Impact of Sex Differences on Clinical Outcomes in Patients Following Primary Revascularization for Acute Myocardial Infarction　- Insights From the Japanese Nationwide Registry.

BACKGROUND: Women with acute myocardial infarction (AMI) often present a worse risk profile and experience a higher rate of in-hospital mortality than men. However, sex differences in post-discharge prognoses remain inadequately investigated. We examined the impact of sex on 1-year post-discharge outcomes in patients with AMI undergoing percutaneous coronary intervention.Methods and Results: We extracted patient-level data for the period January 2017-December 2018 from the J-PCI OUTCOME Registry, endorsed by the Japanese Association of Cardiovascular Intervention and Therapeutics. One-year all-cause and cardiovascular mortality and major adverse cardiovascular events were compared between men and women. In all, 29,856 AMI patients were studied, with 6,996 (23.4%) being women. Women were significantly older and had a higher prevalence of comorbidities than men. Crude all-cause mortality was significantly higher among women than men (7.5% vs. 5.4% [P<0.001] for ST-elevation myocardial infarction [STEMI]; 7.0% vs. 5.2% [P=0.006] for non-STEMI). These sex-related differences in post-discharge outcomes were attenuated after stratification by age. Multivariate analysis demonstrated an increase in all-cause mortality in both sexes with increasing age and advanced-stage chronic kidney disease (CKD). CONCLUSIONS: Within this nationwide cohort, women had worse clinical outcomes following AMI than men. However, these sex-related differences in outcomes diminished after adjusting for age. In addition, CKD was significantly associated with all-cause mortality in both sexes.

Impact of coronary plaque characteristics on periprocedural myocardial injury in elective percutaneous coronary intervention.

OBJECTIVES: To investigate the relationship between periprocedural myocardial injury (PMI) and plaque characteristics detected by multidetector computed tomography (MDCT) and cardiac magnetic resonance imaging (CMR). MATERIALS AND METHODS: This observational retrospective study, between July 2012 and October 2019, included chronic coronary syndrome patients undergoing elective percutaneous coronary intervention (PCI) after MDCT and CMR. High-intensity plaque (HIP) on non-contrast T1-weighted imaging was defined as a coronary plaque-to-myocardium signal intensity ratio of ≥ 1.4. High-risk plaque (HRP) in MDCT displayed ≥ 2 features: positive remodeling, low-attenuation plaque, spotty calcification, and napkin-ring sign. PMI was defined as an increase in cardiac troponin T levels > 5 times the upper normal limit at 24 h after PCI. RESULTS: Ninety-five target lesions in 76 patients (mean age ± standard deviation, 67 years ± 9; 62 males [82%]) were included. Twenty-one patients (24 lesions) were assigned to the PMI group, while 55 patients (71 lesions) to the non-PMI group. Presence of HRP characteristics on MDCT and HIP on CMR was significantly higher in the PMI group. Multivariate logistic regression analysis showed that HRP in MDCT and HIP in CMR were significant independent predictors of PMI. Target lesions with HRP on MDCT and HIP on CMR were significantly more likely to develop PMI. In 141 plaques with ≥ 50% stenosis (76 patients), patients with PMI had significantly more frequent HRP in MDCT and HIP in CMR in target and non-target lesions. CONCLUSIONS: MDCT and CMR can play an important role in the detection of high-risk lesions for PMI following elective PCI. KEY POINTS: • Multivariate logistic regression analysis showed that high-risk plaque on MDCT and high-intensity plaque on MRI were significant independent predictors of periprocedural myocardial injury (PMI). • Target lesions with high-risk plaque on MDCT and high-intensity plaque on CMR were significantly more likely to develop PMI. • In 141 plaques with ≥ 50% stenosis, patients with PMI were significantly more likely to have high-risk plaques on MDCT and high-intensity plaque on CMR in target and non-target lesions.

Potential risk of perioperative thromboembolism in patients with antiphospholipid syndrome who undergo transcatheter aortic valve implantation: A case series.

Antiphospholipid syndrome (APS) is an autoimmune disease characterized by a positive serum antiphospholipid antibody status. Patients with APS usually have an underlying hypercoagulable state, which can increase the risk of perioperative thromboembolism. We describe three patients with APS who underwent transcatheter aortic valve implantation for symptomatic severe aortic stenosis. Of them, two had complicated cerebrovascular events, and the other had no complications. Careful antithrombotic management is essential to minimize the risk of thromboembolism and bleeding in patients with APS.

