Type 2 diabetes metabolomics score and risk of progression to type 2 diabetes among women with a history of gestational diabetes mellitus.

BACKGROUND: Several metabolites are individually related to incident type 2 diabetes (T2D) risk. We prospectively evaluated a novel T2D-metabolite pattern with a risk of progression to T2D among high-risk women with a history of gestational diabetes mellitus (GDM). METHODS: The longitudinal Nurses' Health Study II cohort enroled 116,429 women in 1989 and collected blood samples from 1996 to 1999. We profiled plasma metabolites in 175 incident T2D cases and 175 age-matched controls, all with a history of GDM before the blood draw. We derived a metabolomics score from 21 metabolites previously associated with incident T2D in the published literature by scoring according to the participants' quintile (1-5 points) of each metabolite. We modelled the T2D metabolomics score categorically in quartiles and continuously per 1 standard deviation (SD) with the risk of incident T2D using conditional logistic regression models adjusting for body mass index at the blood draw, and other established T2D risk factors. RESULTS: The percentage of women progressing to T2D ranged from 10% in the bottom T2D metabolomics score quartile to 78% in the highest score quartile. Adjusting for established T2D risk factors, women in the highest quartile had more than a 20-fold greater diabetes risk than women in the lowest quartile (odds ratios [OR] = 23.1 [95% CI = 8.6, 62.1]; p for trend<0.001). The continuous T2D metabolomics score was strongly and positively associated with incident T2D (adjusted OR = 2.7 per SD [95% CI = 1.9, 3.7], p < 0.0001). CONCLUSIONS: A pattern of plasma metabolites among high-risk women is associated with a markedly elevated risk of progression to T2D later in life.

Contribution of periodontal health in cardiovascular secondary prevention: Analyses on hospitalized patients in cardiology units.

AIM: To investigate the association between dental health and incident cardiovascular disease (CVD) in secondary prevention setting. MATERIALS AND METHODS: A total of 888 patients with known CVD hospitalized in the cardiology unit were prospectively enrolled. We assessed the association between missing teeth and three variables of periodontitis and major adverse cardiovascular events (MACE), defined as a composite of cardiac death, acute myocardial infarction, stroke and hospital re-admission for congestive heart failure. RESULTS: During a median (Q1, Q3) follow-up of 4.6 (1.4, 6.7) years, an additional missing tooth was associated with a 3% (95% confidence interval [CI]: 1%-5%) higher hazard of MACE (p = .004). Compared with patients with 0 to ≤4 missing teeth, periods free from MACE (95% CI) by 5 years of follow-up were, on average, shorter by 0.17 (-0.04 to 0.37) years, 0.26 (0.04-0.49) years and 0.59 (0.34-0.85) years in patients with 5 to ≤7, 8 to ≤13 and >13 missing teeth, respectively. No significant associations were observed between periodontal measures and MACE incidence. CONCLUSIONS: In hospitalized patients with existing CVD, the total number of missing teeth was associated with incident MACE.

Association of Modifiable Lifestyle Factors with Plasma Branched-Chain Amino Acid Metabolites in Women.

BACKGROUND: Circulating branched-chain amino acids (BCAAs-isoleucine, leucine, and valine) are strongly associated with higher risk of incident type 2 diabetes (T2D); however, determinants of elevated fasting BCAA concentrations are largely unknown. OBJECTIVES: We aimed to characterize the modifiable lifestyle factors related to plasma BCAAs. METHODS: We performed a cross-sectional analysis among n = 18,897 women (mean ± SD age: 54.9 ± 7.2 y) in the Women's Health Study, free of T2D and cardiovascular disease at baseline blood draw. Lifestyle factors, weight, and height were self-reported via questionnaire, including smoking status, alcohol, leisure-time physical activity (LTPA), diet quality scores [2010 Alternative Healthy Eating Index (without alcohol) (aHEI); alternate Mediterranean Diet (aMED)], and dietary sources of BCAAs. Plasma BCAAs were quantified via NMR spectroscopy. We calculated multivariable-adjusted percentage mean differences (95% CIs) and P values for linear trend of BCAAs stratified by categoric lifestyle factors. We estimated R2 from univariate cubic spline regression models to estimate the variability in BCAAs explained. RESULTS: Compared with women with BMI (in kg/m2) <25.0, BCAAs were 8.6% (95% CI: 8.0%, 9.3%), 15.3% (95% CI: 14.4%, 16.3%), and 21.0% (95% CI: 18.2%, 23.9%) higher for the BMI strata 25.0-29.9, 30.0-39.9, and ≥40.0, respectively (P-trend < 0.0001). Women with higher LTPA and higher alcohol intake compared with lower had modestly (∼1%) lower plasma BCAAs (P-trend = 0.014 and 0.0003, respectively). Differences in smoking status, aHEI, and aMED score were not related to plasma BCAAs. Women with higher dietary BCAAs had dose-response higher plasma BCAA concentrations, 3.4% (95% CI: 2.5%, 4.4%) higher when comparing the highest with the lowest quintile (P-trend < 0.0001). BMI explained 11.6% of the variability of BCAAs, whereas other factors explained between 0.1% and 1%. CONCLUSIONS: Our findings among a large cohort of US women indicate that BMI, but less so diet, physical activity, and other lifestyle factors, is related to plasma BCAAs.This trial was registered at clinicaltrials.gov as NCT00000479.

