An In-depth Single-center Retrospective Assessment of In-Hospital Outcomes in Acute Myocardial Infarction Patients with and without Diabetes.

Objective This study examined variations in in-hospital mortality causes and identified independent mortality predictors among patients with acute myocardial infarction (AMI) with and without diabetes mellitus (DM). Methods We examined factors influencing in-hospital mortality in a single-center retrospective observational study. Separate multivariate analyses were conducted for both groups to identify independent predictors of in-hospital mortality. Patients This study included consecutive patients admitted to Iwate Medical University Hospital between January 2012 and December 2017 with a diagnosis of AMI. Results Of 1,140 patients meeting the AMI criteria (average age: 68.2±12.8 years old, 75% men), 408 (35.8%) had diabetes. The DM group had a 1.87-times higher 30-day mortality rate, a lower prevalence of ST-elevated MI (56.6% vs. 65.3% in non-DM, p=0.004), and more frequent non-cardiac causes of death (32% vs. 14% in non-DM, p=0.046) than the non-DM group. Independent predictors of in-hospital mortality in both groups were cardiogenic shock (CS) [DM: hazard ratio (HR) 6.59, 95% confidence interval (CI) 2.90-14.95; non-DM: HR 4.42, 95% CI 1.99-9.77] and renal dysfunction (DM: HR 5.64, 95% CI 1.59-20.04; non-DM: HR 5.92, 95% CI 1.79-19.53). Among patients with DM, a history of stroke was an additional independent predictor of in-hospital mortality (HR 2.59, 95% CI 1.07-6.31). Conclusion Notable disparities were identified in the causes of death and predictive factors of mortality between these two groups of patients with AMI. To further improve AMI outcomes, individualized management and prioritizing non-cardiac comorbidities during hospitalization may be crucial, particularly in patients with DM.

Preprocedural physiological assessment of coronary disease patterns to predict haemodynamic outcomes post-PCI.

BACKGROUND: Even with intracoronary imaging-guided stent optimisation, suboptimal haemodynamic outcomes post-percutaneous coronary intervention (PCI) can be related to residual lesions in non-stented segments. Preprocedural assessment of pathophysiological coronary artery disease (CAD) patterns could help predict the physiological response to PCI. AIMS: The aim of this study was to assess the relationship between preprocedural pathophysiological haemodynamic patterns and intracoronary imaging findings, as well as their association with physiological outcomes immediately post-PCI. METHODS: Data from 206 patients with chronic coronary syndrome enrolled in the ASET-JAPAN study were analysed. Pathophysiological CAD patterns were characterised using Murray law-based quantitative flow ratio (µQFR)-derived indices acquired from pre-PCI angiograms. The diffuseness of CAD was defined by the pullback pressure gradient (PPG) index. Intracoronary imaging in stented segments after stent optimisation was also analysed. RESULTS: In the multivariable analysis, diffuse disease - defined by the pre-PCI µQFR-PPG index - was an independent factor for predicting a post-PCI µQFR <0.91 (per 0.1 decrease of PPG index, odds ratio 1.57, 95% confidence interval: 1.07-2.34; p=0.022), whereas the stent expansion index (EI) was not associated with a suboptimal post-PCI µQFR. Among vessels with an EI ≥80% and post-PCI µQFR <0.91, 84.0% of those vessels had a diffuse pattern preprocedure. There was no significant difference in EI between vessels with diffuse disease and those with focal disease. The average plaque burden in the stented segment was significantly larger in vessels with a preprocedural diffuse CAD pattern. CONCLUSIONS: A physiological diffuse pattern preprocedure was an independent factor in predicting unfavourable immediate haemodynamic outcomes post-PCI, even after stent optimisation using intracoronary imaging. Preprocedural assessment of CAD patterns could identify patients who are likely to exhibit superior immediate haemodynamic outcomes following PCI.

The Value of a Cystatin C-based Estimated Glomerular Filtration Rate for Cardiovascular Assessment in a General Japanese Population: Results From the Iwate Tohoku Medical Megabank Project.

