Impact of left ventricular ejection fraction and preoperative hemoglobin level on perioperative adverse cardiovascular events in noncardiac surgery.

The prediction of a perioperative adverse cardiovascular event (PACE) is an important clinical issue in the medical management of patients undergoing noncardiac surgery. Although several predictors have been reported, simpler and more practical predictors of PACE have been needed. The aim of this study was to investigate the predictors of PACE in noncardiac surgery. We retrospectively analyzed 723 patients who were scheduled for elective noncardiac surgery and underwent preoperative examinations including 12-lead electrocardiography, transthoracic echocardiography, and blood test. PACE was defined as cardiac death, non-fatal myocardial infarction, unstable angina, congestive heart failure, arrhythmia attack that needs emergency treatment (rapid atrial fibrillation, ventricular tachycardia, and bradycardia), acute pulmonary embolism, asystole, pulseless electrical activity, or stroke during 30 days after surgery. PACE occurred in 54 (7.5%) of 723 patients. High-risk operation (11% vs. 3%, p = 0.003) was more often seen, left ventricular ejection fraction (LVEF) (55 ± 8% vs. 60 ± 7%, p = 0.001) and preoperative hemoglobin level (11.8 ± 2.2 g/dl vs. 12.7 ± 2.0 g/dl, p = 0.001) were lower in patients with PACE compared to those without PACE. By multivariate logistic regression analysis, high-risk operation (odds ratio (OR): 7.05, 95% confidence interval (CI) 2.16-23.00, p = 0.001), LVEF (OR 1.06, every 1% decrement, 95% CI 1.03-1.09, p = 0.001), and preoperative hemoglobin level (OR 1.22, every 1 g/dl decrement, 95% CI 1.07-1.39, p = 0.003) were identified as independent predictors of PACE. Receiver operating characteristic analysis demonstrated that LVEF of 58% (sensitivity = 80%, specificity = 61%, area under the curve (AUC) = 0.723) and preoperative hemoglobin level of 12.2 g/dl (sensitivity = 63%, specificity = 64%, AUC = 0.644) were optimal cut-off values for predicting PACE. High-risk operation, reduced LVEF, and reduced preoperative hemoglobin level were independently associated with PACE in patients undergoing noncardiac surgery.

Cancer-related vulnerable lesions in patients with stable coronary artery disease.

BACKGROUND: Coronary artery disease (CAD) has become a major cause of morbidity and mortality in cancer survivors. It is still unclear whether cancer history influences lesion characteristics. The purpose of this study was to investigate cancer-related lesion morphology in patients with CAD. METHODS: This study enrolled 400 patients with stable CAD. The patients were classified into a cancer survivor group (n = 69) and a noncancer group (n = 331). We investigated coronary lesion morphology by optical coherence tomography, and we assessed the prognosis in terms of both all-cause mortality and major adverse cardiovascular events (MACE). RESULTS: Adenocarcinoma was the most common histopathological diagnosis. Serum C-reactive protein levels were significantly higher in the cancer survivor group than in the noncancer group (cancer survivors 0.12 [0.05-0.42] mg/dL vs. noncancer 0.08 [0.04-0.17] mg/dL, p = 0.019). The cancer survivor group was more likely than the noncancer group to have thrombi (cancer survivors 30.4% vs. noncancer 15.4%, p = 0.004), and layered fibrotic plaques (LFPs; cancer survivors 18.8% vs. noncancer 3.6%, p < 0.0001). Cancer survivors had poorer outcomes than noncancer controls in terms of both all-cause mortality (p = 0.020) and MACE (p = 0.036). CONCLUSIONS: Because of underlying inflammation, CAD patients with cancer had more high-risk lesions than those without cancer, which could result in poorer prognosis for the former. This result might inform the management of CAD in cancer patients in terms of secondary prevention.

Association of decreased variation of coefficient R-R interval with ischemic colitis and small bowel obstruction.

BACKGROUND: The parasympathetic nervous system exerts and controls intestinal tone. Several studies have suggested that the coefficient of the R-R intervals (CVRR) is useful for evaluating the parasympathetic nervous system. OBJECTIVES: This study aimed to evaluate the relationship between gastrointestinal emergencies, specifically ischemic colitis (IC) and small bowel obstruction (SBO), and the autonomic nervous system. METHODS: In this retrospective study, a total of 13 patients with IC or SBO aged ≧65 years were analyzed. CVRR was measured in patients with IC and SBO and controls. RESULTS: CVRR averaged to 8.8% ± 2.5% in controls, 1.4% ± 0.4% in patients with IC, and 2.4% ± 1.0% in SBO groups (p < 0.001). CVRR was significantly lower in patients with IC and SBO than that in controls. CONCLUSION: The results of this study demonstrate the possibility that CVRR may serve as a clinical index for assessing the functioning of the parasympathetic nervous system in patients with IC or SBO.

Comparison of clinical outcomes following percutaneous coronary intervention versus optimal medical therapy based on gray-zone fractional flow reserve in stable angina patients with intermediate coronary artery stenosis (COMFORTABLE prospective study): Study protocol for a multicenter randomized controlled trial.