Determinants of visual-functional mismatches as assessed by coronary angiography and quantitative flow ratio.

OBJECTIVE: We aimed to evaluate the determinants of visual-functional mismatches between quantitative coronary angiography (QCA) and the quantitative flow ratio (QFR). BACKGROUND: The fractional flow reserve (FFR) has been established as a method to estimate the functional stenosis severity of coronary artery disease and to optimize decision-making for revascularization. The QFR is a novel angiography-derived computational index that can estimate the FFR without pharmacologically induced hyperemia or the use of pressure wire. METHODS: A total of 504 de novo intermediate-to-severe stable lesions that underwent angiographic and physiological assessments were analyzed. All lesions were divided into four groups based on the significance of visual (QCA-diameter stenosis [DS] > 50% and ≤ 50%) and functional (QFR ≤ 0.80 and > 0.80) stenosis severity. Patient characteristics, angiographic findings, and physiological indices were compared. RESULTS: One-hundred seventy-eight lesions (35.3%) showed discordant visual-functional assessments; mismatch (QCA-DS > 50% and QFR > 0.80) in 75 lesions (14.9%) and reverse mismatch (QCA-DS ≤ 50% and QFR ≤ 0.80) in 103 lesions (20.4%), respectively. Reverse mismatch was associated with non-diabetes, lower ejection fraction, higher Duke jeopardy score, and lower coronary flow reserve (CFR). Mismatch was associated with smaller QCA-DS, larger reference diameter, shorter lesion length, lower Duke jeopardy score, and higher CFR. Lesion location and microcirculatory resistance was not associated with the prevalence of mismatches. Reverse mismatch group had the higher prevalence of discordant decision-makings between QFR and FFR than the other three groups. CONCLUSIONS: The CFR and subtended myocardial mass were predictors of visual-functional mismatches between QCA-DS and the QFR. Caution should be exercised in lesions showing QCA-DS/QFR reverse mismatch.

Characteristic findings of microvascular dysfunction on coronary computed tomography angiography in patients with intermediate coronary stenosis.

OBJECTIVES: We aimed to assess the prevalence of coexistence of coronary microvascular dysfunction (CMD) in patients with intermediate epicardial stenosis and to explore coronary computed tomography angiography (CCTA)-derived lesion-, vessel-, and cardiac fat-related characteristic findings associated with CMD. METHODS: A retrospective cross-sectional single-center study included a total of 177 patients with intermediate stenosis in the left anterior descending artery (LAD) who underwent CCTA and invasive physiological measurements. The 320-slice CCTA analysis included qualitative and quantitative assessments of plaque, vessel, epicardial fat volume (ECFV) and epicardial fat attenuation (ECFA), and pericoronary fat attenuation (FAI). CMD was defined by the index of microcirculatory resistance (IMR) ≥ 25. RESULTS: In the entire cohort, median fractional flow reserve (FFR) and median IMR values were 0.77 (0.69-0.84) and 19.0 (13.7-27.7), respectively. The prevalence of CMD was 32.8 % (58/177) in the total cohort. The coexistence of CMD and functionally significant stenosis was 34.3 % (37/108), whereas CMD in nonsignificant intermediate stenosis was 30.4 % (21/69). CMD was significantly associated with greater lumen volume (p = 0.031), greater fibrofatty and necrotic component (FFNC) volume (p = 0.030), and greater ECFV (p = 0.030), but not with FAI (p = 0.832) and ECFA (p = 0.445). On multivariable logistic regression analysis, vessel volume, vessel lumen volume, lesion remodeling index, ECFV, and lesion FFNC volume were independent predictors of CMD. CONCLUSIONS: The prevalence of CMD was about one-third in patients with intermediate stenosis in LAD regardless of the presence or absence of functional stenosis significance. The integrated CCTA assessment may help in the identification of CMD. KEY POINTS: • The coexistence of coronary microvascular dysfunction (CMD) and functionally significant stenosis was 34.3 %, whereas CMD in nonsignificant intermediate stenosis was 30.4 %. • Coronary computed tomography angiography (CCTA)-derived CMD characteristics were vessel volume, vessel lumen volume, remodeling index, epicardial fat volume, and fibrofatty necrotic core volume. • Integrated CCTA assessment may help identify the coexistence of CMD and epicardial stenosis.

