Atrial electrical remodeling and function after transcatheter aortic valve replacement in patients with aortic stenosis.

To examine reverse atrial electrical remodeling in patients with aortic stenosis (AS) after trans-catheter aortic valve replacement (TAVR). In 65 consecutive patients with severe AS (83 ± 4 years, 47 (72.3%) females), we analyzed ECG records for the P wave duration (PWD) in lead II and P-terminal force (PTFV1) in V1, and measured cardiac dimensions and function by echocardiography (ECHO) following TAVR. Biomarkers were measured to assess myocardial injury by TAVR. TAVR was successfully performed without major complications: the aortic valve area increased from 0.62 ± 0.14 cm2 to 1.52 ± 0.24cm2, and the trans-aortic pressure gradient decreased from 58.4 ± 15.9 mmHg to 15.0 ± 19.6 mmHg. PWD and PTFV increased immediately after TAVR and returned to the pre-TAVR levels on the next day. Then, the PWD declined toward 6 months after TAVR non-significantly in all patients, but significantly in 25 patients with baseline PWD ≥ 130 ms (P = 0.039). PTFV1 showed no long-term change. Improvement was observed in the ejection fraction, all thickness of the left ventricle and in the left atrial dimensions on ECHO. After recovery from transient aggravation by TAVR procedure, PWD reversed slowly, and the change was significant in those with baseline PWD ≥ 130 ms while change in PTFV1 was not significant at 6 months of follow-up. ECHO showed a reversal of remodeling in the left ventricle and in the left atrial dimension after TAVR.

Incidence and Implications of J waves Observed During Coronary Angiography.

J waves may be observed during coronary angiography (CAG), but they have not been fully studied. We investigated the characteristics of J waves in 100 consecutive patients during CAG. The patients and their family members had no history of cardiac arrest. Approximately 60% of patients had ischemic heart disease, previous myocardial infarction, or angina pectoris, but at the time of this study, the right coronary artery was shown to be normal or patent after stenting. Electrocardiogram was serially recorded to monitor J waves and alteration of the QRS complex during CAG. In 12 patients (12%), J waves (0.249 ± 0.074 mV) newly appeared during right CAG, and in another 13 patients (13%), preexisting J waves increased from 0.155 ± 0.060 mV to 0.233 ± 0.133 mV during CAG. Left CAG induced no J waves or augmentation of J waves. Distinct alterations were observed in the QRS complex during CAG of both coronary arteries. Mechanistically, myocardial ischemia induced by contrast medium was considered to result in a local conduction delay, and when it occurred in the inferior wall, the site of the late activation of the ventricle, the conduction delay was manifested as J waves. In conclusion, J waves were confirmed to emerge or increase during angiography of the right but not the left coronary artery. Myocardial ischemia induced by contrast medium caused a local conduction delay that was manifested as J waves in the inferior wall, the site of the late activation of the ventricle.

J waves induced during coronary angiography in patients with vasospastic angina and its implication.

BACKGROUND: J waves may develop during coronary angiography (CAG). PATIENTS AND RESULTS: Seven patients (61±6 years, 6 male) had vasospastic angina. ST-segment elevation and ventricular fibrillation were documented in all patients. CAG revealed normal arteries, but slurring or notching (J waves) with an amplitude of 0.20±0.06 mV appeared for the first time (n=6) or in an augmented manner (n=1) with distinct alterations in QRS morphology when contrast medium was injected into the right coronary artery. CONCLUSION: In patients with vasospastic angina, J waves observed during CAG can be a manifestation of a local conduction delay caused by contrast medium-induced myocardial ischemia.

Placebo-Controlled, Double-Blind Study of Empagliflozin (EMPA) and Implantable Cardioverter-Defibrillator (EMPA-ICD) in Patients with Type 2 Diabetes (T2DM): Rationale and Design.