BACKGROUND: Epidemiological studies have shown that high circulating cystatin C is associated with a risk of cardiovascular disease (CVD) independent of creatinine-based renal function measurements. The present study investigated the comparison between the cystatin C-based estimated glomerular filtration rate (GFRcys) and creatinine-based GFR (GFRcr) to determine whether these measurements are associated with CV biomarkers and elevated CVD risk in a general Japanese population. METHODS: The Iwate Tohoku Medical Megabank Organization pooled individual participant data from a general population-based cohort study in Iwate prefecture (n = 29,375). Chronic kidney disease (CKD) was estimated using the GFRcys, GFRcr and the urine albumin-to-creatinine ratio (UACR). RESULTS: The prevalence of CKD in the participants was found to be higher based on the GFRcr than the GFRcys. Multiple variable analyses after adjusting for baseline characteristics showed that high-sensitivity cardiac troponin T (hs-cTnT) and N-terminal pro-brain natriuretic peptide (NT-proBNP) were associated with the GFRcys. The area under the receiver operating characteristic (AUROC) curve for identifying individuals with a high Suita score was higher for the GFRcys (AUROC = 0.68) than it was for the GFRcr (AUROC = 0.64, P < 0.001). The GFRcys provided reclassification improvement for the CVD risk prediction model by the GFRcr (net reclassification improvement = 0.341; integrated discrimination improvement = 0.018, respectively, P < 0.001). CONCLUSIONS: The GFRcys is more closely associated with CV biomarkers, including hs-cTnT and NT-proBNP levels, and a high Suita score than the GFRcr, and it provides additional value in the assessment of CVD risk using GFRcr.

Clinical expert consensus document on standards for measurements and assessment of intravascular ultrasound from the Japanese Association of Cardiovascular Intervention and Therapeutics.

Intravascular ultrasound (IVUS) provides precise anatomic information in coronary arteries including quantitative measurements and morphological assessment. To standardize the IVUS analysis in the current era, this expert consensus document summarizes the methods of measurements and assessment of IVUS images.

Treatment strategy modification and its implication on the medical cost of fractional flow reserve-guided percutaneous coronary intervention in Japan.

BACKGROUND: Fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) could improve outcome compared with angiography-guided PCI. However, the economic impact of FFR-guided PCI remains largely unknown in the medical system in Japan. We evaluated the impact of treatment strategy modification by FFR measurement on the direct medical cost using a model analysis with a decision tree model in Japan. METHODS: For the clinical parameters set in the model, the findings from CVIT-DEFER registry were adopted. Cost parameters were considered on the assumption that coronary angiography, FFR measurement, and the treatment are performed at Diagnosis Procedure combination (DPC) hospitals, and the costs were calculated based on the medical fee reimbursement systems in Japan. RESULTS: The probability of deferral of PCI in patients who were allocated to PCI based on coronary angiography was set as 90.1% based on the CVIT-DEFER registry. In the model analysis, the cost of tests was increased by 185,660 JPY per patient by the addition of FFR measurement, but the cost of treatment with PCI was reduced by 561,425 JPY per patient, and the entire cost of treatment was reduced by 322,675 JPY, resulting in the expected reduction in the total expected medical cost by 137,015 JPY per patient. CONCLUSION: Under contemporary Japanese practice, FFR-guided PCI has potential to reduce the medical cost by effective reassessment of coronary stenosis and reducing inappropriate application of PCI.

Multislice computed tomography assessment of everolimus-eluting Absorb bioresorbable scaffolds in comparison with metallic drug-eluting stents from the ABSORB Japan randomised trial.

AIMS: Blooming artefacts limit accurate coronary assessment by multislice computed tomography (MSCT) in metallic stents. We sought to investigate whether bioresorbable vascular scaffolds (BVS) could be better assessed by MSCT. METHODS AND RESULTS: Among 400 patients in the randomised ABSORB Japan trial, a pre-specified MSCT substudy was performed in 98 patients (103 lesions) in the BVS arm and 49 patients (49 lesions) in the cobalt-chromium everolimus-eluting stent (CoCr-EES) arm at 13 months prior to follow-up angiography. The assessability of BVS by MSCT was superior to that of CoCr-EES (94% versus 67%, p<0.001). Blooming artefacts were the main reason CoCr-EES could not be analysed (29%), while marker artefacts precluded analysis in 1.1% of BVS. In the CoCr-EES arm, non-assessable lesions were more prevalent in segments with 2.5 mm stents compared to 3.0 or 3.5 mm stents (75.0% versus 23.5%, p=0.01), while in the BVS arm image quality was good regardless of the diameter. The in-device minimal lumen diameter by MSCT was smaller than that by QCA with a difference of 0.61 mm in the CoCr-EES arm, vs. only 0.026 mm in the BVS arm. CONCLUSIONS: The feasibility of MSCT assessment of BVS-treated lesions was greater than that for lesions with CoCr-EES.

Evaluation of coronary arterial calcification - Ex-vivo assessment by optical frequency domain imaging.