Clinical Significance of Increased Computed Tomography Attenuation of Periaortic Adipose Tissue in Patients With Abdominal Aortic Aneurysms.

BACKGROUND: Recent imaging studies reported an association between vascular inflammation and progression of abdominal aortic aneurysm (AAA). This study investigated the clinical significance of periaortic adipose tissue inflammation derived from multidetector computed tomography angiography (MDCTA).Methods and Results:Patients with asymptomatic AAA (n=77) who underwent an index and >6 months follow-up MDCTA examinations were retrospectively investigated. MDCTA analysis included AAA diameter and the periaortic adipose tissue attenuation index (PAAI). The PAAI was defined as the mean CT attenuation value within a predefined range from -190 to -30 Hounsfield units of adipose tissue surrounding the AAA. The growth rate of the AAA was calculated as the change in diameter. AAA progression (AP) was defined as an AAA growth rate ≥5 mm/year. Univariate and multivariate logistic regression analysis were performed to determine the predictors of AP. AP was observed in 19 patients (24.7%), the median baseline AAA diameter was 38.9 mm (interquartile range [IQR] 32.7-42.9 mm), and the median growth rate was 3.1 mm/year (IQR 1.5-4.9 mm/year). Baseline AAA diameter (odds ratio [OR] 1.16; 95% confidence interval [CI] 1.05-1.28; P=0.001) and PAAI (OR 1.12; 95% CI 1.05-1.20; P=0.004) were independent predictors of AP. CONCLUSIONS: PAAI was an independent and significant predictor of AP, supporting the notion that local adipose tissue inflammation may contribute to aortic remodeling.

First-degree atrioventricular block is significantly associated with incident atrial fibrillation in the population predominantly including participants aged ≥ 60 years.

Some previous studies demonstrated that first-degree atrioventricular block (f-AVB) was associated with incident atrial fibrillation (AF), while evidence is scarce regarding the association between f-AVB and incident AF in older populations. Therefore, we sought to investigate the association of f-AVB with incident AF in the population predominantly including participants aged ≥ 60 years. Eligible participants were residents in Kanazawa City, Japan aged ≥ 40 years who underwent 12-lead ECG at the National Japanese Health Check-up in 2013. Participants with AF detected at the baseline exam and those without adequate follow-up were excluded. f-AVB was defined as PR interval ≥ 220 ms based on the Minnesota code (6-3). The cumulative incidence of AF was estimated by the Kaplan-Meier curve analysis, and statistical significance was evaluated by the Log-rank test. Unadjusted and adjusted hazard ratios (HRs) were computed by Cox proportional hazard models. HRs were adjusted for conventional risk factors for AF. 37,730 participants (mean age, 72.3 ± 9.6 years; male, 37%) were included. Baseline f-AVB was observed in 667 (1.8%) participants. During the median follow-up period of 5 years (interquartile range, 4.0-5.0 years), 691 cases of incident AF were observed. A 5-year cumulative incidence of AF was significantly higher in f-AVB (+) group compared with f-AVB (-) group (6.8% vs 2.1%, p < 0.01). In the fully adjusted model, f-AVB was significantly associated with incident AF (HR, 1.75; 95% confidence interval 1.25-2.45; p value < 0.01). f-AVB was independently associated with incident AF in the population predominantly including participants aged ≥ 60 years.

Impact of pericoronary adipose tissue inflammation on left ventricular hypertrophy and regional physiological indices in stable coronary artery disease patients with preserved systolic function.

