Sex Differences in Bleeding Risk Associated With Antithrombotic Therapy Following Percutaneous Coronary Intervention.

Background: Antithrombotic therapy is crucial for secondary prevention of cardiovascular disease (CVD), but women with CVD may face increased bleeding complications post-percutaneous coronary intervention (PCI) under antithrombotic therapy. However, women are often underrepresented in clinical trials in this field, so evidence for sex-specific recommendations is lacking. Methods and Results: A search on PubMed was conducted for English-language articles addressing bleeding complications and antithrombotic therapy in women. Despite women potentially showing higher baseline platelet responsiveness than men, the clinical implications remain unclear. Concerning antiplatelet therapy post-PCI, although women have an elevated bleeding risk in the acute phase, no sex differences were observed in the chronic phase. However, women require specific considerations for factors such as age, renal function, and weight when determining the dose and duration of antiplatelet therapy. Regarding anticoagulation post-PCI, direct oral anticoagulants may pose a lower bleeding risk in women compared with warfarin. Concerning triple antithrombotic therapy (TAT) post-PCI for patients with atrial fibrillation, there is a lack of evidence on whether sex differences should be considered in the duration and regimen of TAT. Conclusions: Recent findings on sex differences in post-PCI bleeding complications did not provide enough evidence to recommend specific therapies for women. Further studies are needed to address this gap and recommend optimal antithrombotic therapy post-PCI for women.

Ultra-Low-Dose Contrast Using Transluminal Renal Angioplasty: The ULTRA Study.

BACKGROUND: Although severe atherosclerotic renal artery stenosis (ARAS) is a predictor of future cardiovascular events, large trials have not shown the benefits of percutaneous transluminal renal angioplasty (PTRA). This study aimed to validate the safety and efficacy of PTRA using low-concentration digital subtraction angiography (LC-DSA) in patients with severe ARAS and advanced chronic kidney disease (CKD). MATERIALS AND METHODS: This prospective study was conducted between August 2018 and October 2021. Eighteen patients with 20 lesions, CKD stage 3b or worse, and significant renal artery stenosis were included and underwent PTRA using ultra-low-dose contrast medium. The primary endpoint was a change in renal function based on serum creatinine (sCr) level. RESULTS: The mean sCr level significantly improved from 3.34 ± 1.8 mg/dL pre-PTRA to 2.48 ± 1.19 mg/dL at 1 month post-PTRA (P = .02). The mean amount of contrast used was 8.3 ± 3.9 mL per vessel. More severe stenosis and rapid deterioration of renal function before treatment were associated with improved kidney function. No cardiovascular or renal complications such as stroke or contrast-induced nephropathy were observed during the 30-day period. CONCLUSIONS: PTRA using an ultra-low-dose contrast medium is safe and provides acceptable results.

Beta blockers versus calcium channel blockers for provocation of vasospastic angina after drug-eluting stent implantation: a multicentre prospective randomised trial.

BACKGROUND: Drug-eluting stent-induced vasospastic angina (DES-VSA) has emerged as a novel complication in the modern era of percutaneous coronary intervention (PCI). Although beta blockers (BBs) are generally recommended for coronary heart disease, they may promote incidence of DES-VSA. This study aimed to compare the effects of calcium channel blockers (CCBs) perceived to be protective against DES-VSA and BBs on subsequent coronary events after second-generation drug-eluting stent implantation. METHODS: In this multicentre prospective, randomised study, 52 patients with coronary artery disease who underwent PCI for a single-vessel lesion with everolimus-eluting stent placement were randomised into post-stenting BB (N=26) and CCB (N=26) groups and followed for 24 months to detect any major cardiovascular events (MACE). A positive result on acetylcholine provocation testing during diagnostic coronary angiography (CAG) at 9 months was the primary endpoint for equivalence. MACE included all-cause death, non-fatal myocardial infarction, unstable angina, cerebrovascular disease or coronary revascularisation for stable coronary artery disease after index PCI. RESULTS: At 9 months, 42 patients (80.8%) underwent diagnostic coronary angiography and acetylcholine provocation testing. Among them, seven patients in each group were diagnosed with definite vasospasm (intention-to-treat analysis 26.9% vs 26.9%, risk difference 0 (-0.241, 0.241)). Meanwhile, the secondary endpoint, 24-month MACE, was higher in the CCB group (19.2%) than in the BB group (3.8%) (p=0.01). In detail, coronary revascularisation for stable coronary artery disease was the predominant endpoint that contributed to the greater proportion of MACE in the CCB group (CCB (19.2%) vs BB (3.8%), p=0.03). CONCLUSIONS: The incidence of acetylcholine-induced coronary artery spasms did not differ between patients receiving BBs or CCBs at 9 months after PCI. However, a higher incidence of 2-year MACE was observed in the CCB group, suggesting the importance of BB administration. TRIAL REGISTRATION NUMBER: This study was registered at the Japanese University Hospital Medical Information Network (UMIN) Clinical Trial Registry (The Prospective Randomized Trial for Optimizing Medical Therapy After Stenting: Calcium-Beta Trial; UMIN000008321, https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000009536).

