prognosis regardless of age and sex, "diseases" was associated with worse prognosis in younger populations. Thus, physicians may pay more attentions to the reasons that limit exercise in the daily lives of HF patients rather than the low amount of exercise itself.

Prognostic Impacts of Metabolic Syndrome in Patients With Chronic Heart Failure　- A Multicenter Prospective Cohort Study.

BACKGROUND: Metabolic syndrome (MetS) is involved in the increased risk of atherosclerotic cardiovascular diseases. We have previously reported that the prevalence of MetS is more than 2-fold greater in patients with chronic heart failure (CHF) than in the general population in Japan. However, the prognostic impact of MetS in CHF patients remains to be elucidated. METHODS AND RESULTS: In the present nationwide, large-scale clinical study in Japan, we enrolled 4,762 patients with Stage C/D CHF. The prevalence of MetS by the definition of the Japanese Committee for the Diagnostic Criteria in 2005 was 41.3% (50.6% in males, 21.5% in females). MetS was characterized by higher prevalence of males, obesity and lifestyle-related comorbidities, including glucose intolerance, dyslipidemia and hypertension. Multivariate Cox hazard analysis showed that MetS was associated with increased incidence of the composite of all-cause death and atherosclerotic events in males (hazard ratio [HR] 1.28; 95% confidence interval [CI] 1.06-1.54, P=0.011) but not in females (HR 1.23, 95% CI 0.87-1.75, P=0.241). Among the components of MetS, over waist circumference and glucose intolerance were significantly associated with increased incidence of the composite endpoint (HR 1.23, P=0.038, and HR 1.29, P<0.001, respectively) in males but not in females. CONCLUSIONS: The results indicate that MetS only has a negative prognostic impact in male CHF patients. (Circ J 2016; 80: 677-688).

Biomechanical simulation of thorax deformation using finite element approach.

BACKGROUND: The biomechanical simulation of the human respiratory system is expected to be a useful tool for the diagnosis and treatment of respiratory diseases. Because the deformation of the thorax significantly influences airflow in the lungs, we focused on simulating the thorax deformation by introducing contraction of the intercostal muscles and diaphragm, which are the main muscles responsible for the thorax deformation during breathing. METHODS: We constructed a finite element model of the thorax, including the rib cage, intercostal muscles, and diaphragm. To reproduce the muscle contractions, we introduced the Hill-type transversely isotropic hyperelastic continuum skeletal muscle model, which allows the intercostal muscles and diaphragm to contract along the direction of the fibres with clinically measurable muscle activation and active force-length relationship. The anatomical fibre orientations of the intercostal muscles and diaphragm were introduced. RESULTS: Thorax deformation consists of movements of the ribs and diaphragm. By activating muscles, we were able to reproduce the pump-handle and bucket-handle motions for the ribs and the clinically observed motion for the diaphragm. In order to confirm the effectiveness of this approach, we simulated the thorax deformation during normal quiet breathing and compared the results with four-dimensional computed tomography (4D-CT) images for verification. CONCLUSIONS: Thorax deformation can be simulated by modelling the respiratory muscles according to continuum mechanics and by introducing muscle contractions. The reproduction of representative motions of the ribs and diaphragm and the comparison of the thorax deformations during normal quiet breathing with 4D-CT images demonstrated the effectiveness of the proposed approach. This work may provide a platform for establishing a computational mechanics model of the human respiratory system.

Comparison of neointimal coverage and extra-stent lumen between sirolimus and everolimus-eluting stent using optical coherence tomography.

The external lumen of a stent [defined as extra-stent lumen (ESL)] assessed by optical coherence tomography (OCT) may be related to the risk of thrombus formation after sirolimus-eluting stent (SES) implantation. An everolimus-eluting stent (EES) might provide relatively minimal inflammatory reaction and appropriate neointimal coverage. The purpose of this study was to compare the neointimal thickness and ESL between SES and EES. Patients who underwent OCT examination more than 7 months after either SES or EES implantation were enrolled. Stent area (SA), lumen area (LA), neointimal area (NIA) and neointimal thickness (NIT) of each strut were measured at 1-mm intervals between stented segments. The area, angle (summation per cross-section) and depth (maximum distance from adjacent vessel surface to the outline of stent) of ESL were analyzed. A total of 49 lesions were included (SES n = 20, EES n = 29). Mean follow-up period was 11 months. A total of 998 cross-sections and 9874 struts were analyzed. There were no differences in stent area, lumen area and neointimal area (SA: 6.01 ± 1.60 vs. 6.02 ± 1.40 mm(2), p = 0.572, LA: 5.37 ± 1.52 vs. 5.29 ± 1.34 mm(2), p = 0.692, NIA: 0.64 ± 0.49 vs. 0.72 ± 0.37 mm(2), p = 0.493). Mean NIT of SES and EES were 0.11 ± 0.05 and 0.10 ± 0.05 mm, respectively (p = 0.367). Conversely, area, angle and depth of ESL in SES group were significantly greater than those in EES group (0.20 ± 0.39 vs. 0.03 ± 0.09 mm(2), p < 0.001, 56.2 ± 59.1° vs. 20.1 ± 41.9°, p < 0.001, 0.10 ± 0.09 vs. 0.03 ± 0.03 mm, p < 0.001). OCT showed that the efficacy of neointimal growth suppression is similar between SES and EES, whereas the adverse vascular response after EES implantation is smaller than that after SES implantation.

