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Background: Although the use of intravascular ultrasound (IVUS) during percutaneous coronary intervention (PCI) has been shown to improve clinical outcomes, its utilization remains inconsistent. We aimed to assess the association between IVUS-guided PCI and long-term outcomes in Japan, where a high proportion of patients undergo IVUS. Methods: We analyzed 8721 consecutive patients in a multicenter PCI registry. The primary outcome was a composite of death, acute coronary syndrome, and heart failure requiring admission and coronary artery bypass grafting at 2 years after discharge. The secondary outcome was each component of the primary outcome. We used inverse probability-weighted analysis for adjustment. Subgroup analysis was conducted on patients with complex coronary anatomy (eg, those with bifurcation, chronic total occlusion, type C lesion, left main and those who underwent rotational atherectomy). Results: Overall, 83.8% of patients underwent IVUS-guided PCI (mean age, 68.3 ± 11.3 years). After adjustments, the IVUS group had significantly lower rates of death and coronary bypass compared to no IVUS group (hazard ratio [HR], 0.73; 95% CI, 0.55-0.96; and HR, 0.62; 95% CI, 0.39-0.98) at 2-year follow-up, although the primary outcome showed only marginal differences (HR, 0.85; 95% CI, 0.71-1.01). In the subgroup analysis of complex coronary anatomy, the use of IVUS was significantly associated with a reduced risk of the primary outcome (HR, 0.72; 95% CI, 0.55-0.93) as well as death, coronary bypass, and heart failure. Conclusions: IVUS was frequently utilized in our registry and demonstrated potential benefit in reducing mortality and need for coronary bypass surgery, particularly in patients with complex coronary anatomy.
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Young patients who underwent percutaneous coronary intervention (PCI) have shown worse long-term outcomes but remain inadequately investigated. We analyzed 1,186 consecutive young patients (aged ≤55 years) from the Keio Cardiovascular PCI registry who were successfully discharged after PCI (2008 to 2019) and compared them to 5,048 older patients (aged 55 to 75 years). The primary outcome was a composite of all-cause death, acute coronary syndrome, heart failure, bleeding, stroke requiring admission, and coronary artery bypass grafting within 2 years after discharge. In the young patients, the mean age was 48.4 ± 5.4 years, acute coronary syndrome cases accounted for 69.6%, and 92 (7.8%) were female. Body mass index; hemoglobin levels; and proportions of smoking, hyperlipidemia, and ST-elevation myocardial infarction were lower and dialysis or active cancer proportions were higher in young female patients than male patients. A higher number of young female than male patients reached the primary end point and all-cause death (15.2% vs 7.1%, p = 0.01; 4.3% vs 1.0%, p = 0.023), mainly because of noncardiac death (4.3% versus 0.5%, p = 0.001). After covariate adjustment, the primary end point rates were higher among young women than men (hazard ratio 2.00, 95% confidence interval 1.03 to 3.89, p = 0.042). Gender did not predict the primary end point among older patients (vs men; hazard ratio 0.84, 95% confidence interval 0.67 to 1.06, p = 0.14). In conclusion, young women showed worse outcomes during the 2-year post-PCI follow-up, but this gender difference was absent in patients aged 55 to 75 years.
