Prognosis of anemic patients with atrial fibrillation undergoing percutaneous coronary intervention.

BACKGROUND: There are limited data regarding whether anemia is associated with adverse clinical outcomes in patients with atrial fibrillation (AF) after percutaneous coronary intervention (PCI). METHODS: Patients with AF undergoing PCI at 15 institutions between January 2015 and March 2021 were included in this analysis. Based on the baseline hemoglobin levels, moderate to severe anemia was defined as hemoglobin levels <11 g/dL, and mild anemia was defined as hemoglobin levels 11-12.9 g/dL for men and 11-11.9 g/dL for women. Clinical outcomes within 1 year, including major adverse cardiovascular events (MACE: all-cause death, myocardial infarction, stent thrombosis, and stroke) and major bleeding events (BARC 3 or 5), were compared among patients with moderate/severe anemia, mild anemia, and no anemia. RESULTS: In a total of 746 enrolled patients, 119 (16.0%) and 168 (22.5%) patients presented with moderate/severe and mild anemia. The incidence of MACE (22.5%, 11.0%, and 9.1%, log-rank p < 0.001), all-cause death (20.0%, 7.2%, and 4.8%, log-rank p < 0.001), and major bleeding events (10.7%, 6.5%, and 2.7%, log-rank p < 0.001) were the highest in the moderate/severe anemia group compared with the mild and no anemia groups. Multivariable Cox regression analyses determined moderate/severe anemia as an independent predictor for MACE (p = 0.008), all-cause death (p = 0.005), and major bleeding events (p = 0.031) at 1 year after PCI. CONCLUSION: Moderate/severe anemia was significantly associated with the higher incidence of MACE and all-cause death as well as major bleeding events compared with mild and no anemia in AF patients undergoing PCI.

Biomarkers for Risk Stratification in Patients With Type A Acute Aortic Dissection.

Type A acute aortic dissection (AAD) is a fatal disease and thus, accurate and objective risk stratification is essential. In this study, we evaluated the prognostic value of readily available and assessable biomarkers in patients with type A AAD. This was a retrospective, multicenter, observational study. A total of 703 patients with type A AAD diagnosed using contrast-enhanced computed tomography were included. Therapeutic strategies were left to the physician's discretion in a real-world clinical setting. The prognostic value for in-hospital mortality was examined in 15 circulating biomarkers on admission, which are routinely available in clinical practice. Of the 703 patients, 126 (17.9%) died during the hospitalization. Of the 15 biomarkers, the multivariable analysis identified positive cardiac troponin, a low total bilirubin (T-Bil) level, and increased levels of brain natriuretic peptide (BNP) and lactate dehydrogenase (LDH) as significant predictors of in-hospital death. The receiver operating characteristics curve analysis showed that these 4 biomarkers had an independent additive prognostic value. With the cut-off values of T-Bil, BNP, and LDH, in combination with positive troponin, the increase in the number of positive biomarkers was progressively associated with higher in-hospital mortality from 1.3% to 9.8%, 20.5%, 36.4%, and 75.0% (p <0.001). In conclusion, in patients with type A AAD, positive cardiac troponin, a low T-Bil level, and increased levels of BNP and LDH on admission were related to higher in-hospital mortality, with an incremental prognostic value, suggesting that the readily available and assessable biomarkers can aid in decision-making in therapeutic strategies.

Clinical characteristics and outcomes in patients with acute type A aortic intramural hematoma.

BACKGROUND: Although type A acute aortic dissection (AAD) including classic double-channel aorta and intramural hematoma (IMH) is a life-threatening condition, the prognostic impact and predictors of IMH remain to be established. The present study evaluated the prevalence, baseline characteristics, and outcomes of IMH as compared with classic non-thrombosed type A AAD. METHODS: This multicenter registry in Japan retrospectively included 703 patients with type A AAD. IMH was defined as a crescentic or circular area along the ascending aortic wall without contrast enhancement on computed tomography (CT). Non-thrombosed type A AAD was defined as the classic double-channel ascending aorta on contrast-enhanced CT. The primary endpoint was in-hospital mortality. RESULTS: Of the 703 patients with type A AAD, 312 (44.3%) had IMH. Older age was an only baseline patient factor significantly associated with the presence of IMH in the multivariable analysis. The longitudinal extent of dissection was greater in patients with classic non-thrombosed AAD than those with IMH, resulting in an increased risk of end-organ malperfusion in the classic AAD group. During the hospitalization, 41 (13.1%) and 85 (21.7%) patients with and without IMH died (p < 0.001). IMH was associated with lower in-hospital mortality in a multivariable model, irrespective of age and the implementation of surgery. CONCLUSIONS: The present study showed that IMH on CT was frequent among patients with type A AAD. Although IMH was more likely to be present in the elderly, its effect on the better survival was independent of age and surgical treatment.

