Impact of a Cancer History on Cardiovascular Events Among Patients With Myocardial Infarction Who Received Revascularization.

BACKGROUND: It remains controversial whether a cancer history increases the risk of cardiovascular (CV) events among patients with myocardial infarction (MI) who undergo revascularization.Methods and Results: Patients who were confirmed as type 1 acute MI (AMI) by coronary angiography were retrospectively analyzed. Patients who died in hospital or those not undergoing revascularization were excluded. Patients with a cancer history were compared with those without it. A cancer history was examined in the in-hospital cancer registry. The primary outcome was a composite of cardiac death, recurrent type 1 MI, post-discharge coronary revascularization, heart failure hospitalization, and stroke. Among 551 AMI patients, 55 had a cancer history (cancer group) and 496 did not (non-cancer group). Cox proportional hazards model revealed that the risk of composite endpoint was significantly higher in the cancer group than in the non-cancer group (adjusted hazard ratio [HR]: 1.78; 95% confidence interval [CI]: 1.13-2.82). Among the cancer group, patients who were diagnosed as AMI within 6 months after the cancer diagnosis had a higher risk of the composite endpoint than those who were diagnosed as AMI 6 months or later after the cancer diagnosis (adjusted HR: 5.43; 95% CI: 1.55-19.07). CONCLUSIONS: A cancer history increased the risk of CV events after discharge among AMI patients after revascularization.

The observation of below-the-knee artery by optical frequency domain image and angioscopy: a case series.

Background: Endovascular treatment (EVT) is a well-established treatment for patients with chronic limb-threatening ischaemia, and below-the-knee (BTK) artery is its main target, although the re-intervention rate is still high. Understanding of the characteristics of BTK artery atherosclerosis would be required to overcome this issue. In this case series, we elucidated the characteristics of non-stenotic BTK artery atherosclerosis in the patients who received EVT of the superficial femoral artery (SFA) using optical frequency domain imaging (OFDI) and angioscopy. Case summary: We presented five patients who underwent EVT of SFA and subsequent observation of ipsilateral BTK artery using OFDI and angioscopy. Patients one and two had advanced atherosclerosis; however, patients three, four, and five had only mild atherosclerosis. Discussion: All patients had multiple risk factors for atherosclerosis and stenosis/occlusion of the SFA and ipsilateral BTK arteries. Furthermore, some patients had several other atherosclerotic vascular diseases suggesting the presence of advanced systemic atherosclerosis. On the other hand, some patients with multiple BTK artery stenosis/occlusion did not have advanced atherosclerosis in the examined BTK artery. The absence of significant atherosclerosis in a BTK artery in patients with multiple stenoses or occlusion in other ipsilateral BTK arteries may suggest some mechanism of vessel occlusion other than atherosclerosis. Further investigations are needed to clarify the mechanism.

Prognostic Impact of Echocardiographic Congestion Grade in HFpEF With and Without Atrial Fibrillation.

Background: Atrial fibrillation (AF) is common in heart failure with preserved ejection fraction (HFpEF). Objectives: This study aimed to investigate the prognostic value of echocardiographic markers of congestion that can be applied to both AF and patients without AF with HFpEF. Methods: We conducted a multicenter study of 505 patients with HFpEF admitted to hospitals for acute decompensated heart failure. The ratio of early diastolic transmitral flow velocity to mitral annulus velocity (E/e'), the tricuspid regurgitation peak velocity, and the collapsibility of the inferior vena cava were obtained at discharge. Congestion was determined by echocardiography if any one of E/e' ≥14 (E/e' ≥11 for AF), tricuspid regurgitation peak velocity ≥2.8 m/s, or inferior vena cava collapsibility <50% was positive. We classified patients into grade A, grade B, and grade C according to the number of positive congestion indices. The primary endpoint was the composite of cardiovascular death and heart failure hospitalization. Results: During the follow-up period (median: 373 days), 162 (32%) patients experienced the primary endpoint. Grade C patients had a higher risk for the primary endpoint than grade A (HR: 2.98; 95% CI: 1.97-4.52) and grade B patients (HR: 1.92; 95% CI: 1.29-2.86) (log-rank P < 0.0001). Echocardiographic congestion grade improved the predictive value when added to the age, sex, New York Heart Association functional class, and N-terminal pro-B-type natriuretic peptide, not only in sinus rhythm (Uno C-statistic: 0.670 vs 0.655) but in AF (Uno C-statistic: 0.667 vs 0.639). Conclusions: Echocardiographic congestion grade has prognostic value in patients with HFpEF with and without AF.

