Prognosis after switching to electronic cigarettes following percutaneous coronary intervention: a Korean nationwide study.

BACKGROUND AND AIMS: Despite the increasing popularity of electronic cigarettes (E-cigarettes), the prognostic impact of switching to E-cigarettes in smokers with coronary artery disease who have undergone percutaneous coronary intervention (PCI) remains unclear. METHODS: Using a nationwide cohort from the Korean National Health Insurance database, 17 973 adults (≥20 years) identified as smokers (based on a health screening examination within 3 years before PCI) who underwent health screening within 3 years after PCI were enrolled to determine changes in smoking habits. Patients were classified as continued combustible cigarette users, successful quitters, or switchers to E-cigarettes. The group switching to E-cigarettes was further divided into dual users (using both combustible and E-cigarettes) and those exclusively using E-cigarettes. Primary outcomes included major adverse cardiac events (MACEs), a composite of all-cause death, spontaneous myocardial infarction, and repeat revascularization. RESULTS: Among the total population, 8951 patients (49.8%) continued using combustible cigarettes, 1694 (9.4%) were switched to E-cigarettes, and 7328 (40.7%) successfully quit smoking after PCI. During a median follow-up of 2.4 years, the cumulative incidence of MACE was lower among E-cigarette switchers (10%) or quitters (13.4%) than among continued combustible cigarette users (17%). When continued combustible cigarette users were used as the reference, the multivariable-adjusted hazard ratios with 95% confidence intervals for MACE were 0.82 (0.69-0.98) for switchers to E-cigarettes and 0.87 (0.79-0.96) for successful quitters. Compared with dual users, entirely switching to E-cigarettes was associated with a significantly lower MACE risk (hazard ratio 0.71; 95% confidence interval 0.51-0.99). CONCLUSIONS: Among smokers who underwent PCI for coronary artery disease, switching to E-cigarette use (particularly complete transition) or quitting smoking was associated with reduced MACE risk than with continued combustible cigarette use. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov NCT06338761.

Endovascular Treatment for Peripheral Pulmonary Arterial Stenosis in RNF213-Related Vasculopathy.

This brief report reviews the clinical, procedural, and imaging data of 7 patients with p.Arg4810Lys variant of the ring finger protein 213 (RNF213) gene-related peripheral pulmonary arterial stenosis who underwent percutaneous transluminal pulmonary angioplasties (PTPAs) for demographics, clinical presentation, indications for angioplasty, and procedural and clinical outcomes. During median follow-up of 64.4 months since the first confirmed diagnosis, PTPA was performed for 62 segmental pulmonary arteries with 38 sessions of the procedure in 7 patients. Vascular stent placement because of resistance to balloon dilation and immediate elastic recoil was performed in 48 of 62 procedures (77%). Except for 1 death, 6 patients showed an improvement in dyspnea and 5 patients showed a decrease in mean pulmonary arterial pressure (mean, 55.5-42.7 mm Hg) and increase in 6-minute walk distance (mean, 415.5-484.3 m). Reperfusion edema occurred in 4 of 7 patients (57%), which was 6 of 38 sessions (16%).

Clinical significance of residual ischaemia in acute myocardial infarction complicated by cardiogenic shock undergoing venoarterial-extracorporeal membrane oxygenation.

AIMS: Although culprit-only revascularization during the index procedure has been recommended in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS), the reduction in residual ischaemia is also emphasized to improve clinical outcomes. However, few data are available about the significance of residual ischaemia in patients undergoing mechanical circulatory supports. This study aimed to evaluate the effects of residual ischaemia on clinical outcomes in patients with AMI undergoing venoarterial-extracorporeal membrane oxygenation (VA-ECMO). METHODS AND RESULTS: Patients with AMI with multivessel disease who underwent VA-ECMO due to refractory CS were pooled from the RESCUE and SMC-ECMO registries. The included patients were classified into three groups according to residual ischaemia evaluated using the residual Synergy between percutaneous coronary intervention with Taxus and Cardiac Surgery (SYNTAX) score (rSS): rSS = 0, 0 < rSS ≤ 8, and rSS > 8. The primary outcome was 1-year all-cause death. A total of 408 patients were classified into the rSS = 0 (n = 100, 24.5%), 0 < rSS ≤ 8 (n = 136, 33.3%), and rSS > 8 (n = 172, 42.2%) groups. The cumulative incidence of the primary outcome differed significantly according to rSS (33.9 vs. 55.4 vs. 66.1% for rSS = 0, 0 < rSS ≤ 8, and rSS > 8, respectively, overall P < 0.001). In a multivariable model, rSS was independently associated with the risk of 1-year all-cause death (adjusted hazard ratio 1.03, 95% confidence interval 1.01-1.05, P = 0.003). Conversely, the baseline SYNTAX score was not associated with the risk of the primary outcome. Furthermore, when patients were stratified by rSS, the primary outcome did not differ significantly between the high and low delta SYNTAX score groups. CONCLUSION: In patients with AMI with refractory CS who underwent VA-ECMO, residual ischaemia was associated with an increased risk of 1-year mortality. Future studies are needed to evaluate the efficacy and safety of revascularization strategies to minimize residual ischaemia in patients with CS supported with VA-ECMO. CLINICAL TRIAL REGISTRATION: REtrospective and Prospective Observational Study to Investigate Clinical oUtcomes and Efficacy of Left Ventricular Assist Device for Korean Patients With Cardiogenic Shock (RESCUE), NCT02985008.