Additional Effect of Coronary High-Intensity Plaque on T1-Weighted Magnetic Resonance Imaging With Circulating Malondialdehyde-Modified Low-Density Lipoprotein on Cardiac Events.

BACKGROUND: Although elevated levels of oxidized low-density lipoprotein (LDL) could play a critical role in vulnerable plaque, there are no studies that have compared coronary high-intensity plaque (HIP) and circulating malondialdehyde-modified (MDA)-LDL levels for the prediction of cardiac events.Methods and Results:A total of 139 patients with coronary artery stenosis (>70%) were examined with non-contrast T1-weighted magnetic resonance imaging (MRI) (HIP: n=64, non-HIP: n=75). Scheduled percutaneous coronary intervention (PCI) for culprit lesions was performed within 48 h after MRI. HIP was defined as a signal intensity of coronary plaque to cardiac muscle ratio (PMR) ≥1.4. We evaluated the subsequent major adverse cardiac events (MACE) during the follow-up period (5.6±1.3 years). MDA-LDL levels were independently associated with the presence of HIP (P<0.0001). The incidence of MACE was 15%, and it was significantly higher in patients with HIP (27%) than in those without HIP (5%; P=0.011). Cox proportional hazard analysis showed MDA-LDL levels (P=0.007) and PMR (P=0.016) were significantly associated with MACE. For MACE prediction, C-statistic values for MDA-LDL, PMR, and PMR+MDA-LDL were 0.724, 0.791, and 0.800, respectively. Compared with MDA-LDL alone, the addition of PMR to MDA-LDL increased net reclassification improvement by 0.78 (P=0.012). CONCLUSIONS: MDA-LDL levels might be associated with the presence of HIP in patients with coronary artery disease. Furthermore, adding PMR to MDA-LDL levels markedly improved prediction of subsequent MACE after PCI.

Audiovisual telesupport system for cardiovascular catheter interventions: A preliminary report on the clinical implications.

OBJECTIVES: This study aimed to validate the clinical implications of audiovisual telesupport system use. BACKGROUND: An audiovisual telesupport system with supervisors has been effective in guiding procedures when surgeons have limited experience with the technique. However, cardiovascular catheter interventions using an audiovisual telesupport system has not been previously reported. METHODS: Starting in September 2017, two cardiologists in Kamisu Saiseikai Hospital (Kamisu, Japan, with limited cardiologists) began performing cardiovascular catheter interventions using an audiovisual telesupport system. This system enabled them to perform catheter interventions with the support of advisors in the University of Tsukuba (Tsukuba, Japan). We retrospectively assessed procedure time and complications of percutaneous coronary intervention (PCI) and catheter ablation (CA). RESULTS: In the first 10 months, 21 patients with coronary artery disease underwent PCI using this system. The mean procedure duration of PCI was 42 ± 10 min. Nine patients with tachyarrhythmia including supraventricular tachycardia (SVT), ventricular premature contraction (VPC), common atrial flutter, and paroxysmal atrial fibrillation (AF) underwent CA using this system. The mean CA procedure time was 134 ± 31 min for SVT, 100 ± 14 min for VPC, and 200 min for AF. All PCI and CA procedures were successfully performed without any complications. CONCLUSIONS: The audiovisual telesupport system enabled cardiologists with limited human resources to provide safe and high-quality catheter interventions.

In Vivo Evaluation of Tissue Protrusion by Using Optical Coherence Tomography and Coronary Angioscopy Immediately After Stent Implantation.