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Síndrome Coronariana Aguda , Doença da Artéria Coronariana , Infarto do Miocárdio , Intervenção Coronária Percutânea , Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Intervenção Coronária Percutânea/efeitos adversos , Síndrome Coronariana Aguda/epidemiologia , Síndrome Coronariana Aguda/cirurgia , Síndrome Coronariana Aguda/etiologia , Japão/epidemiologia , Fatores Sexuais , Sistema de Registros , Resultado do Tratamento , Doença da Artéria Coronariana/epidemiologia , Doença da Artéria Coronariana/cirurgia , Doença da Artéria Coronariana/etiologiaRESUMO
The relation between chronic kidney disease (CKD) and outcomes in patients receiving percutaneous coronary intervention (PCI) is thought to be bidirectional; these patients are at a higher risk of ischemic and bleeding events. From a Japanese nationwide PCI registry, ischemic (cardiovascular death, nonfatal myocardial infarction, or nonfatal ischemic stroke) and bleeding events (fatal or nonfatal major bleeding) 1 year after discharge among patients who had second- or newer-generation drug-eluting stent implantation were analyzed. Patients on oral anticoagulants were excluded. Patients were stratified according to their preprocedural renal function: CKD stages 1 to 2 (estimated glomerular filtration rate [eGFR] ≥60 ml/min/1.73 m2), 3 (eGFR 30 to 59), or 4 to 5 (eGFR <30), or those receiving dialysis. Overall, 23,349 patients, including 2,798 patients with CKD 3 to 5 (12.0%) and 1,464 patients on dialysis (6.3%), were investigated. One-year ischemic events were observed in 1.5%, 5.2%, 9.7%, and 5.3% in the CKD stages 1-to-2, 3, 4-to-5, and dialysis groups, respectively; patients with CKD stages 3 or 4 to 5 and those receiving dialysis were associated with higher risks of ischemic events after adjustment of covariates than were patients without CKD. Compared with ischemic events, 1-year bleeding events were low, with incidence rates of 1.5%, 2.0%, 3.4%, and 2.3%, respectively. Furthermore, the presence of CKD or dialysis was not associated with a higher risk of bleeding events after adjustment of covariates. In conclusion, in the contemporary nationwide PCI registry, the presence of CKD and dialysis was independently associated with a higher risk of ischemic events but not with bleeding events, and this suggests a need to alter the models of care delivery in these patients.
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Doença da Artéria Coronariana , Hemorragia , Isquemia Miocárdica , Intervenção Coronária Percutânea , Insuficiência Renal Crônica , Humanos , Doença da Artéria Coronariana/epidemiologia , Doença da Artéria Coronariana/cirurgia , Doença da Artéria Coronariana/complicações , Stents Farmacológicos/efeitos adversos , População do Leste Asiático/estatística & dados numéricos , Hemorragia/epidemiologia , Hemorragia/etiologia , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/instrumentação , Sistema de Registros/estatística & dados numéricos , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/epidemiologia , Insuficiência Renal Crônica/terapia , Fatores de Risco , Resultado do Tratamento , Japão/epidemiologia , Isquemia Miocárdica/epidemiologia , Isquemia Miocárdica/etiologia , Diálise Renal/efeitos adversosRESUMO
BACKGROUND: High mortality in patients with acute coronary syndrome (ACS) without standard modifiable cardiovascular risk factors [SMuRFs (e.g. diabetes, hypertension, smoking, and dyslipidemia)] has been reported. However, details regarding their acute presentation and reasons for the excess risk remain unclear. METHOD: Patient-level data were extracted from a multicenter procedure-based registry (KiCS-PCI). We analyzed consecutive patients with ACS who underwent de novo percutaneous coronary intervention (PCI) between 2009 and 2020. The primary outcome of interest was the in-hospital mortality. RESULTS: Among the 10,523 patients with ACS, 7775 met the inclusion criteria. Patients without SMuRFs who underwent PCI [nâ¯=â¯529 (6.8â¯%)] were older [median 71 (IQR: 63-79) vs. 68 (59-76) years, pâ¯<â¯0.001] and more often presented with cardiogenic shock or cardiopulmonary arrest (14.6â¯% vs. 8.6â¯%, pâ¯<â¯0.001; 12.7â¯% vs. 5.3â¯%, pâ¯<â¯0.001, respectively). In patients with ST-elevation myocardial infarction (STEMI), median door-to-balloon time was significantly longer in SMuRF-less patients (90â¯min vs 82â¯min). In-hospital death was significantly higher in SMuRF-less patients [10.2â¯% vs. 4.1â¯%, pâ¯<â¯0.001, adjusted odds ratio, 1.81 (95%CI, 1.26-2.59); pâ¯=â¯0.001], whereas the rate of procedural complications showed no significant difference. When stratified by the ACS presentation pattern, the findings were consistent, although the association between SMuRF-less and the increased risk of in-hospital mortality was not statistically significant in patients with non-ST-elevation- (NSTE)-ACS. CONCLUSIONS: SMuRF-less ACS patients frequently presented with cardiopulmonary arrest and/or cardiogenic shock, leading to high in-hospital mortality. When stratified by the ACS presentation pattern, the association of SMuRF-less and the increased risk of mortality was more prominent in STEMI patients and it was not statistically significant in NSTE-ACS patients. Almost half of these patients had amendable left main trunk or left anterior descending artery disease and treating clinicians should be aware of this paradox to avoid the delay in treatment.
