Platelet-fibrin clot strength and platelet reactivity predicting cardiovascular events after percutaneous coronary interventions.

BACKGROUND AND AIMS: Platelet-fibrin clot strength (PFCS) is linked to major adverse cardiovascular event (MACE) risk. However, the association between PFCS and platelet reactivity and their prognostic implication remains uncertain in patients undergoing percutaneous coronary intervention (PCI). METHODS: In PCI-treated patients (n = 2512) from registry data from January 2010 to November 2018 in South Korea, PFCS using thromboelastography and platelet reactivity using VerifyNow were measured. High PFCS (PFCSHigh) was defined as thromboelastography maximal amplitude ≥ 68 mm, and high platelet reactivity (HPR) was defined as >208 P2Y12 reaction units. Patients were stratified into four groups according to maximal amplitude and P2Y12 reaction unit levels: (i) normal platelet reactivity (NPR)-PFCSNormal (31.8%), (ii) HPR-PFCSNormal (29.0%), (iii) NPR-PFCSHigh (18.1%), and (iv) HPR-PFCSHigh (21.1%). Major adverse cardiovascular event (all-cause death, myocardial infarction, or stroke) and major bleeding were followed up to 4 years. RESULTS: High platelet reactivity and PFCSHigh showed an additive effect for clinical outcomes (log-rank test, P < .001). Individuals with NPR-PFCSNormal, NPR-PFCSHigh, HPR-PFCSNormal, and HPR-PFCSHigh demonstrated MACE incidences of 7.5%, 12.6%, 13.4%, and 19.3%, respectively. The HPR-PFCSHigh group showed significantly higher risks of MACE compared with the NPR-PFCSNormal group [adjusted hazard ratio (HRadj) 1.89; 95% confidence interval (CI) 1.23-2.91; P = .004] and the HPR-PFCSNormal group (HRadj 1.60; 95% CI 1.12-2.27; P = .009). Similar results were observed for all-cause death. Compared with HPR-PFCSNormal phenotype, NPR-PFCSNormal phenotype was associated with a higher risk of major bleeding (HRadj 3.12; 95% CI 1.30-7.69; P = .010). CONCLUSIONS: In PCI patients, PFCS and platelet reactivity demonstrated important relationships in predicting clinical prognosis. Their combined assessment may enhance post-PCI risk stratification for personalized antithrombotic therapy.

Quantitative Understanding of Ionic Channel Network Variation in Nafion with Hydration Using Current Sensing Atomic Force Microscopy.

Proton exchange membranes are an essential component of proton-exchange membrane fuel cells (PEMFC). Their performance is directly related to the development of ionic channel networks through hydration. Current sensing atomic force microscopy (CSAFM) can map the local conductance and morphology of a sample surface with sub-nano resolution simultaneously by applying a bias voltage between the conducting tip and sample holder. In this study, the ionic channel network variation of Nafion by hydration has been quantitatively characterized based on the basic principles of electrodynamics and CSAFM. A nano-sized PEMFC has been created using a Pt-coated tip of CSAFM and one side Pt-coated Nafion, and studied under different relative humidity (RH) conditions. The results have been systematically analyzed. First, the morphology of PEMFC under each RH has been studied using line profile and surface roughness. Second, the CSAFM image has been analyzed statistically through the peak value and full-width half-maximum of the histograms. Third, the number of protons moving through the ionic channel network (NPMI) has been derived and used to understand ionic channel network variation by hydration. This study develops a quantitative method to comprehend variations in the ionic channel network by calculating the movement of protons into the ionic channel network based on CSAFM images. To verify the method, a comparison is made between the NPMI and the changes in proton conductivity under different RH conditions and it reveals a good agreement. This developed method can offer a quantitative approach for characterizing the morphological structure of PEM. Also, it can provide a quantitative tool for interpretating CSAFM images.

Machine learning models to predict the warfarin discharge dosage using clinical information of inpatients from South Korea.