Sex-Based Outcomes of P2Y12 Inhibitor Monotherapy After Three Months of Dual Antiplatelet Therapy in Patients Undergoing Percutaneous Coronary Intervention.

BACKGROUND: In patients undergoing percutaneous coronary intervention (PCI) in the SMART-CHOICE trial, P2Y12 inhibitor monotherapy after three months of dual antiplatelet therapy (DAPT) achieved clinical outcomes comparable to those of 12 months of DAPT. Nonetheless, the effects of sex on these outcomes remain unknown. METHODS: This open-label, non-inferiority, randomized study, conducted in 33 hospitals in South Korea, included 2,993 patients undergoing PCI with drug-eluting stents. Patients were randomly assigned to receive DAPT (aspirin plus a P2Y12 inhibitor) for three months then P2Y12 inhibitor alone for nine months, or DAPT for the entire 12 months. The primary endpoints were major adverse cardiac and cerebrovascular events (a composite of all-cause death, myocardial infarction, or stroke) 12 months after the index procedure. The bleeding endpoints were Bleeding Academic Research Consortium (BARC) bleeding types 2 to 5. RESULTS: Of the patients, 795 (26.6%) were women, who were older and had a higher prevalence of hypertension, diabetes, and dyslipidemia than men. The sexes exhibited comparable primary endpoints (adjusted hazard ratio [HR], 0.93; 95% confidence interval [CI], 0.55-1.55; P = 0.770) and bleeding endpoints (adjusted HR, 1.07; 95% CI, 0.63-1.81; P = 0.811). P2Y12 inhibitor monotherapy vs DAPT was associated with lower risk of BARC type 2 to 5 bleeding in women (adjusted HR, 0.40; 95% CI, 0.16-0.98; P = 0.045) but the difference was not statistically significant when using the Bonferroni correction. The primary endpoints were similar between treatment groups in both sexes. CONCLUSION: In both sexes undergoing PCI, P2Y12 inhibitor monotherapy after three months of DAPT achieved similar risks of the primary endpoints and the bleeding events compared with prolonged DAPT. Therefore, the benefits of early aspirin withdrawal with ongoing P2Y12 inhibitors may be comparable in women and men. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02079194.

Impact of gender on mid-term prognosis of patients undergoing coronary artery bypass grafting.

OBJECTIVES: We evaluated the impact of sex on mid-term prognosis in patients who underwent coronary artery bypass grafting (CABG). Data on gender differences in current management or clinical outcomes after CABG are controversial, and there have been limited data focusing on them. METHODS: This was a retrospective and prospective, single-center, observational study. Between January 2001 and December 2017, 6613 patients who underwent CABG were enrolled from an institutional registry of Samsung Medical Center, Seoul, Korea (Clinicaltrials.gov, NCT03870815) and divided into two groups according to sex (female group, n = 1679 vs. male group, n = 4934). The primary outcome was cardiovascular death or myocardial infarction (MI) at 5 years. Propensity score matching analysis was performed to reduce confounding factors. RESULTS: During a mean follow-up duration of 54 months, a total of 252 cardiovascular death or MIs occurred (female, 78 [7.5%] vs. male, 174 [5.7%]). Multivariate analysis revealed no significant difference in the incidence of cardiovascular death or MI at 5 years between female and male groups (hazard ratio [HR] 1.05; 95% confidence interval [CI] 0.78 to 1.41; p = 0.735). After propensity score matching, the incidence of cardiovascular death or MI was still similar between the two groups (HR 1.08; 95% CI 0.76 to 1.54; p = 0.666). The similarity of long-term outcomes between the two groups was consistent across various subgroups. There was also no significant difference in the risk of 5-year cardiovascular death or MI between males and females according to age (pre- and postmenopausal status) (p for interaction = 0.437). CONCLUSIONS: After adjusting for baseline differences, sex does not appear to influence long-term risk of cardiovascular death or MI in patients undergoing CABG. CLINICAL TRIALS.GOV NUMBER: NCT03870815.