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Síndrome Coronariana Aguda , Doenças Cardiovasculares , Parada Cardíaca , Intervenção Coronária Percutânea , Infarto do Miocárdio com Supradesnível do Segmento ST , Humanos , Intervenção Coronária Percutânea/efeitos adversos , Mortalidade Hospitalar , Choque Cardiogênico/etiologia , Doenças Cardiovasculares/etiologia , Fatores de Risco , Fatores de Risco de Doenças Cardíacas , Sistema de Registros , Parada Cardíaca/etiologia , Resultado do TratamentoRESUMO
We report the case of a 79-year-old woman with essential thrombocythemia who presented with simultaneous two-vessel acute myocardial infarction (AMI) in the subacute phase of takotsubo cardiomyopathy. Despite sufficient anticoagulation therapy with warfarin to prevent thrombus formation in the left ventricle, the patient developed simultaneous two-vessel AMI in the right and left circumflex coronary arteries 16â¯days after the onset of takotsubo cardiomyopathy. Thromboembolism from the left ventricle associated with takotsubo cardiomyopathy was considered a potential cause of this event. However, macroscopic and pathological findings of the aspirated thrombi revealed that the primary cause of AMI was non-organized white platelet thrombi associated with essential thrombocythemia. In addition to oral anticoagulation therapy with warfarin, low-dose aspirin was started. The patient was discharged without any symptoms, and the clinical course has been uneventful for >5â¯years. This case highlights the potential risk of fatal complications associated with essential thrombocythemia, including simultaneous multivessel AMI. Additionally, pathological findings of the thrombi may play a crucial role in clarifying the etiology in such complicated cases. Appropriate antithrombotic therapy should be selected according to the pathogenesis of the condition. Learning objective: We describe a 79-year-old woman with essential thrombocythemia complicated with simultaneous two-vessel acute myocardial infarction (AMI) in the subacute phase of takotsubo cardiomyopathy. Although patients with essential thrombocythemia are highly predisposed to thrombotic events including AMI, the appropriate antithrombotic regimen remains controversial. The macroscopic and pathological findings of the thrombi play a pivotal role in clarifying the etiology, which may lead to the appropriate antithrombotic therapy.
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Toxicity resulting from retained contrast media may cause adverse cardiovascular outcomes (e.g., heart failure and cardiogenic shock) for dialysis patients. However, the association between the administered contrast volume and outcomes of dialysis patients after percutaneous coronary intervention (PCI) has not been sufficiently investigated. We evaluated 953 consecutive dialysis patients (age, 67.9 ± 9.9 years; 30.1% with acute coronary syndrome) who underwent PCI between September 2008 and March 2019. Patients were divided into two groups: those with a contrast volume ≥ 200 ml and those with a contrast volume < 200 ml. The cutoff was 200 ml because 100 ml increment of contrast volume is known to raise the risk of acute kidney injury, and 200 ml is more than the average volume used at most PCI centers. The primary endpoint was a composite of in-hospital death, post-PCI cardiogenic shock and post-PCI heart failure. A multivariable logistic regression model and smooth spline curve were constructed to assess the association between contrast volume and the primary endpoint. The median contrast volume was 157 ml (interquartile range, 115-210 ml). The overall primary endpoint incidence was 6.8% (N = 65). A contrast volume ≥ 200 ml was associated with a higher risk of the primary endpoint (odds ratio 2.91; 95% confidence interval 1.42-6.05; P = 0.004). The smooth spline curve demonstrated a linear relationship between the contrast volume and primary endpoint. In conclusions, the contrast volume was associated with adverse in-hospital outcomes of dialysis patients undergoing PCI. Attention should be focused on the contrast volume used for dialysis patients undergoing PCI.