As warfarin has a narrow therapeutic window and obvious response variability among individuals, it is difficult to rapidly determine personalized warfarin dosage. Adverse drug events(ADE) resulting from warfarin overdose can be critical, so that typically physicians adjust the warfarin dosage through the INR monitoring twice a week when starting warfarin. Our study aimed to develop machine learning (ML) models that predicts the discharge dosage of warfarin as the initial warfarin dosage using clinical data derived from electronic medical records within 2 days of hospitalization. During this retrospective study, adult patients who were prescribed warfarin at Asan Medical Center (AMC) between January 1, 2018, and October 31, 2020, were recruited as a model development cohort (n = 3168). Additionally, we created an external validation dataset (n = 891) from a Medical Information Mart for Intensive Care III (MIMIC-III). Variables for a model prediction were selected based on the clinical rationale that turned out to be associated with warfarin dosage, such as bleeding. The discharge dosage of warfarin was used the study outcome, because we assumed that patients achieved target INR at discharge. In this study, four ML models that predicted the warfarin discharge dosage were developed. We evaluated the model performance using the mean absolute error (MAE) and prediction accuracy. Finally, we compared the accuracy of the predictions of our models and the predictions of physicians for 40 data point to verify a clinical relevance of the models. The MAEs obtained using the internal validation set were as follows: XGBoost, 0.9; artificial neural network, 0.9; random forest, 1.0; linear regression, 1.0; and physicians, 1.3. As a result, our models had better prediction accuracy than the physicians, who have difficulty determining the warfarin discharge dosage using clinical information obtained within 2 days of hospitalization. We not only conducted the internal validation but also external validation. In conclusion, our ML model could help physicians predict the warfarin discharge dosage as the initial warfarin dosage from Korean population. However, conducting a successfully external validation in a further work is required for the application of the models.

Sodium-Glucose Cotransporter-2 Inhibitors After Acute Myocardial Infarction in Patients With Type 2 Diabetes: A Population-Based Investigation.

Background Whether the early use of sodium-glucose cotransporter-2 (SGLT2) inhibitors have cardioprotective effects following acute myocardial infarction is unknown. Thus, we aimed to evaluate the association between the early initiation of SGLT2 inhibitors and cardiac event rates in patients with diabetes with acute myocardial infarction undergoing percutaneous coronary intervention. Methods and Results Based on the National Health Insurance claims data in South Korea, patients who received percutaneous coronary intervention for acute myocardial infarction between 2014 and 2018 were analyzed. Patients given SGLT2 inhibitors or other glucose-lowering drugs were matched based on a propensity score. The primary end point was a composite of all-cause mortality and hospitalizations for heart failure. Major adverse cardiac events (a composite of all-cause death, nonfatal myocardial infarction, and ischemic stroke) were compared as the secondary end point. After 1:2 propensity score matching, the SGLT2 inhibitors group (938 patients) and the no use of SGLT2 inhibitors group (1876 patients) were compared. During a median follow-up of 2.1 years, the early use of SGLT2 inhibitors was associated with lower risks of both the primary end point (9.8% versus 13.9%; adjusted hazard ratio [HR], 0.68 [95% CI, 0.54-0.87]; P=0.002) and secondary end point (9.1% versus 11.6%; adjusted HR, 0.77 [95% CI, 0.60-0.99]; P=0.04). All-cause mortality and hospitalizations for heart failure were also significantly lower in early users of SGLT2 inhibitors. Conclusions The early use of SGLT2 inhibitors in patients with diabetes treated with percutaneous coronary intervention for acute myocardial infarction was associated with a significantly lower risk of cardiovascular events, including all-cause mortality, hospitalizations for heart failure, and major adverse cardiac events.

Quantitative Study of Charge Distribution Variations on Silica-Nafion Composite Membranes under Hydration Using an Approximation Model.

Understanding the ionic structure and charge transport on proton exchange membranes (PEMs) is crucial for their characterization and development. Electrostatic force microscopy (EFM) is one of the best tools for studying the ionic structure and charge transport on PEMs. In using EFM to study PEMs, an analytical approximation model is required for the interoperation of the EFM signal. In this study, we quantitatively analyzed recast Nafion and silica-Nafion composite membranes using the derived mathematical approximation model. The study was conducted in several steps. In the first step, the mathematical approximation model was derived using the principles of electromagnetism and EFM and the chemical structure of PEM. In the second step, the phase map and charge distribution map on the PEM were simultaneously derived using atomic force microscopy. In the final step, the charge distribution maps of the membranes were characterized using the model. There are several remarkable results in this study. First, the model was accurately derived as two independent terms. Each term shows the electrostatic force due to the induced charge of the dielectric surface and the free charge on the surface. Second, the local dielectric property and surface charge are numerically calculated on the membranes, and the calculation results are approximately valid compared with those in other studies.