Temporary Rise in Blood Thrombogenicity in Patients with Acute Myocardial Infarction.

Objective Although blood thrombogenicity seems to be one of the determinant factors for the development of acute myocardial infarction (MI), it has not been dealt with in-depth. This study aimed to investigate blood thrombogenicity and its change in acute MI patients. Methods and Results We designed a prospective, observational study that included 51 acute MI patients and 83 stable coronary artery disease (CAD) patients who underwent cardiac catheterization, comparing thrombogenicity of the whole blood between: (1) acute MI patients and stable CAD patients; and (2) acute and chronic phase in MI patients. Blood thrombogenicity was evaluated by the Total Thrombus-Formation Analysis System (T-TAS) using the area under the flow pressure curve (AUC 30 ) for the AR-chip. Acute MI patients had significantly higher AUC 30 than stable CAD patients (median [interquartile range], 1,771 [1,585-1,884] vs. 1,677 [1,527-1,756], p = 0.010). Multivariate regression analysis identified acute MI with initial TIMI flow grade 0/1 as an independent determinant of high AUC 30 ( ß = 0.211, p = 0.013). In acute MI patients, AUC 30 decreased significantly from acute to chronic phase (1,859 [1,550-2,008] to 1,521 [1,328-1,745], p = 0.001). Conclusion Blood thrombogenicity was significantly higher in acute MI patients than in stable CAD patients. Acute MI with initial TIMI flow grade 0/1 was significantly associated with high blood thrombogenicity by multivariate analysis. In acute MI patients, blood thrombogenicity was temporarily higher in acute phase than in chronic phase.

Out-of-hospital cardiac arrest due to acute myocardial infarction possibly caused by coronary vasospasm.

A 60-year-old man with out-of-hospital cardiac arrest was transported to our hospital by an emergency medical service. Ventricular fibrillation was finally terminated after the initiation of circulation support by percutaneous cardiopulmonary support device. Although acute myocardial infarction was suspected, emergency coronary angiography could not identify the culprit lesion of myocardial infarction while there were multiple intermediate stenotic lesions. Since re-elevation of troponin I was recorded on the 4th day after admission, coronary angiography was performed again, and diffuse severe stenosis in the right coronary artery and total occlusion in the left circumflex coronary artery that disappeared by the injection of isosorbide dinitrate was detected. Therefore, we reached the diagnosis of acute myocardial infarction due to coronary vasospasm. It is very rare that emergency coronary angiogram reveals coronary vasospasm at the culprit lesion of myocardial infarction. The guideline recommends calcium channel antagonist and long-acting nitrates for vasospastic angina; however, it would be really difficult to make correct diagnosis of coronary vasospasm among the patients with acute myocardial infarction or out-of-hospital cardiac arrest. Repeated measurements of troponin and coronary angiography identified the cause of acute myocardial infarction as coronary vasospasm in the present case. .

Transient increase in blood thrombogenicity may be a critical mechanism for the occurrence of acute myocardial infarction.