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Insuficiência Cardíaca , Intervenção Coronária Percutânea , Humanos , Pessoa de Meia-Idade , Idoso , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/métodos , Choque Cardiogênico/epidemiologia , Mortalidade Hospitalar , Meios de Contraste/efeitos adversos , Diálise Renal/efeitos adversos , Hospitais , Insuficiência Cardíaca/complicações , Fatores de Risco , Resultado do TratamentoRESUMO
OBJECTIVES: We aimed to evaluate whether paclitaxel eluting devices increased the risk of death in patients undergoing revascularization for infrainguinal peripheral artery disease using network meta-analyses. METHODS: PUBMED and EMBASE were searched through April 2020 for randomized trials in patients with infrainguinal peripheral artery disease who underwent revascularization with or without a paclitaxel eluting device (balloon/stent). Short-term mortality defined as death at 6-12 months, and long-term mortality defined as death at >12 months after revascularization. RESULTS: Our search identified 57 eligible randomized controlled studies enrolling a total of 9,362 patients comparing seven revascularization strategies (balloon angioplasty vs. bare metal stent vs. covered stent vs. paclitaxel eluting stent vs. other drug eluting stent vs. paclitaxel-coated balloon vs. bypass surgery). Overall, paclitaxel eluting stent and paclitaxel-coated balloons did not increase short-term mortality (eg, vs. balloon angioplasty: paclitaxel-coated balloon OR [95% CI] 1.21 [0.88-1.66], p = .24; paclitaxel eluting stent OR [95%CI] 1.01 [0.63-1.63], p = .97, respectively). In addition, paclitaxel eluting stent did not show significant increase in long-term mortality (eg, vs. balloon angioplasty: OR [95%CI] 1.06 [0.70-1.59], p = .79). However, paclitaxel-coated balloon showed significant increase in long-term mortality compared to balloon angioplasty and bypass (vs. balloon angioplasty: OR [95% CI] 1.48 [1.06-2.07], p = .021; vs. bypass: OR [95%CI] 1.73 [1.05-2.84], p = .031, respectively). CONCLUSIONS: In this meta-analysis of randomized trials, there was no significant increase in mortality with paclitaxel eluting stent, but there was increased risk of long-term mortality in paclitaxel-coated balloon for the treatment of infrainguinal peripheral artery disease.
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Fármacos Cardiovasculares/administração & dosagem , Materiais Revestidos Biocompatíveis , Stents Farmacológicos , Procedimentos Endovasculares/instrumentação , Paclitaxel/administração & dosagem , Doença Arterial Periférica/terapia , Dispositivos de Acesso Vascular , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Metanálise em Rede , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/mortalidade , Desenho de Prótese , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
Clinical trial data suggest that intravascular ultrasound (IVUS) may improve clinical outcomes after PCI. The aim of this study was to investigate the safety of IVUS in its broader use for percutaneous coronary intervention (PCI). A total of 11,570 consecutive patients undergoing PCI between 2008 and 2014 in Japan were analyzed. Associations between IVUS use, PCI-related complications were assessed with logistic regression and propensity score matching analyses. Subgroup analysis was performed in elective PCI patients. IVUS was used in 84.8% of patients (N = 9814; IVUS group); its use was almost universal in elective PCIs (90.8 vs. 81.7% in urgent/emergent PCIs, P < 0.001). The non-IVUS group were older (68.7 ± 11.4 vs. 67.9 ± 10.8 years, P = 0.004), with more comorbid conditions. The non-IVUS group had smaller stent lumens (2.97 ± 0.42 mm vs. 3.09 ± 0.45 mm, P < 0.001) and a higher proportion of plain old balloon angioplasty. After matching, a lower rate of flow-impairing coronary dissections was observed in the IVUS group, although this was limited only to elective PCIs, not among urgent/emergent PCIs (non-IVUS vs. IVUS; 2.7% vs. 1.0%, P = 0.018, 0.7% vs. 1.2%, P = 0.32, respectively). With a multivariate logistic regression analysis, IVUS use remained an independent predictor to reduce risk of flow impairing severe coronary dissection among elective PCIs (odds ratio 0.38, 95% confidence interval 0.22-0.66: P = 0.001). In this Japanese PCI registry, IVUS was used extensively during the study period, particularly in elective cases. Using IVUS was associated with a lower event rate of flow-impairing coronary dissections that was limited to elective PCIs, not among urgent/emergent PCIs, without increasing PCI-related complications.