Clinical Course of Suspected Diagnosis of Pulmonary Tumor Thrombotic Microangiopathy: A 10-Year Experience of Rapid Progressive Right Ventricular Failure Syndrome in Advanced Cancer Patients.

BACKGROUND AND OBJECTIVES: Several cases involving severe right ventricular (RV) failure in advanced cancer patients have been found to be pulmonary tumor thrombotic microangiopathies (PTTMs). This study aimed to discover the nature of rapid RV failure syndrome with a suspected diagnosis of PTTM for better diagnosis, treatment, and prognosis prediction in clinical practice. METHODS: From 2011 to 2021, all patients with clinically suspected PTTM were derived from the one tertiary cancer hospital with more than 2000 in-hospital bed. RESULTS: A total of 28 cases of clinically suspected PTTM with one biopsy confirmed case were included. The most common cancer types were breast (9/28, 32%) and the most common tissue type was adenocarcinoma (22/26, 85%). The time interval from dyspnea New York Heart Association (NYHA) Grade 2, 3, 4 to death, thrombocytopenia to death, desaturation to death, admission to death, RV failure to death, cardiogenic shock to death were 33.5 days, 14.5 days, 7.4 days, 6.4 days, 6.1 days, 6.0 days, 3.8 days and 1.2 days, respectively. The NYHA Grade 4 to death time was 7 days longer in those who received chemotherapy (7.1 days vs. 13.8 days, p value=0.030). However, anticoagulation, vasopressors or intensive care could not change clinical course. CONCLUSIONS: Rapid RV failure syndrome with a suspected diagnosis of PTTM showed a rapid progressive course from symptom onset to death. Although chemotherapy was effective, increased life survival was negligible, and treatments other than chemotherapy did not help to improve the patient's prognosis.

Moderate-Intensity Statins Plus Ezetimibe vs. High-Intensity Statins After Coronary Revascularization: A Cohort Study.

PURPOSE: Whether moderate-intensity statins plus ezetimibe could be an alternative to high-intensity statins in patients with atherosclerotic cardiovascular disease is unclear. We compared the risk of adverse cardiovascular events in patients receiving moderate-intensity statins plus ezetimibe vs. high-intensity statins after a coronary revascularization procedure using data from a large cohort study. METHOD: Population-based cohort study using nationwide medical insurance data from Korea. Study participants (n = 20,070) underwent percutaneous coronary intervention or coronary artery bypass graft surgery between January 1, 2015, and December 31, 2016, and received moderate-intensity statins (atorvastatin 10-20 mg or rosuvastatin 5-10 mg) plus ezetimibe (n = 922) or high-intensity statins (atorvastatin 40-80 mg or rosuvastatin 20 mg; n = 19,148). The primary outcome was a composite of cardiovascular mortality, hospitalization for myocardial infarction (MI), hospitalization for stroke, or revascularization. RESULTS: At 12 months, the incidence rates of the primary outcome were 138.0 vs. 154.0 per 1000 person-years in the moderate-intensity stains plus ezetimibe and the high-intensity statins group, respectively. The fully adjusted hazard ratio [HR] for the primary outcome was 1.11 (95% confidence interval [CI] 0.86-1.42; p = 0.43). The multivariable-adjusted HR for a composite of cardiovascular mortality, hospitalization for MI, or hospitalization for stroke was 1.05 (95% CI 0.74-1.47; p = 0.80). During follow-up, the proportion of patients maintaining their initial lipid-lowering therapy was significantly higher in the moderate-intensity statins plus ezetimibe group than in the high-intensity statins group. CONCLUSIONS: Patients undergoing a coronary revascularization procedure who received moderate-intensity statins plus ezetimibe showed similar rates of major adverse cardiovascular events as patients who received high-intensity statins.

Comprehensive assessment of heart failure in patients with preserved ejection fraction undergoing coronary bypass grafting.

