Relationship between coronary hyper-intensive plaques identified by cardiovascular magnetic resonance and clinical severity of acute coronary syndrome.

BACKGROUND: Coronary hyper-intense plaque (CHIP) detected on T1-weighted cardiovascular magnetic resonance (CMR) has been shown to associate with vulnerable plaque features and worse outcomes in low- and intermediate-risk populations. However, the prevalence of CHIP and its clinical significance in the higher-risk acute coronary syndrome (ACS) population have not been systematically studied. This study aims to assess the relationship between CHIP and ACS clinical severity using intracoronary optical coherence tomography (OCT) as the reference. METHODS: A total of 62 patients with known or suspected coronary artery disease were prospectively enrolled including a clinically diagnosed ACS group (n = 50) and a control group with stable angina pectoris (n = 12). The ACS group consisted of consecutive patients including unstable angina pectoris (n = 27), non-ST-segment-elevation myocardial infarction (non-STEMI) (n = 8), and ST-segment-elevation myocardial infarction (STEMI) (n = 15), respectively. All patients underwent non-contrast coronary CMR to determine the plaque-to-myocardium signal intensity ratio (PMR). RESULTS: Among the four groups of patients, a progressive increase in the prevalence of CHIPs (stable angina, 8%; unstable angina, 26%; non-STEMI, 38%; STEMI, 67%; p = 0.009), and PMR values (stable angina, 1.1; unstable angina, 1.2; non-STEMI, 1.3; STEMI, 1.6; median values, P = 0.004) were observed. Thrombus (7/8, 88% vs. 4/22, 18%, p = 0.001) and plaque rupture (5/8, 63% vs. 2/22, 9%, p = 0.007) were significantly more prevalent in CHIPs than in plaques without hyper-intensity. Elevated PMR was associated with high-risk plaque features including plaque rupture, thrombus, and intimal vasculature. A positive correlation was observed between PMR and the number of high-risk plaque features identified by OCT (r = 0.44, p = 0.015). CONCLUSIONS: The prevalence of CHIPs and PMR are positively associated with the disease severity and high-risk plaque morphology in ACS.

Combined effect of hyperhomocysteinemia and smoking on the severity of coronary artery disease in young adults ≤ 35 years of age: a hospital-based observational study.

BACKGROUND: The prevalence of coronary artery disease (CAD) continues to increase among young Chinese adults. Current smoking has been recognized as a major risk factor for premature CAD, and hyperhomocysteinaemia (HHcy) has also been suggested to be associated with CAD progression. However, the combined effect of current smoking and HHcy on the severity of coronary artery stenosis in young adults is still uncertain. METHODS: We consecutively collected young patients (18-35 years of age), diagnosed with CAD and underwent coronary angiography (CAG) at Anzhen Hospital between January 2013 and May 2020. HHcy was defined as serum homocysteine (Hcy) level > 15 µmol/L. The severity of coronary artery stenosis was evaluated by Gensini Score. The co-effect of current smoking and HHcy on CAD severity as well as the relationship between plasma Hcy, pack-years of smoking and CAD severity were assessed by multivariate linear regression analysis. RESULTS: A total of 989 participants (mean age, 33 years; 96.2% male) fulfilling the criteria were enrolled in this study. Patients with both HHcy and current smoking accounted for 39.1% of all the subjects. Multivariate liner analysis indicated both serum Hcy levels (ß 0.302; 95% CI 0.141-0.462; P < 0.001) and pack-years of smoking (ß 0.523; 95% CI 0.265-0.781; P < 0.001) were independently associated with the severity of coronary artery stenosis after adjusting for other traditional confounders. In addition, serum Hcy levels were correlated with pack-years of smoking in young CAD patients (r = 0.116, P = 0.001). Moreover, combination of HHcy and current smoking was suggested to have higher risk for CAD severity (ß 17.892; 95% CI 11.314-24.469; P < 0.001), compared with HHcy (ß 7.471; 95% CI 0.009-14.934; P = 0.048) or current smoking (ß 7.421; 95% CI 0.608-14.233; P = 0.033) alone. CONCLUSION: Combination of HHcy and smoking is independently associated with the severity of CAD in young patients ≤ 35 years of age.

Associations between hyperhomocysteinemia and the presence and severity of acute coronary syndrome in young adults ≤ 35 years of age.