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Doença da Artéria Coronariana/cirurgia , Vasos Coronários/diagnóstico por imagem , Intervenção Coronária Percutânea/métodos , Sistema de Registros , Cirurgia Assistida por Computador/métodos , Ultrassonografia de Intervenção/métodos , Idoso , Doença da Artéria Coronariana/diagnóstico , Vasos Coronários/cirurgia , Feminino , Seguimentos , Humanos , Japão , Masculino , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
Periprocedural bleeding is associated with an increased risk of mortality during percutaneous coronary intervention (PCI), especially in patients with severe chronic renal insufficiency. Therefore, trans-radial intervention (TRI) should be considered in these patients; however, PCI operators usually avoid this approach because of the risk of radial artery occlusion. We aimed to investigate the associations of TRI and in-hospital complications in these patients. This study included 306 consecutive patients with severe chronic renal insufficiency and/or on dialysis who underwent PCI. Patients were prospectively enrolled and divided according to the access site into TRI group and trans-femoral intervention group. Severe renal insufficiency was defined as estimated glomerular filtration rate < 30 mL/min/1.73 m2. Radial access was limited to the opposite side of the arteriovenous fistula in patients on hemodialysis. The primary study endpoint was the composite of in-hospital bleeding complications and death. TRI benefit was evaluated by inverse probability treatment weighted analysis. TRI was performed in 112 (37.3%) patients. TRI group included older patients with significantly lower rates of diabetes mellitus, dialysis, and three-vessel disease. Crossover to the other approach occurred only in TRI group (2.6%). The primary endpoint was significantly lower in TRI group (11.5% vs. 2.6%, P = 0.006). After an inverse probability treatment weighted analysis, TRI was an independent prognostic factor for a decrease in the primary endpoint (OR 0.19; 95% CI 0.051-0.73; P = 0.015). Radial artery occlusion occurred in three patients on dialysis (9.1%). TRI may determine better in-hospital outcomes in patients with severe chronic renal insufficiency and/or on dialysis.
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Cateterismo Cardíaco/métodos , Doença da Artéria Coronariana/cirurgia , Intervenção Coronária Percutânea/métodos , Diálise Renal , Insuficiência Renal Crônica/terapia , Idoso , Idoso de 80 Anos ou mais , Cateterismo Cardíaco/efeitos adversos , Doença da Artéria Coronariana/mortalidade , Feminino , Artéria Femoral/cirurgia , Taxa de Filtração Glomerular , Hemorragia/etiologia , Mortalidade Hospitalar , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Intervenção Coronária Percutânea/efeitos adversos , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Artéria Radial/cirurgia , Insuficiência Renal Crônica/complicações , Fatores de Risco , Resultado do TratamentoRESUMO
Patients with a coronary aneurysm alone do not generally exhibit continuous murmurs; however, murmurs may be detected in the presence of a fistula. A 57-year-old woman with chest pain was referred to us with a suspected diagnosis of a ruptured sinus of Valsalva aneurysm owing to the presence of a continuous murmur that was detected on physical examination. However, CT revealed a giant right coronary artery aneurysm draining into the right atrium. Consequently, surgery was performed. This case highlights the importance of implementing multiple imaging modalities for adequate differential diagnoses of patients presenting with continuous murmurs.