OBJECTIVE: Although coronary artery bypass grafting is expected to improve the outcomes of patients with advanced coronary artery disease, whether prognosis is different according to preoperative diastolic function remains unclear. This study sought to evaluate the prognostic implications of preoperative heart failure with preserved ejection fraction in patients undergoing coronary artery bypass grafting. METHODS: A total of 3593 consecutive patients with preserved ejection fraction (≥50%) who underwent coronary artery bypass grafting between January 1, 2001, and December 31, 2017, were evaluated. According to Heart Failure Association Pretest Assessment, Echocardiography and Natriuretic Peptide, Functional Testing, Final Etiology score, they were stratified into 3 groups: (1) non-heart failure with preserved ejection fraction (low-risk); (2) indeterminate (intermediate risk); and (3) heart failure with preserved ejection fraction (high risk). The primary outcome was all-cause death at 5 years after surgery. RESULTS: Among the study population, 984 patients (27.4%) had preoperative heart failure with preserved ejection fraction. After coronary artery bypass grafting, 30-day survival in the heart failure with preserved ejection fraction group did not differ significantly from that in the non-heart failure with preserved ejection fraction group. The 5-year survival of the heart failure with preserved ejection fraction group was significantly lower than that of the non-heart failure with preserved ejection fraction group (91.9% vs 97.0%; adjusted hazard ratio, 2.41; 95% confidence interval, 1.29-4.50; P = .006). Follow-up echocardiography for the heart failure with preserved ejection fraction group showed no significant changes in early diastolic mitral annular velocity or left ventricular filling pressure compared with preoperative values. CONCLUSIONS: On the basis of noninvasive assessment using Heart Failure Association Pretest Assessment, Echocardiography and Natriuretic Peptide, Functional Testing, Final Etiology score, a substantial proportion of patients with coronary artery disease who underwent coronary artery bypass grafting had preoperative heart failure with preserved ejection fraction. Preoperative heart failure with preserved ejection fraction was significantly associated with a decrease in the 5-year survival after successful coronary artery bypass grafting.

Optimal Arterial Blood Gas Tensions for the Prognosis of Favorable Neurological Outcomes in Survivors after Extracorporeal Cardiopulmonary Resuscitation.

Our aim is to assess the optimal levels of oxygen and carbon dioxide for the prognosis of favorable neurologic outcomes in survivors after extracorporeal cardiopulmonary resuscitation (ECPR). We obtained the mean levels of PaCO2 and PaO2 in arterial blood gas samples 72 h after ECPR. The primary outcome was the neurological status, according to the Cerebral Performance Categories (CPC) scale, upon discharge. Of 119 (48.6%) survivors, 95 (38.8%) had favorable neurologic outcomes (CPC 1 or 2). There was a U-shaped relationship between mean arterial blood gas tensions and poor neurological outcomes. The risk of poor neurological outcome was lowest in patients with the second tertile of mean PaCO2 (30-42 mm Hg) and PaO2 (120-160 mm Hg). In a multivariable analysis, third tertile of mean PaCO2, third tertile of mean PaO2, age, shockable rhythm, out of hospital cardiac arrest, duration of cardiopulmonary resuscitation, and ECPR at cardiac catheterization lab were found to be significantly associated with poor neurologic outcomes. Additionally, hypercapnia and extreme hyperoxia were found to be significantly associated with poor neurological outcomes after ECPR. Therefore, maintaining adequate arterial levels of oxygen and carbon dioxide may be important for favorable neurological prognoses in survivors after ECPR.

Coronary Microcirculatory Dysfunction and Acute Cellular Rejection After Heart Transplantation.

BACKGROUND: Acute cellular rejection is a major determinant of mortality and retransplantation after heart transplantation. We sought to evaluate the prognostic implications of coronary microcirculatory dysfunction assessed by index of microcirculatory resistance (IMR) for the risk of acute cellular rejection after heart transplantation. METHODS: The present study prospectively enrolled 154 heart transplant recipients who underwent scheduled coronary angiography and invasive coronary physiological assessment 1 month after transplantation. IMR is microcirculatory resistance under maximal hyperemia. By measuring hyperemic mean transit time using 3 injections (4 mL each) of room-temperature saline under maximal hyperemia, IMR was calculated as hyperemic distal coronary pressure×hyperemic mean transit time. The primary end point was biopsy-proven acute cellular rejection of grade ≥2R during 2 years of follow-up after transplantation and was compared by using multivariable Cox proportional hazards regression according to IMR. The incremental prognostic value of IMR, in addition to the model with clinical factors, was evaluated by comparison of C-index, net reclassification index, and integrated discrimination index. RESULTS: The mean age of recipients was 51.2±13.1 years (81.2% male), and the cumulative incidence of acute cellular rejection was 19.0% at 2 years. Patients with acute cellular rejection had significantly higher IMR values at 1 month than those without acute cellular rejection (23.1±8.6 versus 16.8±11.1, P=0.002). IMR was significantly associated with the risk of acute cellular rejection (per 5-U increase: adjusted hazard ratio, 1.18 [95% CI, 1.04-1.34], P=0.011) and the optimal cutoff value of IMR to predict acute cellular rejection was 15. Patients with IMR≥15 showed significantly higher risk of acute cellular rejection than those with IMR<15 (34.4% versus 3.8%; adjusted hazard ratio, 15.3 [95% CI 3.6-65.7], P<0.001). Addition of IMR to clinical variables showed significantly higher discriminant and reclassification ability for risk of acute cellular rejection (C-index 0.87 versus 0.74, P<0.001; net reclassification index 1.05, P<0.001; integrated discrimination index 0.20, P<0.001). CONCLUSIONS: Coronary microcirculatory dysfunction assessed by IMR measured early after heart transplantation showed significant association with the risk of acute cellular rejection. In addition to surveillance endomyocardial biopsy, early stratification using IMR could be a clinically useful tool to identify patients at higher risk of future acute cellular rejection after heart transplantation. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02798731.