Dual antithrombotic therapy with oral anticoagulant and P2Y12 inhibitors in patients with atrial fibrillation after percutaneous coronary intervention.

BACKGROUND: The efficacy and safety of dual antithrombotic therapy (DAT) with oral anticoagulant and P2Y12 inhibitors (P2Y12i) in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) have not been well investigated. The purpose of this study was first to evaluate clinical outcomes of DAT with P2Y12i compared with triple antithrombotic therapy (TAT), and then to compare DAT with low-dose prasugrel and DAT with clopidogrel, in patients with AF undergoing PCI. METHODS: This study was a multicenter, non-interventional, prospective and retrospective registry. A total of 710 patients with AF undergoing PCI between January 2015 and March 2021 at 15 institutions were analyzed. Clinical outcomes within 1 year, including major adverse cardiovascular events (MACE) and major bleeding events (BARC 3 or 5) were compared between patients receiving DAT (n = 239) and TAT (n = 471), and then, compared among prasugrel-DAT (n = 82), clopidogrel-DAT (n = 157), and TAT. RESULTS: The DAT group showed significantly lower incidence of MACE and major bleeding events compared with the TAT group (log-rank p = 0.013 and 0.047). In the multivariable Cox regression analyses, DAT (p = 0.028), acute coronary syndrome (p = 0.025), and anemia (p = 0.015) were independently associated with MACE. In addition, anemia (p = 0.022) was independently associated with, and DAT (p = 0.056) and thrombocytopenia (p = 0.051) tended to be associated with, major bleeding events. When analyzed among the prasugrel-DAT, clopidogrel-DAT, and TAT groups, there were no significant differences in clinical outcomes between the prasugrel-DAT and clopidogrel-DAT groups, and similar trends were observed for both 2 groups in comparison with the TAT group. CONCLUSIONS: In AF patients undergoing PCI, DAT was associated with lower incidence of MACE and major bleeding events compared with TAT. In comparison of P2Y12i, there might be no significant difference in the incidence of MACE and bleeding events between prasugrel-based DAT and clopidogrel-based DAT.

Right versus left coronary artery involvement in patients with type A acute aortic dissection.

BACKGROUND: Type A acute aortic dissection (AAD) complicated by coronary malperfusion is a life-threatening disease. In the present study, we compared the clinical characteristics and prognostic impact of treatment strategies including surgical treatment and percutaneous coronary intervention (PCI) in type A AAD patients with RCA and LCA involvement. METHODS: This multicenter registry included 220 patients with type A AAD and either RCA or LCA involvement. Treatment strategies were left to treating physicians. The primary endpoint was in-hospital death. RESULTS: Of 220 patients, 115 (52.3%) and 105 (47.7%) had RCA and LCA involvement. Patients with LCA involvement were more1 likely to present with Killip class IV on admission than those with RCA involvement. Coronary angiography was performed in 52 of 220 (23.6%) patients, among whom 39 (75.0%) underwent subsequent PCI. During the hospitalization, 93 (42.3%) patients died. Patients with LCA involvement had an increased risk of in-hospital mortality compared to those with RCA involvement (54.3% vs. 31.3%, p < 0.001). In patients with RCA involvement, multivariable analysis identified Killip class IV and no surgical treatment as predictors of in-hospital death, while PCI and surgical treatment were indicated as factors associated with lower in-hospital mortality in patients with LCA involvement. CONCLUSIONS: The rates of RCA and LCA involvement were similar in type A AAD. Immediate PCI as a bridge to subsequent surgical treatment might improve survival in patients with type A AAD complicated by coronary malperfusion, especially in those with LCA involvement.

Prognostic Impact of Branch Vessel Involvement on Computed Tomography versus Clinical Presentation of Malperfusion in Patients With Type a Acute Aortic Dissection.