Systemic low-grade inflammation has been shown to be associated with left ventricular hypertrophy (LVH). However, the relationship between pericoronary adipose tissue attenuation (PCATA) and both LVH and regional physiological indices remains unknown. This study aimed to evaluate the association of PCATA with LVH and regional physiological indices in stable coronary artery disease (CAD) patients with preserved systolic function. A total of 114 CAD patients who underwent coronary CT angiography (CTA) and invasive physiological tests showing ischemia due to a single de novo lesion were included in the study. On proximal 40-mm segments of all three major coronary vessels on CTA, PCATA was assessed by the crude analysis of the mean CT attenuation value [- 190 to - 30 Hounsfield units [HU)] and the culprit vessel PCATA was used for the analysis. Regional physiological indices were invasively obtained by pressure-temperature sensor-tipped wire. The patients were divided into three groups by culprit vessel PCATA tertiles, and clinical, CTA-derived, and physiological indices were compared. Univariable and multivariable analyses were further performed to determine the predictors of LVH. Angiographic stenosis severity, culprit lesion locations, culprit vessel fractional flow reserve, coronary flow reserve, index of microcirculatory resistance, total and target vessel coronary calcium score, and biomarkers including high-sensitivity C-reactive protein were not different among the groups. The left ventricular (LV) mass, LV mass index (LVMI), and LV mass at risk were all significantly different in the three groups with the greatest values in the highest tertile group (all, P < 0.05). On multivariable analysis, male gender, NT-proBNP, and PCATA were independent predictors of LVMI. Culprit vessel PCATA was significantly associated with LVMI, but not with regional physiology in CAD patients with functionally significant lesions and preserved systolic function. Our results may offer insight into the pathophysiological mechanisms linking pericoronary inflammation and LVH to worse prognosis.

Effects of an mHealth App (Kencom) With Integrated Functions for Healthy Lifestyles on Physical Activity Levels and Cardiovascular Risk Biomarkers: Observational Study of 12,602 Users.

BACKGROUND: Mobile health (mHealth) apps are considered to be potentially powerful tools for improving lifestyles and preventing cardiovascular disease (CVD), although only few have undergone large, well-designed epidemiological research. "kencom" is a novel mHealth app with integrated functions for healthy lifestyles such as monitoring daily health/step data, providing tailored health information, or facilitating physical activity through group-based game events. The app is linked to large-scale Japanese insurance claims databases and annual health check-up databases, thus comprising a large longitudinal cohort. OBJECTIVE: We aimed to assess the effects of kencom on physical activity levels and CVD risk factors such as obesity, hypertension, dyslipidemia, and diabetes mellitus in a large population in Japan. METHODS: Daily step count, annual health check-up data, and insurance claim data of the kencom users were integrated within the kencom system. Step analysis was conducted by comparing the 1-year average daily step count before and after kencom registration. In the CVD risk analysis, changes in CVD biomarkers following kencom registration were evaluated among the users grouped into the quintile according to their change in step count. RESULTS: A total of 12,602 kencom users were included for the step analysis and 5473 for the CVD risk analysis. The participants were generally healthy and their mean age was 44.1 (SD 10.2) years. The daily step count significantly increased following kencom registration by a mean of 510 steps/day (P<.001). In particular, participation in "Arukatsu" events held twice a year within the app was associated with a remarkable increase in step counts. In the CVD risk analysis, the users of the highest quintile in daily step change had, compared with those of the lowest quartile, a significant reduction in weight (-0.92 kg, P<.001), low-density lipoprotein cholesterol (-2.78 mg/dL, P=.004), hemoglobin A1c (HbA1c; -0.04%, P=.004), and increase in high-density lipoprotein cholesterol (+1.91 mg/dL, P<.001) after adjustment of confounders. CONCLUSIONS: The framework of kencom successfully integrated the Japanese health data from multiple data sources to generate a large, longitudinal data set. The use of the kencom app was significantly associated with enhanced physical activity, which might lead to weight loss and improvement in lipid profile.

Optical coherence tomography-defined plaque vulnerability in relation to functional stenosis severity stratified by fractional flow reserve and quantitative flow ratio.

