RESUMEN
BACKGROUND: Peripheral pulmonary artery stenosis (PPS) refers to stenosis of the pulmonary artery from the trunk to the peripheral arteries. Although paediatric PPS is well described, the clinical characteristics of adult-onset idiopathic PPS have not been established. Our objectives in this study were to characterise the disease profile of adult-onset PPS. METHODS: We collected data in Japanese centres. This cohort included patients who underwent pulmonary angiography (PAG) and excluded patients with chronic thromboembolic pulmonary hypertension or Takayasu arteritis. Patient backgrounds, right heart catheterisation (RHC) findings, imaging findings and treatment profiles were collected. RESULTS: 44 patients (median (interquartile range) age 39 (29-57)â years; 29 females (65.9%)) with PPS were enrolled from 20 centres. In PAG, stenosis of segmental and peripheral pulmonary arteries was observed in 41 (93.2%) and 36 patients (81.8%), respectively. 35 patients (79.5%) received medications approved for pulmonary arterial hypertension (PAH) and 22 patients (50.0%) received combination therapy. 25 patients (56.8%) underwent transcatheter pulmonary angioplasty. RHC data showed improvements in both mean pulmonary arterial pressure (44 versus 40â mmHg; p<0.001) and pulmonary vascular resistance (760 versus 514â dyn·s·cm-5; p<0.001) from baseline to final follow-up. The 3-, 5- and 10-year survival rates of patients with PPS were 97.5% (95% CI 83.5-99.6%), 89.0% (95% CI 68.9-96.4%) and 67.0% (95% CI 41.4-83.3%), respectively. CONCLUSIONS: In this study, patients with adult-onset idiopathic PPS presented with segmental and peripheral pulmonary artery stenosis. Although patients had severe pulmonary hypertension at baseline, they showed a favourable treatment response to PAH drugs combined with transcatheter pulmonary angioplasty.
Asunto(s)
Hipertensión Pulmonar , Hipertensión Arterial Pulmonar , Estenosis de Arteria Pulmonar , Adulto , Femenino , Humanos , Niño , Estenosis de Arteria Pulmonar/diagnóstico por imagen , Estenosis de Arteria Pulmonar/terapia , Hipertensión Pulmonar/terapia , Constricción Patológica , Arteria Pulmonar/diagnóstico por imagen , Hipertensión Pulmonar Primaria Familiar/tratamiento farmacológicoRESUMEN
Patients with pulmonary hypertension (PH) suffer from poor exercise tolerance due to impaired oxygenation and/or reduced cardiac output. However, the relationship between exercise tolerance and physical function remains unclear. The purpose of this study was to investigate the relationship between exercise tolerance and physical function in patients with PH. A total of 94 patients without left heart disease (61.3 ± 14.7 years old, 69.1% females, 22/8/60/4 patients with Group 1/3/4/5 PH) were retrospectively analysed. Physical function was measured using muscle strength (grip strength, knee extension muscle strength), balance function (one-leg standing time), and gait speed within 7 days of cardiac catheterization. Exercise tolerance was measured using the 6-min walking distance (6-MWD). A total of 194 6-MWD measurements and the corresponding physical function were evaluated in 94 patients. Multivariable linear regression analysis using adaptive-LASSO methods indicated that the World Health Organization functional classification, pulmonary vascular resistance, mixed venous oxygen saturation, grip strength, and gait speed were independently associated with the 6-MWD. Low grip strength (< 28 kg for males and < 18 kg for females; adjusted odds ratio and 95% confidence interval: 2.06 [1.30-3.26], p = 0.002), and slow gait speed (< 1.0 m/s for both sexes; 13.33 [3.61-49.19], p < 0.001) were independent predictors of poor exercise tolerance (6-MWD < 440 m) in a logistic regression analysis. Grip strength and gait speed as measures of physical function, pulmonary vascular resistance, and mixed venous oxygen saturation were associated with exercise tolerance in patients with PH without left heart disease.
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Cardiopatías , Hipertensión Pulmonar , Anciano , Tolerancia al Ejercicio/fisiología , Femenino , Fuerza de la Mano/fisiología , Humanos , Hipertensión Pulmonar/diagnóstico , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Velocidad al CaminarRESUMEN
Adiponectin (APN) has cardioprotective properties and bisoprolol has been reported to increase myocardial APN expression and reduce myocardial damage. Administration of landiolol, which has a higher cardio-selectivity and shorter half-life than bisoprolol, during the percutaneous coronary intervention (PCI) may increase serum APN and high-molecular weight (HMW)-APN, an active form of APN, in patients with stable angina pectoris (SAP). We recruited 70 patients with SAP and randomized them to intravenous landiolol during PCI (N = 35) or control group (N = 35). The primary endpoint was serum APN and HMW-APN level 3 days after PCI. There was no difference in the primary endpoint between the landiolol and control groups (8.93 ± 5.24 vs. 10.18 ± 5.81 µg/mL, p = 0.35 and 3.36 ± 2.75 vs. 4.28 ± 3.13 µg/mL, p = 0.20) for APN and HMW-APN levels, respectively. APN and HMW-APN level were significantly decreased 1 day after PCI [-0.55 ± 0.92 µg/mL (9.87-9.32 µg/mL), p < 0.001 and -0.20 ± 0.45 µg/mL (3.89-3.69 µg/mL), p < 0.001, respectively]. Additionally, the absolute change in HMW-APN was significantly smaller in the landiolol group compared to the control group (-0.08 ± 0.27 vs. -0.31 ± 0.55 µg/mL, p = 0.031). Multiple linear regression analysis showed that use of landiolol was an independent predictor of change in HMW-APN (ß = 0.276, p = 0.014). Serum APN and HMW-APN level 3 days after PCI were similar between patients treated with and without landiolol. APN and HMW-APN decreased 1 day after PCI in the SAP and landiolol mitigated decrease in HMW-APN.