Unmet Needs in Managing Myocardial Infarction in Patients With Malignancy.

Patients with cancer face a high short-term risk of arterial thromboembolism. One of the most fatal manifestations of arterial thromboembolism is myocardial infarction (MI), and patients with cancer face a 3-fold greater risk of MI than patients without cancer. The individual risk for arterial thrombotic events in patients with cancer is determined by the complex interaction of baseline cardiovascular risk factors, cancer type and stage, chemotherapeutic regimen, and other general contributing factors for thrombosis. Managing MI in patients with cancer is a clinical challenge, particularly due to cancer's unique pathophysiology, which makes it difficult to balance thrombotic and bleeding risks in this specific patient population. When patients with cancer present with MI, a limited proportion are treated with guideline-recommended therapy, such as antiplatelet therapy or invasive revascularization. Despite the limited evidence, existing reports consistently suggest similar clinical benefits of guideline-recommended therapy when administered to patients with cancer presenting with MI. In this review, we briefly summarize the available evidence, clinical challenges, and future perspectives on simultaneous management of MI and cancer, with a focus on invasive strategy.

Impact of a Multidisciplinary Round Visit for the Management of Dysphagia Utilizing a Wi-Fi-Based Wireless Flexible Endoscopic Evaluation of Swallowing.

OBJECTIVES: The management of dysphagia requires a multidisciplinary approach, especially in large-scale hospitals. We introduce a novel protocol using a Wi-Fi-based flexible endoscopic evaluation of swallowing (FEES) system and aim to verify its effectiveness in evaluation and rehabilitation of inpatients with dysphagia. METHOD: We conducted novel Wi-Fi-based FEES at the bedside using 3 iPads as monitors and recorders. Functional outcomes of swallowing in 2 different hospitals for acute care with conventional wired or wireless FEES were compared retrospectively. RESULTS: Using the wireless system, we could visit more patients in a short period of time. Furthermore, a large multidisciplinary team was able to be present at the bedside, which made it easy to hold discussions and rapidly devise appropriate rehabilitation strategies. Aspiration pneumonia recurred in a few cases following our intervention with wireless FEES. Functional oral intake score was significantly increased following the intervention. Moreover, the number of deaths during hospitalization using wireless FEES evaluation was lower than those observed using the conventional system. CONCLUSION: Wi-Fi-based wireless FEES system, the first of its kind, allowed our multidisciplinary team to easily and effectively assess inpatients with dysphagia by facilitating simple examinations and intensive transprofessional discussions for patient rehabilitation.

Angiographic Lesion Complexity Score and In-Hospital Outcomes after Percutaneous Coronary Intervention.

OBJECTIVE: We devised a percutaneous coronary intervention (PCI) scoring system based on angiographic lesion complexity and assessed its association with in-hospital complications. BACKGROUND: Although PCI is finding increasing application in patients with coronary artery disease, lesion complexity can lead to in-hospital complications. METHODS: Data from 3692 PCI patients were scored based on lesion complexity, defined by bifurcation, chronic total occlusion, type C, and left main lesion, along with acute thrombus in the presence of ST-segment elevation myocardial infarction (1 point assigned for each variable). RESULTS: The patients' mean age was 67.5 +/- 10.8 years; 79.8% were male. About half of the patients (50.3%) presented with an acute coronary syndrome, and 2218 (60.1%) underwent PCI for at least one complex lesion. The patients in the higher-risk score groups were older (p < 0.001) and had present or previous heart failure (p = 0.02 and p = 0.01, respectively). Higher-risk score groups had significantly higher in-hospital event rates for death, heart failure, and cardiogenic shock (from 0 to 4 risk score; 1.7%, 4.5%, 6.3%, 7.1%, 40%, p < 0.001); bleeding with a hemoglobin decrease of >3.0 g/dL (3.1%, 11.0%, 13.1%, 10.3%, 28.6%, p < 0.001); and postoperative myocardial infarction (1.5%, 3.1%, 3.8%, 3.8%, 10%, p = 0.004), respectively. The association with adverse outcomes persisted after adjustment for known clinical predictors (odds ratio 1.72, p < 0.001). CONCLUSION: The complexity score was cumulatively associated with in-hospital mortality and complication rate and could be used for event prediction in PCI patients.