P2Y12 inhibitor monotherapy in complex percutaneous coronary intervention: A post-hoc analysis of SMART-CHOICE randomized clinical trial.

BACKGROUND: It remains unclear whether P2Y12 monotherapy, especially clopidogrel, following short-duration dual antiplatelet therapy (DAPT) is associated with favorable outcomes in patients undergoing complex percutaneous coronary intervention (PCI). Therefore, this study analyzed the efficacy and safety of P2Y12 inhibitor monotherapy, mostly clopidogrel (78%), in complex PCI following short-term DAPT. METHODS: The post-hoc analysis of the SMART-CHOICE trial involving 2,993 patients included 498 cases of complex PCIs, defined by at least one of the following features: 3 vessels treated, ≥ 3 stents implanted, ≥ 3 lesions treated, bifurcation with ≥ 2 stents implanted, and a total stent length of ≥ 60 mm. The primary endpoint was major adverse cardiac and cerebrovascular event (MACCE), defined as the composite of all-cause death, myocardial infarction, and stroke. The primary safety endpoint included bleeding, defined as Bleeding Academic Research Consortium (BARC) types 2 to 5. RESULTS: Complex PCI group had a higher risk of MACCE (4.0% vs. 2.3%, hazard ratio [HR] = 1.74, 95% confidence interval [CI]: 1.05-2.89, p = 0.033) and a similar risk of BARC types 2-5 bleeding (2.6% vs. 2.6%, HR = 1.02, 95% CI: 0.56-1.86, p = 0.939) compared with those without complex PCIs. Patients undergoing complex PCIs, followed by P2Y12 inhibitor monotherapy and 12 months of DAPT exhibited similar rates of MACCE (3.8% vs. 4.2%, HR = 0.92, 95% CI: 0.38-2.21, p = 0.853). CONCLUSIONS: P2Y12 inhibitor monotherapy, mostly clopidogrel, following 3 months of DAPT did not increase ischemic events in patients with complex PCIs.

Impact of age on the outcomes of extracorporeal cardiopulmonary resuscitation: analysis using inverse probability of treatment weighting.

OBJECTIVES: Patient selection is crucial to improving the outcomes of extracorporeal cardiopulmonary resuscitation (ECPR). However, ECPR's efficacy with older patients remains unknown. METHODS: We reviewed patients who underwent extracorporeal membrane oxygenation (ECMO) for refractory cardiac arrest from January 2006 to December 2018. Exclusion criteria were age <18 years, cannulation failure and ECMO applied at another hospital. We divided patients into 2 groups with an age cut-off of 66 years, using the Contal and O'Quigley method for overall survival. We performed inverse probability of treatment weighting (IPTW) between the 2 groups and set the primary outcome as overall survival. RESULTS: We included 318 patients in our study (≤66 years, n = 199; >66 years, n = 119). Before IPTW, we observed that the older group had a higher frequency of diabetes, hypertension, and myocardial infarction. In the young group, more patients had out-of-hospital cardiac arrest as compared with the older group. The hospital mortality rate was 55% (48.7% in the young group, 65.5% in the older group; P = 0.004). In the multivariable analysis after IPTW, the older group showed worse outcomes in overall survival [hazard ratio (HR) = 2.02; 95% confidence interval (CI), 1.50-2.70; P < 0.001] and neurological outcomes at discharge (odds ratio = 2.95; 95% CI, 1.69-5.14; P = <0.001). ECMO insertion during catheterization (HR = 0.57; 95% CI, 0.36-0.90; P = 0.015) and recovery of spontaneous circulation before pump-on (HR = 0.67; 95% CI, 0.50-0.89; P = 0.007) were positive predictors, but initial asystole rhythm, non-cardiac cause (HR = 2.39; 95% CI, 1.59-3.61; P < 0.001), out-of-hospital cardiac arrest (HR = 1.86; 95% CI, 1.24-2.79; P = 0.003) and prolonged cardiopulmonary resuscitation to pump-on time (HR = 1.01; 95% CI, 1.01-1.02; P < 0.001) were negative predictors for overall survival. CONCLUSIONS: Older patients who had ECPR had significantly worse survival and neurological outcomes. For patients older than age 66 years, more careful patient selection is critically important for improving the efficacy of ECPR.