INTRODUCTION: Type 2 diabetes (T2DM) is associated with cardiovascular death, including sudden cardiac death due to arrhythmias. Patients with an implantable cardioverter-defibrillator (ICD) are also at high risk of developing a clinically significant ventricular arrhythmia. It has been reported that sodium-glucose cotransporter 2 (SGLT2) inhibitors can reduce cardiovascular deaths; however, the physiological mechanisms of this remain unclear. It is, however, well known that SGLT2 inhibitors increase blood ketone bodies, which have been suggested to have sympatho-suppressive effects. Empagliflozin (EMPA) is an SGLT2 inhibitor. The current clinical trial titled "Placebo-controlled, double-blind study of empagliflozin (EMPA) and implantable cardioverter-defibrillator (EMPA-ICD) in patients with type 2 diabetes (T2DM)" was designed to investigate the antiarrhythmic effects of EMPA. METHODS: The EMPA-ICD study is a prospective, multicenter, placebo-controlled, double-blind, randomized, investigator-initiated clinical trial currently in progress. A total of 210 patients with T2DM (hemoglobin A1c 6.5-10.0%) will be randomized (1:1) to receive once-daily placebo or EMPA, 10 mg, for 24 weeks. The primary endpoint is the number of clinically significant ventricular arrhythmias for 24 weeks before and 24 weeks after study drug administration, as documented by the ICD. The secondary endpoints of the study are the change from baseline concentrations in blood ketone and catecholamine 24 weeks after drug treatment. CONCLUSION: The EMPA-ICD study is the first clinical trial to assess the effect of an SGLT2 inhibitor on clinically significant ventricular arrhythmias in patients with T2DM and an ICD. TRIAL REGISTRATION: Unique trial number, jRCTs031180120 ( https://jrct.niph.go.jp/latest-detail/jRCTs031180120 ).

Blood Pressure Increases Before Pulse Rate During the Nocturnal Period in Hypertensive Patients.

Ambulatory blood pressure monitoring (ABPM) is used for the evaluation of out-of-office blood pressure (BP), however, knowledge concerning the detailed behavior of nocturnal blood pressure (BP) and pulse rate (PR) is limited.A total of 190 participants (64 ± 15 years, 46.3% males) underwent ABPM for diagnosis of hypertension or evaluation of hypertensive therapy. BP and PR were measured automatically by the oscillometric method. From the hourly average ABPM values, the nocturnal time courses (0 AM to 6 AM) of SBP and PR were determined and compared to each other.In general, SBP fell to the lowest level at around midnight and started to increase progressively towards dawn while PR stayed unchanged until 7 AM. Age and gender affected the time course of SBP, most distinctly in the female patients aged ≥ 60 years. The time course of the increase of SBP was very similar in the patients, with BP dipping and non-dipping. The cardiothoracic ratio (CTR) slightly and renal dysfunction modestly facilitated the increase of nocturnal SBP. The nocturnal increase in SBP was not accompanied by an increase of PR in any group or subgroup. The pathophysiology and clinical significance of the early and exclusive increase in nocturnal BP need to be investigated.Average ABPM values in these hypertensive patients showed that BP starts to increase toward dawn without an increase in PR and that this discrepant behavior between BP and RP was most distinct in females 60 or older. The mechanism and clinical significance of such a discordant variation in BP and PR need to be elucidated.

Utility of Saline-Induced Resting Full-Cycle Ratio Compared with Resting Full-Cycle Ratio and Fractional Flow Reserve.

BACKGROUND: The saline-induced distal coronary pressure/aortic pressure ratio predicted fractional flow reserve (FFR). The resting full-cycle ratio (RFR) represents the maximal relative pressure difference in a cardiac cycle. Therefore, the present study aimed to compare the results of saline-induced RFR (sRFR) with FFR. METHODS: Seventy consecutive lesions with only moderate stenosis were included. The FFR, RFR, and sRFR values were compared. The sRFR was assessed using an intracoronary bolus infusion of saline (2 mL/s) for five heartbeats. The FFR was obtained after an intravenous injection of papaverine. RESULTS: Overall, the FFR, sRFR, and RFR values were 0.78 ± 0.12, 0.79 ± 0.13, and 0.83 ± 0.14, respectively. With regard to anatomical morphology were 40, 18, and 12 cases of focal, diffuse, and tandem lesion. There was a significant correlation between the sRFR and FFR (R = 0.96, p < 0.01). There were also significant correlations between the sRFR and FFR in the left coronary and right coronary artery (R = 0.95, p < 0.01 and R = 0.98, p < 0.01). Furthermore, significant correlations between sRFR and FFR were observed in not only focal but also in nonfocal lesion including tandem and diffuse lesions (R = 0.93, p < 0.01 and R = 0.97, p < 0.01). A close agreement on FFR and sRFR was shown using the Bland-Altman analysis (95% CI of agreement: -0.08-0.07). In the receiver operating characteristic curve analysis, the cutoff value of sRFR to predict an FFR of 0.80 was 0.81 (area under curve, 0.97; sensitivity 90.6%; and specificity 98.2%). CONCLUSION: The sRFR can accurately and safely predict the FFR and might be effective for diagnosing ischemia.