BACKGROUND: The relationship between the characteristics of tissue protrusion detected by using optical coherence tomography (OCT) and the findings of coronary angioscopy (CAS) immediately after stent implantation were evaluated.Methods and Results:A total of 186 patients (192 stents) underwent OCT before and after stenting and were observed by using CAS immediately after stenting and at the chronic phase. Patients were assigned to irregular protrusion, smooth protrusion, and disrupted fibrous tissue protrusion groups according to OCT findings. Serum high-sensitivity C-reactive protein (hs-CRP) levels were measured before and after stent implantation. The grade of yellow color (YC) and neointimal coverage (NC), and incidence of thrombus in the stented segment were evaluated by using CAS. After stent implantation, maximum YC grade (smooth, 0.64±0.80; disrupted fibrous tissue, 0.50±0.77; irregular, 1.50±1.09; P<0.0001), a prevalence of Max-YC grade of 2 or 3 (smooth, 17%; disrupted fibrous tissue, 17%; irregular, 50%; P<0.0001) and thrombus (smooth, 15%; disrupted fibrous tissue, 10%; irregular, 69%; P=0.0005), and elevated hs-CRP levels (smooth, 0.22±0.89; disrupted fibrous tissue, -0.05±0.29; irregular, 0.75±1.41; P=0.023) were significantly higher in irregular protrusion than in the other 2 groups. In the chronic phase, maximum- and minimum-NC grade and heterogeneity index, and thrombus did not differ significantly among the 3 groups. CONCLUSIONS: Irregular protrusion was associated with atherosclerotic yellow plaque, incidence of thrombus, and vascular inflammation. The angioscopic findings in the chronic phase may endorse the clinical efficacy of second- and third-drug eluting stents, regardless of the tissue protrusion type.

Impact of coronary artery disease and revascularization on recurrence of atrial fibrillation after catheter ablation: Importance of ischemia in managing atrial fibrillation.

INTRODUCTION: There are few studies analyzing the association between the presence of coronary artery disease (CAD) and recurrence of atrial fibrillation (AF). This study evaluated the clinical impact of concomitant CAD and coronary revascularization on the recurrence of AF after catheter ablation. METHODS AND RESULTS: From April 2008 to December 2015, 700 consecutive patients were treated with pulmonary vein isolation for AF as the initial procedure. Of those, 681 patients who simultaneously underwent coronary angiography were investigated. Patients with at least one coronary stenosis (≥70%) were classified as having obstructive CAD. Of 681 patients, 90 patients had CAD and 42 patients underwent percutaneous coronary intervention (PCI) for lesions with perfusion abnormalities on single-photon emission tomography. The recurrence of AF was significantly more frequent in patients with CAD (56%) than in those without CAD (39%) (P = .0011). On multivariable analysis, the predictors of AF recurrence were persistent or long-standing persistent AF [hazard ratio (HR): 1.36; 95% confidence interval (CI): 1.04-1.77; P = .023], left atrial diameter (HR: 1.04; 95% CI: 1.02-1.06; P < .0001), and concomitant CAD (HR: 1.45; 95% CI: 1.05-1.97; P = .024). The recurrence of AF in patients with PCI (38%) was significantly lower than in those without PCI (72%) (P = .0006), and E/E' significantly improved in patients with PCI (71%) than in those without PCI (42%; P = .001). Performing PCI for concomitant CAD significantly reduced AF recurrence (HR: 0.39; 95% CI: 0.20-0.72; P = .002). CONCLUSION: Patients with CAD had a significantly higher rate of AF recurrence than those without CAD. Coronary revascularization may reduce the recurrence of AF with improvement of left ventricular diastolic function.

Coronary high-intensity plaque on T1-weighted magnetic resonance imaging and its association with myocardial injury after percutaneous coronary intervention.

AIMS: Non-contrast T1-weighted imaging (T1WI) has emerged as a novel non-invasive imaging for vulnerable coronary plaque showing a high-intensity plaque (HIP). However, the association between HIP and percutaneous coronary intervention (PCI) has not been evaluated. We investigated the association between the presence of HIP and the incidence of myocardial injury after PCI. METHODS AND RESULTS: A total of 77 patients with stable angina were imaged with non-contrast T1WI by using a 1.5 T magnetic resonance system (HIP and non-HIP group, N = 31 and 46 patients, respectively). We defined HIP as a coronary plaque to myocardium signal intensity ratio (PMR) of ≥1.4. High-sensitive cardiac troponin-T (hs-cTnT) was measured at baseline and 24 h after PCI. Percutaneous coronary intervention-related myocardial injury (PMI) was defined as an elevation of hs-cTnT >5× 99th percentile upper reference limit. High-intensity plaque was associated with the characteristics of ultrasound attenuation and positive remodelling on intravascular ultrasound. Although baseline hs-cTnT was similar between the groups, increase in hs-cTnT was significantly greater in the HIP vs. non-HIP group (0.065 [0.023-0.304] vs. 0.017 [0.005-0.026], P < 0.001). Percutaneous coronary intervention-related myocardial injury occurred more frequently in the HIP than non-HIP group (58.1 vs. 10.9%, P < 0.001), and the cut-off value of PMR found to be 1.44 for predicting PMI (sensitivity 78.3% and specificity 81.5%). In multivariate analysis, a PMR of ≥1.4 was a significant predictor of PMI (odds ratio 5.63, 95% confidence interval 1.28-24.7, P = 0.022). CONCLUSION: High-intensity plaque on non-contrast T1WI was characterized as vulnerable coronary plaque on IVUS and was associated with higher incidence of PMI.