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Ruptura Aórtica , Aneurisma Coronário/complicações , Aneurisma Coronário/diagnóstico por imagem , Seio Aórtico , Fístula Vascular/complicações , Fístula Vascular/diagnóstico por imagem , Aneurisma Coronário/cirurgia , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/cirurgia , Diagnóstico Diferencial , Feminino , Átrios do Coração/diagnóstico por imagem , Átrios do Coração/cirurgia , Humanos , Pessoa de Meia-Idade , Tomografia Computadorizada por Raios X/métodos , Fístula Vascular/cirurgiaRESUMO
Although exercise testing has become a standard procedure before discharge for patients with acute coronary syndrome, a fatal accident during the test is extremely rare. A 60-year-old man was admitted for a non-ST-segment elevation myocardial infarction. A coronary angiogram showed stenosis at the distal lesion of the circumflex, and a balloon angioplasty was performed. His recovery was smooth, and a cardiopulmonary exercise test was performed 5 days after admission. At 2.5 metabolic equivalents, he suddenly went into cardiac arrest, and percutaneous cardiopulmonary support was initiated. Echocardiography revealed the presence of a large amount of pericardial effusion, and emergency cardiac surgery was performed to repair the free-wall rupture. This highlights the importance of careful monitoring of patients with percutaneous coronary intervention during cardiopulmonary exercise testing.
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Teste de Esforço/efeitos adversos , Ruptura Cardíaca Pós-Infarto/etiologia , Angioplastia Coronária com Balão , Estenose Coronária/terapia , Evolução Fatal , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio sem Supradesnível do Segmento ST/terapia , Intervenção Coronária Percutânea , Derrame Pericárdico/etiologia , Complicações Pós-Operatórias/etiologiaRESUMO
There is a growing interest in the optimizing care of acute coronary syndrome (ACS) in young patients, largely owing to their potential for longer life expectancy. Herein, we aimed to investigate the clinical characteristics and outcome of young ACS patients (e.g. under 60 year old) from a Japanese multicenter percutaneous coronary intervention (PCI) registry (KiCS-PCI). KiCS-PCI registered consecutive ACS patients from 15 institutions, and 1560 (24.0%) out of 6499 ACS-related PCI involved patients aged <60 years. In this group, prevalence of dyslipidemia, smoking and family history of premature coronary artery disease (CAD) was higher, while the other classical risk factors were lower when compared to the old patients. After adjustment for known confounders, presentation with cardiogenic shock (CS) before PCI (OR 32.57, 95% CI 12.06-87.97), culprit lesion of LMT (OR 7.53, 95% CI 1.26-44.98), multi-vessel disease (OR 3.82, 95% CI 1.37-10.63) and higher body mass index (OR 1.12, 95% CI 1.00-1.24) showed association with higher in-hospital mortality in young patients. Multi-vessel disease (OR 4.1, 95% CI 1.9-8.9) and chronic kidney disease (OR 3.56, 95% CI 2.26-5.68) were associated with CS presentation. CS presentation was inversely associated with classical risk factors such as hypertension (OR 0.61, 95% CI 0.38-0.96), family history of CAD (OR 0.49, 95% CI 0.25-0.96), and dyslipidemia (OR 0.45, 95% CI 0.29-0.71) and culprit lesion of RCA (OR 0.60, 95% CI 0.37-0.94). Overall, ACS in the younger population was observed frequently, accounting for a quarter of ACS-related PCI. CS was a harbinger for in-hospital mortality in these patients.