Type A acute aortic dissection (AAD) is a life-threatening disease. The use of contrast-enhanced computed tomography (CT) for diagnosing AAD has increased, and CT can provide pathophysiologic information on dissection such as intramural hematoma (IMH), longitudinal extent of dissection, and branch vessel involvement. However, the prognostic impact of these CT findings is poorly investigated. This multicenter registry included 703 patients with type A AAD. The longitudinal extent of dissection and IMH was determined on CT. Branch vessel involvement was defined as dissection extended into coronary, cerebral, and visceral arteries on CT. The evidence of malperfusion was defined based on clinical presentations. The primary endpoint was in-hospital death. Of 703 patients, 126 (18%) died during hospitalization. Based on contrast-enhanced CT findings, longitudinal extent of dissection was not associated with in-hospital death, while patients with IMH had lower in-hospital mortality than those without (13% vs 22%, p = 0.004). Coronary, cerebral, and visceral artery involvement on CT was found in 6%, 55%, and 32%. In patients with coronary artery involvement, 90% had clinical coronary malperfusion, while only 25% and 21% of patients with cerebral and visceral artery involvement had clinical evidence of corresponding organ malperfusion. Multivariable analysis showed evidence of malperfusion as a significant factor associated with in-hospital mortality. In conclusions, branch vessel involvement on CT was not always associated with end-organ malperfusion in patients with type A AAD, especially in cerebral and visceral arteries. Clinical evidence of malperfusion was significantly associated with in-hospital mortality beyond branch vessel involvement on CT.

Positive Myocardial Uptake of Bone Scintigraphic Agents Associated with Cardiac Amyloidosis: Frequency of Positive Uptake Data Based on Daily Clinical Practice.

Objective: The bone scan plays an important role for detecting number of conditions relating to bones, including: bone cancer or bone metastasis, bone inflammation. Extraosseous uptake, in particular, myocardial uptake, was observed in some patients examined with the bone scans. Positive uptake of 99mTc-labeled bone radiotracers is associated with cardiac amyloidosis. However, the frequency and cause of positive cardiac 99mTc-MDP uptake have not been fully studied. In this regard, the aim of this study was to assess the frequency and characteristics of patients with high myocardi-al uptake of bone scintigraphy in daily clinical practice setting. Methods: We retrospectively analyzed 4180 bone scintigraphies performed in daily clinical practice during 7-years period. The intensity of the myocardial uptake was graded based on a visual scale ranging from 0 to 3 points. Score 0 indicates the absence of uptake. Score 1 defined uptake less than that of bone (referred to as the adjacent rib). Uptake similar to that of bone was classified score 2. Score 3 was defined as uptake greater than that of reference bone. Positive myocardial uptake included a visual score 2 or 3. Result: Positive 99mTc-MDP myocardial uptake occurred in 12 patients among 4180 patients (0.3%). 7 of 12 positive scan patients were consistent with amyloidosis confirmed by biopsy. In these patients, the mean age was 75.6 ± 5.2 years old. Ten cases showed biventricular uptake and 2 showed LV uptake only. Conclusion: Positive cardiac uptake of bone scintigraphic agents was present in 0.3% of bone scintigraphies in a clinical practice setting. This may be a sign of cardiac amyloidosis involvement which may give the presence of extraosseous bone tracer uptake its own importance and a new role.

Contrast media injection into right coronary artery caused thrombus extraction to aorta that may have resulted in left main trunk thrombosis.

A 59-year-old man with inferior acute myocardial infarction underwent an urgent coronary angiography and as a result a total occlusion of the ostial right coronary artery (RCA) was observed. Interestingly, the thrombus in the RCA clearly shortened within 2.3 s during the contrast media injection. While we prepared for percutaneous coronary intervention (PCI) of the RCA, ventricular fibrillation occurred and pulseless electrical activity continued in spite of repeated cardioversion. Despite no stenosis in the left main trunk (LMT) in the initial coronary angiography, the LMT was totally occluded. Following aspiration therapy on the LMT with percutaneous cardiopulmonary support, PCI of the RCA was performed. A coronary angiography should be carefully performed if a lot of thrombi exist in the coronary ostium because LMT embolism may have been caused by thrombus extraction from the RCA by contrast media injection.

Hyperuricemia as a risk factor for progressive renal insufficiency after coronary intervention in patients with chronic kidney disease.