Asunto(s)
Adiponectina/sangre , Antagonistas de Receptores Adrenérgicos beta 1/administración & dosificación , Angina Estable/terapia , Enfermedad de la Arteria Coronaria/terapia , Morfolinas/administración & dosificación , Intervención Coronaria Percutánea , Urea/análogos & derivados , Antagonistas de Receptores Adrenérgicos beta 1/efectos adversos , Anciano , Anciano de 80 o más Años , Angina Estable/sangre , Angina Estable/diagnóstico , Biomarcadores/sangre , Enfermedad de la Arteria Coronaria/sangre , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Femenino , Humanos , Japón , Masculino , Persona de Mediana Edad , Peso Molecular , Morfolinas/efectos adversos , Intervención Coronaria Percutánea/efectos adversos , Estudios Prospectivos , Factores de Tiempo , Resultado del Tratamiento , Urea/administración & dosificación , Urea/efectos adversosRESUMEN
The AB5000 Circulatory Support System is paracorporeal pulsatile ventricular assist device. The AB Portable Driver is a portable console for this system. We experienced two cases with accelerated hemolysis while receiving support by the AB Portable Driver. The purpose of this study was to clarify the mechanical differences associated with the hemolysis between the AB5000 console and the AB Portable Driver. The mock circulatory system modeled by an AB5000 ventricle and a blood sampling bag of vinyl chloride was run with an AB5000 console or AB Portable Driver. The peak drive-line pressure, the mean arterial cannula pressure and the pumping rate of the VAD were recorded. The AB5000 console generated a peak drive-line pressure of 280-300 mm Hg in LVAD mode and 210-220 mm Hg in RVAD mode, approximately 100 mm Hg lower than officially documented. In contrast, the AB Portable Driver generated pressures of 310-330 mm Hg in LVAD mode and 230-250 mm Hg in RVAD mode, 65-95 mm Hg higher than officially documented. The AB Portable Driver console generates higher drive-line pressures than the AB5000 console, possibly explaining the accelerated hemolysis.
Asunto(s)
Insuficiencia Cardíaca/terapia , Corazón Auxiliar/efectos adversos , Hemólisis , Adulto , Diseño de Equipo , Femenino , Insuficiencia Cardíaca/patología , Humanos , Presión , Adulto JovenRESUMEN
BACKGROUND: There is no information on differences in the effects of moderate- and low-intensity statins on coronary plaque in patients with acute coronary syndrome (ACS). The aim of this study was to compare the effects of 4 different statins in patients with ACS, using intravascular ultrasound (IVUS). METHODSâANDâRESULTS: A total of 118 patients with ACS who underwent IVUS before percutaneous coronary intervention and who were found to have mild to moderate non-culprit coronary plaques were randomly assigned to receive either 20 mg/day atorvastatin or 4 mg/day pitavastatin (moderate-intensity statin therapy), or 10 mg/day pravastatin or 30 mg/day fluvastatin (low-intensity statin therapy). IVUS at baseline and at end of 10-month treatment was available in 102 patients. Mean percentage change in plaque volume (PV) was -11.1±12.8%, -8.1±16.9%, 0.4±16.0%, and 3.1±20.0% in the atorvastatin, pitavastatin, pravastatin, and fluvastatin groups, respectively (P=0.007, ANOVA). Moderate-intensity statin therapy induced regression of PV, whereas low-intensity statin therapy produced insignificant progression (-9.6% vs. 1.8%, P<0.001). On multivariate linear regression analysis, moderate-intensity statin therapy (P=0.02) and uric acid at baseline (P=0.02) were significant determinants of large percent PV reduction. LDL-C at follow-up did not correlate with percent PV change. CONCLUSIONS: Moderate-intensity statin therapy induced regression of coronary PV, whereas low-intensity statin therapy resulted in slight progression of coronary PV in patients with ACS. (Circ J 2016; 80: 1634-1643).