Clinical predictors of contrast-induced acute kidney injury in patients undergoing emergency versus elective percutaneous coronary intervention.

BACKGROUND: To evaluate the incidence and clinical predictors of contrast-induced acute kidney injury (CI-AKI) in patients with ST-segment elevation myocardial infarction (STEMI), unstable angina pectoris/non-STEMI (UAP/NSTEMI), and stable AP (SAP) undergoing percutaneous coronary intervention (PCI). METHODS AND RESULTS: We enrolled 1,954 patients (SAP, n=1,222; UAP/NSTEMI, n=277; STEMI, n=455) who underwent PCI. Patients were categorized according to contrast media volume/estimated glomerular filtration rate ratio (CV/eGFR low: <2.0, mid: 2.0-2.9, high: ≥3.0). CI-AKI was defined as an increase in serum creatinine of 0.5mg/dl or 25% within 1 week from contrast-medium injection. The incidence of CI-AKI was highest among the STEMI patients (SAP, 4.24%; UAP/NSTEMI, 10.7%; STEMI, 16.1%, P<0.01). Significant predictors of CI-AKI were emergency PCI (odds ratio [OR] 3.70; 95% confidence interval [CI] 2.55-5.37; P<0.001), ejection fraction <40% (OR 2.04; 95% CI 1.24-3.36; P=0.005), and hemoglobin <10g/dl (OR 0.02; 95% CI 1.17-4.55; P=0.02) after multivariate logistic regression analysis. In the SAP group, a CV/eGFR ratio ≥3.0 was a significant predictor of CI-AKI (P=0.048), but not in UAP/NSTEMI and STEMI patients. CONCLUSIONS: UAP/NSTEMI and STEMI patients undergoing emergency PCI were at high risk for CI-AKI regardless of CV/eGFR ratio. Minimizing the dose of contrast medium based on eGFR might be valuable in reducing the risk of CI-AKI in SAP patients.

Novel use of the ultra-short-acting intravenous ß1-selective blocker landiolol for supraventricular tachyarrhythmias in patients with congestive heart failure.

The purpose of this study was to find a safe dosing regimen for landiolol, an ultra-short-acting ß-adrenergic blocking agent, to rapidly control supraventricular tachyarrhythmias (SVTs) in patients with heart failure (HF). Landiolol is reported to have good effects in the treatment of SVTs after cardiac surgery. We evaluated 52 patients with SVT and symptoms of HF (NYHA class III/IV, 10/42; EF 32 ± 12 %) on admission because of ischaemic disease (n = 10), non-ischaemic cardiomyopathy (n = 32), or valvular disease (n = 10). Paroxysmal/persistent atrial fibrillation and atrial tachycardia were present in 16 (30 %), 23 (45 %), and 13 (25 %) patients, respectively. The patients first underwent conventional therapy with carperitide, dobutamine, or milrinone. Intravenous landiolol was administered at an infusion rate of 1 µg/kg/min and, if no adverse effects developed, the maintenance dose, titrated to HR and blood pressure response, was increased. At an average dose of 10.8 ± 9.4 µg/kg/min, mean HR significantly decreased significantly from 133 ± 27 to 82 ± 15 beats/min (P < 0.01), whereas systolic blood pressure did not differ from baseline to attainment of an effective dose level (105 ± 21 vs. 101 ± 19 mmHg, P = ns). Within 60 min after initiation of therapy, all patients had achieved a 20 % reduction in HR at the maintenance dose. Transient asymptomatic hypotension requiring cessation of landiolol therapy occurred in three patients. Intravenous administration of landiolol was both effective in rapidly controlling HR for up to 24 h and useful as bridging treatment to additional therapy of oral ß blockade, pulmonary vein catheter ablation, or cardiac resynchronisation therapy in patients with HF.