BACKGROUND: The prevalence of acute coronary syndrome (ACS) continues to increase among young Chinese adults. Homocysteine (HCY) has been suggested as a promoter of atherosclerosis leading to coronary artery disease (CAD). Yet, it remains uncertain whether HCY is associated with the ACS and the severity of coronary artery stenosis in young adults. METHODS: Young patients (18-35 years of age) diagnosed with ACS who underwent coronary angiography (CAG) at Anzhen Hospital between January 2013 and June 2019 were assigned to the ACS group. As confirmed by CAG during the same period, an equivalent age-matched population without CAD was assigned to the non-CAD group. A serum HCY level > 15 µmol/L was defined as hyperhomocysteinemia (HHCY). The Gensini score assessed the severity of coronary artery stenosis. RESULTS: A total of 1103 participants, including 828 ACS patients and 275 non-CAD subjects, were enrolled in this study. Young ACS patients had higher level of serum HCY and greater prevalence of HHCY compared with non-CAD subjects [for HCY, 16.55 (11.93-29.68) vs 12.50 (9.71-17.42), P < 0.001; for HHCY prevalence, 62.08% vs 26.18%, P < 0.001]. Multivariate logistic regression analysis with the stepwise method indicated that HHCY was an independent predictor associated with the presence of ACS, after adjusting for traditional confounders (OR, 4.561; 95% CI, 3.288-6.327; P < 0.001). Moreover, young ACS patients with HHCY had increased prevalence of ST-segment elevation myocardial infarction (STEMI) (P = 0.041), multi-vessel disease (P = 0.036), and decreased value of left ventricular ejection fraction (LVEF) (P = 0.01). Also, the HCY level was significantly correlated with Gensini Score in ACS patients (r = 0.142, P < 0.001). CONCLUSION: HHCY is significantly associated with the presence of ACS and the severity of coronary artery stenosis in young adults ≤ 35 years of age.

Gender-specific associations between atherogenic index of plasma and the presence and severity of acute coronary syndrome in very young adults: a hospital-based observational study.

OBJECTIVE: The value of atherogenic index of plasma (AIP) as a predictive biomarker for coronary artery disease (CAD) remains controversial. In addition, whether AIP is associated with the risk of acute coronary syndrome (ACS) in very young adults has not been well established. METHODS: We consecutively collected very young adults (≤35 years of age) undergoing coronary angiography (CAG) at Anzhen Hospital, between January 2008 and December 2017. Total of 1, 478 very young participants, including 1, 059 ACS patients and 419 non-CAD subjects, were enrolled in the present study. RESULTS: Very young patients with ACS had higher AIP level compared with non-CAD participants (0.35 ± 0.30 vs 0.21 ± 0.33, P < 0.001). According to Gensini Score (GS) and number of lesion vessel, patients were divided into four groups, respectively. With the elevated GS score and number of lesion vessels, the AIP level increased gradually (Pfor trend all< 0.05). Multivariate logistic regression analyses suggested that AIP remained to be independently associated with the presence of ACS and was superior to traditional lipid profiles (for AIP, OR = 2.930, 95% CI = 1.855-4.627, P < 0.001; for total cholesterol, OR = 1.152, 95% CI = 1.048-1.266, P = 0.003; for triglyceride, OR = 1.078, 95% CI = 0.991-1.172, P = 0.079; for low-density lipoprotein cholesterol, OR = 1.046, 95% CI = 1.015-1.078, P < 0.001), after adjustment for other traditional confounders. Moreover, the prevalence of ACS, acute myocardial infarction, unstable angina pectoris and the value of GS were also elevated as AIP quartiles increased (Pfor trend < 0.001). Subgroup analysis based on gender revealed that AIP was only independently associated with the ACS risk in male. CONCLUSIONS: AIP was independently associated with the presence and severity of ACS in very young patients in a gender-dependent manner, which might be superior to traditional lipid profiles.

Prognosis of Elevated Mitral Valve Pressure Gradient After Transcatheter Edge-to-Edge Repair: Systematic Review and Meta-Analysis.

Elevation in mitral valve pressure gradient (MVPG) after mitral valve transcatheter edge-to-edge repair (M-TEER) is common, however, evidence on its prognosis is scarce and debatable. Thus, this study aims to investigate the impact of increased MVPG after M-TEER on outcomes. Studies reporting the associations between the elevated MVPG after M-TEER and outcomes were identified in a systematic search of published literatures. Associations were pooled by meta-analysis using a random-effects model. The primary outcome was the composite of all-cause mortality and heart failure (HF) hospitalization. Seven observational studies with 2,730 patients (mean age, 77.7 ± 9.3 years; male, 64.4%; functional mitral regurgitation [MR], 65.2%) were eligible for the present analysis. M-TEER was performed entirely using the MitraClip system (Abbott), followed by 29.7% of patients having increased MVPG. Elevated postprocedural MVPG was not associated with a higher risk of the primary outcome, compared to low MVPG [hazard ratio (HR) = 1.22; 95% confidence interval (CI) 0.95-1.58; p = 0.12; I2 = 53.5%). However, the prognosis of elevated MVPG was observed in degenerative MR patients (HR = 1.37; 95% CI 1.03-1.84; p = 0.03; I2 = 0%), whereas not in functional MR patients. Patients with low MVPG + high residual MR had a higher risk of the primary outcome than those with high MVPG + low residual MR after M-TEER (HR = 1.50; 95% CI 1.10-2.03; p = 0.01; I2 = 13%). In conclusion, elevated MVPG seems to predict adverse outcomes mainly in patients with degenerative MR. Future studies are needed to prove these findings.

