Early Initiation of Dapagliflozin during Hospitalization for Acute Heart Failure Is Associated with a Shorter Hospital Stay.

Objective Sodium-glucose co-transporter-2 inhibitors (SGLT2is), such as dapagliflozin, have a diuretic effect, and their early initiation to treat acute heart failure (AHF) may improve outcomes; however, the significance of the timing of starting dapagliflozin after hospital admission remains unclear. Methods We performed a post hoc analysis of a prospective, observational registry. Participants were divided into the early (E) group and late (L) group using the median time to the initiation of dapagliflozin (6 days) as the cut-off. We evaluated the relationship between the time to the initiation of dapagliflozin after hospital admission and patient characteristics and the length of the hospital stay. Patients Study subjects were 118 patients with AHF admitted between January 2021 and April 2022 who were started on dapagliflozin treatment (10 mg/day). Results Patients were divided into the E group (n=63) and L group (n=55). The HF severity as evaluated by the New York Heart Association class and the N-terminal pro-brain natriuretic peptide level was not significantly different between the groups. The time to the initiation of dapagliflozin and length of hospital stay showed a significant positive correlation (p<0.001, r=0.46). The hospital stay was significantly shorter in group E [median, 16.5 days; interquartile range (IQR): 13-22 days] than in group L (median, 22 days; IQR: 17-27 days; p=0.002). A multivariate logistic regression analysis showed that the early initiation of dapagliflozin was independently associated with a shorter hospital stay, even after multiple adjustments. Conclusion Early initiation of dapagliflozin after hospital admission is associated with a shorter hospital stay, suggesting it is a key factor for shortening hospital stays.

Impact of the COVID-19 pandemic on the hospitalizations, time course, presenting symptoms, and mid-term outcomes in patients with myocardial infarctions in a Japanese multi-center registry.

To investigate the impact of the coronavirus disease 2019 (COVID-19) pandemic on myocardial infarctions (MIs), consecutive MI patients were retrospectively reviewed in a multi-center registry. The patient characteristics and 180-day mortality for both ST-segment elevation myocardial infarctions (STEMIs) and non-STEMIs (NSTEMIs) in the after-pandemic period (7 April 2020-6 April 2021) were compared to the pre-pandemic period (7 April 2019-6 April 2020). Inpatients with MIs, STEMIs, and NSTEMIs decreased by 9.5%, 12.5%, and 4.1% in the after-pandemic period. The type of the presenting symptoms (as classified as typical symptoms, atypical symptoms, and out-of-hospital cardiac arrests [OHCAs]) did not differ between the two time periods for both STEMIs and NSTEMIs, while the rate of OHCAs was numerically higher in the after-pandemic period for the STEMIs (12.1% vs. 8.0%, p = 0.30). The symptom-to-admission time (STAT) did not differ between the two time periods for both STEMIs and NSTEMIs, but the door-to-balloon time (DTBT) for STEMIs was significantly longer in the after-pandemic period (83.0 [67.0-100.7] min vs. 70.0 [59.0-88.7] min, p = 0.004). The 180-day mortality did not significantly differ between the two time periods for both STEMIs (15.9% vs. 11.4%, p = 0.14) and NSTEMIs (9.9% vs. 8.0%, p = 0.59). In conclusion, hospitalizations for MIs decreased after the COVID-19 pandemic. Although the DTBTs were significantly longer in the after-pandemic period, the mid-term outcomes for MIs were preserved.

Effect of Atorvastatin on Microcirculation Evaluated by Vascular Occlusion Test with Peripheral Near-Infrared Spectroscopy.