PERIRHINAL CORTEX LEARNS A PREDICTIVE MAP (INTERNAL MODEL) OF THE TASK ENVIRONMENT.

Goal-directed tasks involve acquiring an internal model, known as a predictive map, of relevant stimuli and associated outcomes to guide behavior. Here, we identified neural signatures of a predictive map of task behavior in perirhinal cortex (Prh). Mice learned to perform a tactile working memory task by classifying sequential whisker stimuli over multiple training stages. Chemogenetic inactivation demonstrated that Prh is involved in task learning. Chronic two-photon calcium imaging, population analysis, and computational modeling revealed that Prh encodes stimulus features as sensory prediction errors. Prh forms stable stimulus-outcome associations that expand in a retrospective manner and generalize as animals learn new contingencies. Stimulus-outcome associations are linked to prospective network activity encoding possible expected outcomes. This link is mediated by cholinergic signaling to guide task performance, demonstrated by acetylcholine imaging and perturbation. We propose that Prh combines error-driven and map-like properties to acquire a predictive map of learned task behavior.

Impact of annealing temperature on the remanent polarization and tunneling electro-resistance of ferroelectric Al-doped HfOx tunnel junction memory.

The ferroelectric characteristics of a metal-ferroelectric-metal (MFM) ferroelectric tunneling junction (FTJ) capacitor device are investigated herein. The device consists of an aluminum-doped hafnium oxide (HAO) insulator sandwiched between tungsten (W) and titanium nitride (TiN) metal electrodes. Rapid thermal annealing (RTA) is performed for 20 s under a nitrogen atmosphere at temperatures of 750 °C, 800 °C, and 850 °C to find that ferroelectricity with a large remanent polarization (Pr) of 41.28 µC cm-2 can be obtained at the optimum annealing temperature of 800 °C. The presence of ferroelectricity is confirmed by polarization-switching positive-up-negative-down (PUND) measurements and by the hysteric polarization-voltage (P-V) loop. All devices exhibit excellent reliability, with an endurance of up to ∼106 cycles and long retention characteristics. In addition, the interfacial paraelectric capacitance (Ci) values of the three HAO FTJs are investigated via pulse-switching measurements. The results indicate that the HAO film annealed at 800 °C for 20 s exhibits an excellent tunneling electro-resistance (TER) ratio of 186% and this is attributed to the extra paraelectric layer formed between the ferroelectric layer and the bottom electrode. The detailed findings of this study are expected to assist in the development of hafnium oxide-based ferroelectric non-volatile memory applications.

Cardiovascular Event Rates in Statin-Treated Korean Patients with Cardiovascular Disease: Estimates from a Real-World Population Using Electronic Medical Record Data.

PURPOSE: To estimate the risk of recurrent cardiovascular events in a real-world population of very high-risk Korean patients with prior myocardial infarction (MI), ischemic stroke (IS), or symptomatic peripheral artery disease (sPAD), similar to the Further cardiovascular OUtcomes Research with proprotein convertase subtilisin-kexin type 9 Inhibition in subjects with Elevated Risk (FOURIER) trial population. METHODS: This retrospective study used the Asan Medical Center Heart Registry database built on electronic medical records (EMR) from 2000 to 2016. Patients with a history of clinically evident atherosclerotic cardiovascular disease (ASCVD) with multiple risk factors were followed up for 3 years. The primary endpoint was a composite of MI, stroke, hospitalization for unstable angina, coronary revascularization, and all-cause mortality. RESULTS: Among 15,820 patients, the 3-year cumulative incidence of the composite primary endpoint was 15.3% and the 3-year incidence rate was 5.7 (95% CI 5.5-5.9) per 100 person-years. At individual endpoints, the rates of deaths, MI, and IS were 0.4 (0.3-0.4), 0.9 (0.8-0.9), and 0.8 (0.7-0.9), respectively. The risk of the primary endpoint did not differ significantly between recipients of different intensities of statin therapy. Low-density lipoprotein cholesterol (LDL-C) goals were only achieved in 24.4% of patients during the first year of follow-up. CONCLUSION: By analyzing EMR data representing routine practice in Korea, we found that patients with very high-risk ASCVD were at substantial risk of further cardiovascular events in 3 years. Given the observed risk of recurrent events with suboptimal lipid management by statin, additional treatment to control LDL-C might be necessary to reduce the burden of further cardiovascular events for very high-risk ASCVD patients.