[Aortic Valve Replacement after Balloon Valvuloplasty for Aortic Valve Stenosis in a Dialysis Patient with Cardiogenic Shock;Report of a Case].

A 67-year-old man on chronic hemodialysis was admitted with worsening congestive heart failure due to critical aortic stenosis. Echocardiography showed severe aortic stenosis with a valve area of 0.67 cm2 and an ejection fraction of 0.31. Cardiac catheterization revealed severe pulmonary hypertension with pulmonary artery pressures of 62/32 mmHg. In the middle of cardiac catheterization, the systolic pressure declined to 60 mmHg due to cardiogenic shock. Dopamine hydrochloride and dobutamine hydrochloride infusions were necessary to maintain a systolic pressure greater than 80 mmHg. Balloon aortic valvuloplasty was urgently performed. The patient's symptoms rapidly resolved except for angina on exertion. One month later, elective aortic valve replacement was performed. The postoperative course was uneventful and the he was discharged on the 60th postoperative day. A follow-up echocardiogram 6 months postoperatively revealed normal prosthetic valve function and an ejection fraction of 0.6.

Appropriateness of coronary interventions in Japan by the US and Japanese standards.

BACKGROUND: Appropriateness use criteria (AUC) are widely used to assess quality of care. American professional organizations and Japanese experts have both developed original AUC for percutaneous coronary intervention (PCI). However, rating discrepancies have not been investigated. METHODS: Patients registered in the Japanese multicenter PCI registry were analyzed. We assessed the appropriateness of PCI based on both the US and Japanese criteria and compared the ratings. A logistic regression analysis was performed to identify clinical predictors of inappropriate ratings under both standards. RESULTS: From a total of 4,950 nonacute, consecutive PCIs, 1,982 and 2,077 procedures could be successfully rated using the US and Japanese criteria, respectively. The major difference between the 2 criteria was the rating of "asymptomatic, low- or intermediate-risk patients, no lesion in the proximal left anterior descending coronary artery (PLAD)"; this scenario was deemed appropriate in the Japanese but not in the US criteria. As a consequence, the rate of inappropriate PCI using the Japanese criteria (5.2%) was substantially lower when compared with the rating using the US criteria (15%). Common clinical variables associated with "inappropriate" PCI were male, multivessel diseases, and lesions in the non-PLAD. Suboptimal antianginal medication was also a significant predictor of inappropriate PCI under the US but not under the Japanese criteria. CONCLUSIONS: Significant and clinically relevant rating discrepancies were observed between the US and Japanese criteria-based assessments, owing largely to the ratings of asymptomatic, non-PLAD-related, low- or intermediate-risk cases.

Impact of acute kidney injury on in-hospital outcomes in patients with DeBakey type III acute aortic dissection.

The relation between the incidence and severity of acute kidney injury (AKI) and clinical outcomes remains unclear in patients with DeBakey type III acute aortic dissection (AAD). We retrospectively assessed 56 patients admitted to our hospital for type III AAD within 48 hours of the onset of symptoms. The presence of AKI was identified, and its severity was staged on the basis of changes in serum creatinine (SCr) levels within 7 days after admission. We investigated the relations between AKI and clinical presentations, in-hospital complications, and predischarge renal function; AKI was observed in 20 patients (36%). After adjusting for age, gender, and body mass index, the incidence of AKI was associated with a history of hypertension, electrocardiographic ST-T changes, DeBakey type IIIb, and SCr level on admission. Maximum white blood cell count and serum C-reactive protein level were higher in patients with AKI than in those without AKI. AKI was associated with a greater incidence of in-hospital complications (70% vs 39%, p = 0.03) and higher SCr levels at discharge (1.1 [range 1.0 to 2.0] vs 0.9 [range 0.7 to 1.0] mg/dl, p = 0.0001). These associations were more pronounced in patients with relatively severe AKI. Multivariate analysis revealed that SCr level on admission and DeBakey type IIIb with renal artery involvement were major predictors of AKI. In conclusion, renal function on admission and renal artery involvement were significant risk factors for AKI, which was associated with poor outcomes and enhanced inflammatory response during hospitalization in patients with type III AAD.