Although the mechanism for the occurrence of acute myocardial infarction (MI) has been investigated by many pathological and clinical studies, it has not been adequately clarified yet. Although the disruption of vulnerable plaque is a well-known cause of acute MI, there are many silent plaque disruptions detected in the coronary artery by intravascular imaging studies. Therefore, many vulnerable plaques may disrupt and heal without causing acute MI. Some additional mechanisms other than the disruption of vulnerable plaque would be essential for the onset of acute MI. On the other hand, blood thrombogenicity would change dynamically due to circadian rhythms and many other factors. The combination of plaque and blood thrombogenicity would play an important and determinant role for the onset of acute MI.

Clinical and Angiographic Features of Patients With Out-of-Hospital Cardiac Arrest and Acute Myocardial Infarction.

BACKGROUND: Sudden cardiac arrest is a serious complication of acute myocardial infarction (MI). Although in-hospital mortality from MI has decreased, the mortality of MI patients complicated with out-of-hospital cardiac arrest (OHCA) remains high. However, the features of acute MI patients with OHCA have not been well known. OBJECTIVES: We sought to characterize the clinical and angiographic features of acute MI patients with OHCA comparing with those without OHCA. METHODS: We retrospectively analyzed 480 consecutive patients with acute MI undergoing percutaneous coronary intervention. Patients complicated with OHCA were compared with patients without OHCA. RESULTS: Of the patients, 141 (29%) were complicated with OHCA. Multivariate analysis revealed that age (odds ratio [OR]: 0.8; 95% confidence interval [CI]: 0.7 to 0.9 per 5 years; p < 0.001), estimated glomerular filtration rate (OR: 0.8; 95% CI: 0.7 to 0.8 per 10 ml/min/1.73 m2; p < 0.001), peak creatine kinase-myocardial band (OR: 1.3; 95% CI: 1.2 to 1.4 per 102 U/l; p < 0.001), calcium-channel antagonists use (OR: 0.4; 95% CI: 0.2 to 0.7; p = 0.002), the culprit lesion at the left main coronary artery (OR: 5.3; 95% CI: 1.9 to 15.1; p = 0.002), and the presence of chronic total occlusion (OR: 2.9; 95% CI: 1.5 to 5.7; p = 0.001) were significantly associated with OHCA. CONCLUSIONS: Younger age, no use of calcium-channel antagonists, worse renal function, larger infarct size, culprit lesion in the left main coronary artery, and having chronic total occlusion were associated with OHCA.

Prognostic impact of nutritional status and physical capacity in elderly patients with acute decompensated heart failure.

AIMS: Nutritional status as well as physical capacity is related to prognosis in patients with heart failure. The purpose of this study was to explore a simple prognostic indicator in patients with acute decompensated heart failure (ADHF) by including both nutritional status and physical capacity. METHODS AND RESULTS: Patients hospitalized with ADHF (N = 203; mean age, 81 years) were enrolled. We evaluated the geriatric nutritional risk index (GNRI) on hospital admission and at discharge. A GNRI score < 92 was defined as malnutrition. Physical capacity was evaluated by simple walking test to determine if patients could walk 200 m, with a Borg scale score ≤ 13, without critical changes in vital signs. Primary endpoints were mortality and heart failure rehospitalization within 2 years. A total of 49% and 48% of patients showed malnutrition on admission and at discharge, respectively. Malnutrition at discharge was more strongly related to mortality [hazard ratio (HR) 3.382, 95% confidence interval (CI) 1.900-6.020, P < 0.0001)] than that on admission (HR 2.448, 95% CI 1.442-4.157, P = 0.001) by univariable analysis. Malnutrition at discharge was related to mortality (HR 2.370, 95% CI 1.166-4.814, P = 0.02), but malnutrition on admission was not related (HR 1.538, 95% CI 0.823-2.875, P = 0.18) by multivariable analysis. Almost half of patients (45%) could not walk 200 m, which was significantly related to mortality by univariable analysis (HR 3.303, 95% CI 1.905-5.727, P < 0.0001), but was not by multivariable analysis (HR 1.990, 95% CI 0.999-3.962, P = 0.05). The combined index including both GNRI and simple walking test was an independent and stronger predictor of mortality than either index alone by multivariable analysis (HR 2.249, 95% CI 1.362-3.716, P < 0.01). Neither malnutrition nor low physical capacity was related to heart failure rehospitalization by univariable analysis (HR 0.702, 95% CI 0.483-1.020, P = 0.06; HR 1.047, 95% CI 0.724-1.515, P = 0.81, respectively). Malnutrition at discharge significantly reduced heart failure rehospitalization by multivariable analysis (HR 0.431, 95% CI 0.266-0.698, P < 0.01). When patients were classified into Group G (both nutritional status and physical capacity at discharge were good), Group E (either was good), and Group B (both were bad), mortality rates were significantly different among the groups (log rank P < 0.0001). CONCLUSION: A simple indicator including both nutritional status and physical capacity may predict 2 year mortality in elderly patients with ADHF.