Effects of Oxygen Flow Rate on Metal-to-Insulator Transition Characteristics in NbOx-Based Selectors.

In this work, NbOx-based selector devices were fabricated by sputtering deposition systems. Metal-to-insulator transition characteristics of the device samples were investigated depending on the oxygen flow rate (3.5, 4.5, and 5.5 sccm) and the deposition time. The device stack was scanned by transmission electron microscopy (TEM) and energy-dispersive X-ray spectroscopy (EDS). The yields, including MIT, nonlinear, and Ohmic, in working devices with different deposition conditions were also evaluated. Moreover, we observed the trend in yield values as a function of selectivity. In addition, the current-voltage (I-V) curves were characterized in terms of DC and pulse endurance. Finally, the switching speed and operating energies were obtained by applying a triangular pulse on the devices, and the recovery time and drift-free characteristics were obtained by the paired pulses.

Antithrombotic Therapy After Acute Coronary Syndromes or Percutaneous Coronary Interventions in East Asian Populations.

Because guidelines and recommendations in response to multiple randomized clinical trials (RCTs) of new therapies undergo rapid changes, antithrombotic therapies for patients after acute coronary syndrome, or percutaneous coronary intervention, are becoming more complex in daily clinical practice. The proportion of Asian populations enrolled in landmark RCTs is substantially low, which limits the direct application of trial findings into clinical practice in Asian countries. Moreover, compared with Caucasian patients, East Asian patients are considered to have a different ischemia/bleeding propensity in response to antithrombotic therapy, known as the "East Asian paradox" (ie, more bleeding events but fewer thromboembolic events). Coincident with consecutive RCTs in Western populations to optimize antithrombotic strategies, several such studies have now been conducted in East Asian cohorts. Herein, we provide a comprehensive summary of the key RCTs in this regard and propose future directions and perspectives for optimal antithrombotic therapies in East Asian patients.

ß-COP Regulates TWIK1/TREK1 Heterodimeric Channel-Mediated Passive Conductance in Astrocytes.

Mature astrocytes are characterized by a K+ conductance (passive conductance) that changes with a constant slope with voltage, which is involved in K+ homeostasis in the brain. Recently, we reported that the tandem of pore domains in a weak inward rectifying K+ channel (TWIK1 or KCNK1) and TWIK-related K+ channel 1 (TREK1 or KCNK2) form heterodimeric channels that mediate passive conductance in astrocytes. However, little is known about the binding proteins that regulate the function of the TWIK1/TREK1 heterodimeric channels. Here, we found that ß-coat protein (COP) regulated the surface expression and activity of the TWIK1/TREK1 heterodimeric channels in astrocytes. ß-COP binds directly to TREK1 but not TWIK1 in a heterologous expression system. However, ß-COP also interacts with the TWIK1/TREK1 heterodimeric channel in a TREK1 dependent manner and enhances the surface expression of the heterodimeric channel in astrocytes. Consequently, it regulates TWIK1/TREK1 heterodimeric channel-mediated passive conductance in astrocytes in the mouse brain. Taken together, these results suggest that ß-COP is a potential regulator of astrocytic passive conductance in the brain.

Analysis of Ionic Domain Evolution on a Nafion-Sulfonated Silica Composite Membrane Using a Numerical Approximation Model Based on Electrostatic Force Microscopy.

It is important to characterize the proton transport mechanisms of proton exchange membranes (PEMs). Electrostatic force microscopy (EFM) is used to characterize the ionic structures of membranes. In this study, we attempted to quantitatively analyze the proton conductivity enhancement of Nafion-sulfonated silica (SSA) composite membranes with variations in the ionic channel distribution. This study involved several steps. The morphology and surface charge distribution of both membranes were measured using EFM. The measured data were analyzed using a numerical approximation model (NAM) that was capable of providing the magnitude and classification of the surface charges. There were several findings of ionic channel distribution variations in Nafion-SSA. First, the mean local ionic channel density of Nafion-SSA was twice as large as that of the pristine Nafion. The local ionic channel density was non-uniform and the distribution of the ionic channel density of Nafion-SSA was 23.5 times larger than that of pristine Nafion. Second, local agglomerations due to SSA were presumed by using the NAM, appearing in approximately 10% of the scanned area. These findings are meaningful in characterizing the proton conductivity of PEMs and imply that the NAM is a suitable tool for the quantitative assessment of PEMs.