The Effect of Dapagliflozin Treatment on Epicardial Adipose Tissue Volume and P-Wave Indices: An Ad-hoc Analysis of The Previous Randomized Clinical Trial.

AIM: Epicardial adipose tissue (EAT) may be associated with arrhythmogenesis. P-wave indices such as P-wave dispersion and P-wave variation indicated a slowed conduction velocity within the atria. This study investigated the effect of dapagliflozin on EAT volume and P-wave indices. METHODS: In the present ad hoc analysis, 35 patients with type 2 diabetes mellitus and coronary artery disease were classified into dapagliflozin group (n=18) and conventional treatment group (n=17). At baseline, EAT volume, HbA1c and plasma level of tumor necrotic factor-α (TNF-α) levels, echocardiography, and 12-lead electrocardiogram (ECG) were performed. EAT volume was measured using computed tomography. Using 12-lead ECG, P-wave indices were measured. RESULTS: At baseline, EAT volumes in the dapagliflozin and conventional treatment groups were 113±20 and 110±27 cm3, respectively. Not only HbA1c and plasma level of TNF-α but also echocardiography findings including left atrial dimension and P-wave indices were comparable between the two groups. After 6 months, plasma level of TNF-α as well as EAT volume significantly decreased in the dapagliflozin group only. P-wave dispersion and P-wave variation significantly decreased in the dapagliflozin group only (-9.2±8.7 vs. 5.9±19.9 ms, p=0.01; -3.5±3.5 vs. 1.7±5.9 ms, p=0.01). The change in P-wave dispersion correlated with changes in EAT volume and plasma level of TNF-α. In multivariate analysis, the change in EAT volume was an independent determinant of the change in P-wave dispersion. CONCLUSION: Dapagliflozin reduced plasma level of TNF-α, EAT volume, and P-wave indices, such as P-wave dispersion. The changes in P-wave indices were especially associated with changes in EAT volume.The number and date of registration: UMIN000035660, 24/Jan/2019.

The Determinants and Outcomes of Myocardial Injury After Transcatheter Aortic-Valve Implantation: SAPIEN 3 Study.

BACKGROUND: The effect of myocardial injury (MI) post-transcatheter aortic valve implantation (TAVI) on clinical outcomes is controversial. This study aimed to evaluate the effect of MI severity on clinical outcome and left ventricle function 30 days post-TAVI and determine MI post-TAVI predictors. METHODS: Overall, 138 consecutive patients who underwent successful transfemoral TAVI using SAPIEN3 and diagnosed using echocardiography and computed tomography were analyzed. High-sensitivity cardiac troponin T (TnT) was evaluated at baseline, immediately, and at 24, 48, and 72 h post-TAVI. Echocardiography findings and N-terminal pro-B-type natriuretic peptide (Nt-pro BNP) levels were evaluated 30 days post-TAVI. RESULTS: Mean age and STS score were 84.4 ±â€¯3.5 years and 6.4 ±â€¯3.2%, respectively. All cases showed severe aortic valve stenosis. Peri-procedural MI was observed in 48 of 100 patients (48.0%). Patients were grouped into MI (n = 48) and non-MI (n = 52), without significant difference in characteristics. Pre-balloon aortic valvuloplasty rate and total pacing time were significantly higher in MI vs non-MI. Total rapid pacing time (TRPT) was an independent predictor for MI (OR 1.06; 95% CI 1.01-1.16; p = 0.04). Echocardiography and Nt-pro BNP changes 30 days post-TAVI were similar between groups. CONCLUSION: Peri-procedural MI, assessed by TnT changes, was observed in 48% of patients. The MI was not associated with overt cardiac dysfunction, and the recovery of left ventricular function and Nt-pro BNP level occurred similarly by 30 day post-TAVI between both groups. In multivariate analysis, TRPT was associated with MI after SAPIEN3 implantation. TRIAL REGISTRATION NUMBER: UMIN000036669.

