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.

CVIT 2023 clinical expert consensus document on intravascular ultrasound.

Intravascular ultrasound (IVUS) provides precise anatomic information in coronary arteries including quantitative measurements and morphological assessment. To standardize the IVUS analysis in the current era, this updated expert consensus document summarizes the methods of measurements and assessment of IVUS images and the clinical evidence of IVUS use in percutaneous coronary intervention.

Diagnosis and Prognostic Value of the Underlying Cause of Acute Coronary Syndrome in Optical Coherence Tomography-Guided Emergency Percutaneous Coronary Intervention.

Background The prognostic impact of optical coherence tomography-diagnosed culprit lesion morphology in acute coronary syndrome (ACS) has not been systematically examined in real-world settings. Methods and Results This investigator-initiated, prospective, multicenter, observational study was conducted at 22 Japanese hospitals to identify the prevalence of underlying ACS causes (plaque rupture [PR], plaque erosion [PE], and calcified nodules [CN]) and their impact on clinical outcomes. Patients with ACS diagnosed within 24 hours of symptom onset undergoing emergency percutaneous coronary intervention were enrolled. Optical coherence tomography-guided percutaneous coronary intervention recipients were assessed for underlying ACS causes and followed up for major adverse cardiac events (cardiovascular death, myocardial infarction, heart failure, or ischemia-driven revascularization) at 1 year. Of 1702 patients with ACS, 702 (40.7%) underwent optical coherence tomography-guided percutaneous coronary intervention for analysis. PR, PE, and CN prevalence was 59.1%, 25.6%, and 4.0%, respectively. One-year major adverse cardiac events occurred most frequently in patients with CN (32.1%), followed by PR (12.4%) and PE (6.2%) (log-rank P<0.0001), primarily driven by increased cardiovascular death (CN, 25.0%; PR, 0.7%; PE, 1.1%; log-rank P<0.0001) and heart failure trend (CN, 7.1%; PR, 6.8%; PE, 2.2%; log-rank P<0.075). On multivariate Cox regression analysis, the underlying ACS cause was associated with 1-year major adverse cardiac events (CN [hazard ratio (HR), 4.49 [95% CI, 1.35-14.89], P=0.014]; PR (HR, 2.18 [95% CI, 1.05-4.53], P=0.036]; PE as reference). Conclusions Despite being the least common, CN was a clinically significant underlying ACS cause, associated with the highest future major adverse cardiac events risk, followed by PR and PE. Future studies should evaluate the possibility of ACS underlying cause-based optical coherence tomography-guided optimization.

SYNTAX Score and 1-Year Outcomes in the OPTIVUS-Complex PCI Study Multivessel Cohort.

BACKGROUND: The optimal revascularization strategy in patients with multivessel disease and intermediate SYNTAX score (SS) has not been fully elucidated. This study aimed to investigate the clinical outcomes of optimal intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) stratified by SS. METHODS: This was a substudy of the OPTIVUS-Complex PCI study Multivessel Cohort, which aimed to meet the prespecified criteria for optimal stent expansion after IVUS-guided PCI. A total of 1,005 patients were divided into 3 groups according to SS: low, ≤22; intermediate, 23 to 32; and high, ≥33. The primary end points were major adverse cardiac and cerebrovascular events (MACCE) defined as a composite of death, myocardial infarction, stroke, or coronary revascularization. RESULTS: The cumulative 1-year incidence of the primary end point was significantly higher in patients with high SS than in those with intermediate or low SS (25.0%, 10.9%, and 9.5%, respectively; p = 0.003). This difference was mainly caused by the incidence of coronary revascularization. In the multivariable Cox proportional hazards models, the excess risk of patients with high versus low SS remained significant for the primary end point (hazard ratio 3.19, 95% confidence interval 1.65 to 6.16, p <0.001), whereas the excess risk of patients with intermediate versus low SS was no longer significant (hazard ratio 1.20, 95% confidence interval 0.72 to 2.01, p = 0.46). CONCLUSIONS: After IVUS-guided multivessel PCI, patients with intermediate SS had a similar 1-year risk of MACCE to that of patients with low SS, whereas patients with high SS had a higher 1-year risk of MACCE than those with low SS.

Current clinical use of intravascular ultrasound imaging to guide percutaneous coronary interventions (update).