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Síndrome Coronario Agudo/terapia , Enfermedad de la Arteria Coronaria/terapia , Inhibidores de Hidroximetilglutaril-CoA Reductasas/administración & dosificación , Intervención Coronaria Percutánea , Placa Aterosclerótica/terapia , Síndrome Coronario Agudo/patología , Anciano , Enfermedad de la Arteria Coronaria/patología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Placa Aterosclerótica/patología , Estudios ProspectivosRESUMEN
Acute coronary syndrome (ACS) is one of the main causes of cardiovascular death. According to rapid aging of society, the peak age of ACS onset has grown older globally. Despite growing recognition of the necessity to build the ACS prevention strategy in the elderly, patients background and culprit lesion morphology of these elderly ACS patients have not been well studied. We sought to assess the clinical characteristics and intravascular ultrasound (IVUS) findings of the culprit lesions in elderly ACS patients. One-hundred and fifty-eight consecutive ACS patients whose culprit lesions imaged by pre-intervention IVUS were divided into two groups based on the age of onset: elderly [E] group (≥75 years, n = 65) and non-elderly [NE] group (<75 years, n = 93). As compared with NE group, hemoglobin (12.7 ± 2.0 g/dL vs. 13.7 ± 1.6 g/dL, p = 0.001), estimated glomerular filtration rate (62.5 ± 22.5 mL/min/1.73 m(2) vs. 75.5 ± 20.5 mL/min/1.73 m(2), p = 0.0001), and body mass index (22.9 ± 3.4 kg/m(2) vs. 24.5 ± 3.4 kg/m(2), p = 0.003) were significantly lower, and comorbid malignancy was more common (20.0 vs 6.5 %, p = 0.01) in E group. Although whole culprit segment was not positively remodeled (mean vessel area was 15.2 ± 5.6 mm(3)/mm vs. 16.2 ± 5.1 mm(3)/mm, p = 0.16) in E group, at maximum external elastic membrane site of the culprit lesion, lumen area was smaller (5.5 ± 3.2 mm(2) vs. 6.7 ± 3.5 mm(2), p = 0.04), and plaque burden tended to be more abundant (70 ± 13 vs. 66 ± 13 %, p = 0.08). Interestingly, echo attenuation arc of culprit attenuated plaque was significantly greater in E group than in NE group (157 ± 83° vs. 118 ± 60°, p = 0.01). In conclusion, extracardiac comorbidity was more common in elderly ACS patients, and their culprit coronary lesions were still rupture prone, and "vulnerable."
Asunto(s)
Síndrome Coronario Agudo/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Vasos Coronarios/diagnóstico por imagen , Ultrasonografía Intervencional , Síndrome Coronario Agudo/mortalidad , Factores de Edad , Anciano , Anciano de 80 o más Años , Comorbilidad , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/mortalidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Placa Aterosclerótica , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Factores de Riesgo , Rotura EspontáneaRESUMEN
Endothelial and vascular smooth muscle dysfunction of epicardial coronary arteries play a pivotal role in the pathogenesis of vasospastic angina (VSA). However, coronary microvascular (MV) function in patients with VSA is not fully understood. In the present study, subjects without coronary obstruction were divided into two groups according to the acetylcholine provocation test: VSA group (n = 29) and non-VSA group (n = 21). Hyperemic MV resistance (hMR) was measured using a dual-sensor (Doppler velocity and pressure)-equipped guidewire, and guidewire-derived hemodynamic parameters were compared. There were no between-group differences in clinical demographics, including potential factors affecting MV function (e.g., diabetes). Although coronary flow velocity reserve was similar between the two groups [2.4 ± 1.0 (VSA group) vs. 2.4 ± 0.9 (non-VSA group); P = 0.8], coronary vessel resistance and hMR were significantly elevated in the VSA group compared with the non-VSA group (2.6 ± 3.1 vs. 1.2 ± 0.8, P = 0.04; 1.9 ± 0.6 vs. 1.6 ± 0.5, P = 0.03, respectively). Coronary vasospasm, older age, E/e', and estimated glomerular filtration rate were significantly associated with MV dysfunction [defined as ≥ median value of hMR (1.6)] in univariate analysis. Coronary vasospasm most strongly predicted higher hMR in multivariate logistic regression analysis (odds ratio, 4.61; 95% confidence interval, 0.98-21.60; P = 0.053). In conclusion, coronary MV resistance is impaired in patients with VSA compared with non-VSA patients, whereas coronary flow velocity reserve is maintained at normal levels in both groups. In vivo assessment of hMR might be a promising index of coronary MV dysfunction in patients with VSA.