OBJECTIVES: We sought to investigate that the quantitative flow ratio (QFR) might be associated with optical coherence tomography (OCT)-defined plaque vulnerability. BACKGROUND: Both functional stenosis severity and plaque instability are related to adverse clinical outcomes in patients with coronary artery disease. Recent studies have shown an association between physiological stenosis severity and the presence of thin-cap fibroatheroma (TCFA). Measurement of QFR is a novel method for rapid computational estimation of fractional flow reserve (FFR). METHODS: We investigated 327 de novo intermediate-to-severe coronary lesions in 295 stable patients who underwent OCT, FFR, and QFR computation. The lesions were divided into tertiles based on either the FFR or QFR. The OCT findings were compared among these tertiles of FFR and QFR. Each tertile was defined as follows: FFR-T1 (FFR < 0.72), FFR-T2 (0.72 ≤ FFR ≤ 0.79), and FFR-T3 (FFR > 0.79) and QFR-T1 (QFR < 0.73), QFR-T2 (0.73 ≤ QFR ≤ 0.78), and QFR-T3 (QFR > 0.78). RESULTS: The prevalence of OCT-defined TCFA showed graded differences in proportion to the QFR tertiles (25.0% vs. 12.8% vs. 6.6%, p = .003). An overall significant difference in the prevalence of TCFA was found among FFR tertiles (p = .048), although pairwise comparison did not show statistical significance. Compared with FFR-based classifications, the model that integrated the FFR and QFR categorization improved the incremental reclassification efficacy (relative integrated discrimination improvement, 0.069; p = .002; continuous net reclassification improvement, 0.356; p = .022) for predicting the presence of TCFA. CONCLUSIONS: OCT-defined plaque instability was associated with the QFR in angiographically intermediate-to-severe lesions. Compared with the FFR alone, the QFR can provide incremental efficacy in predicting the presence of TCFA.

Clinical significance of the presence of puff-chandelier ruptures detected by nonobstructive aortic angioscopy.

OBJECTIVE: This study aimed to investigate the prevalence and prognostic significance of atherosclerotic aortic plaques (AAPs) or specific AAP types detected by nonobstructive angioscopy (NOA) in patients who underwent percutaneous coronary intervention (PCI). BACKGROUND: Although recent studies have reported the presence of various patterns of AAPs, identified by NOA, the clinical significance of the presence of AAPs remains elusive. METHODS: In this retrospective, multicenter cohort study, a total of 167 patients who underwent PCI and intra-aortic scans with NOA were studied. The association between AAPs and the incidence of major adverse cardiac events (MACEs), including cardiac death, myocardial infarction, stroke, and clinically driven unplanned revascularizations, was assessed. RESULTS: AAPs were detected in 126 patients (75%) who underwent NOA. MACEs occurred in 28 (17%) patients during the follow-up (median 2.9 years [range 2.1-3.8]). Among all types of AAPs, only puff-chandelier rupture (PCR) showed a significant difference in frequency between patients with and those without MACEs: 21 (75%) and 49 (35%), respectively (p < .001). Multivariable Cox proportional hazard analysis revealed that PCR (hazard ratio [HR] 3.73, 95% confidence interval [CI] 1.57-8.87, p = .004) and chronic kidney disease (HR 2.97, 95% CI 1.37-6.44, p = .010) were independent predictors of MACEs. Kaplan-Meier analysis revealed that PCR was significantly associated with more frequent MACEs. CONCLUSION: The detection of PCR in the aorta using NOA was significantly associated with an increased risk of subsequent adverse events after PCI.

All Resting Physiological Indices May Not Be Equivalent　- Comparison Between the Diastolic Pressure Ratio and Resting Full-Cycle Ratio.

BACKGROUND: Differences between resting full-cycle ratio (RFR) and diastolic pressure ratio (dPR) have not been sufficiently discussed. This study aimed to investigate if there is a difference in diagnostic performance between RFR and dPR for the functional lesion assessment and to assess if there are specific characteristics for discordant revascularization decision-makings between RFR and dPR.Methods and Results:A total of 936 intermediate lesions in 776 patients who underwent measurements of fractional flow reserve (FFR), coronary flow reserve (CFR), and the index of microcirculatory resistance (IMR) were retrospectively studied. Physiological indices were measured from anonymized pressure recordings at an independent core laboratory. Both RFR and dPR measures were highly correlated (r=0.997, P<0.001), with equivalent diagnostic performance relative to FFR-based decision-makings measured by using a dichotomous threshold of 0.80 (accuracy, 79.7% vs. 80.1%, respectively, P=0.960). The rate of diagnostic discordance was 4.7% (44/936), with no RFR-/dPR+ lesions observed. An overall significant difference in FFR and CFR values were detected among RFR/dPR-based classifications. The prevalence of positive studies was significantly higher for RFR than dPR (54.3% vs. 49.6%, respectively, P=0.047) when using the cut-off value of 0.89. CONCLUSIONS: Both RFR and dPR were highly correlated, but the prevalence of positive studies was significantly different. The revascularization rate may differ significantly according to the resting index used.

Defining heterogeneity of epicardial functional stenosis with low coronary flow reserve by unsupervised machine learning.