AIMS: The purpose of this study was to determine the diagnostic ability of optical frequency domain imaging (OFDI) to carry out quantitative and qualitative evaluation of coronary calcification in comparing with ex vivo human autopsy heart specimens. METHODS: Analysis was carried out in 25 coronary artery specimen obtained from 16 cadavers that were imaged ex-vivo imaging by OFDI and intravascular ultrasound (IVUS). Of 235 cross-sections obtained for histologic evaluation, 149 were classified as showing calcified plaques, and in this group a comparison between histology versus co-registered images by OFDI and IVUS was performed. RESULTS: Maximum thickness of calcification measured by OFDI was well correlated with histology (rs = 0.70, p < 0.0001) whereas IVUS was not useful for quantitative analysis because of the presence of acoustic shadows occurring behind calcifications. Furthermore qualitative evaluation could be carried out using OFDI, for calcifications with vague or invisible outer borders by OFDI had lipid contents (lipid pool or histologic necrotic core) more frequently as compared to those with a clear outer border (79% vs. 24%, p < 0.0001). We also found that calcified nodules, a well-recognized thrombogenic substrate, demonstrated atypical appearance in OFDI, showing irregular surfaces with high attenuation. CONCLUSION: OFDI demonstrated a greater ability than IVUS to provide quantitative and qualitative evaluation of coronary arterial calcification. Precise recognition of calcified plaque morphology by OFDI may serve to determine the treatment strategy of patients having atherosclerotic coronary disease.

Serial endovascular assessment of polytetrafluoroethylene-covered stent: Capabilities and limitations of intravascular imaging modalities affected by a temporal factor.

A 47-year-old male who previously underwent coronary bypass graft surgery was transferred to our hospital for treatment of bare metal in-stent restenosis (ISR) of severely calcified left main (LM) coronary lesion. During a repeat coronary intervention, LM coronary perforation occurred after rotational atherectomy followed by balloon dilatation. Hemostasis was successfully achieved by implantation of a single polytetrafluoroethylene (PTFE)-covered stent. Although intravascular ultrasound (IVUS) and optical coherence tomography (OCT) were documented, any additional information was not obtained except stent expansion. Routine 6-month follow-up angiography revealed no findings of restenosis. Three representative imaging modalities, IVUS, OCT, and angioscopy were applied to visualize and differentiate any structures within the PTFE-covered stent. Intravascular findings included, (1) vascular structures outside the covered stent could be observed sufficiently by both IVUS and OCT at this time that could not be seen at all just after implantation, (2) neointimal hyperplasia distributed dominantly at both stent edges, and (3) in-stent micro thrombi still existed even 6 months after implantation. Intravascular findings of PTFE-covered stent may vary between the observational periods. Furthermore, vascular healing process of this special stent may be different from those of non-covered mesh stents. .

Predicting successful guidewire crossing through chronic total occlusion of native coronary lesions within 30 minutes: the J-CTO (Multicenter CTO Registry in Japan) score as a difficulty grading and time assessment tool.

OBJECTIVES: This study sought to establish a model for grading lesion difficulty in interventional chronic total occlusion (CTO) treatment. BACKGROUND: Owing to uncertainty of success of the procedure and difficulties in selecting suitable cases for treatment, performance of interventional CTO remains infrequent. METHODS: Data from 494 native CTO lesions were analyzed. To eliminate operator bias, the objective parameter of successful guidewire crossing within 30 min was set as an end point, instead of actual procedural success. All observations were randomly assigned to a derivation set and a validation set at a 2:1 ratio. The J-CTO (Multicenter CTO Registry of Japan) score was determined by assigning 1 point for each independent predictor of this end point and summing all points accrued. This value was then used to develop a model stratifying all lesions into 4 difficulty groups: easy (J-CTO score of 0), intermediate (score of 1), difficult (score of 2), and very difficult (score of ≥ 3). RESULTS: The set end point was achieved in 48.2% of lesions. Independent predictors included calcification, bending, blunt stump, occlusion length >20 mm, and previously failed lesion. Easy, intermediate, difficult, and very difficult groups, stratified by J-CTO score, demonstrated stepwise, proportioned, and highly reproducible differences in probability of successful guidewire crossing within 30 min (87.7%, 67.1%, 42.4%, and 10.0% in the derivation set and 92.3%, 58.3%, 34.8%, and 22.2% in the validation set, respectively). Areas under receiver-operator characteristic curves were comparable (derivation: 0.82 vs. validation: 0.76). CONCLUSIONS: This model predicted the probability of successful guidewire crossing within 30 min very well and can be applied for difficulty grading.