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Angina de Pecho/fisiopatología , Vasoespasmo Coronario/fisiopatología , Microcirculación , Resistencia Vascular , Acetilcolina/farmacología , Anciano , Velocidad del Flujo Sanguíneo , Estudios de Casos y Controles , Vasos Coronarios/efectos de los fármacos , Vasos Coronarios/fisiopatología , Femenino , Tasa de Filtración Glomerular , Humanos , Hiperemia/fisiopatología , Flujometría por Láser-Doppler , Masculino , Persona de Mediana EdadRESUMEN
Despite current standards of care aimed at achieving targets for low-density lipoprotein cholesterol (LDL-C), many patients remain at high residual risk of cardiovascular events. We sought to assess the LDL-C-dependent differences in culprit intravascular ultrasound (IVUS) morphologies and clinical characteristics in patients with acute coronary syndrome (ACS). Eighty-six consecutive ACS patients whose culprit lesions imaged by preintervention IVUS were divided into two groups based on the fasting LDL-C level on admission: a low-LDL-C group (LDL-C <2.6 mmol/l, n = 45) and a high-LDL-C group (LDL-C ≥2.6 mmol/l, n = 41). Patients with stable angina with LDL-C <2.6 mmol/l (n = 30) were also enrolled as an age- and gender-matched control. The low-LDL-C ACS group was significantly older (72 ± 12 vs 64 ± 14 years, P = 0.007) and more diabetic (47 % vs 15 %, P = 0.001). Importantly, IVUS morphologies were comparable between low- and high-LDL-C ACS groups (all P not significant), whereas culprit plaque was more hypoechoic and less calcified in the low-LDL-C ACS group than in the low-LDL-C stable angina group. Furthermore, compared with the low-LDL-C ACS nondiabetic group, the low-LDL-C ACS diabetic group was more obese, more triglyceride rich (1.3 ± 0.6 vs 0.9 ± 0.4 mmol/l, P = 0.003), and more endothelially injured, but no different for the culprit IVUS morphologies. In multivariate analysis, diabetes was independently associated with a low LDL-C level on admission in patients with ACS. There was no relationship between the LDL-C level at onset and culprit-plaque IVUS morphologies in ACS patients, although culprit plaque in the low-LDL-C ACS group was more vulnerable than in the low-LDL-C stable angina group. In patients with low-LDL-C levels, diabetes with atherogenic dyslipidemia might be the key residual risk.
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Síndrome Coronario Agudo/diagnóstico por imagen , LDL-Colesterol/sangre , Vasos Coronarios/diagnóstico por imagen , Dislipidemias/sangre , Ultrasonografía Intervencional , Síndrome Coronario Agudo/epidemiología , Anciano , Anciano de 80 o más Años , Angina Estable/diagnóstico por imagen , Angina Estable/epidemiología , Biomarcadores/sangre , Estudios de Casos y Controles , Distribución de Chi-Cuadrado , Comorbilidad , Estudios Transversales , Diabetes Mellitus/epidemiología , Dislipidemias/epidemiología , Femenino , Humanos , Japón/epidemiología , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Placa Aterosclerótica , Valor Predictivo de las Pruebas , Factores de RiesgoRESUMEN
A 47-year-old woman diagnosed with stage IV left-sided breast cancer (T3N3aM1; OSS, HEP, LYM) 6 months back presented with respiratory distress. On admission, she developed respiratory failure, requiring 4 L of oxygen support. Pulmonary embolism was ruled out because computed tomography revealed no obvious pulmonary artery thrombus. Transthoracic echocardiography revealed a significant enlargement of the right ventricle and atrium. Pulmonary hypertension was confirmed via right heart catheterization. Pulmonary artery wedge aspiration cytology revealed adenocarcinoma cells. Based on these findings, we diagnosed the patient with pulmonary tumor thrombotic microangiopathy (PTTM) caused by breast cancer. Immediate chemotherapy (paclitaxel and bevacizumab) for breast cancer and concurrent treatment for pulmonary hypertension and disseminated intravascular coagulation were initiated. We could successfully control her condition with paclitaxel and bevacizumab for a year, and the patient survived for 1 year and 8 months. PTTM is a rare disease characterized by pulmonary hypertension and hypoxemia arising due to tumor embolization of the peripheral pulmonary arteries. PTTM is a rapidly progressing condition with no established treatment guidelines; its pathogenesis involves vascular endothelial growth factor (VEGF). This report highlighted the potential of bevacizumab, known for its anti-VEGF effect, in improving the pathological condition of patients with PTTM caused by breast cancer.
RESUMEN
BACKGROUND: Pulmonary hypertension (PH) has recently been described as a complex clinical syndrome affecting multiple organ systems, including the heart, lungs, and skeletal muscle, each of which plays an important role in exercise capacity. However, the relationship between exercise capacity and skeletal muscle abnormalities in patients with PH has not been fully elucidated. METHODS: We retrospectively analysed the exercise capacity and measures of skeletal muscle of 107 patients with PH without left heart disease (mean age 63 ± 15 years, 32.7% males, n = 30/6/66/5 in the clinical classification Group 1/3/4/5). RESULTS: Sarcopenia, low appendicular skeletal muscle mass index, low grip strength, and slow gait speed, determined by international criteria, were found in 15 (14.0%), 16 (15.0%), 62 (57.9%), and 41 (38.3%) patients, respectively. The mean 6-min walk distance of all patients was 436 ± 134 m and was independently associated with sarcopenia (standardised ß = -0.292, p < 0.001). All patients with sarcopenia showed reduced exercise capacity defined as 6-min walk distance < 440 m. Multivariable logistic regression analysis showed that each of the components of sarcopenia was associated with reduced exercise capacity (adjusted odds ratio and 95% confidence interval of appendicular skeletal muscle mass index: 0.39 [0.24-0.63] per 1 kg/m2, p = 0.006, grip strength: 0.83 [0.74-0.94] per 1 kg, p = 0.003, and gait speed: 0.31 [0.18-0.51] per 0.1 m/s, p < 0.001). CONCLUSIONS: Sarcopenia and its components are associated with reduced exercise capacity in patients with PH. A multifaceted evaluation may be important in the management of reduced exercise capacity in patients with PH.