BACKGROUND: Even in the current drug-eluting stent era, revascularization for coronary stenosis with fractional flow reserve (FFR) between 0.75 and 0.80, the so-called "gray zone," is a matter of debate. Previous studies have reported conflicting results regarding outcomes of revascularization versus deferral for coronary stenosis when FFR values are in the gray zone, but these studies have had differing designs and populations. We therefore will investigate whether medical therapy plus percutaneous coronary intervention (PCI) is superior to medical therapy alone in reducing major cardiovascular events in patients presenting with coronary stenosis with gray zone FFR values. METHODS/DESIGN: This is a prospective, multicenter, open-label, parallel group, randomized, controlled, superiority study. A total of 410 eligible participants will be recruited and randomized to either the medical therapy plus PCI group or the medical therapy alone group. The primary endpoint is 1-year major adverse cardiac events (MACEs), defined as a combined endpoint of all-cause death, nonfatal myocardial infarction (MI), or unplanned target vessel revascularization (TVR). Secondary endpoints include MACE at 2 and 5 years. Moreover, each individual component of the primary endpoint, cardiovascular death, target vessel-related and non-target vessel-related MI, all MI, clinically driven TVR or non-TVR, all revascularization, stent thrombosis, and angina symptom status will be evaluated at 1, 2, and 5 years. DISCUSSION: This is the first prospective, multicenter, randomized, controlled study to investigate the superiority of medical therapy plus PCI over medical therapy by itself in reducing major cardiovascular events in patients presenting with coronary stenosis with "gray zone" FFR values. The results will help interventional cardiologists in making revascularization decisions regarding coronary stenosis with gray zone FFR values. TRIAL REGISTRATION: University Hospital Medical Information Network Clinical Trials Registry, UMIN000031526 . Registered on 1 March 2018.

Optical coherence tomography-derived anatomical criteria for functionally significant coronary stenosis assessed by fractional flow reserve.

BACKGROUND: For the identification of functionally significant coronary artery disease, there have not been any dedicated optical coherence tomography (OCT) studies reported previously, although OCT can clearly detect coronary vessel lumina at higher resolution than intravascular ultrasound (IVUS). METHODS AND RESULTS: OCT and fractional flow reserve (FFR) measurements were performed in 62 intermediate coronary lesions in 59 patients. FFR was calculated as the ratio of distal coronary pressure divided by proximal coronary pressure during maximal hyperemia. FFR <0.75 was used as the threshold for diagnosing functionally significant stenosis. Minimal lumen area (MLA), minimal lumen diameter (MLD) and percent lumen area stenosis were measured by OCT. FFR values correlated significantly with OCT-derived MLA (r=0.75, P<0.01), MLD (r=0.76, P<0.01) and percent lumen area stenosis (r=-0.77, P<0.01). Receiver-operating characteristic curve suggested an OCT-derived MLA <1.91 mm(2) (sensitivity 93.5%, specificity 77.4%), MLD <1.35 mm (sensitivity 90.3%, specificity 80.6%) and percent lumen area stenosis >70.0% (sensitivity 96.8%, specificity 83.9%) as the best cutoff values for a FFR <0.75. CONCLUSIONS: Anatomical measurements of coronary stenosis obtained by OCT show significant correlation with FFR. OCT has the potential to predict functionally significant stenosis, although the present OCT-derived parameters were smaller than those reported in previous IVUS studies.

Effect of direct renin inhibitor, aliskiren, on peripheral blood monocyte subsets and myocardial salvage in patients with primary acute myocardial infarction.

BACKGROUND: It remains unclear whether angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II type 1 receptor blockers (ARBs) have fully delivered the expected reduction in cardiovascular diseases. We investigated the effects of adding the direct renin inhibitor (DRI), aliskiren, to an ACEI or an ARB on monocyte subsets and myocardial salvage in patients with primary acute myocardial infarction (AMI). METHODS AND RESULTS: Twenty-one consecutive patients were treated with an ACEI or an ARB (non-DRI group), and another 21 consecutive patients received aliskiren combined with an ACEI or an ARB (DRI group). Two monocyte subsets (CD14(+)CD16(-) and CD14(+)CD16(+)) were measured by flow cytometry. The extent of myocardial salvage 7 days after AMI was evaluated by cardiac magnetic resonance imaging. Both plasma renin activity and aldosterone levels were significantly lower in the DRI group than in the non-DRI group. Peak levels of CD14(+)CD16(-) monocyte number and ratio were also significantly lower in the DRI group. The extent of myocardial salvage was significantly higher in the DRI group than in the non-DRI group (44.8 [41.2-53.1] vs. 36.0 [28.5-42.6], P=0.001). CONCLUSIONS: A DRI combined with an ACEI or an ARB can better improve the extent of myocardial salvage after AMI than an ACEI or an ARB alone in association with the decrease in circulating CD14(+)CD16(-) monocytes.

Impact of hinge motion on in-stent restenosis after sirolimus-eluting stent implantation.

BACKGROUND: A tortuous lesion with hinge motion is reportedly a risk factor for in-stent restenosis (ISR) after bare metal stent implantation. Sirolimus-eluting stents (SESs) implantation has dramatically reduced ISR. However, SES is a closed-cell design stent, which has low conformability and flexibility. Several studies have reported a relationship between tortuous lesions and stent fracture, which is one of the causes of ISR. The efficacy of SES in a tortuous lesion with hinge motion has not been fully evaluated. The aim of this study was to investigate the relationship between tortuous lesions and ISR after SES implantation. METHODS AND RESULTS: Three year clinical follow-up data after SES implantation, including 6-9 month scheduled follow-up coronary angiography in 399 consecutive patients with 537 lesions, were obtained. Δangle was defined as the difference in the angle of the target lesion between the diastole and systole before the procedure. The incidence of ISR was 8.2%. The mean maximal angle and Δangle were larger in the ISR group (47 ± 22° vs. 37 ± 21°, P=0.004 and 20 ± 13° vs. 13 ± 10°, P < 0.0001, respectively). Independent predictors of ISR were Δangle, hemodialysis, aortic ostium stenting, and diabetes mellitus. Hinge motion-associated ISR (Δangle ≥ 16°) occurred in 28 lesions: stent fracture in 9, stent recoil in 6, edge injury in 10, and others in 3. CONCLUSIONS: The amount of hinge motion in tortuous lesions should be considered in the selection of drug eluting stent types.