The vascular occlusion test (VOT) with peripheral near-infrared spectroscopy (NIRS) is a non-invasive method to evaluate peripheral microcirculation. Statin therapy is widely used for patients with dyslipidaemia and contributes to reducing low-density lipoprotein cholesterol (LDL-C) levels and adverse cardiovascular events. However, it is not yet clear whether statin treatment improves peripheral microcirculation assessed by VOT with NIRS. In the present study, using VOT with NIRS, we evaluated the effect of statin therapy on peripheral microcirculation in patients with dyslipidaemia before and after statin therapy. METHODS: A total of six consecutive patients with dyslipidaemia who had not received statin therapy (6 males, mean age 71.8 ± 7.4 years) were enrolled. All patients were administered atorvastatin and their peripheral microcirculation assessed using VOT with NIRS (NIRO-200NX, Hamamatsu Photonics K.K., Japan) before and after statin therapy. The NIRS probe was attached to the right thenar eminence and brachial artery blood flow was blocked for 3 min at 50 mmHg above the resting systolic blood pressure. Maximum and minimum values of NIRS parameters after the VOT were used to determine concentration changes for total haemoglobin (ΔcHb), oxyhaemoglobin (ΔO2Hb), deoxyhaemoglobin (ΔHHb), and tissue oxygenation index (ΔTOI). RESULTS: During the follow-up period (mean 30.3 ± 6.5 days), LDL-C level decreased from 129.7 ± 26.3 to 67.5 ± 20.2 mg/dL (p-value = 0.031), ΔTOI increased from 24.0 ± 5.3 to 33.7 ± 6.3% (p-value = 0.023), and ΔO2Hb increased from 16.4 ± 5.3 to 20.0 ± 6.6 µmol/L (p-value = 0.007). ΔcHb and ΔHHb did not change significantly. CONCLUSION: ΔO2Hb and ΔTOI were significantly increased during the follow-up period. These findings suggest that ΔO2Hb and ΔTOI could assess the improvement of peripheral microcirculation by statin therapy. Compared to ΔTOI, ΔO2Hb seems to be a more useful parameter to evaluate peripheral microcirculation.

Association between the Angle of the Left Subclavian Artery and Procedural Time for Percutaneous Coronary Intervention in Patients with Acute Coronary Syndrome.

Background: The effect of left subclavian artery tortuosity during percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS) remains unclear. Methods: Of 245 ACS patients (from November 2019 and May 2021), 79 who underwent PCI via a left radial approach (LRA) were included. We measured the angle of the left subclavian artery in the coronal view on CT imaging as an indicator of the tortuosity and investigated the association between that angle and the clinical variables and procedural time. Results: Patients with a left subclavian artery angle of a median of <70 degrees (severe tortuosity) were older (75.4 ± 11.7 vs. 62.9 ± 12.3 years, P < 0.001) and had a higher prevalence of female sex (42.1% vs. 14.6%, P=0.007), hypertension (94.7% vs. 75.6%, P=0.02), and subclavian artery calcification (73.7% vs. 34.2%, P < 0.001) than those with that ≥70 degrees. The left subclavian artery angle correlated negatively with the sheath cannulation to the first balloon time (ρ = -0.51, P < 0.001) and total procedural time (ρ = -0.32, P=0.004). A multiple linear regression analysis revealed that the natural log transformation of the sheath insertion to first balloon time was associated with a subclavian artery angle of <70 degrees (ß = 0.45, P < 0.001). Conclusion: Our study showed that lower left subclavian artery angles as a marker of the tortuosity via the LRA were strongly associated with a longer sheath insertion to balloon time and subsequent entire procedure time during the PCI.

Bradyarrhythmia Suspected to be Associated with Sleep Apnea Syndrome.