Sex difference in long-term clinical outcomes after percutaneous coronary intervention: A propensity-matched analysis of National Health Insurance data in Republic of Korea.

OBJECTIVE: We investigated the gender difference in the 5-year outcome after percutaneous coronary intervention (PCI) using an unselected population data. BACKGROUND: Sex-specific outcome after percutaneous coronary intervention (PCI) is not consistent among studies. METHODS: A total of 48,783 patients were enrolled from a Korean nationwide cohort of PCI in year 2011. Outcomes adjusted with age and propensity for clinical characteristics were compared. Primary outcome was 5-year cumulative incidence of all-cause death. Nonfatal major adverse clinical event (MACE) consisting of revascularization, shock, or stroke was also assessed. RESULTS: In unadjusted analysis, women were older and had higher frequency of comorbidities including hypertension, hyperlipidemia, and diabetes compared to men (p < .001, all). Women had higher 5-year death risk than men (21.8 vs. 17.3%; hazard ratio [HR] 1.29, 95% confidential interval [CI] 1.23-1.34). In propensity score-matched analysis (N = 28,924), women had lower 5-year death risk (20.2 vs. 26.1%, HR 0.75, 95% CI 0.71-0.78). This lower death risk in women was consistent in subgroup analyses of age, risk factors, and clinical diagnosis including angina or acute myocardial infarction (p < .05, all). CONCLUSIONS: Older age and more common comorbidities in women contributed to the apparent worse outcome after PCI in women. After adjusting these disadvantages, women had better outcome after PCI than men.

Outcomes of extracorporeal membrane oxygenation in adults with active hematologic and nonhematologic malignancy.

Although the number of cancer patients admitted to the intensive care unit is increasing, the data on the use of extracorporeal membrane oxygenation in patients with malignancy are limited. We applied extracorporeal membrane oxygenation to carefully selected patients with active hematologic malignancy or nonhematologic malignancy who experienced respiratory or cardiac failure despite maximal conventional therapy. Patients with active malignancy who underwent extracorporeal membrane oxygenation in our institution between January 2012 and December 2016 were included in this study. The primary outcome of this study was defined as survival to hospital discharge. We also investigated the factors associated with survival to hospital discharge. There were 30 (30.6%) and 68 (69.4%) patients in the hematologic malignancy group and the nonhematologic malignancy group, respectively. Patients in the hematologic malignancy group were younger, more neutropenic, more hypotensive, had a lower Charlson Comorbidity Index, higher sequential organ failure assessment score, and lower platelet count than those in the nonhematologic malignancy group. Forty-six (46.9%) patients were successfully weaned off extracorporeal membrane oxygenation, and 30 (30.6%) patients survived until hospital discharge. Hospital survival rate and survival status 6 months after hospital discharge were significantly lower in patients with hematologic malignancy than in those with nonhematologic malignancy (13.3% vs. 38.2%, P = .026 and 3.3% vs. 26.5%, P = .017, respectively). Multivariate analysis identified an active hematologic malignancy, older age, acidosis, thrombocytopenia, high vasoactive-inotrope score, and respiratory failure as the risk factors for in-hospital death. Patients with hematologic malignancy requiring extracorporeal membrane oxygenation support had significantly lower rates of hospital survival and 6-month survival after discharge than patients with nonhematologic malignancy. Therefore, extracorporeal membrane oxygenation for treating cardiac or respiratory failure should only be considered in highly selected patients with hematologic malignancy.

Practical guidance for P2Y12 inhibitors in acute myocardial infarction undergoing percutaneous coronary intervention.

AIMS: Potent P2Y12 inhibitors for dual antiplatelet therapy (DAPT) is crucial for managing acute myocardial infarction; however, the selection of drugs is based on limited clinical information such as age and body weight. The current study sought to develop and validate a new risk scoring system that can be used to guide the selection of potent P2Y12 inhibitors by balancing ischaemic benefit and bleeding risk. METHODS AND RESULTS: Derivation cohort of 10 687 patients who participated in the Korea Acute Myocardial Infarction Registry-National Institutes of Health study was used to construct a new scoring system. We combined the ischaemic and bleeding models to establish a simple clinical prediction score. Among the low score group (n = 1764), the observed bleeding risk (8.7% vs. 4.4%, P < 0.001) due to potent P2Y12 inhibitors exceeded ischaemic benefit (1.3% vs. 2.2%, P = 0.185) during 12 months. Conversely, the high score group (n = 1898) showed an overall benefit from taking potent P2Y12 inhibitors from the standpoint of observed ischaemic (17.1% vs. 8.6%, P < 0.001) and bleeding events (10.1% vs. 6.8%, P = 0.073). The performance of ischaemic [integrated area under the curve (iAUC) = 0.809] and bleeding model (iAUC = 0.655) was deemed to be acceptable. CONCLUSION: The new scoring system is a useful clinical tool for guiding DAPT by balancing ischaemic benefit and bleeding risk, especially among Asian populations. Further validation studies with other cohorts will be required to verify that the new system meets the needs of real clinical practice.