First-in-human evaluation of an independently developed Chinese robot-assisted system for percutaneous coronary intervention.

BACKGROUND: Several studies have proved the safety and feasibility of robot-assisted percutaneous coronary intervention (PCI) in reducing the occupational hazards of interventionists while achieving precision medicine. However, an independently developed robot-assisted system for PCI in China has not yet emerged. This study aimed to evaluate the safety and feasibility of a robot-assisted system for elective PCI in China. METHODS: This preclinical trial included 22 experimental pigs and preliminarily supported the safety and feasibility of the ETcath200 robot-assisted system for PCI. Then, eleven patients with coronary heart disease who met the inclusion criteria and had clinical indications for elective PCI were enrolled. PCI was performed using a robot-assisted system. The primary outcomes were clinical success (defined as visual estimated residual stenosis < 30% after PCI and no major adverse cardiovascular events during hospitalization and within 30 days after PCI) and technical success (defined as the ability to use the robot-assisted system to complete PCI successfully without conversion to the traditional manual PCI). RESULTS: Eleven patients were included in this clinical trial. A drug-eluting stent with a diameter of 3 mm (interquartile range: 2.75-3.5 mm) and a length of 26 mm (interquartile range: 22-28 mm) was deployed in all patients. The clinical success rate was 100%, with no PCI-related complications and no in-hospital or 30-day major adverse cardiovascular events, and the technical success rate was 100%. CONCLUSIONS: The results strongly suggest that the use of the independently developed robot-assisted system in China for elective PCI is feasible, safe, and effective.

Efficacy and Safety of Evolocumab in Reducing Low-Density Lipoprotein Cholesterol Levels in Chinese Patients with Non-ST-segment Elevation Acute Coronary Syndrome.

AIMS: This study aims to explore early intensive lipid-lowering therapy in patients with non- ST-segment elevation acute coronary syndrome (NSTE-ACS). BACKGROUND: Lowering low-density lipoprotein cholesterol (LDL-C) levels can reduce cardiovascular morbidity and mortality in patients with atherosclerotic cardiovascular disease. Due to many reasons, the need for early intensive lipid-lowering therapy is far from being met in Chinese NSTE-ACS patients at high risk of recurrent ischaemic events. OBJECTIVE: This study evaluates the feasibility, safety and efficacy of starting evolocumab in hospitals to lower LDL-C levels in Chinese patients with NSTE-ACS. METHODS: In this prospective cohort study initiated by researchers, 334 consecutive patients with NSTEACS who had sub-standard LDL-C levels (LDL-C ≥2.3 mmol/L after regular oral statin treatment for at least 4 weeks; or LDL-C ≥3.2 mmol/L without regular oral statin treatment) were included. Patients who agreed to treatment with evolocumab (140 mg subcutaneously every 2 weeks, initiated in hospital and used for 12 weeks after discharge) were enrolled in the evolocumab group (n=96) and others in the control group (n=238). All enrolled patients received regular statin treatment (atorvastatin 20 mg/day or rosuvastatin 10 mg/day; doses unchanged throughout the study). The primary endpoint was the change in LDL-C levels from baseline to week 12. RESULTS: Most patients (67.1%) had not received regular statin treatment before. In the evolocumab group, LDL-C levels decreased significantly at week 4 and remained stable at week 8 and 12 (all p<0.001). At week 12, the LDL-C percentage change from baseline in the evolocumab group was - 79.2±12.7% (from an average of 3.7 to 0.7 mmol/L), while in the control group, it was -37.4±15.4% (from an average of 3.3 to 2.0 mmol/L). The mean difference between these 2 groups was -41.8% (95% CI -45.0 to -38.5%; p<0.001). At week 12, the proportion of patients with LDL-C levels <1.8 mmol/L and 1.4 mmol/L in the evolocumab group was significantly higher than in the control group (96.8 vs 36.1%; 90.6 vs 7.1%; both p<0.001). The incidences of adverse events and cardiovascular events were similar in both the groups. CONCLUSION: In this prospective cohort study, we evaluated the early initiation of evolocumab in NSTEACS patients in China. Evolocumab combined with statins significantly lowered LDL-C levels and increased the probability of achieving recommended LDL-C levels, with satisfactory safety and good tolerance.

Transcatheter Aortic Valve Implantation in Sievers Type 0 vs. Type 1 Bicuspid Aortic Valve Morphology: Systematic Review and Meta-Analysis.