There are 3 main reasons to promote the practical application of IVUS during PCI. First reason is to understand the mechanism of vessel dilatation. Even if angiographic stenoses are similar, their pathophysiologies are different. It is important to understand what can happen by dilating coronary artery with balloon/stent, and to develop a strategy to achieve the maximum effect. Second reason is to anticipate possible complications and to reduce them in advance. In that case, we can deal with it as calmly as possible. Third reason is to validate the PCI performed. This should lead to further improvements of the procedures, which in turn will lead to improved short- and long-term prognosis. Then, high-quality PCI could be possible. This review summarizes the standard usage of IVUS in routine clinical practice and the use of IVUS in specific situations, especially complex lesions.

Rationale and design of the TACTICS registry: Optical coherence tomography guided primary percutaneous coronary intervention for patients with acute coronary syndrome.

BACKGROUND: Recent retrospective investigations have suggested that optical coherence tomography (OCT) enables the diagnosis of underlying acute coronary syndrome (ACS) causes such as plaque rupture, plaque erosion, and calcified nodule. The relationships of these etiologies with clinical outcomes, and the clinical utility of OCT-guided primary percutaneous coronary intervention (PCI) are not systematically studied in real-world ACS treatment settings. METHODS: The TACTICS registry is an investigator-initiated, prospective, multicenter, observational study to be conducted at 21 hospitals in Japan. A total of 700 patients with ACS (symptom onset within 24 h) undergoing OCT-guided primary PCI will be enrolled. The primary endpoint of the study is to identify the underlying causes of ACS using OCT-defined morphological assessment of the culprit lesion. The key secondary clinical endpoints are hazard ratios of the composite of cardiovascular death, non-fatal myocardial infarction, heart failure, or ischemia-driven revascularization in patients with underlying etiologies at the 12- and 24-month follow-ups. The feasibility of OCT-guided primary PCI for ACS will be assessed by the achievement rates of optimal post-procedural results and safety endpoints. CONCLUSION: The TACTICS registry will provide an overview of the underlying causes of ACS using OCT, and will reveal any difference in clinical outcomes depending on the underlying causes. The registry will also inform on the feasibility of OCT-guided primary PCI for patients with ACS.

CVIT expert consensus document on primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) update 2022.

Primary Percutaneous Coronary Intervention (PCI) has significantly contributed to reducing the mortality of patients with ST-segment elevation myocardial infarction (STEMI) even in cardiogenic shock and is now the standard of care in most of Japanese institutions. The Task Force on Primary PCI of the Japanese Association of Cardiovascular Interventional and Therapeutics (CVIT) society proposed an expert consensus document for the management of acute myocardial infarction (AMI) focusing on procedural aspects of primary PCI in 2018. Updated guidelines for the management of AMI were published by the European Society of Cardiology (ESC) in 2017 and 2020. Major changes in the guidelines for STEMI patients included: (1) radial access and drug-eluting stents (DES) over bare-metal stents (BMS) were recommended as a Class I indication, (2) complete revascularization before hospital discharge (either immediate or staged) is now considered as Class IIa recommendation. In 2020, updated guidelines for Non-ST-Elevation Myocardial Infarction (NSTEMI) patients, the followings were changed: (1) an early invasive strategy within 24 h is recommended in patients with NSTEMI as a Class I indication, (2) complete revascularization in NSTEMI patients without cardiogenic shock is considered as Class IIa recommendation, and (3) in patients with atrial fibrillation following a short period of triple antithrombotic therapy, dual antithrombotic therapy (e.g., DOAC and single oral antiplatelet agent preferably clopidogrel) is recommended, with discontinuation of the antiplatelet agent after 6 to 12 months. Furthermore, an aspirin-free strategy after PCI has been investigated in several trials those have started to show the safety and efficacy. The Task Force on Primary PCI of the CVIT group has now proposed the updated expert consensus document for the management of AMI focusing on procedural aspects of primary PCI in 2022 version.

Clinical expert consensus document on intravascular ultrasound from the Japanese Association of Cardiovascular Intervention and Therapeutics (2021).

Intravascular ultrasound (IVUS) provides precise anatomic information in coronary arteries including quantitative measurements and morphological assessment. To standardize the IVUS analysis in the current era, this updated expert consensus document summarizes the methods of measurements and assessment of IVUS images and the clinical evidence of IVUS use in percutaneous coronary intervention.

Clinical expert consensus document on standards for measurements and assessment of intravascular ultrasound from the Japanese Association of Cardiovascular Intervention and Therapeutics.