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Síndrome Coronariana Aguda/cirurgia , Intervenção Coronária Percutânea/mortalidade , Síndrome Coronariana Aguda/mortalidade , Idoso , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/estatística & dados numéricos , Prognóstico , Sistema de Registros , Fatores de Risco , Choque Cardiogênico/mortalidade , Choque Cardiogênico/cirurgiaRESUMO
We report a case with 46-year-old man diagnosed with mitochondrial cardiomyopathy in the dilated phase of hypertrophic cardiomyopathy. Since cardiac magnetic resonance imaging, beta-methyl-p-123I-iodophenyl-pentadecanoic myocardial scintigraphy, and positron emission tomography/computed tomography revealed no remarkable findings, we performed electron microscopic examination, which aided in diagnosing mitochondrial cardiomyopathy. Muscle biopsy was also compatible with mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes and DNA analysis also concluded it. Since muscle biopsy is less invasive for patients compared to endomyocardial biopsy, cardiologists need to consider it. The diagnosis of mitochondrial cardiomyopathy is helpful because it is a genetic condition and also for consideration of device therapy, as well as management for acute crisis.
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BACKGROUND: The "smoker's paradox" is an otherwise unexplained phenomenon in which the mortality of smokers after acute myocardial infarction is reduced, contrary to expectations. It has been suggested that an association with antiplatelet agents exists, but the true mechanism remains largely unidentified. METHODSâANDâRESULTS: The analysis included 6,195 consecutive patients who underwent percutaneous coronary intervention (PCI) for acute coronary syndrome, registered in the Japanese multicenter PCI registry. Smokers were significantly younger and had less comorbidity than non-smokers. Unadjusted in-hospital mortality rate, general complication rate, and bleeding complication rate were lower in smokers than in non-smokers. After adjustment, the trend persisted and smoking was not associated with overall mortality (odds ratio [OR], 0.90; 95% confidence interval [CI]: 0.61-1.34; P=0.62), and was associated with lower overall (P=0.032) and bleeding complication events (P=0.040). Clopidogrel effectively reduced the occurrence of in-hospital complications and major adverse cardiac events in smokers compared with non-smokers (OR, 0.55; 95% CI: 0.53-0.98 vs. OR, 1.20; 95% CI: 0.87-1.67; and OR, 0.37; 95% CI: 0.20-0.70 vs. OR, 1.48; 95% CI: 0.90-2.43, respectively). CONCLUSIONS: The smoker's paradox was largely explained by confounding factors related to the lower risk profile of smokers, and they benefited from a positive modification of the efficacy of clopidogrel. (Circ J 2016; 80: 1590-1599).
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Síndrome Coronariana Aguda , Mortalidade Hospitalar , Intervenção Coronária Percutânea , Ticlopidina/análogos & derivados , Síndrome Coronariana Aguda/mortalidade , Síndrome Coronariana Aguda/terapia , Idoso , Idoso de 80 Anos ou mais , Clopidogrel , Intervalo Livre de Doença , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fumar/mortalidade , Fumar/terapia , Taxa de Sobrevida , Ticlopidina/administração & dosagemRESUMO
We report the case of a 50-year-old man with eosinophilic myocarditis and bronchial asthma treated successfully with prednisolone. He was initially diagnosed with eosinophilia, and complained of acute chest pain with electrocardiographic changes and elevation of cardiac enzymes. Coronary angiography showed no atherosclerotic changes; therefore, we performed endomyocardial biopsy and started oral prednisolone therapy immediately. His general condition improved with the disappearance of eosinophilia upon treatment. He was finally diagnosed with eosinophilic granulomatosis with polyangiitis complicated by eosinophilic myocarditis. This case report highlights that eosinophilic myocarditis may occur in association with systemic disease, and early steroid therapy is essential.