Background: Transcatheter aortic valve implantation (TAVI) has achieved satisfactory outcomes in the selected patients with bicuspid aortic valve (BAV), predominately type 1 BAV (~90%). However, there are few reports about the safety and efficacy of TAVI in type 0 BAV. Therefore, in the current study, we aimed to compare procedural and 30-day outcomes after TAVI between type 0 and type 1 BAV. Methods: Studies comparing the outcomes of TAVI in Sievers type 0 vs. type 1 BAV were retrieved from PubMed, EMBASE, Cochrane Library, and Web of Science from inception to May 2021. The data were extracted regarding the study characteristics and outcomes. The odds ratios (ORs) with 95% CIs were pooled for procedural and 30-day outcomes. Results: Six observational studies were included with determined type 0 BAV in 226 patients and type 1 BAV in 902 patients. The patients with type 0 BAV were slightly younger, had larger supra-annular structure, and more frequently implanted self-expanding prosthesis compared with type 1 BAV. In the pooled analyses, the patients with type 0 BAV had a similar incidence of procedural death (OR = 2.6, 95% CI 0.7-10.3), device success (OR = 0.6; 95% CI 0.3-1.3), and ≥ mild (OR = 0.8; 95% CI 0.4-1.6) or moderate (OR = 0.9, 95% CI 0.4-1.8) paravalvular leak, whereas significantly higher mean aortic gradient (mean difference = 1.4 mmHg, 95% CI 0.03-2.7) and increased coronary compromise risk (OR = 7.2; 95% CI 1.5-34.9), compared with type 1 BAV. Meanwhile, the incidence of death (OR = 1.2; 95% CI 0.5-3.1), stroke (OR = 0.5; 95% CI 0.1-2.4), and new pacemaker (OR = 0.6; 95% CI 0.2-2.2) at 30 days were not significantly different between the BAV morphologies (p > 0.05). The treatment effect heterogeneity across the studies for the above outcomes were low. Conclusions: The patients with type 0 BAV appear to have similar short-term outcomes after TAVI compared with type 1 BAV. Whereas, TAVI for type 0 BAV aortic stenosis might lead to an elevated coronary obstruction risk and suboptimal aortic valvular hemodynamics.

[Randomized study on T stenting and small protrusion technique versus simple stenting for patients with coronary artery bifurcation lesions and with big size side branch].

OBJECTIVE: To explore the feasibility and safety of T stenting and small protrusion (TAP) technique and compare the efficacy with simple stenting in patients with coronary bifurcation lesions and with big size side branch. METHODS: A total of 142 eligible patients were recruited and 127 patients completed the study (simple stenting group 58 and TAP technique group 69). RESULTS: Major adverse cardiovascular event rate was similar at 12 months follow up between the groups (TAP technique group 13.0% versus simple stenting group 12.1%, P > 0.05). The rate of procedural-related myocardial infarction, procedure and fluoroscopy time, contrast volumes were also similar between 2 groups (all P > 0.05). At 8 months, coronary angiography revealed that the restenosis rate of the ostium of side branch in TAP group was significantly lower than that of simple stenting group (17.1% versus 3.8%, P < 0.05). Overall restenosis rate was similar between the groups (P > 0.05). CONCLUSION: Both TAP technique and simple stenting are feasible and effective strategies for treating patients with bifurcation lesions.

[Safety and feasibility of transradial coronary angiography at the outpatient clinic].

OBJECTIVE: To evaluate the safety and feasibility of transradial coronary angiography at the outpatient clinic. METHODS: From February 2007 to June 2007, 100 outpatients who received transradial coronary angiography in Anzhen hospital were included in this analysis, 100 inpatients underwent coronary angiography were selected as control group. Primary endpoints included success rate, percent of angiographic catheter use with different diameters, adverse events during the procedure (such as death, malignant arrhythmia, acute myocardial infarction, coronary artery spasm, coronary artery dissection, perforation or occlusion, etc.) and after the procedure (such as death, acute myocardial infarction, upper limb haematoma, osteofascial compartment syndrome, radial artery pseudoaneurysm or occlusion, etc.). RESULTS: The success rate (100% vs. 100%), procedure duration time [(12.5 +/- 3.4) min vs.(10.8 +/- 3.6) min, P = 0.517] and exposition time [(4.3 +/- 1.0) min vs. (4.1 +/- 1.0) min, P = 0.629] were similar between the outpatient and inpatient groups. Radial and coronary artery spasm were the main adverse events during the angiography, and haematoma was the main adverse event after the angiography. There were no significant differences of adverse events between the 2 groups. The total cost of the outpatient group was significantly lower than the inpatient control group [(4012 +/- 238) yuan vs. (5329 +/- 371) yuan, P < 0.001]. Expenditure including chemical tests, medicine, nursing care, room and board all decreased significantly. CONCLUSION: Transradial coronary angiography application at the outpatient clinic was safe and feasible for stable patients, and this procedure could decrease the medical expenditure and shorten the admission time.