Differential effects of dual antiplatelet therapy in patients presented with acute coronary syndrome vs. stable ischaemic heart disease after coronary artery bypass grafting.

AIMS: The current study sought to evaluate whether long-term clinical outcomes according to the use of dual antiplatelet therapy (DAPT) or single antiplatelet therapy (SAPT) differed between acute coronary syndrome (ACS) and stable ischaemic heart disease (SIHD) patients who underwent coronary artery bypass grafting surgery (CABG). METHODS AND RESULTS: Between January 2001 and December 2017, 3199 patients with ACS (55.3%) and 2583 with SIHD (44.7%) who underwent isolated CABG were enrolled. The study population was stratified using DAPT or SAPT in ACS patients and SIHD patients. The primary outcome was a cardiovascular death or myocardial infarction (MI) at 5 years. After CABG, DAPT was more frequently used in patients with ACS than in those with SIHD [n = 1960 (61.3%) vs. n = 1313 (50.8%), P < 0.001]. Among patients with ACS, the DAPT group showed a significantly lower risk of cardiovascular death or MI at 5 years than the SAPT group [DAPT vs. SAPT, 4.0% vs. 7.8%, hazard ratio (HR) 0.521, 95% confidence interval (CI) 0.339-0.799; P = 0.003]. In contrast, among patients with SIHD, there was no significant difference in the rate of cardiovascular death or MI at 5 years between the use of DAPT and SAPT (4.0% vs. 4.0%, HR 0.991, 95% CI 0.604-1.626; P = 0.971). These findings were robust to multiple sensitivity analyses and competing risk analysis. In the subgroup analysis, the use of DAPT was associated with a significantly lower risk of cardiovascular death or MI among SIHD patients with a previous percutaneous coronary intervention (PCI), with a significant interaction between the use of DAPT and PCI history (interaction P = 0.011). CONCLUSION: Among ACS patients who underwent CABG, the use of DAPT was associated with lower cardiovascular death or MI than the use of SAPT, but this was not the case in SIHD patients. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03870815.

Safety of 3-Month Dual Antiplatelet Therapy After Implantation of Ultrathin Sirolimus-Eluting Stents With Biodegradable Polymer (Orsiro): Results From the SMART-CHOICE Trial.

Background This study sought to investigate the safety of 3-month dual antiplatelet therapy (DAPT) in patients receiving ultrathin sirolimus-eluting stents with biodegradable polymer (Orsiro). Methods and Results The SMART-CHOICE (Smart Angioplasty Research Team: Comparison Between P2Y12 Antagonist Monotherapy vs Dual Anti- platelet Therapy in Patients Undergoing Implantation of Coronary Drug-Eluting Stents) randomized trial compared 3-month DAPT followed by P2Y12 inhibitor monotherapy with 12-month DAPT in 2993 patients undergoing percutaneous coronary intervention. The present analysis was a prespecified subgroup analysis for patients receiving Orsiro stents. As a post hoc analysis, comparisons between Orsiro and everolimus-eluting stents were also done among patients receiving 3-month DAPT. Of 972 patients receiving Orsiro stents, 481 patients were randomly assigned to 3-month DAPT and 491 to 12-month DAPT. At 12 months, the target vessel failure, defined as a composite of cardiac death, target vessel-related myocardial infarction, or target vessel revascularization, occurred in 8 patients (1.7%) in the 3-month DAPT group and in 14 patients (2.9%) in the 12-month DAPT group (hazard ratio [HR], 0.58; 95% CI, 0.24-1.39; P=0.22). In whole population who were randomly assigned to receive 3-month DAPT (n=1495), there was no significant difference in the target vessel failure between the Orsiro group and the everolimus-eluting stent group (n=1014) (1.7% versus 1.8%; HR, 0.96; 95% CI, 0.41-2.22; P=0.92). Conclusions In patients receiving Orsiro stents, clinical outcomes at 1 year were similar between the 3-month DAPT followed by P2Y12 inhibitor monotherapy and 12-month DAPT strategies. With 3-month DAPT, there was no significant difference in target vessel failure between Orsiro and everolimus-eluting stents. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02079194.