Sleep apnea syndrome (SAS) is a condition in which apnea and hypoventilation at night cause hypoxemia and impaired wakefulness during the day, resulting in a general malaise and dozing. Sleep apnea has been implicated in the development of hypertension, ischemic heart disease, arrhythmia, heart failure, and cerebrovascular disease.1) Approximately 50% of patients with sleep-disordered breathing have an arrhythmia. In severe cases with an apnea-hypopnea index (AHI) of 30 or more, the frequency of arrhythmias during sleep is two to four times that of individuals without SAS. Bradyarrhythmias such as sinus bradycardia, sinus arrest, and atrioventricular block occurs at night in about 5%-10% of patients with sleep-disordered breathing.2)During nocturnal sleep, vagal excitation causes excessive muscle relaxation of the upper airway, leading to periodic airway diameter reduction, which increases snoring and obstructive apnea. As a result, hypoxemia is likely, further increasing vagal tone and leading to bradycardia. An increase in ventilation rate and volume quickly compensates for the decrease in arterial partial pressure of oxygen during apnea, which leads to new bradycardia due to a decrease in the partial pressure of oxygen in arterial blood, which suppresses vagal tone and respiration.3)We experienced a case of a 44-year-old patient with bradyarrhythmia that might be associated with SAS. After continuous positive airway pressure treatment, AHI decreased, and very long cardiac arrests resolved.

Prognostic Significance of a Combination of Cardiogenic Shock and the Critical Culprit Lesion Location in ST-Elevation Myocardial Infarctions.

Both cardiogenic shock (CS) and critical culprit lesion locations (CCLLs), defined as the left main trunk and proximal left anterior descending coronary artery, are associated with worse outcomes in ST-elevation myocardial infarctions (STEMIs). We aimed to examine how the combination of CS and/or CCLLs affected the prognosis in Japanese STEMI patients in the primary percutaneous coronary intervention era (PPCI-era). The subjects included 624 STEMI patients admitted to our hospital between January 2013 and April 2020. They were divided into four groups according to the combination of CS and CCLLs: CS (-) CCLL (-) group [n = 405], CS (-) CCLL (+) group [n = 150], CS (+) CCLL (-) group [n = 25], and CS (+) CCLL (+) group [n = 44]. The cumulative incidences of all-cause death at 30 days and 1 year were 3.5% and 6.4% in the CS (-) CCLL (-), 3.3% and 5.6% in the CS (-) CCLL (+), 32.0% and 32.0% in the CS (+) CCLL (-), and 50.0% and 65.9% in the CS (+) CCLL (+) group, respectively. After a multivariate adjustment, the CS (+) CCLL (+) group was independently associated with all-cause death (hazard ratio: 17.00, 95% confidence interval: 7.12-40.59 versus the CS (-) CCLL (-) group). In the CS (+) CCLL (+) group, compared to years 2013-2017, the IMPELLA begun to be used (44.4% versus 0%), and intra-aortic balloon pumps significantly decreased (44.4% versus 92.3%) during years 2018-2020, while the medications upon discharge did not significantly differ. The 30-day mortality was numerically lower during years 2018-2020 than years 2013-2017 (Log-rank test, P = 0.092). In conclusion, the prognosis of STEMIs varies greatly depending on the combination of CS and CCLLs, and in particular, patients with both CS and CCLLs had the poorest prognosis during the modern PPCI-era.

Venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome due to an acute type B aortic dissection: a case report.

Acute type B aortic dissection is sometimes complicated by acute respiratory failure requiring mechanical ventilation. Herein, we describe our experience in a rare acute type B aortic dissection-associated respiratory failure case culminating in acute respiratory distress syndrome. The patient was a 45-year-old man admitted with a complaint of sudden chest pain radiating to his back. On computed tomography, an acute type B aortic dissection was diagnosed. He had no dyspnea on admission, but his respiratory function subsequently deteriorated, and severe acute respiratory distress syndrome was diagnosed on Day 4. Venovenous extracorporeal membrane oxygenation with anticoagulation plus continuous renal replacement therapy for oliguria improved the oxygenation, and the patient was weaned from the extracorporeal membrane oxygenation on Day 8. This patient fully recovered without worsening the aortic dissection, using venovenous extracorporeal membrane oxygenation with anticoagulation plus a continuous renal replacement therapy.

Three-Dimensional Fluid Dynamical Features of Coronary Plaque Rupture Provoking Acute Coronary Syndrome.