[Comparison between drug eluting stent and coronary artery bypass grafting surgery for the treatment of unprotected left main coronary artery disease in elderly patients].

OBJECTIVE: To compare the 2 years outcome of elderly patients with ULMCA stenosis undergoing coronary artery bypass grafting (CABG) or drug eluting stent (DES). METHODS: From January 2004 to June 2006, 295 patients with ULMCA stenosis and age > or = 70 years undergoing coronary revascularization with either CABG (n = 206) or DES (n = 89) were enrolled in this analysis. All-cause death, non-fatal myocardial infarction and target lesion revascularization (TLR) were recorded during 2 years follow-up. RESULTS: The cumulative rate of 2-year mortality were 10.2% (n = 21) in CABG-treated patients and 13.3% (n = 12) in DES-treated patients (P = 0.428). The survival rate during 2-year follow-up was 89.2% for CABG-treated patients and 86.4% for DES-treated patients (P = 0.668). The incidence of 2-year myocardial infarction was 7.8% (n = 16) in CABG-treated patients and 10.1% (n = 9) in DES-treated patients (P = 0.501). The incidence of target lesion revascularization (TLR) was 4.9% (n = 10) in CABG-treated patients and 13.5% (n = 12) in DES-treated patients (P = 0.015). In the multivariable analysis, age (HR: 1.04, 95% CI: 1.01-1.09, P = 0.024), left ventricular dysfunction (ejection fraction < 30%, HR: 4.97, 95% CI: 1.22-24.85, P = 0.018) and type 2 diabetes (HR: 2.22, 95% CI: 1.31-4.86, P = 0.001) were independent predictors of 2-year mortality. CONCLUSION: In this study, 2-year mortality was comparable in elderly patients with ULMCA stenosis underwent CABG or DES. However, the rate of TLR was significantly higher in patients treated with DES than that receiving CABG operation.

[Effects of upstream tirofiban versus downstream tirofiban on platelet aggregation and clinical outcomes in patients with high-risk acute coronary syndromes undergoing percutaneous coronary interventions].

OBJECTIVE: To observe the effects of upstream versus downstream application of tirofiban on platelet aggregation and clinical outcomes (major adverse cardiovascular event, MACE) in patients with high-risk non-ST-segment elevation acute coronary syndromes (NSTE-ACS) undergoing percutaneous coronary intervention (PCI). METHODS: From July 2006 to July 2007, 160 high-risk NSTE-ACS patients undergoing PCI were randomized to receive upstream (4-6 h prior PCI) tirofiban and downstream (immediately prior to PCI) tirofiban. Platelet aggregation inhibition was determined at admission, before coronary angiography and after PCI. Incidences of MACE at 1, 3, 7, 30 and 180 days after PCI were compared. The incidences of bleeding complications and thrombocytopenia during tirofiban treatments were recorded. RESULTS: The extent of platelet aggregation inhibition post tirofiban was significantly greater in upstream tirofiban than that in downstream tirofiban group (8% vs. 42%, P<0.05). The incidences of MACE at various time points were similar between the two groups (all P>0.05). Aging, hypertension and type-2 diabetes were independent risk factors of MACE. The incidences of major and minor bleeding complications as well as mild thrombocytopenia during tirofiban treatments were similar between the two groups (2.5% vs. 1.3%, 1.3% vs. 1.3% and 1.3% vs. 1.3%, respectively; all P>0.05). CONCLUSION: On top of aspirin and clopidogrel, upstream application of tirofiban is associated with increased platelet aggregation inhibition but the incidences of MACE up to 180 days post tirofiban are similar in the upstream and downstream tirofiban treated patients with high-risk NSTE-ACS after PCI. Aging, hypertension and type-2 diabetes were independent risk factors of MACE in these patients.

High Serum Secreted Frizzled-Related Protein 5 Levels Associates with Early Improvement of Cardiac Function Following ST-Segment Elevation Myocardial Infarction Treated by Primary Percutaneous Coronary Intervention.