The Characteristics and Clinical Outcomes of Direct Oral Anticoagulantsin Patients with Atrial Fibrillation and Chronic Kidney Disease: From the Database of A Single-Center Registry.

BACKGROUND: This study aimed to evaluate the characteristics and clinical outcomes (major bleeding [MB] and thromboembolic events [TEEs]) of atrial fibrillation (AF) patients with chronic kidney disease (CKD)who receiveddirect oral anticoagulant (DOAC) therapy. METHODS: Data prospectivelycollected from a single-center registry containing 2,272 patients with DOAC prescription for AF (apixaban [n=1,014], edoxaban [n=267], rivaroxaban [n=498], and dabigatran[n=493]) were retrospectively analyzed. Patients were monitored for two years and classified into the CKD (n=1460) andnon-CKD groups(n=812). MB and TEEs were evaluated. RESULTS: The mean age was 72±10 years, with the CHADS2,CHA2DS2-VASc, and HAS-BLED scores being 1.95±1.32, 3.21±1.67, and 1.89±0.96,respectively.Incidence rates of MB and TEEs were 2.3%/year and 2.1%/year, respectively. The CKD groupwasolderand had lower body weight and higher CHADS2,CHA2DS2-VASc, and HAS-BLED scoresthanthe non-CKD group.Kaplan-Meier curve analysis revealed that the incidence of MB and TEEs was higher in the CKD group. Multiple logistic regression analysis in the CKD group revealed thatage andstroke history were independent determinants of TEEs, and low body weighttended to be a determinant of MB.The inappropriate low dose use was higher for apixaban than other DOACs in the CKD group. Consequently, for apixaban, the incidence of stroke was significantly higherin the CKD group than in the non-CKD group. CONCLUSIONS: Patients with CKDwere characterized by factors that predisposed them to MB and TEEs, such as older age and low body weight. In a single-center registry, only treatment with apixaban in the CKD group led to a higher incidence of TEEs.

The effect of the debulking by excimer laser coronary angioplasty on long-term outcome compared with drug-coating balloon: insights from optical frequency domain imaging analysis.

This study evaluated the 1-year efficacy of excimer laser coronary angioplasty (ELCA) before drug-coated balloon (DCB) dilatation for the treatment of in-stent restenosis (ISR). Forty consecutive patients with ISR were treated by DCB with or without the use of ELCA (ELCA plus DCB, N = 20; DCB alone, N = 20). Debulking efficiency (DE) value was defined as the neointima area on optical frequency domain imaging (OFDI) debulked by ELCA. The patients in the ELCA plus DCB group were divided into two groups (greater DE (GDE), N = 10; smaller DE (SDE), N = 10) based on the median value of DE. Thereafter, the ISR segment was prepared with a scoring balloon, followed by DCB. At follow-up, binary restenosis and target lesion revascularization (TLR) were evaluated. There were no significant differences in baseline characteristics such as age, comorbidity, and ISR type. Overall, the incidence of neoatherosclerosis in the ISR segment was 17.5%. Post-PCI, acute gain of minimum lumen diameter on quantitative coronary angiography and of minimum lumen area on OFDI was numerically higher in the GDE than in the SDE and the DCB alone group. At follow-up, the occurrences of binary restenosis and TLR in the ELCA plus DCB group were 20.0% and 10.0%; these values in the DCB alone group were 20.0% and 20.0%, respectively. Two patients from the SDE and none from the GDE developed TLR. DCB alone treatment was inferior to ELCA plus DCB treatment. However, greater ELCA debulking might be required to obtain optimal outcomes.

Accentuation of J waves by intracoronary administration of multiple agents in a patient with vasospastic angina: Implications for pathogenesis.

A 64-year-old man was resuscitated from out-of-hospital VF, and coronary spasm was provoked by ergonovine at catheterization. An ECG was analyzed before and after each intracoronary injection of drugs or contrast medium. The baseline ECG showed nondiagnostic J waves in leads II, III, and aVF, but administration of acetylcholine, contrast medium and nitroglycerin into the right coronary artery induced a distinct augmentation of J-wave amplitudes with changes in the QRS morphology. Transient ischemia induced by the intracoronary administration of these agents seemed to be the mechanism underlying the increase in J-wave amplitudes.