Preoperative cardiac troponin below the 99th-percentile upper reference limit and 30-day mortality after noncardiac surgery.

Preoperative high-sensitivity cardiac troponin (hs-cTn) above the 99th-percentile upper reference limit (URL) is associated with mortality after noncardiac surgery. This study aimed to evaluate whether preoperative hs-cTn concentrations above the lowest limit of detection (LOD) but below the 99th-percentile URL can predict mortality after noncardiac surgery.From January 2010 to April 2019, a total of 12,415 noncardiac surgical patients with preoperative hs-cTn I below the 99th-percentile URL were enrolled. The patients were divided into two groups according to preoperative hs-cTn I concentration: (1) [hs-cTn] below the LOD (6 ng/L), and (2) mildly elevated [hs-cTn] but below the 99th-percentile URL (40 ng/L). The primary outcome was 30-day mortality. Of the 12,415 patients enrolled, 7958 (64.1%) were in the LOD group whereas 4457 (35.9%) were in the mild elevation group. The incidence of 30-day mortality was significantly greater in the mild elevation group (2.1% vs. 4.0% hazard ratio [HR] 1.73; 95% confidence interval [CI] 1.39-2.16; p < 0.001) in the multivariate analyses. The propensity score matched analyses also produced a similar result (2.6% vs. 4.2% HR 1.61; 95% CI 1.26-2.07; p < 0.001). The threshold at which the risk of mortality increased corresponded to a preoperative hs-cTn I ≥ 12 ng/L. Patients with preoperative hs-cTn I above the LOD and below the 99th-percentile URL had greater 30-day mortality after noncardiac surgery.

Mildly Elevated Cardiac Troponin below the 99th-Percentile Upper Reference Limit after Noncardiac Surgery.

BACKGROUND AND OBJECTIVES: In patients with perioperative cardiac troponin (cTn) I below the 99th-percentile upper range of limit (URL), mortality according to cTn I level has not been fully evaluated. This study evaluated the association between postoperative cTn I level above the lowest limit of detection but within the 99th-percentile URL and 30-day mortality after noncardiac surgery. METHODS: Patients with cTn I values below the 99th-percentile URL during the perioperative period were divided into a no-elevation group with cTn I at the lowest limit of detection (6 ng/L) and a minor elevation group with cTn I elevation below the 99th percentile URL (6 ng/L < cTn I < 40 ng/L). The primary outcome was 30-day mortality. RESULTS: Of the 5,312 study participants, 2,582 (48.6%) were included in the no-elevation group and 2,730 (51.4%) were included in the minor elevation group. After propensity score-matching, the minor elevation group showed significantly increased 30-day mortality (0.5% vs. 2.3%; hazard ratio, 4.30; 95% confidence interval, 2.23-8.29; p<0.001). The estimated cutoff value of cTn I to predict 30-day mortality was 6 ng/L with the area under the receiver operating characteristic curve 0.657. CONCLUSIONS: A mild elevation of cTn I within the 99th-percentile URL after noncardiac surgery was significantly associated with increased 30-day mortality as compared with the lowest limit of detection. TRIAL REGISTRATION: Clinical Research Information Service Identifier: KCT0004244.

Impact of previous percutaneous coronary intervention on cardiovascular outcomes and mortality after lung cancer surgery: A nationwide study in Korea.

BACKGROUND: The number of patients with operable lung cancer with a history of percutaneous coronary intervention (PCI) has increased. However, cardiovascular outcomes and mortality, according to the time from PCI to surgery, and the follow-up time after surgery are largely unknown. Here, we aimed to compare the cardiovascular outcomes and mortality of these patients with a history of PCI to those of patients without a history of PCI. METHODS: Using the Korean National Health Insurance Service Database, we selected 30 750 patients who underwent surgery for lung cancer between 2006 and 2014. Study outcome variables were all-cause mortality, revascularization, intensive care unit (ICU) readmission, and stroke incidence. Patients were followed-up until 2016. RESULTS: Of the 30 750 patients, 513 (1.7%) underwent PCI before surgery. The PCI group did not show an increased risk of death, ICU readmission, or stroke within one year of surgery, despite an increased risk of revascularization. However, one year after surgery, they showed a higher risk of death and revascularization than the non-PCI group. The risk of revascularization was highest when the interval between PCI and surgery was <1 year and remained high when the interval was >3 years. CONCLUSIONS: Patients who underwent PCI before surgery for lung cancer were at a higher risk of death than those in the non-PCI group at one year after surgery. In addition, they showed higher short- and long-term risks of revascularization than patients in the non-PCI group. Careful long-term management of cardiovascular risk is necessary for this population.