Low CFR is associated with poor prognosis, whereas it is a heterogeneous condition according to the actual coronary flow, such as high resting or low hyperemic coronary flow, which should have different physiological traits and clinical implications. This study aimed to detect and define the sub-phenotypes of vessels with low coronary flow reserve (CFR) epicardial disease by unsupervised machine-learning methods. Hierarchical clustering was applied to 376 vessels from 364 patients with CFR less than the median and fractional flow reserve ≤ 0.8 from a global, multicenter registry. Detailed features of coronary flow physiology and survivals from vessel-oriented composite outcomes (VOCO) were assessed according to the clusters. Clustering defined three distinct physiological subgroups (PS). PS1 (n = 151) were characterized by high resting coronary flow, dominantly left anterior descending artery (LAD) lesions. PS2 (n = 131) were, in contrast, low hyperemic coronary flow, mainly LAD lesions. PS3 (n = 82) mostly consisted of non-LAD lesions with similar flow status to PS1 except for the low hyperemic Pd. Survivals from VOCO were significantly different according to the clusters (p = 0.005) and PS3 had the highest rate of VOCO. In a COX proportional model predicting VOCO, there was a significant interaction between PCI and PSs, suggesting potentially different effects of PCI on outcome between PS1 and PS2. The unsupervised machine-learning approaches provided unique insights into low CFR condition. Among low CFR epicardial lesions, high resting flow with low hyperemic Pd might be related to poor prognosis, and low hyperemic flow in LAD could benefit from elective PCI. CLINICAL TRIAL REGISTRATION INFORMATION: https://clinicaltrials.gov/ct2/show/NCT03690713 , NCT03690713.

Circulatory dynamics changes are an additional predictor of successful pulmonary vein isolation during cryoballoon ablation.

The association between circulatory dynamics changes during cryoballoon applications and a successful pulmonary vein isolation (PVI) is unknown. Seventy atrial fibrillation patients who underwent PVI with 28-mm second-generation cryoballoons and single 3-min freezes were included. Intra-procedural parameters including circulatory dynamics changes during cryoapplications, were compared between 113 successful applications (30 left superior PVs[LSPVs], 30 left inferior PVs[LIPVs], 25 right superior PVs[RSPVs], and 28 right inferior PVs[RIPVs]) and 47 failed applications (10 LSPVs, 9 LIPVs, 8 RSPVs, and 20 RIPVs). In all individual PVs, lower nadir balloon temperatures (MinTemps) and longer thawing times (ThawTimes) significantly predicted a successful PVI. In addition, greater systolic blood pressure drops following releasing the PV occlusion (SBP-drops) significantly predicted a successful right PV PVI, and longer elapse times during SBP-drops significantly predicted a successful RIPV PVI. Composite parameters incorporating MinTemps and ThawTimes, SBP-drops, and ThawTimes showed the highest area under the curve to predict a successful left PV (0.876 for LSPVs, 0.851 for LIPVs) and right PV (0.927 for RSPVs, 0.980 for RIPVs) PVI, respectively. If the ThawTime (≥ 30 s) and SBP-drop (≤ - 21 mmHg) cutoff values were achieved for the RIPVs, the positive predictive value was 100%. In contrast, if both criteria were not achieved for the RIPVs, the negative predictive value was 100%. In the second-generation cryoballoon PVI, the MinTemp and ThawTime were significantly associated with acute success for all four PVs. In addition, SBP-drops further improved the accuracy of predicting a successful right PV PVI, especially of the RIPV.

Prognostic implication of global myocardial blood flow in patients with ST-segment elevation myocardial infarction.

The prognostic implications of cardiovascular magnetic resonance imaging (CMR)-derived hyperemic myocardial blood flow (MBF) in patients with ST-elevation myocardial infarction (STEMI) are unknown. This study sought to investigate the incremental prognostic value of hyperemic MBF over conventional CMR markers to identify patients with high risk of future incidence of patient-oriented composite outcomes (POCO) and major adverse cardiac events (MACE) after STEMI. A total of 237 patients who presented with STEMI were prospectively enrolled. The CMR protocol included left-ventricular ejection fraction (LVEF), late gadolinium enhancement (LGE) and microvascular obstruction (MVO) measurement, and volumetric MBF assessment. During a median follow-up of 2.6 years, 47 patients experienced POCO (primary outcome) and 21 patients had MACE. In a multivariable model, multivessel disease, LGE, MVO, and hyperemic MBF were independently associated with POCO. Addition of hyperemic MBF to the model consisting of GRACE score, multivessel disease, LVEF, LGE, and MVO significantly improved the predictive efficacy (integrated discrimination improvement 0.020, p = 0.021). Patients with low hyperemic MBF had significantly higher incidence of MACE compared to those with high hyperemic MBF in propensity score matching analysis (p = 0.018). In conclusion, CMR-derived hyperemic MBF could provide independent and incremental prognostic value over LVEF, LGE, and MVO in patients with STEMI.