Dual-source computed tomography coronary angiography in patients with high heart rate.

Although single-source 64-multislice computed tomography coronary angiography (SSCTA) needs to reduce heart rate (HR), dual-source computed tomography coronary angiography (DSCTA) can acquire images even in tachycardia. The accuracy of DSCTA during tachycardia is compared to the accuracy of SSCTA at reduced HR. Patients who received invasive coronary angiography and either SSCTA or DSCTA were included. In the SSCTA group, HR was reduced to <65 beats per minute (bpm) with ß-blocker (n = 27), while in the DSCTA group patients whose HR was >65 bpm were selected (n = 27). The diagnostic accuracy for significant coronary stenosis was calculated by comparing the invasive coronary angiography. Using dual-Doppler echocardiography, isovolumic relaxation time (IRT) and diastasis time (DT) were evaluated in these patients. In SSCTA, sensitivity was 89 %, specificity 99 %, the positive predictive value (PPV) 94 %, and the negative predictive value (NPV) was 98 %. In DSCTA, sensitivity was 96 %, the specificity was 99 %, PPV was 91 %, and NPV was 99 % (all NS compared to SSCTA). When HR was >75 bpm, DT was markedly shortened (<83 ms), however IRT was maintained >85 ms. Thus, the image reconstruction at the phase of IRT is feasible in DSCTA because of its temporal resolution of 83 ms. High temporal resolution of DSCTA shows equivalent accuracy of coronary stenosis detection to SSCTA, without reducing heart rate, because of its image reconstruction at IRT.

Impact of physical activity on cardiovascular events in patients with chronic heart failure. A multicenter prospective cohort study.

BACKGROUND: We have previously demonstrated that the prevalence of metabolic syndrome in chronic heart failure (CHF) is more than double compared with the general population in Japan. However, the impact of physical activity on cardiovascular events in CHF patients remains to be fully elucidated. METHODS AND RESULTS: We performed a prospective, nationwide large-scale multicenter study of 9,178 patients with stage A/B/C/D CHF in Japan. We obtained the baseline physical activity data for 7,292 and yearly changes in physical activity data during a 3-year follow-up period for 4,353 patients. We divided the patients into high- and low-exercise groups by using the median value of physical activity in the stage A/B and C/D groups. In both groups, patients who exercised more were characterized by younger age and less advanced stage of CHF. Importantly, the baseline physical activity levels were significantly associated with all-cause death, heart failure (HF) hospitalization and other cardiovascular events (except acute myocardial infarction, stroke, HF hospitalization). Furthermore, the yearly change in physical activity level was also significantly associated with HF hospitalization and other cardiovascular events in both groups. CONCLUSIONS: The baseline level of physical activity and its yearly changes are significantly associated with all-cause death and major cardiovascular events in both stage A/B and C/D patients, suggesting that physical activity could be an important therapeutic target to improve the long-term prognosis of CHF patients.

Tongue muscle-derived stem cells express connexin 43 and improve cardiac remodeling and survival after myocardial infarction in mice.

BACKGROUND: Cell transplantation therapy for heart failure is hindered by poor differentiation into cardiomyocytes and arrhythmias caused by the poor expression of connexin 43 (Cx43). A new stem cell source for cardiac regeneration is needed. METHODS AND RESULTS: Tongue muscle-derived Sca-1(+) cells (TDSCs) were isolated from normal and green fluorescence protein (GFP)-transgenic mouse tongues using surface antigen Sca-1. Cardiomyogenic differentiation was confirmed by measuring the calcium transient and the expression of cardiac-specific genes. The formation of gap junctions was confirmed by the expression of Cx43 and the dye transfer method. The contraction of regenerated cells was demonstrated by the calcium transients. GFP mouse-derived TDSCs were transplanted into hearts in a model of acute myocardial infarction. Three months after transplantation, LV remodeling was attenuated and the survival rate was improved compared with the control group. CONCLUSIONS: TDSCs form gap junctions and improve cardiac function and long-term survival after myocardial infarction.