Cacao liquor procyanidins prevent postprandial hyperglycaemia by increasing glucagon-like peptide-1 activity and AMP-activated protein kinase in mice.

Procyanidins have been reported to possess potential for the prevention of hyperglycaemia. However, there are very few data for procyanidins about the difference the degree of polymerisation (DP) has on anti-hyperglycaemic effects. Moreover, the underlying molecular mechanisms by which procyanidins suppress hyperglycaemia are not yet fully understood. In the present study, we prepared procyanidin fractions with different DP, namely low-DP (DP≤3) and high-DP (DP≥4) fractions, from a cacao liquor procyanidin-rich extract (CLPr). These fractions were administered orally to Institute of Cancer Research (ICR) mice and their anti-hyperglycaemic effects were examined. We found that CLPr and its fractions prevent postprandial hyperglycaemia accompanied by an increase in the plasma glucagon-like peptide-1 (GLP-1) level with or without glucose load. In the absence of glucose load, both fractions increased the plasma insulin level and activated its downstream signalling pathway in skeletal muscle, resulting in promotion of the translocation of GLUT4. Phosphorylation of AMP-activated protein kinase (AMPK) was also involved in the promotion of GLUT4 translocation. High- and low-DP fractions showed a similar activation of insulin and AMPK pathways. In conclusion, cacao liquor procyanidins prevent hyperglycaemia by promoting GLUT4 translocation in skeletal muscle, and both the GLP-1-activated insulin pathway and the AMPK pathway are involved in the underlying molecular mechanism.

Dynamicity of hypothermia-induced J waves and the mechanism involved.

BACKGROUND: J waves develop during hypothermia, but the dynamicity of hypothermia-induced J waves is poorly understood. OBJECTIVE: The purpose of this study was to investigate the mechanism of the rate-dependent change in the amplitude of hypothermia-induced J waves. METHODS: Nineteen patients with severe hypothermia were included (mean age 70 ± 12 years; 16 men [84.2%]). The rectal temperature at the time of admission was 27.8° ± 2.5°C. In addition to prolonged PR, QRS complex, and corrected QT intervals, the distribution of prominent J waves was widespread in all 19 patients. RESULTS: Nine patients showed changes in RR intervals. When the RR interval shortened from 1353 ± 472 to 740 ± 391 ms (P = .0002), the J-wave amplitude increased from 0.50 ± 0.29 to 0.61 ±0.27 mV (P = .0075). The J-wave amplitude increased in 7 patients (77.8%) and decreased in 2 patients (22.2%) after short RR intervals. The augmentation of J waves at short RR intervals was associated with a significant prolongation of ventricular activation time (35 ± 5 ms vs 46 ± 5 ms; P = .0020), suggesting accentuated conduction delay. Increased conduction delay at short RR intervals was suggested to accentuate the phase 1 notch of the action potential and J waves in hypothermia. None developed ventricular fibrillation, and in 2 of 9 patients with atrial fibrillation, atrial fibrillation persisted after rewarming to normothermia. CONCLUSION: J waves in severe hypothermia were augmented after short RR intervals in 7 patients as expected for depolarization abnormality, whereas 2 patients showed a bradycardia-dependent augmentation as expected for transient outward current-mediated J waves. Increased conduction delay at short RR intervals can be responsible for the accentuation of the transient outward current and J waves during severe hypothermia.

The comparison of early healing 1-month after PCI among CoCr-everolimus-eluting stent (EES), biodegradable polymer (BP)-EES and BP-sirolimus-eluting stent: Insights from OFDI and coronary angioscopy.