Anatomical variations affect radial artery spasm and procedural achievement of transradial cardiac catheterization.

Transradial cardiac catheterization (TRCC) has unique technical challenges such as access difficulty related to anatomical variations and/or radial artery (RA) spasm. We sought to evaluate the incidence of anatomical variations of the RA and whether they would affect RA spasm and procedural achievement of TRCC. A total of 744 consecutive patients who underwent TRCC were analyzed by routine radial arteriography. Anatomical variations were defined as abnormal origin of the RA and/or radioulnar loop and/or tortuous configuration. RA spasm was defined as >75 % stenosis at first radial arteriography. Overall, anatomical variations were noted in 68 patients (9.1 %), including 39 cases of abnormal origin (5.2 %), 11 cases of radioulnar loop (1.5 %), and 42 cases of tortuous configuration (5.6 %). Transradial procedures failed in 26 patients (3.5 %), and more frequently in patients with anatomical variation than in those with normal anatomy (23.5 % vs 1.5 %, P < 0.001). Importantly, on multivariate analysis the presence of anatomical variation was a distinct predictor of transradial procedure failure (odds ratio (OR) 17.80; 95 % CI 7.55-43.73; P < 0.001). RA spasm was observed in 83 patients (11.2 %), and more frequently in patients with anatomical variation than in those with normal anatomy (35.3 % vs 8.7 %, P < 0.001). Anatomical variation (OR 4.74; 95 % CI 2.61-8.47; P < 0.001) and female gender (OR 2.23; 95 % CI 1.01-4.73; P = 0.041) were distinct predictors of RA spasm. Anatomical variations were observed in 9.1 % of the patients, and strongly correlated with RA spasm and procedural achievement of TRCC.

Disparity in the application of guideline-based medical therapy after percutaneous coronary intervention: analysis from the Japanese prospective multicenter registry.

BACKGROUND: Despite the known benefits of evidence-based medical care in patients with coronary artery disease, disparities exist in the application of guideline-based medical therapy (GBMT) after percutaneous coronary intervention (PCI), particularly in patients who have undergone revascularization procedures. Underestimation of risk, overestimation of side effects, and preference of the treating physician to prioritize invasive procedures may all affect the prescription pattern. OBJECTIVE: We sought to describe how GBMT is prescribed after PCI in Japan. METHODS: From September 2008 to 2010, 1,612 patients underwent PCI with stenting at 14 Japanese hospitals participating in the Japanese Cardiovascular Database Registry. GBMT was defined as treatment including dual antiplatelet therapy, beta-adrenoceptor antagonists (beta-blockers) and/or calcium channel blockers, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, and statins. RESULTS: Overall, 749 patients (46.5%) were discharged on GBMT. Notably, the prescription rate of GBMT became lower with age (e.g. from 50.3% [age 50-59 years] to 35.9% [age over 80 years]). In addition, patients presenting with acute coronary syndrome (ACS) tended to receive GBMT more frequently (ST-segment elevation myocardial infarction [STEMI] 33.8 vs. 18.3%; p<0.001; non-ST-segment elevation myocardial infarction [NSTEMI] 8.5 vs. 5.9%; p=0.042), whereas patients presenting with cardiogenic shock (CS) had lower prescription rates of GBMT (2.1 vs. 4.1%; p=0.032). Overall age (odds ratio [OR] 0.647; p=0.020), as well as the acute and emergent presentation (OR 3.229; p<0.001 for STEMI; OR 2.122; p<0.001 for NSTEMI; OR 0.35; p=0.002 for CS) were also associated with prescription of GBMT. CONCLUSION: Only about half of the post-PCI patients were discharged on ideal GBMT. Elderly patients and those presenting with non-ACS status or hemodynamic compromise tended not to receive GBMT, and required more attention for optimization of their care.

Left main trunk perforation sealed by 90 second perfusion balloon inflation.

Coronary perforation is a rare but serious complication of percutaneous coronary intervention. In our case, kissing balloon technique caused the perforation. We took care of balloon diameter and inflation pressure, but we did not consider that the proximal lumen could take elliptical rather than circular shape. Then perforation occurred at the proximal side of the kissing balloon technique. Fortunately, we could achieve hemostasis successfully by 90 seconds perfusion balloon inflation. You must consider not only balloon diameter and inflation pressure but also balloon form as an important safety factor for the kissing balloon technique on the left main trunk.

Detection of attenuated plaque in stable angina with 64-multidetector computed tomography: a comparison with intravascular ultrasound.