Prognostic Value of Phase-Contrast Cine-Magnetic Resonance Imaging-Derived Global Coronary Flow Reserve in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome Treated With Urgent Percutaneous Coronary Intervention.

BACKGROUND: Phase-contrast cine-magnetic resonance imaging (PC-CMR) of the coronary sinus (CS) is a promising approach for quantifying coronary sinus flow (CSF) and global coronary flow reserve (G-CFR). We evaluated the prognostic value of G-CFR using PC-CMR in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS).Methods and Results:The study prospectively enrolled 116 NSTE-ACS patients who underwent uncomplicated urgent PCI within 48 h of symptom onset. Post-PCI (median, 20 days) PC-CMR images of the CS were acquired to assess absolute CSF at rest and during maximum hyperemia. The association of G-CFR with major adverse cardiac events (cardiac death, nonfatal myocardial infarction, late revascularization, or hospitalization for congestive heart failure) was investigated. Rest and maximal hyperemic CSF and corrected G-CFR were 1.27 [interquartile range, 0.79-1.73] mL/min/g, 2.95 [2.02-3.84] mL/min/g, and 2.42 [1.69-3.34], respectively. At a median follow-up of 17 months, cardiac event-free survival was significantly worse in patients with a corrected G-CFR <2.33 (log-rank χ2=19.5, P<0.001). Cox proportional-hazards analysis showed that corrected G-CFR (hazard ratio, 0.434, 95% CI, 0.270-0.699, P<0.001) and NT-pro BNP at admission (hazard ratio, 1.0001, 95% CI, 1.0000-1.0001, P=0.007) were independent predictors of adverse cardiac events during follow-up. CONCLUSIONS: In NSTE-ACS patients successfully revascularized within 48 h of onset, post-PCI PC-CMR-derived G-CFR provided significant prognostic information independent of infarct size and conventional risk scores.

Interrelationship in the prognostic efficacy of regional coronary flow reserve, fractional flow reserve, high-sensitivity cardiac troponin-I and NT-proBNP in patients with stable coronary artery disease.

This study aimed to investigate the combined efficacy in prediction of major adverse cardiac events (MACE) by coronary regional physiological indices including coronary flow reserve (CFR) or fractional flow reserve (FFR) and high-sensitivity cardiac troponin-I (hs-cTnI) or N-terminal pro brain natriuretic peptide (NT-proBNP). Impaired CFR, decreased FFR, elevated cardiac troponin, and NT-proBNP are all associated with increased MACE, while these interaction or collinearity remains uncertain. The study included 429 patients with stable coronary artery disease (CAD) evaluated hs-cTnI and NT-proBNP levels before regional physiological measurement during coronary angiography. Patients were followed up for MACE including all-cause death, myocardial infarction, hospital admission for heart failure and target vessel remote revascularization. Median hs-cTnI and NT-proBNP values were 4 ng/L and 85 ng/L, respectively. Regional CFR was significantly albeit weakly correlated with hs-cTnI and NT-proBNP, while fractional flow reserve (FFR) was only linked to hs-cTnI. The addition of hs-cTnI and NT-proBNP on clinical backgrounds and angiographic score significantly improved predictive accuracy for MACE incidence, and further consideration of FFR and CFR could refine the model. The combined stratification using hs-cTnI, NT-proBNP, FFR and CFR could efficiently stratify patient risk for MACE. In patients with stable CAD, integrated assessment of cardiac biomarkers and physiological indices could be useful for predicting future cardiovascular events.

Electrocardiographic morphology of multiple ventricular arrhythmias originating from the right ventricular outflow tract: inverse correlation of the amplitude in the inferior leads and anatomic height of the origin.