Asunto(s)
Cardiopatías , Hipertensión Pulmonar , Sarcopenia , Masculino , Humanos , Persona de Mediana Edad , Anciano , Femenino , Sarcopenia/diagnóstico , Sarcopenia/epidemiología , Hipertensión Pulmonar/diagnóstico , Hipertensión Pulmonar/epidemiología , Hipertensión Pulmonar/complicaciones , Estudios Retrospectivos , Tolerancia al Ejercicio , Músculo Esquelético , Fuerza de la Mano/fisiología , Fuerza Muscular/fisiologíaRESUMEN
BACKGROUND: Ruptured plaque and culprit lesions associated with anterior acute myocardial infarction cluster mainly in the proximal segment of the left anterior descending coronary artery (LAD). This study investigated whether the tissue characteristics of plaque in the proximal LAD differs from that of plaque in the distal LAD as assessed by integrated backscatter (IB)-intravascular ultrasound (IVUS). METHODS AND RESULTS: IVUS interrogation was used to study 107 non-culprit intermediate plaques in 68 patients with angina pectoris who underwent percutaneous coronary interventions. Proximal and distal segments were defined as <30 mm and > or =30 mm from the ostium, respectively. IB-IVUS images were recorded, and the average percentage values of each plaque component (lipid, fibrosis, dense fibrosis, and calcification) were compared between segments. Plaques in the proximal segment (n=51) had a higher %lipid content (36 vs 19%, P<0.01) and a lower %fibrosis content (57 vs 64%, P<0.01) than did plaques in the distal segment (n=56). Multiple linear regression analysis showed that proximal plaques had a higher %lipid content, independently of other coronary risk factors and plaque burden (P<0.01). CONCLUSIONS: The %lipid and %fibrosis contents differ significantly between plaques in the proximal segment and those in the distal segment of the LAD. (Circ J 2010; 74: 142 - 147).
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Angina de Pecho/diagnóstico por imagen , Estenosis Carotídea/diagnóstico por imagen , Vasos Coronarios/diagnóstico por imagen , Ultrasonografía Intervencional/métodos , Anciano , Angina de Pecho/metabolismo , Angina de Pecho/patología , Estenosis Carotídea/metabolismo , Estenosis Carotídea/patología , Vasos Coronarios/metabolismo , Vasos Coronarios/patología , Femenino , Fibrosis , Humanos , Metabolismo de los Lípidos , Masculino , Persona de Mediana Edad , Análisis de Regresión , Estudios RetrospectivosRESUMEN
The Diamondback 360® coronary orbital atherectomy system (OAS) can safely debulk calcified lesions by pullback of the crown, if the crown is advanced to the distal of the lesion. The aim of this study was to compare crossability with two types of crown in OAS. Thirty-six consecutive severely calcified lesions in 33 patients who underwent percutaneous coronary intervention with the coronary OAS were included. The micro crown was used in 18 consecutive lesions from April 2018 to February 2019, and the classic crown with the glide assist was used in 18 consecutive lesions from March 2019 to August 2019. Good crossability was defined as the ability to cross the lesion before orbital atherectomy or to cross the lesion with a first session of orbital atherectomy. We also tried to elucidate whether the crown could cross the lesion without using the glide assist in 13 consecutive lesions at the end of the classic crown cases. Good crossability was more often observed in cases with the classic crown (17 of 18 lesions, 94%) than the micro crown (6 of 18 lesions, 33%) (P < 0.001). In 13 consecutive lesions at the end of the classic crown cases, the crown could cross the lesion in 4 lesions (31%) without use of the glide assist or orbital atherectomy, and in 11 lesions (85%) with only use of the glide assist (P = 0.005). The classic crown with the glide assist is superior to the micro crown in terms of crossability for severely calcified lesions.
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Aterectomía Coronaria/instrumentación , Enfermedad de la Arteria Coronaria/cirugía , Calcificación Vascular/cirugía , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Intervención Coronaria Percutánea/instrumentación , Estudios Retrospectivos , Stents , Resultado del Tratamiento , Ultrasonografía IntervencionalRESUMEN
BACKGROUND: Lipoprotein (a) [Lp(a)] has been reported to be a residual risk factor in patients who have achieved target lipid levels. The aim of the present study was to investigate the associations of Lp(a) with plaque progression and major cardiovascular events in patients with acute coronary syndromes (ACS). METHODS: The Yokohama-ACS study included 102 patients with ACS who underwent intravascular ultrasound (IVUS) at baseline and at 10-month follow-up after percutaneous coronary intervention (PCI). The patients were randomly assigned to receive either moderate- or low-intensity statin therapy. IVUS was performed to measure the plaque volume at non-culprit lesions. We enrolled 76 patients for whom Lp(a) levels at 10-month follow-up were available. RESULTS: The patients were divided into 2 groups according whether their Lp(a) levels were ≤20 mg/dl [low Lp(a) group; n = 49] or >20 mg/dl [high Lp(a) group; n = 27]. Baseline characteristics and low-density lipoprotein cholesterol levels at 10-month follow-up were similar in the low Lp(a) group and high Lp(a) group (87 ± 29 mg/dl vs. 93 ± 27 mg/dl, p = 0.42). The low Lp(a) group had significant plaque regression, whereas the high Lp(a) group showed slight plaque progression (-6.8% vs. 2.5%, p = 0.02). Ninety-five percent of the prognostic data were obtained 5 years after PCI. The cumulative event-free survival rate was significantly lower in the high Lp(a) group (p = 0.02; log-rank test). CONCLUSIONS: Lp(a) levels may be an alternative predictor of further plaque regression and the likelihood of major adverse cardiovascular events in statin-treated ACS patients.