BACKGROUND: To clarify multidetector computed tomography (MDCT) findings of attenuated plaque detected by intravascular ultrasound (IVUS). METHODS AND RESULTS: One hundred and fifty-four patients with stable angina underwent MDCT before IVUS. The attenuated plaque was identified in the targeted artery with IVUS, and the same artery was analyzed with MDCT for the presence of a high density area (HDA) >130 Hounsfield units (HU), and a low density area (LDA) <30 HU. A HDA in attenuated plaque was compared with that in calcified plaque. Ten attenuated plaques and 15 calcified plaques were identified in 9 of 154 patients (males=9, 66.2 ± 9.5 years). Eight of the 10 attenuated plaques and all 15 calcified plaques were accompanied with a HDA on MDCT. The HDA ranged from 174 to 667 HU (mean 389.0 ± 148.3 HU) in the 8 attenuated plaques, and from 545 to 1,205 HU (mean 920.9 ± 215.9 HU) in 15 calcified plaques. There was a significant difference in CT density of the HDA between the attenuated and calcified plaque (P<0.001). All attenuated plaques contained LDA <30 HU in the portions without HDA. CONCLUSIONS: MDCT has the ability to demonstrate attenuated plaque as the combination of HDA (approximately 400 HU on average) and LDA <30 HU. The HDA can be differentiated from calcified plaque by its lower CT density value.

Successful percutaneous coil embolization of coronary-pulmonary, -carotid, and -internal mammary artery fistulas.

We herein describe a 57-year-old man with coronary-pulmonary artery fistulas that had abnormal connections between the left common carotid artery and the left internal mammary artery. The patient was treated with percutaneous coil embolization using antegrade (via the coronary artery) and retrograde (via the pulmonary artery) approaches. Coronary artery fistulas have diverse anatomical variations, and it is important to thoroughly evaluate the anatomy before beginning any mode of treatment, surgical or endovascular. In the case reported herein, multislice computed tomography played a pivotal role in the preprocedure evaluation.

Outcomes of intravascular ultrasound-guided percutaneous coronary intervention with drug-eluting stents versus bare metal stents for acute coronary syndrome in octogenarians.

The number of percutaneous coronary interventions (PCI) performed for octogenarians with acute coronary syndrome (ACS) continue to increase. The short- and long-term outcomes of intravascular ultrasound (IVUS)-guided PCI with drug-eluting stents (DES) or bare metal stents (BMS) for ACS in octogenarians, however, remain largely unknown. We analyzed clinical outcomes of octogenarians undergoing IVUS-guided PCI for ACS with either DES or BMS. During the study period, a total of 776 patients with ACS underwent IVUS-guided PCI and 75 of them were octogenarians. In-hospital mortality tended to be lower in the DES group than in the BMS group. Between 6 months and 1 year of follow up, treatment with DES compared with BMS tended to result in fewer target lesion revascularizations. Major adverse cardiac events were similar between patients receiving DES and BMS. In octogenarians with ACS treated with IVUS-guided PCI, DES appears as safe as BMS, providing similar short- and long-term outcomes.

Impact of drug alteration to maintain rhythm control in paroxysmal atrial fibrillation. - Subanalysis from J-RHYTHM study -.

BACKGROUND: The Japanese Rhythm Management Trial for Atrial Fibrillation (J-RHYTHM) study showed rhythm control was associated with fewer changes in the assigned treatment strategy compared to rate control in atrial fibrillation (AF). The aim was to describe how antiarrhythmics (AAs) were altered in the rhythm control arm and whether altering AAs would impact long-term outcomes. METHODS AND RESULTS: Of 390 enrolled patients, 23.5% altered their AAs (drug alteration [DA] group). The hard endpoint (HE) was defined as a composite of death, stroke, embolism, major bleeding or heart failure hospitalization; soft endpoint (SE) was defined physical/psychological disability requiring alteration of treatment strategy. The patients were followed for 1.7 years. No significant difference was noted in the occurrence of HE (4.0% vs 6.5%, P=0.31), but DA-group patients had higher rates of SE (9.3% vs 18.4%, P=0.017) compared to single AA patients. The DA group was also associated with the occurrence of SE after adjustment (HR 1.90, P=0.042). When the DA group was subdivided according to the use of class III drugs or change of drugs between classes, there were no differences in outcomes. CONCLUSIONS: The need to change AA was associated with physical/psychological disabilities that seemed not to be relieved simply by changing AAs, and this should be considered as a marker for refractory paroxysmal AF requiring other strategies.