Electronic Medical Record-Based Machine Learning Approach to Predict the Risk of 30-Day Adverse Cardiac Events After Invasive Coronary Treatment: Machine Learning Model Development and Validation.

BACKGROUND: Although there is a growing interest in prediction models based on electronic medical records (EMRs) to identify patients at risk of adverse cardiac events following invasive coronary treatment, robust models fully utilizing EMR data are limited. OBJECTIVE: We aimed to develop and validate machine learning (ML) models by using diverse fields of EMR to predict the risk of 30-day adverse cardiac events after percutaneous intervention or bypass surgery. METHODS: EMR data of 5,184,565 records of 16,793 patients at a quaternary hospital between 2006 and 2016 were categorized into static basic (eg, demographics), dynamic time-series (eg, laboratory values), and cardiac-specific data (eg, coronary angiography). The data were randomly split into training, tuning, and testing sets in a ratio of 3:1:1. Each model was evaluated with 5-fold cross-validation and with an external EMR-based cohort at a tertiary hospital. Logistic regression (LR), random forest (RF), gradient boosting machine (GBM), and feedforward neural network (FNN) algorithms were applied. The primary outcome was 30-day mortality following invasive treatment. RESULTS: GBM showed the best performance with area under the receiver operating characteristic curve (AUROC) of 0.99; RF had a similar AUROC of 0.98. AUROCs of FNN and LR were 0.96 and 0.93, respectively. GBM had the highest area under the precision-recall curve (AUPRC) of 0.80, and the AUPRCs of RF, LR, and FNN were 0.73, 0.68, and 0.63, respectively. All models showed low Brier scores of <0.1 as well as highly fitted calibration plots, indicating a good fit of the ML-based models. On external validation, the GBM model demonstrated maximal performance with an AUROC of 0.90, while FNN had an AUROC of 0.85. The AUROCs of LR and RF were slightly lower at 0.80 and 0.79, respectively. The AUPRCs of GBM, LR, and FNN were similar at 0.47, 0.43, and 0.41, respectively, while that of RF was lower at 0.33. Among the categories in the GBM model, time-series dynamic data demonstrated a high AUROC of >0.95, contributing majorly to the excellent results. CONCLUSIONS: Exploiting the diverse fields of the EMR data set, the ML-based 30-day adverse cardiac event prediction models demonstrated outstanding results, and the applied framework could be generalized for various health care prediction models.

Deficiency of TTYH1 Expression Reduces the Migration and Invasion of U2OS Human Osteosarcoma Cells.

The Tweety homolog (TTYH) chloride channel family is involved in oncogenic processes including cell proliferation, invasion, and colonization of cancers. Among the TTYH family, TTYH1 is highly expressed in several cancer cells, such as glioma, breast, and gastric cancer cells. However, the role of TTYH1 in the progression of osteosarcoma remains unknown. Here, we report that deficient TTYH1 expression results in the inhibition of the migration and invasion of U2OS human osteosarcoma cells. We found that TTYH1 was endogenously expressed at both mRNA and protein levels in U2OS cells and that these channels were located at the plasma membrane of the cells. Moreover, we found that silencing of the TTYH1 with small interfering RNA (siRNA) resulted in a decrease in the migration and invasion of U2OS cells, while the proliferation of the cells was not affected. Additionally, treatment with TTYH1 siRNA significantly suppressed the mRNA expression of epithelial−mesenchymal transition (EMT)-regulated transcription factors such as Zinc E-Box Binding Homeobox 1 (ZEB1) and SNAIL. Most importantly, the expression of matrix metalloproteinase (MMP)-2, MPP-9, and N-cadherin was dramatically reduced following the silencing of TTYH1. Taken together, our findings suggest that silencing of TTYH1 expression reduces migration and invasion of U2OS cells and that TTYH1 may act as a potential molecular target for osteosarcoma treatment.

Conditional deletion of TMEM16A in cholinergic neurons of the medial habenula induces anhedonic-like behavior in mice.