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Síndrome Coronario Agudo/sangre , Enfermedad de la Arteria Coronaria/sangre , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Lipoproteína(a)/sangre , Placa Aterosclerótica/sangre , Síndrome Coronario Agudo/tratamiento farmacológico , Anciano , Enfermedad de la Arteria Coronaria/tratamiento farmacológico , Progresión de la Enfermedad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Placa Aterosclerótica/tratamiento farmacológico , Ultrasonografía IntervencionalRESUMEN
BACKGROUND: Sleep-disordered breathing (SDB) is associated with cardiovascular complications. However, the effect of SDB on renal function in patients with acute coronary syndrome (ACS) treated by percutaneous coronary intervention (PCI) remains unclear. METHODS: We enrolled 154 consecutive ACS patients without heart failure. A sleep study was performed immediately after PCI. RESULTS: The mean apnea-hypopnea index (AHI) was 16.4±13.1, and 33 patients (21%) had severe SDB, defined as AHI≥25. Estimated glomerular filtration rate (eGFR) values on admission (60±12mL/min/1.73m2 vs. 67±17mL/min/1.73m2, p=0.046) and at discharge (54±15mL/min/1.73m2 vs. 63±15mL/min/1.73m2, p=0.002) were lower in patients with severe SDB than in those patients without severe SDB. Multiple linear regression analysis showed that AHIs were significantly correlated with absolute changes in eGFR values from admission to discharge (ß=0.201, p=0.004). Median 24-h urinary noradrenaline excretion measured on the same day of the sleep study was higher [297 (interquartile range {IQR}: 232-472) vs. 174 (IQR: 107-318)µg/day, p=0.021] in patients with severe SDB. On multivariate logistic regression analysis, the presence of severe SDB was a significant predictor (adjusted odds ratio 3.76, 95% confidence interval 1.06-13.9, p=0.047) for eGFR of less than 45mL/min/1.73m2 at discharge. This association was independent of age, eGFR on admission, and a presentation of ST-segment elevation myocardial infarction. CONCLUSION: In patients with ACS who undergo PCI, severe SDB is associated with impaired renal function on admission and its deterioration during hospitalization. Further studies will be needed to conclude that SDB would be a therapeutic target in ACS.
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Síndrome Coronario Agudo/fisiopatología , Enfermedades Renales/fisiopatología , Síndromes de la Apnea del Sueño/fisiopatología , Síndrome Coronario Agudo/cirugía , Anciano , Femenino , Tasa de Filtración Glomerular , Hospitalización , Humanos , Modelos Lineales , Masculino , Persona de Mediana Edad , Intervención Coronaria PercutáneaRESUMEN
The impact of chronic kidney disease (CKD) and potential pharmacologic intervention on clinical outcomes after percutaneous coronary intervention (PCI) for chronic total occlusions (CTOs) remains unknown. A total of 1,463 patients underwent successful CTO-PCI between August 2004 and December 2014. Major adverse cardiovascular events (MACE) defined as the composite of all-cause death, myocardial infarction and target lesion revascularization, cardiac death, and stent thrombosis were compared between patients with and without CKD (555 and 908 patients, respectively). The results demonstrated higher risks of MACE (log-rank p = 0.015), all-cause death (log-rank p <0.001), and cardiac death (log-rank p <0.001) in the CKD group compared with the non-CKD group. Multivariable analyses demonstrated that CKD was an independent predictor for MACE (hazard ratio 1.23, 95% confidence interval 1.02 to 1.47, p = 0.03). With regard to pharmacotherapy, statin use was associated with significantly lower rates of MACE in the CKD group (log-rank p = 0.003). In conclusion, the presence of CKD would be an important predictor of long-term clinical outcomes in patients who underwent CTO-PCI, and use of statin may influence in reducing the adverse clinical outcomes.