Relation of Chronic Total Occlusion to In-Hospital Mortality in the Patients With Sudden Cardiac Arrest Due to Acute Coronary Syndrome.

Although the presence of chronic total occlusion (CTO) has been associated with long-term mortality in the patients with ST-segment elevation myocardial infarction, the influence of having CTO on in-hospital mortality in sudden cardiac arrest (SCA)-acute coronary syndrome (ACS) patients has not been reported. Therefore, we examined the association between the presence of CTO and in-hospital mortality in those patients. Consecutive 106 SCA-ACS patients who received coronary angiography were retrospectively included. The factors associated with in-hospital mortality were analyzed. Among 106 patients, 40 (38%) patients died during hospitalization. Multivariate analysis revealed presence of CTO dependent on infarct-related artery (IRA-dependent-CTO) (hazard ratio [HR] = 2.88, p = 0.004), diabetes mellitus (HR = 2.04, p = 0.044), percutaneous cardiopulmonary support use (HR = 2.22, p = 0.045), successful recanalization (HR = 0.31, p = 0.004), and peak creatine kinase muscle-brain fraction (HR = 1.11, p < 0.001) were significantly associated with mortality. In conclusion, presence of IRA-dependent-CTO was significantly associated with in-hospital mortality in SCA-ACS patients.

Feasibility of late gadolinium enhancement magnetic resonance imaging to detect ablation lesion gaps in patients undergoing cryoballoon ablation of paroxysmal atrial fibrillation.

BACKGROUND: Although late gadolinium enhancement magnetic resonance imaging (LGE-MRI) allows the identification of lesions and gaps after a cryothermal balloon (CB) ablation of paroxysmal atrial fibrillation (PAF), the accuracy has not yet been well established. METHODS: The subjects consisted of 10 consecutive patients who underwent a second ablation procedure among our cohort of 80 patients who underwent LGE-MRI after the CB ablation of PAF. LGE-MRI scar regions were compared with electroanatomical mapping during the second procedure. In the analysis, the unilateral pulmonary vein (PV) antrum was divided into 7 regions. RESULTS: The gap characterization analysis was performed in 140 regions around 40 PVs in total. There were 16 LGE-MRI gaps around 11 PVs (mean 1.6 ± 1.4 gaps/patient) in 7 patients and 14 electrical gaps around 10 PVs in 8 patients (mean 1.4 ± 1.1 gaps/patient). The locations of 13 electrical gaps were well matched to that on the LGE-MRI, whereas the remaining 1 electrical gap had not been predicted on the LGE-MRI. Compared to the electrical gaps in the second procedure, the sensitivity and specificity of the LGE-MRI gaps were 93% (13 LGE-MRI gaps of 14 electrical gaps) and 98% (123 LGE-MRI scars out of 126 electrical scars), respectively. CONCLUSION: LGE-MRI can accurately localize the lesion gaps after CB ablation of PAF.