BACKGROUND: Third-generation stents with abluminal biodegradable polymer (BP) might facilitate early healing. Therefore, we compared early healing between second-generation and third-generation stents using coronary angioscopy (CAS) and optical frequency domain imaging [OFDI]. METHODS: We prospectively enrolled 30 consecutive patients with stent implantation for acute coronary syndrome (cobalt­chromium [CoCr] everolimus-eluting stent [EES] [n = 10], BP-EES [n = 10], and BP-sirolimus eluting stent [SES] [n = 10]). All patients underwent CAS and OFDI 1 month after initial percutaneous coronary intervention. On OFDI, the stent coverage (SC), thrombus, and peri-strut low intensity area (PLIA) were assessed. CAS findings were recorded for the grade of SC, grade of yellow color (YC), and grade of the thrombus (TG). RESULTS: On OFDI, the incidences of any thrombus at the 1-month follow-up were 70%, 80%, and 80% in the CoCr-EES, BP-EES, and BP-SES groups, respectively. The percentage of coverage was comparable among the groups (CoCr-EES 79.8 vs. BP-EES 79.9 vs. BP-SES 80.1%, P = 0.96). However, the number of struts with PLIA was numerically higher in the BP-SES group than in the CoCr-EES and BP-EES groups (46.4 ±â€¯25.1 vs. 21.6 ±â€¯13.2 vs. 22.0 ±â€¯7.2%, P = 0.08). In the CoCr-EES, BP-EES, and BP-SES groups, mean grades of SC were 1.25 ±â€¯0.5, 1.25 ±â€¯0.5, and 0.85 ±â€¯0.70 (P = 0.60); mean grades of YC were 0.75 ±â€¯0.5, 0.80 ±â€¯0.45, and 0.88 ±â€¯0.37 (P = 0.65), and mean grades of TG were 1.00 ±â€¯1.00, 1.20 ±â€¯0.83, and 0.88 ±â€¯0.64 (P = 0.75), respectively. CONCLUSION: Third-generation stents are not inferior to second-generation stents regarding stent coverage. However, PLIA on OFDI was often observed with BP-SESs, indicating involvement of the fibrin component.

The Comparison of Inappropriate-Low-Doses Use among 4 Direct Oral Anticoagulants in Patients with Atrial Fibrillation: From the Database of a Single-Center Registry.

BACKGROUND: Inappropriate doses of direct oral anticoagulants (DOACs) are often prescribed. This study evaluated the prevalence, outcomes, and predictors of the prescription of inappropriately low doses of 4 types of DOACs in patients with atrial fibrillation (AF). METHODS: We retrospectively analyzed prospectively collected data from a single-center registry with 2272 patients prescribed DOACs for AF (apixaban: 1014; edoxaban: 267; rivaroxaban: 498; dabigatran: 493). Patients were monitored for 2years and classified into appropriate-dose (n = 1,753; including appropriate low doses), inappropriate-low-dose (n = 490) and inappropriate-high-dose groups (n = 29). Major bleeding (MB) and thromboembolic events (TEEs) were evaluated. RESULTS: The mean age was 72 ± 10years. The CHADS2 and HAS-BLED scores were 1.95 ± 1.32 and 1.89 ± .96, respectively. Overall, the incidences of MB and TEE were 2.3 and 2.1 per 100-patinet year, respectively. The inappropriate-low-dose group had younger age, heavier body weight, and higher creatinine clearance value than the appropriate-dose group. Multiple logistic regression analyses demonstrated the following independent determinants of the prescription of an inappropriately low dose: apixaban: HAS-BLED score; edoxaban: age; rivaroxaban: age, creatinine clearance value, HAS-BLED score, CHADS2 score, and antiplatelet therapy; dabigatran: age. There were not significant differences in the incidence of major bleeding and stroke/systemic emboli among the inappropriate-low-dose group of 4 DOACs compared with the appropriate-dose group of 4 DOACs. CONCLUSIONS: In a single-center registry, 23% of patients with AF treated with a DOAC received an inappropriate dose. Several clinical factors, such as age and the creatinine clearance value, can identify patients at risk of under-treatment with DOACs.

The utility of total lipid core burden index/maximal lipid core burden index ratio within the culprit plaque to predict filter-no reflow: insight from near-infrared spectroscopy with intravascular ultrasound.