Prevalence and clinical implication of metabolic syndrome in chronic heart failure.

BACKGROUND: Metabolic syndrome (MetS) is a pathological condition with a clustering of metabolic components and is a well-known risk and prognostic factor for ischemic heart disease (IHD). However, the prevalence and clinical significance of MetS remain to be fully elucidated in chronic heart failure (CHF), an important clinical syndrome caused by various cardiac abnormalities. METHODS AND RESULTS: The present nationwide, large-scale clinical study enrolled 3,603 patients with stage C/D CHF from 6 institutes in Japan. First, the prevalence of MetS in CHF patients was demonstrated to be 45% in males and 19% in females, which is more than double compared with the general population in Japan. The CHF patients with MetS were characterized by younger age, higher prevalence of current smoking and drinking, IHD, and hypertensive heart disease, whereas the prevalence of HF with preserved ejection fraction and MetS was higher in elderly female patients. Next, the contribution of the metabolic components (waist circumference, hypertension, glucose intolerance/diabetes mellitus and dyslipidemia) was found to be comparable between the ischemic and the non-ischemic CHF patients. CONCLUSIONS: The prevalence of MetS in CHF patients is more than double compared with the general population in Japan and suggest that the metabolic components may have a substantial effect on the development of both ischemic and non-ischemic CHF.

Once-daily glatiramer acetate decreases magnetic resonance imaging disease activity in Japanese patients with relapsing-remitting multiple sclerosis.

OBJECTIVE: Multiple sclerosis (MS) prevalence, clinical patterns, and treatment responses vary between races and geographical latitudes. Glatiramer acetate (GA; Copaxone) has provided a safe, effective treatment option for relapsing-remitting MS patients in the USA, European nations, and other countries for decades. The objective of the present study was to assess the safety and efficacy of GA in reducing magnetic resonance imaging disease activity in Japanese patients with active relapsing-remitting MS. METHODS: This phase 2, multicenter, open-label, single-arm, 52-week study measured the effect of GA 20 mg once-daily on magnetic resonance imaging disease activity. GA efficacy was evaluated through week 36, and safety through week 52. The primary end-point was change in the mean number of T1-weighted gadolinium-enhancing (GdE) lesions from pretreatment (weeks -8, -4 and baseline) to weeks 28, 32 and 36. Secondary end-points included a change in mean number of new T2-weighted lesions, GdE lesion and T2 lesion volumes, annualized relapse rate, and Expanded Disability Status Scale scores. RESULTS: GA therapy reduced the number of new GdE lesions by 65.66% (95% CI 33.19-82.35%). The number of new T2 lesions and GdE lesion volume were also reduced from pretreatment. The annualized relapse rate was reduced by 42% compared with the 1 year before treatment. Changes in T2 lesion volume and Expanded Disability Status Scale scores were favorable, but less pronounced. Most common adverse events were injection-site reactions. CONCLUSIONS: The present study confirmed the well-established safety, tolerability and efficacy profile of GA in Japanese MS patients.

Serial changes in the three-dimensional aspect of the side-branch ostium jailed by a drug-eluting stent assessed by optical coherence tomography.

The present study investigated serial changes in the three-dimensional (3D) aspect of the jailed side-branch (SB) ostium. We evaluated 32 patients who underwent examination with optical coherence tomography (OCT) both at baseline and at follow-up. After reconstruction of the 3D images, we classified the configuration of overhanging struts at the SB orifice into three groups according to the 3D aspect of the jailing configuration. The number of compartments divided by the stent strut was counted. The side-branch flow area (SBFA), i.e., the area of the SB ostium except for jailing struts, was measured by cut-plane analysis. Forty-eight SBs of 25 patients were analyzed. Thirteen SBs were classified as the No-jail type (N-type), 19 as the Simple-jail type (S-type; no longitudinal link at the carina), and 16 as the Complex-jail type (C-type; had a link at the carina). In the N-type, the SBFA was significantly increased at follow-up (P = 0.018). In the C-type, the SBFA was significantly decreased at follow-up (P = 0.002). Percent reduction of SBFA in the C-type group was significantly greater than that in the N-type or S-type groups (S-type vs. C-type P = 0.002, N-type vs. C-type P < 0.001). 3D-OCT images showed that some of the compartments were filled with tissue. The number of compartments was significantly decreased at follow-up (P < 0.001). In the C-type group, the SBFA was significantly decreased and small compartments were filled with tissue. These findings suggest that stent jail complexity is associated with the progression of SB ostial stenosis.