The medial habenula (mHb), a subregion of the habenula, is involved in diverse brain functions, such as nicotine addiction, anxiety, and anhedonia. We recently reported that TMEM16A deficiency, a calcium-activated chloride channel, decreased the activity of mHb cholinergic neurons. Since downregulated activity in cholinergic neurons of the mHb is involved in anhedonia-like behavior, we here investigated whether conditional deletion of TMEM16A in mHb cholinergic neurons also displays anhedonia-like behavior. The conditional deletion of TMEM16A in the mHb cholinergic neurons of mice (TMEM16A cKO mice) was generated by crossing ChaT-Cre (+) with floxed TMEM16A f/f mice. TMEM16A cKO mice displayed significantly reduced social interaction, sucrose preference, female urine sniffing, and increased marble burying. These behavioral data suggest the potential role of TMEM16A in anhedonic-like behavior in mice. Taken together, the presented data suggest that TMEM16A-mediated mHb activity might be a therapeutic target for anhedonia-related symptoms.

Neuroinflammation Induced by Transgenic Expression of Lipocalin-2 in Astrocytes.

Transgenic mice are a useful tool for exploring various aspects of gene function. A key element of this approach is the targeted overexpression of specific genes in cells or tissues. Herein, we report for the first time, the generation and characterization of conditional transgenic (cTg) mice for lipocalin-2 (LCN2) expression. We generated the R26-LCN2-transgenic (LCN2-cTg) mice that carried a loxP-flanked STOP (neo) cassette, Lcn2 cDNA, and a GFP sequence. When bred with Tg mice expressing Cre recombinase under the control of various tissues or cell-specific promoters, Cre-mediated recombination deletes the STOP cassette and allows the expression of LCN2 and GFP. In this study, we achieved the recombination of loxP-flanked LCN2 in hippocampal astrocytes of cTg mouse brain, using a targeted delivery of adeno-associated virus (AAVs) bearing Cre recombinase under the control of a GFAP promoter (AAVs-GFAP-mCherry-Cre). These mice with localized LCN2 overexpression in astrocytes of the hippocampus developed neuroinflammation with enhanced glial activation and increased mRNA and protein levels of proinflammatory cytokines. Furthermore, mice showed impairment in cognitive functions as a typical symptom of hippocampal inflammation. Taken together, our study demonstrates the usefulness of LCN2-cTg mice in targeting specific cells at various organs for conditional LCN2 expression and for subsequent investigation of the functional role of cell-type-specific LCN2 within these sites. Moreover, the LCN2-cTg mice with targeted expression of LCN2 in hippocampal astrocytes are a new in vivo model of neuroinflammation.

Ischemic Burden Assessment Using Single Photon Emission Computed Tomography in Single Vessel Chronic Total Occlusion of Coronary Artery.

BACKGROUND AND OBJECTIVES: Studies evaluating the nature of ischemic burden of chronic total occlusion (CTO) vessels are still lacking. METHODS: A total of 165 patients with single vessel CTO >2.5 mm in an epicardial coronary artery who underwent single photon emission computed tomography (SPECT) were enrolled in the study. Ischemic burden was calculated with the use of semi-quantitative SPECT analysis, and was defined as the summed difference score (SDS) divided by the maximal limit of the score (=SDS/68). RESULTS: The mean age of the participants was 59.5 years and the CTO of the left anterior descending coronary artery (LAD), left circumplex coronary artery (LCX), and right coronary artery (RCA) accounted for 93 (56.4%), 18 (10.9%), and 54 (32.7%) patients, respectively. The median ischemic burden of the total population was 8.8%, and it was highest in the LAD CTO (10.3%) compared with the LCX (5.9%) and RCA CTO (5.9%, p<0.001). High-ischemic burden (ischemic burden >10%) was observed in 66 patients (40.0%), and in 47 patients (50.5%) of the LAD CTO. Ischemic burden was different according to the CTO location only in LAD CTO. The statistically significant predictors for high-ischemic burden were hypertension, baseline ejection fraction >45%, LAD CTO, proximal CTO location, and de novo CTO. Japanese-CTO score and Rentrop scale collateral grade were not associated with high-ischemic burden. CONCLUSIONS: Only 40% of patients with single vessel CTO had ischemic burden >10%. For CTO vessels, measurement of ischemic burden using SPECT prior to revascularization may be helpful in identifying beneficial subjects.