AIM: Coronary plaque rupture is the main cause of acute coronary syndrome (ACS), but the role of blood flow features around plaque rupture for ACS is still unknown. The present study aimed to assess the relationship between the geometric configuration of ruptured plaque and ACS occurrence using computational fluid dynamics (CFD) by moving particle method in patients with coronary artery disease. METHODS: In this study, 45 patients with coronary artery disease who underwent three-dimensional intravascular ultrasound (IVUS) and had a coronary ruptured plaque (24 plaques with provoked ACS, 21 without) were included. To compare the difference in blood flow profile around ruptured plaque between the patients with and without ACS, the IVUS images were analyzed via the novel CFD analysis. RESULTS: There were no significant differences in localized flow profile around ruptured plaque between the two groups when the initial particle velocity was 10.0 cm/s corresponded to a higher coronary flow velocity at ventricular diastole. However, when it was 1.0 cm/s corresponded to lower coronary flow velocity at ventricular systole, particles with lower velocity (0 ≤ V ≤ 5 cm/s) were more prevalent around ACS-PR ( p=0.035), whereas particles with higher velocity (10 ≤ V ≤ 20 cm/s) were more often detected in silent plaque ruptures (p=0.018). CONCLUSIONS: Three-dimensional IVUS revealed that coronary plaque rupture was a complex one with a wide variety of its stereoscopic configuration, leading to various patterns of the local coronary flow profile. A novel CFD analysis suggested that the local flow was more stagnant around ACS-provoked ruptures than in silent ones.

Application of Peripheral Near Infrared Spectroscopy to Assess Risk Factors in Patient with Coronary Artery Disease: Part 1.

Obesity, a risk factor of coronary artery disease, is known to cause peripheral microcirculatory disturbances. This study evaluated the relationship between the degree of obesity and peripheral microcirculatory disturbances, using peripheral near infrared spectroscopy (NIRS) with a vascular occlusion test (VOT). We compared correlations between the NIRS parameter changes induced by VOT and body mass index (BMI) in patients with and without statin therapy. A NIRS probe was set on the right thenar eminence, brachial artery blood flow was blocked for 3 min, and then released. Although total hemoglobin (ΔcHb), deoxyhemoglobin (ΔHHb) and tissue oxygenation index (ΔTOI) were not correlated with BMI, a significant negative correlation was found between oxyhemoglobin (ΔO2Hb) and BMI in the overall study population (r = -0.255, p-value 0.02). In addition, a significant negative correlation was found between ΔO2Hb and BMI in patients without statin therapy (r = -0.353, p-value 0.02) but not in patients with statin therapy (r = -0.181, p-value 0.27). These findings suggest that ΔO2Hb may be a useful indicator to assess peripheral microcirculation.

Application of Peripheral Near Infrared Spectroscopy to Assess Risk Factors in Patient with Coronary Artery Disease: Part 2.

Epicardial adipose tissue (EAT) is associated with visceral fat and various cardiac disorders, such as atrial fibrillation and adverse cardiovascular events. Therefore, it is important to develop a simple and non-invasive inspection method to assess EAT, to prevent unfavorable cardiac events. This study assessed correlations between near-infrared spectroscopy (NIRS) changes induced by a vascular occlusion test (VOT) and EAT volume measured by cardiac computed tomography (CCT) in patients with suspected coronary artery disease. We also assessed correlations between body mass index (BMI) and EAT volume in the same population. In addition, these correlations were compared in patients treated with statin therapy and in those without statin therapy. A NIRS probe was set on the right thenar eminence, and brachial artery blood flow was blocked for 3 min before being released. A negative correlation was found between oxyhemoglobin (ΔO2Hb) and EAT volume in the overall study population (r = -0.236, p = 0.03). Interestingly, although a strong correlation was observed in patients without statin therapy (r = -0.488, p < 0.001), this correlation was not observed in patients with statin therapy (r = 0.157, p = 0.34). These findings suggest that NIRS measurements with VOT may be a useful method to identify patients with high EAT volume and high cardiovascular risks.