Filter-no reflow (FNR) is a phenomenon wherein flow improves after the retrieve of distal protection. Near-infrared spectroscopy with intravascular ultrasound (NIRS-IVUS) enables lipid detection. We evaluated the predictors of FNR during PCI using NIRS-IVUS. Thirty-two patients who underwent PCI using the Filtrap® for acute coronary syndrome (ACS) were enrolled. The culprit plaque (CP) was observed using NIRS-IVUS. Total lipid-core burden index (T-LCBI) and maximal LCBI over any 4-mm segment (max-LCBI4mm) within CP were evaluated. T-LCBI/max-LCBI4mm ratio within CP was calculated as an index of the extent of longitudinal lipid expansion. The attenuation grade (AG) and remodeling index (RI) in CP were analyzed. AG was scored based on the extent of attenuation occupying the number of quadrants. The patients were divided into FNR group (N = 8) and no-FNR group (N = 24). AG was significantly higher in FNR group than in no-FNR group (1.6 ± 0.6 vs. 0.9 ± 0.42, p = 0.01). RI in FNR group tended to be greater than in no-FNR group. T-LCBI/max-LCBI4mm ratio within the culprit plaque was significantly higher in FNR group than in no-FNR group (0.50 ± 0.10 vs. 0.33 ± 0.13, p < 0.01). In multivariate logistic regression analysis, AG > 1.04 (odds ratio [OR] 18.4, 95% confidence interval [CI] 1.5-215.7, p = 0.02) and T-LCBI/max-LCBI4mm ratio > 0.42 (OR 14.4, 95% CI 1.2-176.8, p = 0.03) were independent predictors for the occurrence of FNR. The use of T-LCBI/max-LCBI4mm ratio within CP might be an effective marker to predict FNR during PCI in patients with ACS.

The effect of dapagliflozin treatment on epicardial adipose tissue volume.

BACKGROUND: Glycosuria produced by sodium-glucose co-transporter-2 (SGLT-2) inhibitors is associated with weight loss. SGLT-2 inhibitors reportedly might reduce the occurrence of cardiovascular events. Epicardial adipose tissue (EAT) is a pathogenic fat depot that may be associated with coronary atherosclerosis. The present study evaluated the relationship between an SGLT-2 inhibitor (dapagliflozin) and EAT volume. METHODS: In 40 diabetes mellitus patients with coronary artery disease (10 women and 30 men; mean age of all 40 patients was 67.2 ± 5.4 years), EAT volume was compared prospectively between the dapagliflozin treatment group (DG; n = 20) and conventional treatment group (CTG; n = 20) during a 6-month period. EAT was defined as any pixel that had computed tomography attenuation of - 150 to - 30 Hounsfield units within the pericardial sac. Metabolic parameters, including HbA1c, tumor necrotic factor-α (TNF-α), and plasminogen activator inhibitor-1 (PAI-1) levels, were measured at both baseline and 6-months thereafter. RESULTS: There were no significant differences at baseline of EAT volume and HbA1c, PAI-1, and TNF-α levels between the two treatment groups. After a 6-month follow-up, the change in HbA1c levels in the DG decreased significantly from 7.2 to 6.8%, while body weight decreased significantly in the DG compared with the CTG (- 2.9 ± 3.4 vs. 0.2 ± 2.4 kg, p = 0.01). At the 6-month follow-up, serum PAI-1 levels tended to decline in the DG. In addition, the change in the TNF-α level in the DG was significantly greater than that in the CTG (- 0.5 ± 0.7 vs. 0.03 ± 0.3 pg/ml, p = 0.03). Furthermore, EAT volume significantly decreased in the DG at the 6-month follow-up compared with the CTG (- 16.4 ± 8.3 vs. 4.7 ± 8.8 cm3, p = 0.01). Not only the changes in the EAT volume and body weight, but also those in the EAT volume and TNF-α level, showed significantly positive correlation. CONCLUSION: Treatment with dapagliflozin might improve systemic metabolic parameters and decrease the EAT volume in diabetes mellitus patients, possibly contributing to risk reduction in cardiovascular events.

The Impact of Cancer on Major Bleeding and Stroke/Systemic Emboli in Patients Using Direct Oral Anticoagulants:From the Database of a Single-Center Registry.

BACKGROUND: Few data are available on direct oral anticoagulant (DOAC) use in patients with cancer and atrial fibrillation (AF). METHODS: We retrospectively analyzed prospectively collected data from a single-center registryon 2,272 patients who tookDOACs for AF (apixaban:1,014; edoxaban:267; rivaroxaban:498; dabigatran:493). Patients were monitored for 2 years andclassified into non-cancer (n=2009) and cancer group (n=263) (cancer onset during DOAC treatment, active canceratDOAC administration, and cancer history).Major bleeding (MB) and thromboembolic events (TEEs) were evaluated. RESULTS: The mean age was 73±10 years. CHADS2 and HAS-BLED scores were 1.95±1.32 and 1.89±0.96,respectively.In the present study, the prevalence of gastrointestinal and genitourinary cancer was 61% and 8%, respectively.The MB and TEEs incidences were 2.4 and 2.2 per 100-patient years, respectively. The appropriate dosing rate, body weight, and Ccrvalue in cancer patients were significantly lower than those in non-cancer patients. Cancer patients were significantly older than non-cancer patients. In MB patients diagnosed with gastrointestinal or genitourinary cancer during follow-up, the clinically relevant bleeding such as melena or hematuria occurred.Additionally, there was a significantly higher MB incidence in cancer patients than in non-cancer patients (p<0.01). CONCLUSIONS: AF patients with cancer was associated with a higher risk of MB compared with those without cancer despite higher rate of inappropriate low dose. Bleeding such as melena and hematuria after DOAC administration might suggest that the symptoms are associated with cancer of the site.