AIM: Several members of secreted frizzled-related protein (SFRP) are involved in the process of myocardial ischemia-reperfusion injury. However, little is known about the role of SFRP5 in patients with acute ST-segment elevation myocardial infarction (STEMI). METHODS: In this cross-sectional study, 85 patients with first-time anterior STEMI who underwent timely primary percutaneous coronary intervention (PCI) and 35 patients without coronary artery disease (CAD) were enrolled. Serum SFRP5 levels were measured using an enzyme-linked immunosorbent assay kit. Patients with STEMI were divided into low-SFRP5 and high-SFRP5 groups according to their median baseline serum SFRP5 levels. To evaluate cardiac function and structure after infarction, the left ventricular ejection fraction (LVEF) and left ventricular end-diastolic volume (LVEDV) were measured using echocardiography. The associations between changes in LVEF and reduced LVEF (≤ 50%) and clinical variables were determined by univariate and multivariate analyses. RESULTS: Baseline serum SFRP5 levels were significantly higher in patients with STEMI than in those without CAD (23.3 ng/mL vs 19.8 ng/mL, P=0.008), although they decreased over time. Also, baseline serum SFRP5 levels were inversely correlated with peak hypersensitive cardiac troponin I (hs-cTnI) levels (r=-0.234, P=0.025) and peak hypersensitive C-reactive protein (hs-CRP) levels (r=-0.262, P=0.015). A multivariate linear regression model showed that changes in LVEF were positively correlated with serum SFRP5 levels at baseline (ß= 0.249, 95% confidence interval (CI) 0.018-0.245, P=0.024) and 24 h after admission (ß=0.220, 95% CI 0.003-0.264, P=0.045). At 3 months, LVEF in patients with high SFRP5 levels was significantly improved over baseline [(60.8±7.1) % vs (56.1±7.5) %, P=0.001]. LVEF was also significantly higher in patients with high SFRP5 levels than in those with low at the 3-month follow-up [(60.8±7.1) % vs (56.8±8.9) %, P=0.028]. Consequently, high serum SFRP5 levels at baseline were associated with a decreased risk of reduced LVEF at 3 months, independent of peak hs-cTnI and baseline cardiac function (hazard ratio 0.190, 95% CI 0.036-0.996; P=0.049). CONCLUSIONS: High serum SFRP5 levels measured during the acute phase of STEMI were significantly associated with promoting myocardial recovery at an early phase following primary PCI, suggesting that SFRP5 is a potential therapeutic target in acute STEMI.

Optimal Revascularization Threshold of Fractional Flow Reserve and its Effect on Outcomes: Perspectives From a High-Volume Center in China.

This study aimed to investigate the favorable revascularization threshold for fractional flow reserve (FFR) in daily practice. Between March 2013 and March 2017 in a high-volume center in China, 903 patients with 1210 lesions underwent coronary intervention with adjunctive FFR and were consecutively enrolled. The mean FFR was 0.80 ± 0.11, revascularization was deferred for 68% of lesions, and the median follow-up period was 21 months. For lesions with an FFR > 0.80, deferral of revascularization appeared safe. In contrast, for lesions with an FFR ≤ 0.80, deferral of revascularization was associated with a greater risk of target lesion failure (TLF) than revascularization (hazard ratio [HR] 4.63, 95% confidence interval [CI] 2.02-10.06, P < .001). For lesions with an FFR value in the gray-zone (0.76-0.80), medical treatment alone was less effective than revascularization ( P = .020). For deferred lesions, FFR was an independent predictor for the future risk of TLF, when data were categorized (HR [FFR ≤ 0.75 vs FFR ≥ 0.86] 3.35, 95% CI 1.13-9.97, P = .030; HR [FFR 0.76-0.80 vs FFR ≥ 0.86] 4.01, 95% CI 1.73-9.31, P = .001) or continuous (HR 0.004, 95% CI 0.00-0.13, P = .002). Thus, an FFR value of 0.80 appears to be the optimal threshold for decision-making regarding revascularization and risk stratification.

Association Between Insulin Resistance and Coronary Plaque Vulnerability in Patients With Acute Coronary Syndromes: Insights From Optical Coherence Tomography.

We investigated the correlation between insulin resistance (IR) and optical coherence tomography and identified culprit plaque characteristics in patients with acute coronary syndrome (ACS). Patients with ACS who underwent selective coronary intervention were prospectively enrolled. A total of 159 culprit lesions were identified in 145 patients. Culprit plaque characteristics, including thin-cap fibroatheroma (TCFA) and spotty calcification, were analyzed. The IR was assessed using the homeostasis model assessment of IR (HOMA-IR). Patients were divided into 4 interquartile ranges (IQRs) according to HOMA-IR values. The prevalence rates of TCFA were significantly different among the 4 groups (17.5% [IQR1 group] vs 17.9% [IQR2 group] vs 35.0% [IQR3 group] vs 55.0% [IQR4 group]; P = .001). Minimal fibrous cap thickness was inversely correlated with HOMA-IR level (141.35 [56.28] µm vs 142.82 [82.17] µm vs 102.14 [36.52] µm vs 96.00 [41.82] µm; P < .001). Spotty calcification prevalence was also significantly different among the 4 groups (5.9% vs 17.6% vs 32.4% vs 44.1%; P < .001). Compared with the bottom quartile, patients with elevated HOMA-IR values had higher prevalence of macrophage infiltration ( P < .001) and microvessels ( P = .023). On multivariate analysis, Ln HOMA-IR (odds ratio: 6.022; 95% confidence interval: 3.007-12.060; P < .001) was the independent predictor for spotty calcification. The current study showed increased IR was independently associated with plaque vulnerability, spotty calcification in particular, in ACS.