Effect of drug-coated balloon angioplasty on in-stent restenotic coronary lesions analyzed with optical coherence tomography and serial coronary artery angioscopy.

Drug-coated balloon angioplasty (DCBA) has been recognized for its utility in preventing in-stent re-restenosis (ISR); however, imaging of the neointima immediately after treatment and during follow-up has only been described in a few case reports. This study aimed to determine the efficacy and mechanism of the DCBA using imaging studies both immediately after the DCBA and during the follow-up period. We enrolled 15 consecutive patients who underwent DCBA for in-stent restenosis (ISR). The in-stent neointimal volume was evaluated using optical coherence tomography (OCT), and the in-stent yellow grade was assessed using coronary angioscopy (CAS) immediately after DCBA and during the median follow-up period of 9 (8-15) months. The neointimal volume was significantly reduced from 77.1 ± 36.2 mm3 at baseline to 60.2 ± 23.9 mm3 immediately after DCBA (p = 0.0012 vs. baseline) and to 46.7 ± 21.9 mm3 during the follow-up (p = 0.0002 vs. post DCBA). The yellow grade of the residual plaques at the ISR lesion, which indicated plaque vulnerability, was significantly decreased in the follow-up CAG (from baseline: 1.79 ± 1.03, during the follow-up: 0.76 ± 0.82; p < 0.0001). These data suggest that DCBA may inhibit neointimal formation and provide angioscopic intimal stabilization for ISR lesions.

A case of giant saphenous vein graft aneurysm followed serially after coronary artery bypass surgery.

Saphenous vein graft aneurysm (SVGA) is one of the chronic complications after coronary aorta bypass grafting (CABG) and may be caused by atherosclerosis-like phenomena of the vein graft, weakness around the vein valve, rupturing of the suture of the graft anastomosis, or perioperative graft injury. We describe a case of a large, growing saphenous vein graft aneurysm that was followed serially by chest radiography and computed tomography. Eighteen years after CABG, an SVGA (23 × 24 mm) was incidentally detected. The patient was asymptomatic and was followed conservatively. Four years later, coronary computed tomographic angiography showed that the giant aneurysm had grown to 52.1 by 63.8 mm and revealed a second, smaller aneurysm. Finally, the SVG was ultimately resected without bypass via off-pump surgery. Therefore, this case suggested that aggressive treatment that includes surgical intervention should be considered before the aneurysm becomes larger, even if it is asymptomatic.

Tissue characteristics of non-culprit plaque in patients with acute coronary syndrome vs. stable angina: a color-coded intravascular ultrasound study.

Patients with acute coronary syndrome (ACS) are thought to have multiple vulnerable coronary plaques. We analyzed non-culprit plaques in patients with ACS vs. stable angina pectoris (SAP) by means of color-coded intravascular ultrasound (iMap-IVUS). Patients who underwent percutaneous coronary intervention were divided into an ACS group (n = 39) and an SAP group (n = 35). Non-culprit lesions were imaged by 40-MHz iMap-IVUS, and the plaque characteristics were compared between the two groups. Plaque volume was similar between the two groups. The fibrotic volume (%FV) was less in the ACS group than in the SAP group (70.2 ± 10.4 vs. 76.5 ± 7.2 %, respectively, P < 0.01), whereas the lipidic volume and necrotic volume (%NV) were greater in the ACS group (8.2 ± 0.4 vs. 6.3 ± 0.4 %, P < 0.01; 15.1 ± 7.9 vs. 9.9 ± 4.8 %, P < 0.01). An inverse correlation was found between %FV and total plaque volume (ACS group: r = -0.52, P < 0.01; SAP group: r = -0.31, P = 0.01), and a positive correlation was found between %NV and total plaque volume (ACS group: r = 0.56, P < 0.01; SAP group: r = 0.41, P < 0.01). Furthermore, the slope of the regression line showing the relation between plaque volume and necrotic volume was significantly steeper for the ACS group than for the SAP group (P < 0.05). Non-culprit lesions are particularly vulnerable in ACS patients. Non-culprit lesions are particularly vulnerable in ACS patients. Furthermore, the stronger correlation between plaque volume and %NV was observed in ACS patients than in SAP patients.