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Oclusión Coronaria/cirugía , Insuficiencia Renal Crónica/epidemiología , Anciano , Enfermedades Cardiovasculares/mortalidad , Enfermedad Crónica , Comorbilidad , Oclusión Coronaria/epidemiología , Trombosis Coronaria/epidemiología , Dislipidemias/epidemiología , Femenino , Humanos , Hipertensión/epidemiología , Japón , Masculino , Persona de Mediana Edad , Mortalidad , Análisis Multivariante , Infarto del Miocardio/epidemiología , Revascularización Miocárdica/estadística & datos numéricos , Intervención Coronaria Percutánea , Modelos de Riesgos Proporcionales , Sistema de Registros , Diálisis Renal , Insuficiencia Renal Crónica/terapia , Stents , Accidente Cerebrovascular/epidemiologíaRESUMEN
Negative T waves in precordial leads are often seen in patients with acute coronary syndrome (ACS), but also occur in those with acute pulmonary embolism (APE). However, little attention has been given to differences in negative T waves between patients with these 2 diseases. The present study examines the value of electrocardiograms for discriminating between 40 patients with APE and 87 patients with ACS who had negative T waves in the precordial leads (V(1) to V(4)) on the admission electrocardiogram. In 77 patients (89%) with ACS, the culprit lesion was confirmed angiographically to be located in the left anterior descending coronary artery. Pulmonary P waves, S(1)S(2)S(3) pattern, S(1)Q(3)T(3) pattern, low voltage, and clockwise rotation were specific for APE, but sensitivities of these findings were very low. In patients with APE, negative T waves were commonly present in leads II, III, aVF, V(1), and V(2), but were less frequent in leads I, aVL, and V(3) to V(6) (p <0.05). Negative T waves in leads III and V(1) were observed in only 1% of patients with ACS compared with 88% of patients with APE (p <0.001). The sensitivity, specificity, positive predictive value, and negative predictive value of this finding for the diagnosis of APE were 88%, 99%, 97%, and 95%, respectively. In conclusion, the presence of negative T waves in both leads III and V(1) allows APE to be differentiated simply but accurately from ACS in patients with negative T waves in the precordial leads.
Asunto(s)
Electrocardiografía , Sistema de Conducción Cardíaco/fisiopatología , Infarto del Miocardio/diagnóstico , Embolia Pulmonar/diagnóstico , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/fisiopatología , Valor Predictivo de las Pruebas , Embolia Pulmonar/fisiopatología , Sensibilidad y EspecificidadRESUMEN
BACKGROUND: Although acute coronary syndrome (ACS) mainly arises from plaque ruptures (PR), precise mechanisms underlying ACS without PR are unknown. We sought to examine clinical, angiographic and intravascular ultrasound (IVUS) characteristics of ACS without PR. METHODS AND RESULTS: Culprit lesions of 161 ACS patients were categorized by the presence or absence of PR (PR group: n=57, Non-PR group: n=104). Lower abdominal circumference (86±10cm vs 90±9cm, p=0.02), lower prevalence of myocardial infarction (53% vs 82%, p=0.0002), and higher prevalence of definite vasospasm (15% vs 2%, p=0.006) were found in Non-PR group. Morphologically, Non-PR group was associated with simpler Ambrose classification (36% vs 14%, p=0.004), less hypoechoic plaque (45% vs 65%, p=0.04) and lower incidence of IVUS-detected thrombus (21% vs 54%, p<0.0001), compared with PR group. On quantitative IVUS, although minimum lumen area (MLA) was similar between the groups, vessel (14.2±5.4mm(2) vs 17.5±5.1mm(2), p=0.0002) and plaque (11.6±5.0mm(2) vs 14.9±4.9mm(2), p<0.0001) areas were significantly smaller at MLA site in Non-PR group than in PR group. On multivariate analysis, average plaque area was only an independent IVUS-predictor of non-rupture ACS (odds ratio: 0.85, p=0.01). CONCLUSION: Compared to ACS with PR, non-rupture ACS arise from more hyperechoic (allegedly "stable") plaque with smaller vessel and plaque area, leading to lower incidence of thrombotic occlusion. Coronary vasospasm might be a possible pathogenic mechanism underlying non-rupture ACS.
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Síndrome Coronario Agudo/diagnóstico por imagen , Vasos Coronarios/diagnóstico por imagen , Placa Aterosclerótica/diagnóstico por imagen , Ultrasonografía Intervencional/métodos , Anciano , Anciano de 80 o más Años , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Factores de RiesgoRESUMEN
BACKGROUND: An early IV beta blocker during primary percutaneous coronary intervention (PCI) has been shown to reduce infarct size in ST-segment elevation acute myocardial infarction (STEMI), although the underlying mechanism is unknown. The aim of this study was to investigate the efficacy of early infusion of landiolol, the short-acting beta-1 adrenergic receptor blocker, on the reperfusion status in a STEMI. METHODS: We conducted a prospective, single-group trial of landiolol during the primary PCI for a STEMI. Landiolol was started intravenously just before reperfusion. The reperfusion status and outcomes in 55 treated patients were compared with those in 60 historical controls treated without landiolol. The optimal reperfusion was assessed by an ST-segment resolution (STR), coronary flow, and myocardial brush grade (MBG) after reperfusion. RESULTS: Patients in the landiolol group achieved a higher rate of an STR (64% vs. 42%, p=0.023) and MBG 2/3 (64% vs. 45%, p=0.045), whereas coronary flow was comparable between the two groups. A multivariate analysis showed that landiolol use was an independent predictor of an STR (odds ratio 2.99, 95% confidence interval 1.25-7.16, p=0.014). The incidence of non-sustained ventricular tachycardia (27% vs. 50%, p=0.014), hypotension (15% vs. 32%, p=0.046), and progression to Killip class grade III or IV (0% vs. 10%, p=0.028) were lower in the landiolol group. CONCLUSION: Early infusion of landiolol during the primary PCI was associated with optimal reperfusion and a lower incidence of adverse events in comparison with the control group.