A prospective, double-blind, randomized, controlled trial on the efficacy and cardiorenal safety of iodixanol vs. iopromide in patients with chronic kidney disease undergoing coronary angiography with or without percutaneous coronary intervention.

OBJECTIVES: This study was undertaken to compare the renal safety as well as cardiovascular (CV) effects and diagnostic image quality of iso-osmolar iodixanol vs. low-osmolar iopromide in patients with chronic kidney disease (CKD) undergoing coronary interventions. BACKGROUND: With the growing number of contrast-enhanced procedures being performed for coronary artery disease management, the safety and efficacy of iodinated contrast media (CM) have come under increased scrutiny. METHODS: : Patients with CKD (CrCl < or =60 mL/min) were randomized to iodixanol (n = 106) or iopromide (n = 102). The primary endpoint was incidence of contrast-induced nephropathy (CIN), defined as an increase in serum creatinine (SCr) > or =25% or 0.5 mg/dL within 72 hr of CM administration. Secondary endpoints were mean SCr increase, a composite of CV events in-hospital and 30 days postdischarge, and diagnostic image quality. RESULTS: : CIN incidence was significantly lower with iodixanol than iopromide (5.7% vs. 16.7%; P = 0.011). Baseline SCr (OR 2.21, 95% CI: 1.25-3.47; P = 0.031), iopromide use (OR 2.56, 95% CI: 1.18-5.76; P = 0.024), and CM volume (OR 2.01, 95% CI: 1.01-3.21; P = 0.038) were identified as independent risk factors for CIN. Cardiovascular events were reduced with iodixanol (1.9% vs. 8.8%; P = 0.025); diagnostic image quality was similar for both CM (P = 0.353). CONCLUSIONS: : Consistent with several previous trials comparing iso-osmolar iodixanol and low-osmolar comparator CM, iodixanol was associated with a lower incidence of CIN and fewer CV events than iopromide.

Safety and feasibility of transradial approach for primary percutaneous coronary intervention in elderly patients with acute myocardial infarction.

BACKGROUND: Transradial coronary intervention has been widely used because of its effects in lowering the incidence of complications in vascular access site and improving patient satisfaction compared to the femoral approach. This study aimed to investigate the safety and feasibility of transradial approach for primary percutaneous coronary intervention (PCI) in elderly patients with acute myocardial infarction (AMI). METHODS: A total of 103 consecutive elderly patients (age = 65 years) who were diagnosed as having AMI were indicated for PCI. Among them, 57 patients received primary PCI via the transradial approach (transradial intervention, TRI group), and 46 underwent primary PCI via the transfemoral approach (transfemoral intervention, TFI group). The success rate of puncture, puncture time, cannulation time, reperfusion time, the total time for PCI, the success rate of PCI, the use rates of temporary pacemaker and intra-aortic balloon pump (IABP), and the total length of hospital stay of the patients in the two groups were compared. After the procedure, vascular access site complications and major adverse cardiovascular events (MACE) in the two groups in one month were observed. RESULTS: The success rates of puncture (98.2% vs 100.0%) and PCI (96.5% vs 95.7%) for the patients in the TRI and TFI groups were not statistically significant (P > 0.05). The puncture time ((2.4 +/- 1.1) vs (2.0 +/- 0.9) minutes), cannulation time ((2.7 +/- 0.5) vs (2.6 +/- 0.5) minutes), reperfusion time ((16.2 +/- 4.5) vs (15.4 +/- 3.6) minutes), total time of the procedure ((44.1 +/- 6.8) vs (41.2 +/- 5.7) minutes), use rates of temporary pacemaker (1.8% vs 2.2%) and IABP (0 vs 2.2%) in the two groups were not statistically significant (P > 0.05), but the hospital stay of the TFI group was longer than that of the TRI group ((10.1 +/- 4.6) vs (7.2 +/- 2.6) days, P < 0.01). A radial occlusion was observed in the TRI group, but no ischemic syndrome in hand. In the TFI group, 4 patients had hematosis, 1 had pseudoaneurysm, and 1 had major bleeding. Statistical significance in vascular access site complications was seen in the two groups (1.8 % vs 13.1%, P < 0.05). Three patients died in the two groups respectively in one month, and there was no statistical significance in MACE in the two groups (5.3% vs 6.5%, P > 0.05). CONCLUSION: The transradial approach for primary PCI is safe and feasible for elderly patients with AMI.

Long-term outcome of patients of over 85 years old with acute coronary syndrome undergoing percutaneous coronary stenting: a comparison of bare metal stent and drug eluting stent.