Coronary vasodilation by the use of sublingual nitroglycerin using 64-slice dual-source coronary computed tomography angiography.

BACKGROUND: Sublingual nitroglycerin capsules or spray is routinely used to treat anginal attacks and to maximally dilate the epicardial coronary arteries during coronary angiography. These dilated coronary vessels have an advantage, but increased heart rates were disadvantageous for coronary computed tomography angiography (CTA). PURPOSE: The influence of applying nitroglycerin was analyzed regarding the coronary diameter, coronary luminal attenuation, evaluable number of coronary segments, heart rate (HR), HR variability, the optimal reconstruction phase, and image scoring of CTA in the same patients using a 64-slice dual-source CT. METHODS AND SUBJECTS: Fifty-two patients with atypical chest pain underwent coronary CTA before and after the administration of sublingual nitroglycerin without heart rate control. The coronary diameter and luminal attenuation were measured on short-axial images in each coronary segment. The coronary vasodilation ratios (VRs) were calculated from the coronary diameters at the same location before and after the use of nitroglycerin. The local institutional review board approved this study and written informed consent was obtained from all the patients. RESULTS: No significant differences were noted in the HR variability or optimal reconstruction phase, despite an increase in HR after the use of nitroglycerin. Nitroglycerin significantly enlarged the coronary artery diameter, and VRs of each coronary segment ranged from 7.54% to 22.26%. As compared with baseline coronary diameter, VRs of minor segments (16.91%) were significantly larger than those of major segments (11.35%), and the magnitude of VR correlated with the baseline coronary diameter (r=-0.48, p<0.001). Coronary luminal attenuation significantly increased due to additional administration of contrast material after the use of nitroglycerin (p<0.01), but no significant difference was noted in the image quality after the use of nitroglycerin. CONCLUSION: Sublingual nitroglycerin significantly enlarged the coronary diameters, especially in peripheral small coronary arteries, and increased the evaluable number of coronary segments on coronary CTA.

New quantitative method to diagnose coronary in-stent restenosis by 64-multislice computed tomography.

BACKGROUND: The aim of this study is to evaluate the accuracy of a newly developed quantitative method using 64-multislice computed tomography angiography (CTA) to detect coronary in-stent restenosis (ISR). METHODS AND RESULTS: CTA was performed in 45 patients who underwent stent implantation (79 lesions) and the accuracy to diagnose ISR was evaluated by comparing with invasive coronary angiography (ICA). CTA was evaluated both visually and quantitatively using a new stent restenosis index (SRI) utilizing CT densities at proximal and distal artery lumen from the stented region and the correction value depending on the stent diameter. ICA showed 11 ISR (14%). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for visual evaluation were 78%, 75%, 35%, 95%, and 76%, respectively. On the other hand, the quantitative evaluation using SRI represents 82%, 93%, 64%, 97%, and 91%, respectively. CONCLUSIONS: Evaluation of ISR using SRI is superior to the visual estimation of CTA.

Serial three-dimensional optical coherence tomography assessment of strut coverage and intraluminal structures after drug-eluting stent implantation.

Understanding of intraluminal structure and distribution of uncovered struts after drug-eluting stent implantation are limited by only 2-dimensional (2D) optical coherence tomography (OCT) images. We compared tissue coverage with 3-dimensional (3D) OCT and 2D quantitative analyses, and changes in intraluminal structure immediately after (baseline) everolimus-eluting stent (EES) implantation and at follow-up. The 2D analyses of uncovered struts ratio and tissue coverage thickness at a 0.5-mm interval were compared to 3D-OCT images and visually classified for the degree of tissue coverage. The difference in tissue coverage at baseline and follow-up after EES implantation was evaluated with tissue coverage scores (TCS) calculated by the 3D-OCT classification (Grade 0-3). 3D-OCT classifications were negatively correlated with uncovered-to-total struts (r = -0.864, P < 0.001) and positively correlated with tissue coverage thickness (r = 0.905, P < 0.001). Follow-up TCS was greater than baseline TCS (0.2 ± 0.4 vs. 1.4 ± 0.5, P < 0.001). Moreover, changes in intraluminal structures and longitudinal distribution of uncovered struts were assessed. Incomplete stent appositions, in-stent dissections, and thrombi were decreased at follow-up, indicating progressive arterial healing. The distribution of uncovered-to-total struts could be assessed by 3D-OCT, which was related to 2D analysis. Significant correlations between 3D-OCT classifications and quantitative analyses were shown. The classification and visual assessment of intraluminal structures by 3D-OCT were useful in evaluating arterial healing after EES implantation.