It is unclear whether the electrocardiogram amplitude in the inferior leads (Amp-I) can always predict the height of the origin of right ventricular outflow tract arrhythmias (RVOT-VAs). We analyzed patients who received catheter ablation of multiple RVOT-VAs in the same session in our hospital from 2011 to 2016. Two distinguished RVOT-VAs, those with anatomically higher origins (HOs) and lower origins (LOs), were identified and compared to measure the longitudinal distance. Amp-I was uniquely determined for each OTVA as the highest amplitude in leads II, III, and aVF and compared between the HO-VAs and LO-VAs. In total, out of 187 patients who underwent catheter ablation of RVOT-VAs, 9 (4.8%) had multiple right OTVAs successfully treated. Four cases (Group A) had HO-VAs (10.8 ± 5.3 mm from an LO) with a lower Amp-I (1.28 ± 0.46 mV) than the LO-VAs (1.81 ± 0.59 mV), whereas the other 4 patients (Group B) had HO-VAs with a higher Amp-I (1.91 ± 0.23 mV) than the LO-VAs (1.26 ± 0.35 mV). In Group A, all HO-VAs originated from the lateral free wall and had notched R waves in the inferior leads, whereas all LOs with higher Amp-Is were located on the septum. In one patient, the HO and LO were at almost the same height, while a VA from a lateral origin had lower notched R waves in the inferior leads. A divided excitation from high lateral origins may result in not only QRS notching, but also a reduction in the QRS amplitude. In patients harboring multiple RVOT-VAs, VAs arising from the high lateral free wall could have lower Amp-Is than VAs from low septal origins.

High-sensitivity cardiac troponin decrease after percutaneous coronary intervention in patients with stable coronary artery disease.

Baseline cardiac troponin is a strong predictor of major adverse cardiac events (MACE), and the high sensitive assay can provide risk stratification under the 99th percentile values. Currently, prognostic benefit of PCI has not been established in patients with stable coronary artery disease (CAD), and the influence on baseline troponin levels is unknown. This study aimed to investigate the impact of PCI on baseline high-sensitivity cardiac troponin-I (hs-cTnI) levels and the association with MACE incidence. For 401 patients with stable CAD who were indicated for PCI, baseline hs-cTnI levels were measured before PCI for two times (the average: pre-PCI hs-cTnI) and 10 months after PCI (post-PCI remote hs-cTnI). Hs-cTnI day-to-day variability was assessed based on the pre-PCI values and patients were divided into three groups (Increase/No change/Decrease group) according to the extent of hs-cTnI change (post-PCI remote hs-cTnI minus pre-PCI hs-cTnI) considering the day-to-day variability. A total of 77 patients were categorized into Decrease group. Although Decrease group had significantly higher pre-PCI hs-cTnI levels compared to the other groups, this group had lowest incidence of MACE (p < 0.001). Hs-cTnI changes were independently associated with MACE incidence after adjustment (HR 2.069, 95% CI 1.032-4.006, p = 0.041 for Increase group vs. No change group; HR 0.143, 95% CI 0.008-0.680, p = 0.009 for Decrease group vs. No change group). Hs-cTnI change following PCI was significantly predicted by pre-PCI hs-cTnI, hs-cTnI variability, the presence of dyslipidemia, multivessel disease, and lesions with chronic total occlusion or low quantitative flow ratio. In conclusion, PCI could lower hs-cTnI levels in a certain subset of patients, in whom prognostic benefit might be expected by the intervention.

Impact of Transradial Catheterization on Vascular Function of the Brachial Artery Assessed by Flow-Mediated Dilatation.

BACKGROUND: Few studies have evaluated long-term vascular function after radial access catheterization. Furthermore, the impact of repeated catheterization remains unknown. We investigated flow-mediated dilatation (FMD) of the brachial artery after transradial catheterization. METHODS: We prospectively enrolled 50 patients with suspected coronary artery disease referred for diagnostic coronary angiography. No ad-hoc percutaneous coronary interventions (PCI) had been performed at the time of the index procedure. In 30 patients (63.8%), PCI and/or repeated follow-up diagnostic catheterization were subsequently performed via the radial artery used at the index catheterization. FMD was successfully measured before catheterization, at 24 h after catheterization, and after long-term follow-up (mean, 32 months; range, 24-43) in 47 patients. FMD at follow-up was compared between patients receiving only one procedure and those receiving multiple procedures via the same arteries. RESULTS: FMD was significantly decreased after catheterization and recovered well in long-term follow-up (3.7 ± 1.6%, 3.0 ± 1.7%, and 3.9 ± 1.6%). There was no significant difference in follow-up FMD between the patients undergoing single catheterization and those with multiple procedures (3.4 ± 1.3 vs. 4.3 ± 1.7, p = 0.06). When the patients were divided into two groups according to the median follow-up FMD value, no significant predictive factor was identified for worse FMD. CONCLUSIONS: After transradial catheterization, FMD of the brachial artery temporarily decreased but recovered in long-term follow-up. Recovery of FMD was not jeopardized by repeated catheterization, which suggests the potential of the brachial artery to recover endothelial function after repeated transradial procedures.