The development of renal insufficiency after percutaneous coronary intervention (PCI) is associated with increases in morbidity and mortality. Recent studies have reported that hyperuricemia (HU) results in hypertension, intrarenal vascular disease, and renal injury. We postulated that HU contributes to progressive renal disease after PCI. We studied 139 patients with chronic kidney disease (CKD) undergoing elective PCI including 59 HU patients. We assessed the relationship between HU and the development of renal insufficiency after PCI by estimating traditional contrast-induced nephropathy (CIN) and persistent postprocedural nephropathy (PPN) defined as an increase in creatinine ≥0.2 mg/dl of the baseline value 2 weeks after procedure. CIN and PPN were seen in 6.5 and 28.8% respectively. The incidence of PPN was higher in HU patients than in non-HU patients (p < 0.001) although the incidence of CIN was not significantly different between the two groups. PPN was more frequently observed in hyperuricemic patients irrespective of association with hypertension (with and without hypertension, p < 0.001 and p = 0.034, respectively). By univariate analysis, HU and hypertension are associated with PPN although there was no significant predictor of CIN in this study. Multivariate analysis showed HU and hypertension were independent predictors of PPN. HU is a predictor of slow and mild development of renal insufficiency after PCI in patients with CKD.

Thrombolysis increases the risk of free wall rupture in patients with acute myocardial infarction undergoing percutaneous coronary intervention.

In spite of the progress made in acute angiographic evaluation and obtaining durable reperfusion of acute myocardial infarction (AMI) in the past two decades, cardiac free wall rupture (FWR) is still one of the causes of mortality following AMI. In this study, we evaluated the role of thrombolysis in the risk of FWR in AMI patients treated with acute percutaneous coronary intervention (PCI). Among 3,786 consecutive AMI patients seen between 1985 and 2003, 3,066 patients were treated by primary PCI or rescue PCI, with or without additional thrombolysis. FWR occurred in 24 of 3,066 patients (0.8%) treated by PCI; female gender (1.4% vs 0.6%, P=0.001), age >75 years, (1.4% vs 0.6%, P=0.001) left main coronary artery (LMCA)-related infarction, (4.5% vs all other arteries, P=0.015), and thrombolytic use (3.1% vs 0.4%, P<0.001) were all associated with higher rates of FWR by univariate analysis. In patients treated with PCI and thrombolysis, FWR occurred in 2.7% with optimal PCI results but in only 4.9% if PCI was unsuccessful (P=NS). The incidence of FWR in patients with optimal PCI without thrombolysis was 0.4% (P<0.001). Multivariable analysis identified thrombolytic use (odds ratio [OR]: 8.49, 95% confidence interval [CI]: 3.66-19.7, P<0.001), LMCA-related infarction (OR: 7.06, 95% CI: 1.89-26.4, P=0.004), and female gender (OR: 3.02, 95% CI: 1.27-7.21, P=0.013) as independent predictors of FWR. Thrombolysis is one of the contributing causes of FWR in AMI patients undergoing PCI, even when PCI is successful.

Coronary angioplasty reduces free wall rupture and improves mortality and morbidity of acute myocardial infarction.

BACKGROUND: Free wall rupture (FWR) is one of the major causes of mortality in acute myocardial infarction (AMI). To what extent coronary angioplasty for AMI would modify the predictors of FWR is not clear. METHODS: In prospective database of consecutive 3,138 AMI patients seen between May 1985 to May 2002, 3,096 patients (98.7%) who underwent emergent coronary angiography were analyzed retrospectively. The incidence of FWR was determined by univariate and multivariate analyses. RESULTS: FWR after admission occurred in 40 (1.3%) patients. A higher rate of FWR was associated with: 1) not having coronary angioplasty (3.2% vs. 0.9%, p< 0.0001); 2) thrombolytic agents usage (2.4% vs. 1.0%, p = 0.004); 3) female gender (2.5% vs. 1.1%, p = 0.0004); 4) failed reperfusion (5.4% vs. 0.9%, p< 0.0001); and 5) LMT-related infarct (4.7% vs. 1.2%, p = 0.02) in univariate analysis. Five conditions were identified as significant protective or predictive factors of FWR in multivariate logistic regression analysis: having coronary angioplasty (odds ratio [OR]: 0.45, 95% confidence interval [95% CI] 0.22-0.94, p = 0.03), failed reperfusion (OR: 4.57, 95% CI: 2.31-9.05, p< 0.0001), LMT-related infarct (OR: 4.96, 95% CI: 1.42-17.34, p = 0.01), female gender (OR: 2.17, 95% CI: 1.11-4.25, p = 0.02) and age (OR: 1.04, 95% CI: 1.00-1.07, p = 0.03). Coronary angioplasty alone resulted in a lower incidence of FWR (0.5%) than thrombolysis alone (1.6%, p = 0.02), coronary angioplasty with thrombolysis (3.3%, p< 0.0001) and without either treatment (6.3%, p< 0.0001). CONCLUSIONS: Angiographic reperfusion success was the most significant protective factor from FWR. Coronary angioplasty reduced FWR complicating AMI and its concomitant fatality.