3D optical coherence tomography: new insights into the process of optimal rewiring of side branches during bifurcational stenting.

AIMS: We describe three-dimensional optical coherence tomography (3D-OCT) guided bifurcation stenting and the clinical utility of 3D-OCT. METHODS AND RESULTS: Twenty-two consecutive patients who underwent OCT examination to confirm the recrossing position after stent implantation in a bifurcation lesion were enrolled. Frequency domain OCT images were obtained to check the recrossing position and 3D reconstructions were performed off-line. The recrossing position was clearly visualised in 18/22 (81.8%) cases. In 13 cases, serial 3D-OCT could be assessed both before and after final kissing balloon post-dilation (FKBD). We divided these cases into two groups according to the presence of the link between hoops at the carina: free carina type (n=7) and connecting to carina type (n=6). All free carina types complied with the distal rewiring. The percentage of incomplete stent apposition (%ISA) of free carina type at the bifurcation segment after FKBD was significantly smaller than that of the connecting to carina type (0.7±0.9% vs. 12.2±6.5%, p=0.0074). CONCLUSIONS: 3D-OCT confirmation of the recrossing into the jailed side branch is feasible during PCI and may help to achieve distal rewiring and favourable stent positioning against the side branch ostium, leading to reduction in ISA and potentially better clinical outcomes.

Evaluation of image quality on a per-patient, per-vessel, and per-segment basis by noninvasive coronary angiography with 64-section computed tomography: dual-source versus single-source computed tomography.

PURPOSE: The purpose of this study was to evaluate the image quality (IQ) of dual-source CT (DSCT) versus single-source CT (SSCT). MATERIALS AND METHODS: A total of 100 patients underwent 64-section CT coronary angiography (50 DSCT, 50 SSCT). Three observers evaluated the IQ of each coronary segment using a four-point scale (1, excellent; 2, good; 3, fair; 4, no assessment). The IQ of DSCT coronary angiography was compared with SSCT coronary angiography on a per-patient, per-vessel, and per-segment basis using the chi-squared test. RESULTS: The DSCT image quality score (IQS) was significantly lower on a per-patient basis and per-vessel basis for all vessels and on a per-segment basis for some segments (1, 2, 4PD, 4AV, 7, 9, 11, 12, 13) compared with SSCT. The DSCT IQS was significantly lower for certain segments (2, 4PD, 11, 13) with high heart rates (≥70 beats/min). The DSCT IQS was significantly lower for certain segments (1, 2, 3, 4PD, 4AV, 7, 8, 9, 10, 12, 13) with low heart rates (<70 beats/min). CONCLUSION: DSCT showed a significantly better IQ than SSCT, especially in patients with low heart rates.

Systolic reconstruction in patients with low heart rate using coronary dual-source CT angiography.

OBJECTIVES: The purpose of our study was to determine the relationship between the predictive factors and systolic reconstruction (SR) as an optimal reconstruction window in patients with low heart rate (LHR; less than 65 bpm). METHODS: 391 patients (262 male and 129 female, mean age; 67.1±10.1 years of age) underwent coronary CTA without the additional administration of a beta-blocker. Affecting factors for SR were analyzed in age, gender, body weight (BW), diabetes mellitus (DM), coronary arterial disease (CAD), ejection fraction (EF), systolic and diastolic body pressure (BP) and heart rate variability (HRV) during coronary CTA. RESULTS: In 29 (7.4%) of the 391 patients, SR was needed, but there was no apparent characteristic difference between the systolic and diastolic reconstruction groups in terms of gender, age, BW, DM, CAD and EF. In a multivariate analysis, the co-existence of DM [P<0.05; OR, 0.27; 95% CI, 0.092-0.80], diastolic BP [P<0.01; OR, 0.95; 95% CI, 0.92-0.98] and HRV [P<0.01; OR, 0.98; 95% CI, 0.96-0.99] were found to be the factors for SR. In gender-related analysis, HRV was an important factor regardless of sex, but co-existence of DM affected especially for female and BP for male. CONCLUSION: Especially in the patients with LHR who had a medication of DM, high HRV or high BP, SR, in addition to DR, was needed to obtain high-quality coronary CTA images.