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Antagonistas de Receptores Adrenérgicos beta 1/administración & dosificación , Morfolinas/administración & dosificación , Infarto del Miocardio/diagnóstico , Infarto del Miocardio/tratamiento farmacológico , Reperfusión Miocárdica/métodos , Intervención Coronaria Percutánea/métodos , Urea/análogos & derivados , Anciano , Femenino , Humanos , Infusiones Intravenosas , Masculino , Persona de Mediana Edad , Infarto del Miocardio/fisiopatología , Estudios Prospectivos , Resultado del Tratamiento , Urea/administración & dosificaciónRESUMEN
BACKGROUND: Drug-eluting stents are replacing bare-metal stents, but in-stent restenosis (ISR) remains a problem. Reactive hyperemia index (RHI) assessed by peripheral arterial tonometry evaluates endothelial function noninvasively. We prospectively assessed the prognostic value of RHI in predicting ISR after percutaneous coronary intervention. METHODS AND RESULTS: RHI was measured before percutaneous coronary intervention and at follow-up (F/U) angiography (F/U RHI; 6 and 9 months post bare-metal stents- and drug-eluting stents- percutaneous coronary intervention, respectively) in 249 consecutive patients. At F/U, ISR (stenosis >50% of diameter) was seen in 68 patients (27.3%). F/U natural logarithm (RHI) was significantly lower in patients with ISR than in those without (0.52±0.23 versus 0.65±0.27, P<0.01); no between-group difference in initial natural logarithm (RHI) (0.60±0.26 versus 0.62±0.25, P=0.56) was seen. By multivariate logistic regression analysis, even after adjusting for other significant parameters in univariate analysis, F/U natural logarithm (RHI) independently predicted ISR (odds ratio: 0.13; 95% CI: 0.04-0.48; P=0.002). In receiver operating-characteristic analysis, F/U RHI was the strongest predictor of ISR (area under the curve: 0.67; 95% CI: 0.60-0.75; P<0.01; RHI <1.73 had 67.6% sensitivity, 64.1% specificity); area under the curve significantly improved from 0.62 to 0.70 when RHI was added to traditional ISR risk factors (P=0.02). Net reclassification index was significant after addition of RHI (26.5%, P=0.002). CONCLUSIONS: Impaired RHI at F/U angiography independently correlated with ISR, adding incremental prognostic value to the ISR-risk stratification following percutaneous coronary intervention. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov/. Unique identifier: NCT02131935.
Asunto(s)
Reestenosis Coronaria/etiología , Stents Liberadores de Fármacos , Hiperemia/etiología , Anciano , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/cirugía , Reestenosis Coronaria/fisiopatología , Endotelio Vascular/fisiología , Femenino , Oclusión de Injerto Vascular/etiología , Oclusión de Injerto Vascular/fisiopatología , Humanos , Hiperemia/fisiopatología , Masculino , Manometría/métodos , Intervención Coronaria Percutánea , Pronóstico , Estudios Prospectivos , Factores de RiesgoRESUMEN
BACKGROUND: The IMPROVE-IT trial showed that the clinical benefit of statin/ezetimibe combination appeared to be pronounced in patients with prior statin therapy. We hypothesized that the antiatherosclerotic effect of atorvastatin/ezetimibe combination was pronounced in patients with statin pretreatment. METHODS: In the prospective, randomized, controlled, multicenter PRECISE-IVUS trial, 246 patients undergoing intravascular ultrasound-guided percutaneous coronary intervention were randomized to atorvastatin/ezetimibe combination or atorvastatin alone. The dosage of atorvastatin was uptitrated with a treatment goal of lowering low-density lipoprotein cholesterol to below 70 mg/dl in both groups. Serial volumetric intravascular ultrasound was performed at baseline and 9-12 month follow-up to quantify the coronary plaque response in 202 patients. We compared the intravascular ultrasound endpoints in all subjects, stratified by the presence or absence of statin pretreatment. RESULTS: The baseline low-density lipoprotein cholesterol level (100.7 ± 23.1 mg/dl vs. 116.4 ± 25.9 mg/dl, p < 0.001) and lathosterol (55 (38 to 87)) µg/100 mg total cholesterol vs. 97 (57 to 149) µg/100 mg total cholesterol, p < 0.001) was significantly lower, and campesterol/lathosterol ratio (3.9 (2.4 to 7.4) vs. 2.6 (1.5 to 4.1), p < 0.001) was significantly increased in patients with statin pretreatment. Contrary to the patients without statin pretreatment (-1.3 (-3.1 to -0.1)% vs. -0.9 (-2.3 to 0.9)%, p = 0.12), the atorvastatin/ezetimibe combination showed a significantly stronger reduction in delta percent atheroma volume, compared with atorvastatin alone, in patients with statin pretreatment (-1.8 (-3.6 to -0.3)% vs. -0.1 (-1.6 to 0.8)%, p = 0.002). CONCLUSION: Compensatory increase in cholesterol absorption observed in statin-treated patients might attenuate the inhibitory effects of statins on coronary plaque progression. A low-dose statin/ezetimibe combination might be a promising option in statin-hyporesponder.