Association between the epicardial adipose tissue thickness and the presence of multivessel disease in patients with acute myocardial infarction.

AIM: Epicardial adipose tissue (EAT) is implicated in the development of coronary atherosclerosis.We sought to investigate the association between the EAT thickness and presence of multivessel disease (MV) in patients with acute myocardial infarction (AMI). METHODS: We enrolled 45 consecutive patients with AMI who underwent primary percutaneous coronary intervention (PCI). The EAT thickness was measured on echocardiography. A follow-up study was performed using coronary angiography with coronary angioscopy two weeks after primary PCI. RESULTS: Based on the angiographic findings, 21 patients had single-vessel disease (SV) and 24 patients had MV. The EAT thickness in the patients with SV was significantly smaller than that in the patients with MV (1.9±0.9 mm vs 2.8±1.3 mm, p=0.005, respectively). A multivariate logistic analysis demonstrated that the EAT thickness was the only independent predictor of MV (odds ratio=1.987, 95% confidence interval: 1.089-3.626, p=0.025). An EAT thickness of 2.3 mm was determined to be the optimal cut-off value for predicting MV, with a sensitivity of 70.8% and specificity of 71.4%. Between the thin EAT (＜2.3 mm) and the thick EAT (≥2.3 mm) groups, there were no difference in the number of intense yellow plaques in the non-infarct-related artery evaluated on angioscopy (2.0±2.2 vs 1.8±2.0, p=0.365, respectively). CONCLUSIONS: The EAT thickness is closely associated with the presence of MV, but not vessel vulnerability in the non-infarct-related artery, in patients with AMI. Measuring the EAT provides important information for treating patients with AMI.

Impact of coronary plaque burden and composition on periprocedural myocardial infarction and coronary flow reserve after percutaneous coronary intervention.

Periprocedural myocardial infarction (PMI) is one of the major complications of percutaneous coronary intervention (PCI). We investigated the influence of coronary plaque burden and characteristics on PMI using intravascular ultrasound (IVUS) with radiofrequency-based tissue characterization technology (iMAP). The study population consisted of 33 consecutive patients with stable angina pectoris who underwent PCI. IVUS images were recorded before and after PCI for offline analysis, and coronary flow reserve (CFR) was measured after PCI. PMI was defined as a post-PCI cardiac troponin T elevation > 5 × 99(th) percentile of the upper reference limit (0.014 ng/mL). Plaque volume in patients with PMI (n = 12) was significantly greater than that in patients without PMI (n = 21) (240.4 ± 106.0 mm(3) versus 152.1 ± 76.9 mm(3), P = 0.0096). The iMAP-IVUS analysis demonstrated that the fibrotic, lipidic, and necrotic tissue volume within culprit lesions were also greater in patients with PMI than in patients without PMI (129.4 ± 52.2 mm(3) versus 94.6 ± 40.8 mm(3), P = 0.041; 26.8 ± 10.5 mm(3) versus 15.8 ± 11.5 mm(3), P = 0.011; and 81.3 ± 48.4 mm(3) versus 40.2 ± 33.6 mm(3), P = 0.0071, respectively). Multivariate logistic analysis demonstrated that necrotic tissue volume was the only independent predictor of PMI. Multiple regression analysis demonstrated that the post-PCI CFR values signifi cantly correlated with percent plaque burden, and there were no correlations with the percent tissue burden of each plaque component. In conclusion, the iMAP-IVUS analyses demonstrate that necrotic tissue volume is a potent predictor of PMI. Microcirculatory disturbance after PCI is significantly influenced by percent plaque burden, regardless of plaque compositions.