Multicenter Study of the Validity of Additional Freeze Cycles for Cryoballoon Ablation in Patients With Paroxysmal Atrial Fibrillation: The AD-Balloon Study.

BACKGROUND: Pulmonary vein isolation (PVI) is a cornerstone of catheter ablation in patients with paroxysmal atrial fibrillation, and balloon-based ablation has been recently performed worldwide. The second-generation cryoballoon (CB2) ablation has proven to be highly effective in achieving freedom from paroxysmal atrial fibrillation. However, there are some debatable questions, including the ideal number of freeze cycles. METHODS: The AD-Balloon study (Multicenter Study of the Validity of Additional Freeze Cycles for Cryoballoon Ablation) was designed as a prospective, multicenter, and randomized clinical trial for investigation of the optimal strategy of freeze cycles for the CB2 ablation. One hundred and ten consecutive patients (aged 64±11 years) were randomly assigned to 2 groups after achieving a PVI by the CB2 ablation: 3-minute freeze cycles were added to each pulmonary vein (AD group: n=55) or not (non-AD group: n=55). Delayed-enhancement magnetic resonance imaging was also performed 1 to 2 months after the PVI to assess the ablation lesions. RESULTS: The patient characteristics did not differ between the 2 groups. A complete PVI was achieved in all patients. The total number of freeze cycles and durations for all pulmonary veins were significantly shorter in the non-AD group than in the AD group (5.7±1.6 versus 9.1±1.6 cycles, P<0.0001, and 932±244 versus 1483±252 seconds, P<0.0001). The cumulative freedom from any atrial tachyarrhythmia at 1 year was 87.3% in the AD group and 89.1% in the non-AD group (log-rank test P=0.78). There was no significant difference in the frequency of gaps on the PVI lines in the delayed-enhancement magnetic resonance imaging (46% in the AD group versus 36% in the non-AD group; P=0.38). CONCLUSIONS: No benefit was found in the patients receiving additional 3-minute freeze cycles after the complete PVI with the CB2 ablation, suggesting that an insurance freeze after achieving a PVI with the CB2 may be unnecessary and time consuming.

The role of successful catheter ablation in patients with paroxysmal atrial fibrillation and prolonged sinus pauses: outcome during a 5-year follow-up.

AIMS: Although patients with paroxysmal atrial fibrillation (AF) and prolonged sinus pauses [tachycardia-bradycardia syndrome (TBS)] are generally treated by permanent pacemaker, catheter ablation has been reported to be a curative therapy for TBS without pacemaker implantation. The purpose of this study was to define the potential role of successful ablation in patients with TBS. METHODS AND RESULTS: Of 280 paroxysmal AF patients undergoing ablation, 37 TBS patients with both AF and symptomatic sinus pauses (age: 62 ± 8 years; mean maximum pauses: 6 ± 2 s) were analysed. During the 5.8 ± 1.2 years (range: 5-8.7 years) follow-up, both tachyarrhythmia and bradycardia were eliminated by a single procedure in 19 of 37 (51%) patients. Repeat procedures were performed in 14 of 18 patients with tachyarrhythmia recurrence (second: 12 and third: 2 patients). During the repeat procedure, 79% (45 of 57) of previously isolated pulmonary veins (PVs) were reconnected to the left atrium. Pulmonary vein tachycardia initiating the AF was found in 46% (17 of 37) and 43% (6 of 14) of patients during the initial and second procedure, respectively. Finally, 32 (86%) patients remained free from AF after the last procedure. Three patients (8%) required pacemaker implantation, one for the gradual progression of sinus dysfunction during a period of 6.5 years and the others for recurrence of TBS 3.5 and 5.5 years after ablation, respectively. CONCLUSION: Catheter ablation can eliminate both AF and prolonged sinus pauses in the majority of TBS patients. Nevertheless, such patients should be continuously followed-up, because gradual progression of sinus node dysfunction can occur after a long period of time.