Multimodality intracoronary imaging in spontaneous coronary artery dissection: impacts of intravascular ultrasound, optical coherence tomography, and coronary angioscopy.

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome and its etiology and pathogenesis have not been well understood. Intracoronary imaging modalities with intravascular ultrasound and optical coherence tomography would enable a precise diagnosis in this entity. Coronary angioscopy is also a unique tool for allowing direct visualization of the luminal surface of a vessel. We described an interesting case of SCAD documented with multimodality intracoronary imaging showing the presence of superficial lipid plaque nearby the coronary dissection entry point, which might have been associated with fragility of the arterial wall and the subsequent development of SCAD.

Instant subacute stent thrombosis after maximum-load cardiopulmonary exercise test in a clopidogrel poor metabolizer with acute coronary syndrome.

A 63-year-old man with a hobby of full marathon and triathlon fainted while commuting on a 25-km one-way bicycle trip and was admitted to the hospital after return of spontaneous circulation. The patient was diagnosed with acute coronary syndrome, and contrast-enhanced computed tomography for trauma diagnosis indicated suspicion of liver injury. Although coronary angiography revealed a severe stenotic lesion in the left anterior descending artery, percutaneous coronary intervention (PCI) was deferred because of thrombolysis in myocardial infarction grade 3 flow. Following neurological recovery, the patient was started on dual antiplatelet therapy (aspirin and clopidogrel). On day 11, a 3.0/34-mm Resolute Onyx stent (Medtronic, Dublin, Ireland) was deployed following rotablation. As a pre-discharge evaluation, a maximum-load cardiopulmonary exercise test was performed 8 days after PCI. However, the patient developed stent thrombosis after 2 h. Subsequently, the patient was diagnosed as a clopidogrel poor metabolizer using a blood test. Learning objective: Existing guidelines recommend a cardiopulmonary exercise test (CPET) before or immediately after the discharge of patients with acute coronary syndrome (ACS). However, the safety of the maximum-load CPET has not been established, especially in clopidogrel poor metabolizers with ACS. Acute maximal exercise induces platelet aggregation; therefore, further discussion is needed regarding the timing of CPET, exercise load level, and patient observation post-CPET in ACS patients after stent placement.

Subendocardial Ischemia Caused by Acute Severe Aortic Regurgitation Due to Aortic Root Dissection: A Case Report and Literature Review.

Electrocardiogram (ECG) findings showing ST-segment depression in a wide range of leads and ST-segment elevation in aVR are found in patients with acute coronary syndrome with multivessel coronary lesions and left main trunk lesions. A 64-year-old man with a history of eosinophilic granulomatosis presented with chest pain and dyspnea. Although an ECG showed the above findings, he was diagnosed with acute severe aortic regurgitation (AR) complicating aortic root dissection and successfully underwent urgent Bentall operation. These ECG findings indicated that acute severe AR caused subendocardial ischemia.

Posterior circumflex humeral artery pathological lesions with digital ischemia in an elite volleyball player: A case report and literature review.

The posterior circumflex humeral artery, a branch of the axillary artery, is compressed by the humeral head during repeated abduction and external rotation of the shoulder joint owing to its anatomical structure. This damages the vascular endothelium, resulting in thrombi, arterial dissection, and aneurysms, a condition known as posterior, circumflex humeral artery pathological lesions. A thrombus may form at the site and becomes a peripheral embolus, resulting in peripheral arterial occlusion.A 21-year-old right-handed elite man college volleyball player noticed coldness and pain in his right hand during a game. Cyanosis was present except in the middle finger, and the beating radial artery was palpable; however, the ulnar artery was not. Doppler ultrasound examination revealed thrombus occlusion of the ulnar artery and common palmar artery of the index finger. Peripheral arterial occlusion was diagnosed due to embolization of a thrombus from this site. The patient stopped practicing volleyball immediately after the onset of symptoms and was started on cilostazol 200 mg and rivaroxaban 15 mg. Subjective coldness of the fingers improved one week after the start of treatment. The patient resumed practice four weeks after the start of treatment and participated in a game by the seventh week.Posterior circumflex humeral artery pathological lesions are caused by overhead motions such as pitching. They are most commonly reported in athletes playing volleyball, although rare, and many cases of aneurysm formation have been reported.Observing a cold sensation in the periphery after practice is necessary for screening.