Intravascular ultrasound (IVUS) provides precise anatomic information in coronary arteries including quantitative measurements and morphological assessment. To standardize the IVUS analysis in the current era, this expert consensus document summarizes the methods of measurements and assessment of IVUS images.

CVIT expert consensus document on primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) in 2018.

While primary percutaneous coronary intervention (PCI) has significantly contributed to improve the mortality in patients with ST segment elevation myocardial infarction even in cardiogenic shock, primary PCI is a standard of care in most of Japanese institutions. Whereas there are high numbers of available facilities providing primary PCI in Japan, there are no clear guidelines focusing on procedural aspect of the standardized care. Whilst updated guidelines for the management of acute myocardial infarction were recently published by European Society of Cardiology, the following major changes are indicated; (1) radial access and drug-eluting stent over bare metal stent were recommended as Class I indication, and (2) complete revascularization before hospital discharge (either immediate or staged) is now considered as Class IIa recommendation. Although the primary PCI is consistently recommended in recent and previous guidelines, the device lag from Europe, the frequent usage of coronary imaging modalities in Japan, and the difference in available medical therapy or mechanical support may prevent direct application of European guidelines to Japanese population. The Task Force on Primary Percutaneous Coronary Intervention of the Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT) has now proposed the expert consensus document for the management of acute myocardial infarction focusing on procedural aspect of primary PCI.

Post-cardiac injury syndrome after a simple coronary stenting.

An 80-year-old male patient underwent a coronary angioplasty without signs of complications. The day after the procedure, the patient complained of chest pain. The electrocardiogram showed a widespread ST segment elevation. A chest X-ray revealed pulmonary congestion with pleural effusion. There was no significant pericardial effusion detected with an echocardiogram. An administration of diuretics was initiated. After he showed an improvement of symptoms, the administration of diuretics was tapered. However, a deterioration of the oxygenation level was re-observed. The echocardiogram confirmed a cardiac tamponade at this time. The oxygenation level recovered after pericardiocentesis and pleurocentesis. Post-cardiac injury syndrome was suspected to be the cause of this clinical course, and the patient was given an intravenous administration of hydrocortisone followed by an oral administration of prednisone. All clinical parameters started to improve drastically.

Neointimal calcification after stenting and chronic kidney disease.

The timing and incidence of neointimal calcification after stenting (NIC) is largely unknown. The purpose of our study was to elucidate the characteristics of NIC. The presence of NIC in patients who underwent intravascular ultrasound between June 30, 2009 and June 30, 2012 was analyzed. The patients were divided into two groups based on the follow-up period: < 365 days or ≥ 365 days. A total of 181 images were analyzed. Those with NIC had a lower estimated glomerular filtration rate [51 (6-60) versus 61 (52-72) mL/minute/1.73 m²; P < 0.01] and longer time after stenting [3198 (1710-3684) versus 211 (180-516) days; P < 0.01] compared to those without NIC. NIC during short-term follow-up was observed only in patients who were on hemodialysis. On the other hand, NIC in the long-term follow-up was observed only in patients with bare metal stents. The development of NIC was related to renal function and time after stenting. NIC in the short-term and the long-term follow-up was observed only in patients who were on hemodialysis and who were implanted with a bare metal stent, respectively.

A case report of acute myocardial infarction induced by coronary spasm. Intravascular findings.

A 53-year-old male complaining of chest pain was admitted to our hospital with suspected acute myocardial infarction (AMI). Emergent coronary angiography (CAG) determined a totally occluded middle right coronary artery (RCA). Thrombus aspiration was conducted, followed by intravascular ultrasound (IVUS) imaging. Diffuse intima plus media thickness was identified at the obstruction site and a thrombus was observed proximally to the occlusion site on IVUS. Following isosorbide dinitrate (ISDN) administration, dilatation of the RCA was confirmed. IVUS study indicated the luminal dilatation was achieved by the release of the diffuse intima plus media thickening. Of note, plaque volume showed no significant difference after administration of ISDN at any vessel site. These results clearly show that luminal dilatation and vessel dilatation were achieved from the redistribution of plaque volume (intima plus media). A follow-up CAG showed no significant stenosis in the RCA. After a provocation test using methylergometrine maleate, the RCA was totally occluded at the very site of the initial event. The involvement of vasospasm as a cause of AMI in the present case was doubly confirmed with characteristic IVUS images of vasospasm in the acute phase and with a provocation test at follow-up.