"J waves" induced after short coupling intervals: a manifestations of latent depolarization abnormality?

Aims: To confirm the presence of tachycardia-induced slur or notch in the terminal portion of the QRS complexes in a general patient population. Methods and results: A tachycardia-induced J wave was defined as a slur or notch in the terminal portion of the QRS complexes newly induced at short RR intervals during atrial premature contractions (APCs) or atrial electrical stimulation in the electrophysiological study (EPS). Twenty-three out of 2000 patients with general diseases were involved. All patients with aborted sudden cardiac death, ventricular fibrillation or a family history of sudden cardiac death were excluded. The mean age was 72 ± 9 years, and 11 patients were male (47.8%). When the RR interval was shortened from 821 ± 142 ms to 464 ± 52 ms in the conducted APCs (P < 0.0001), J waves became diagnostic (0.02 ± 0.03 mV to 0.20 ± 0.07 mV, P < 0.0001). J waves were confined to the inferior leads in 22 (95.7%) patients and were notched in 11 (47.8%) and slurred in 12 (52.2%) patients. The induction of J waves was accompanied by visible changes of the QRS morphology. When the post-APC RR interval was prolonged to 992 ± 305 ms (P = 0.0154 vs. baseline), the J waves were similar to baseline levels. During the EPS, J wave induction was confirmed during atrial stimulation. There were no characteristic clinical or ECG features in the patients with tachycardia-induced J waves. Conclusions: J waves can be newly induced by short RR intervals in a general patient population, and a conduction delay is the likely mechanism causing such J waves.

Comparison of clinical outcomes of coronary artery stent implantation in patients with end-stage chronic kidney disease including hemodialysis for three everolimus eluting (EES) stent designs: Bioresorbable polymer-EES, platinum chromium-EES, and cobalt chrome-EES.

BACKGROUNDS: New-generation bioresorbable polymer-everolimus eluting stents (BP-EES) are available. This study aimed to compare the clinical outcomes for BP-EES compared to more established stent designs, namely the platinum chromium-EES (PtCr-EES) and cobalt chrome-EES(CoCr-EES) in patients with the end-stage chronic kidney disease (CKD) including hemodialysis (HD). METHODS: One-hundred-forty-one consecutive stents (BP-EES [n = 44], PtCr-EES [n = 45], and CoCr-EES [n = 52]) were implanted in 104 patients with CKD. All patients underwent a follow-up coronary angiography at 12 months after implantation. End-stage CKD was defined as an estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m2 , or the need for HD. The following outcome variables were compared among the three stent groups after implantation and the 12-month follow-up: target lesion revascularization (TLR), stent thrombosis (ST), and major adverse cardiac event (MACE). Minimal stent diameter (MSD) and %diameter-stenosis (%DS) were measured using quantitative coronary angiography. RESULTS: The overall rate of TLR and MACE was 14.6% and 30.8%, respectively, with no incidence of ST. Immediately after implantation, the MSD (P = 0.22) and %DS (P = 0.42) were equivalent among the three groups. However, at the 12-month follow-up, a tendency towards higher TLR was observed for the BP-EES group (22.7%) compared with the PtCr-EES (8.8%) and CoCr-EES (9.6%) groups (P = 0.07). Late loss in lumen diameter was also significantly greater for the BP-EES (0.51 ± 0.64 mm) group than either the PtCr-EES (0.20 ± 0.61 mm) and CoCr-EES (0.25 ± 0.70 mm) groups (P = 0.03). CONCLUSIONS: BP-EES might increase the risk of in-stent restenosis in patients with end-stage of CKD or the need for HD.