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BACKGROUND: Obesity is associated with advanced cardiovascular disease. However, some studies have reported the "obesity paradox" after percutaneous coronary intervention (PCI). The relationship between body mass index (BMI) and clinical outcomes after PCI has not been thoroughly investigated, especially in Asian populations. METHODS: We studied 10,142 patients who underwent PCI at 15 Japanese hospitals participating in the JCD-KICS registry from September 2008 to April 2013. Patients were divided into four groups according to BMI: underweight, BMI <18.5 (n=462); normal, BMI ≥ 18.5 and <25.0 (n=5,945); overweight, BMI ≥ 25.0 and <30.0 (n=3,100); and obese, BMI ≥ 30.0 (n=635). RESULTS: Patients with a high BMI were significantly younger (p<0.001) and had a higher incidence of coronary risk factors such as hypertension (p<0.001), hyperlipidemia (p<0.001), diabetes mellitus (p<0.001), and current smoking (p<0.001), than those with a low BMI. Importantly, patients in the underweight group had the worst in-hospital outcomes, including overall complications (underweight, normal, overweight, and obese groups: 20.4%, 11.5%, 8.4%, and 10.2%, p<0.001), in-hospital mortality (5.8%, 2.1%, 1.2%, and 2.7%, p<0.001), cardiogenic shock (3.5%, 2.0%, 1.5%, and 1.6%, p=0.018), bleeding complications (10.0%, 4.5%, 2.6%, and 2.8%, p<0.001), and receiving blood transfusion (7.6%, 2.7%, 1.6%, and 1.7%, p<0.001). BMI was inversely associated with bleeding complications after adjustment by multivariate logistic regression analysis (odds ratio, 0.95; 95% confidence interval, 0.92-0.98; p=0.002). In subgroup multivariate analysis of patients without cardiogenic shock, BMI was inversely associated with overall complications (OR, 0.98; 95% CI, 0.95-0.99; p=0.033) and bleeding complications (OR, 0.95; 95% CI, 0.91-0.98; p=0.006). Furthermore, there was a trend that BMI was moderately associated with in-hospital mortality (OR, 0.94; 95% CI, 0.88-1.01; p=0.091). CONCLUSIONS: Lean patients, rather than obese patients are at greater risk for in-hospital complications during and after PCI, particularly for bleeding complications.
Assuntos
Índice de Massa Corporal , Intervenção Coronária Percutânea/efeitos adversos , Complicações Pós-Operatórias , Idoso , Idoso de 80 Anos ou mais , Povo Asiático , Bases de Dados Factuais , Diabetes Mellitus Tipo 2/epidemiologia , Diabetes Mellitus Tipo 2/etiologia , Feminino , Hemorragia/etiologia , Mortalidade Hospitalar , Hospitais , Humanos , Hiperlipidemias/epidemiologia , Hiperlipidemias/etiologia , Hipertensão/epidemiologia , Hipertensão/etiologia , Incidência , Japão , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Sistema de Registros , Fatores de RiscoRESUMO
To improve the modest efficacy of mesenchymal stem cell (MSC) transplantation, the treatment of human MSCs with angiotensin receptor blockers (ARBs) was investigated. MSCs were cultured with or without the medium containing 3 µmol/l of ARBs before cardiomyogenic induction. After cardiomyogenic induction in vitro, cardiomyogenic transdifferentiation efficiency (CTE) was calculated by immunocytochemistry using anticardiac troponin-I antibody. In the nude rat chronic myocardial infarction model, we injected MSCs pretreated with candesartan (A-BM; n = 18) or injected MSCs without pretreatment of candesartan (BM; n = 25), each having survived for 2 weeks. The left ventricular function, as measured by echocardiogram, was compared with cardiomyogenic transdifferentiation in vivo, as determined by immunohistochemistry. Pretreatment with ARBs significantly increased the CTE in vitro (10.1 ± 0.8 n = 12 vs. 4.6 ± 0.3% n = 25, p < .05). Transplantation of candesartan-pretreated MSCs significantly improved the change in left ventricular ejection fraction (BM; -7.2 ± 2.0 vs. A-BM; 3.3 ± 2.3%). Immunohistochemistry revealed significant improvement of cardiomyogenic transdifferentiation in A-BM in vivo (BM; 0 ± 0 vs. A-BM; 0.014 ± 0.006%). Transplantation of ARB-pretreated MSCs significantly improved cardiac function and can be a promising cardiac stem cell source from which to expect cardiomyogenesis.