BACKGROUND: Patients aged over 85 years have been under-represented in percutaneous coronary intervention (PCI) trials despite an increase in referrals for PCI. The long-term safety and efficacy of percutaneous coronary stenting in patients aged over 85 years with acute coronary syndrome (ACS) remain unclear. Moreover it is unknown whether there are differences between bare metal stent (BMS) and drug eluting stent (DES) in this special population. METHODS: A total of 80 patients with ACS aged over 85 years undergoing stenting (BMS group n = 21 vs DES group n = 59) were retrospectively studied. In-hospital, one year and overall clinical follow-up (12 - 36 months) of major adverse cardiac events (MACEs) including cardiac deaths, myocardial infarction, target lesion revascularization (TLR) and target vessel revascularization (TVR) as well as stroke and other major bleeding were compared between the two groups. RESULTS: In the entire cohort, the procedure success rate was 93.8% with TIMI-3 coronary flow post-PCI in 93.8% of the vessels and the procedure related complication was 17.5%. The incidence of in-hospital MACEs in BMS group was higher (14.3% vs 6.8%, P = 0.30). The 1-year incidence of MACEs in DES group was 7.0% while there was no MACE in the BMS group. Clinical follow-up for 12 - 36 months showed that the overall survival free from MACE was 82.9% and the incidence of MACE in the BMS group was lower (5.3% vs 21.1%, P = 0.20). Multivariate regression analysis showed that the creatinine level (OR: 1.013; 95% CI: 1.006 - 1.020; P = 0.004) and hypertension (OR: 3.201; 95% CI: 1.000 - 10.663; P = 0.04) are two major factors affecting the long-term MACE. CONCLUSIONS: Percutaneous coronary stenting in patients aged over 85 years is safe and provides good short and long-term efficacy. Patients with renal dysfunction and hypertension may have a relatively high incidence of MACE.

Transradial approach for coronary angioplasty in Chinese elderly patients.

BACKGROUND: The radial artery is currently regarded as a useful vascular access site for coronary procedures. This study was conducted to investigate the feasibility and safety of the percutaneous radial artery approach for angioplasty in the elderly. METHODS: Two thousand and fifty-eight consecutive patients (762 elderly, age = 65 years; and 1296 non-elderly, age < 65 years, respectively) who underwent transradial coronary angioplasty were recruited in this study. Study endpoints included procedure success rate, procedure time, vascular complications at access site, and major adverse cardiac and cerebrovascular events during hospitalization. RESULTS: Elderly patients were more likely to present with unstable angina and renal dysfunction. The incidence of radial and brachiocephalic trunk anatomical tortuosity was higher in elderly patients than that in non-elderly patients (11.5% vs 3.7%; 8.9% vs 2.6%, P < 0.01, respectively). However, procedural success rate (94.7% vs 95.6%) and total mean procedure time ((67.9 +/- 27.3) minutes vs (58.6 +/- 38.5) minutes) for transradial coronary angioplasty were not significantly different between the two groups. Clinical course during the hospitalization was slightly worse in the elderly patients because of more adverse cardiac and cerebrovascular events after the procedure. However, the incidence of vascular complications was not significantly different between the elderly and non-elderly patients. CONCLUSION: Although the incidence of radial and brachiocephalic trunk anatomical tortuosity is higher in elderly patients, transradial coronary intervention can be performed with similar safety and procedural success in these patients as compared with non-elderly patients.

Association between baseline platelet count and severe adverse outcomes following percutaneous coronary intervention.

OBJECTIVE: The aim is to evaluate the association between baseline platelet count (PC) and severe adverse outcomes following percutaneous coronary intervention (PCI) in current real-world practice. METHODS: A total of 18,788 patients underwent PCI with drug-eluting stents constituted the study population. Patients were categorized as having low (< 150 × 1000/µL), normal (150-300 × 1000/µL), and high (≥ 300 × 1000/µL) baseline PC. The primary endpoints included in-hospital and follow-up all-cause mortality. The secondary endpoint was major bleeding requiring a blood transfusion. RESULTS: In-hospital mortality rates for patients with low, normal, and high baseline PC were 0.6%, 0.4%, and 0.4%, respectively (P = 0.259). Similarly, mortality rates during long-term follow-up (median 23.8 months) for patients with low, normal, and high baseline PC were 0.9%, 0.6%, and 0.7%, respectively (P = 0.079). After multivariate adjustment, patients with low or high baseline PC tended to have similar risks for both in-hospital and follow-up mortality compared with the normal group. Subgroup analyses failed to demonstrate an independent prognostic value of baseline PC in specific population groups except patients who undwent transfemoral PCI. There was also no significant difference in the incidence of major bleeding requiring a blood transfusion in the low, normal, and high groups (0.5%, 0.3%, and 0.3%, respectively; P = 0.320). After multivariate adjustment, low or high baseline PC did not significantly increase the risk of major bleeding. CONCLUSION: There is no significant association between baseline PC and severe adverse outcomes following PCI in current real-world practice.