Clinical Impacts of Urinary Neutrophil Gelatinase-Associated Lipocalin in Patients With Chronic Kidney Disease Undergoing Percutaneous Coronary Intervention.

BACKGROUND: Chronic kidney disease (CKD) is associated with poor prognosis in patients undergoing percutaneous coronary intervention (PCI). Urinary neutrophil gelatinase-associated lipocalin (NGAL) is a biomarker for renal injury. However, the association between urinary NGAL concentrations and renal and cardiovascular events in patients with CKD undergoing PCI has not been elucidated. This study investigated the clinical impact of urinary NGAL concentrations on renal and cardiovascular outcomes in patients with non-dialysis CKD undergoing PCI.Methods and Results: We enrolled 124 patients with non-dialysis CKD (estimated glomerular filtration rate <60 mL/min/1.73 m2) undergoing elective PCI. Patients were divided into low and high NGAL groups based on the median urinary NGAL concentration measured the day before PCI. Patients were monitored for renal and cardiovascular events during the 2-year follow-up period. Kaplan-Meier analyses showed that the incidence of renal and cardiovascular events was higher in the high than low NGAL group (log-rank P<0.001 and P=0.032, respectively). Multivariate Cox proportional hazards analyses revealed that urinary NGAL was an independent risk factor for renal (hazard ratio [HR] 4.790; 95% confidence interval [CI] 1.537-14.924; P=0.007) and cardiovascular (HR 2.938; 95% CI 1.034-8.347; P=0.043) events. CONCLUSIONS: Urinary NGAL could be a novel and informative biomarker for predicting subsequent renal and cardiovascular events in patients with CKD undergoing elective PCI.

Prognostic impact of polypharmacy and discharge medications in octogenarians and nonagenarian patients with acute heart failure.

With the increasing frequency of heart failure (HF) in elderly patients, polypharmacy has become a major concern owing to its adverse outcomes. However, reports on the clinical impact of polypharmacy and discharge medications in hospitalized super-aged patients with acute HF are rare. Data from 682 patients aged 80 years or older, hospitalized for treating acute HF, were analyzed. We recorded the number of medications at discharge and classified them into three groups: HF, non-HF cardiovascular, and non-cardiovascular medications. We investigated the correlation of polypharmacy, defined as daily administration of 10 or more medications at discharge, and the use of discharge medications with post-discharge prognosis. Polypharmacy was recorded in 24.3% of enrolled patients. Polypharmacy was not an independent predictor of all-cause mortality, the incidence of cardiac-related death, or HF-associated rehospitalization; however, the number of non-cardiovascular medications, multiple usage of potentially inappropriate medications, use of mineralocorticoid receptor antagonists, and doses of loop diuretics were associated with poor prognosis. Polypharmacy was significantly associated with higher mortality in patients with Barthel index ≥ 60 at discharge; hence, physical function at discharge was useful for the stratification of prognostic impacts of polypharmacy. The current study demonstrated that polypharmacy was not essentially associated with poor prognosis in super-aged patients with acute HF. Appropriate medications that consider the patient's physical function, rather than polypharmacy itself, are important for the management of HF.

Clinical features, future cardiac events, and prognostic factors following percutaneous coronary intervention in young female patients.

BACKGROUND: The proportion of young females among the patients who undergo percutaneous coronary intervention (PCI) is relatively small, and information on their clinical characteristics is limited. This study investigated the clinical characteristics and prognostic factors for future cardiac events in young females who underwent PCI. METHODS: This multicenter observational study included 187 consecutive female patients aged < 60 years who underwent PCI in seven hospitals. The primary composite endpoint was the incidence of cardiac death, nonfatal myocardial infarction, and target vessel revascularization. RESULTS: The mean patient age was 52.1 ± 6.1 years and 89 (47.6%) had diabetes, and renal dysfunction (an estimated glomerular filtration rate < 60 mL/min/1.73 m2) was observed in 38 (20.3%). During a median follow-up of 3.3 years, the primary endpoint occurred in 28 patients. The Cox proportional hazards models showed that renal dysfunction was an independent predictor for the primary endpoint (hazard ratio 3.04, 95% confidence interval 1.25-7.40, p = 0.01), as well as multivessel disease (hazard ratio 2.79, 95% confidence interval 1.12-6.93, p = 0.03). Patients with renal dysfunction had a significantly higher risk for the primary endpoint than those without renal dysfunction. CONCLUSIONS: Renal dysfunction was strongly associated with future cardiac events in young females who underwent PCI.

The association between oral health status and physical function in elderly patients with acute heart failure.

OBJECTIVES: Oral health problems are common and are associated with various geriatric conditions in older adults. The importance of oral health has not been fully highlighted in the assessment and management of patients with heart failure. Here, we investigated the association between oral health status and the decline in physical function during hospitalization in elderly patients with acute heart failure. MATERIALS AND METHODS: We evaluated oral health using the revised oral assessment guide in 77 patients aged 65 years or older who were admitted to hospital for acute heart failure. Oral health problems were defined as a revised oral assessment guide score ≥9. RESULTS: Oral health problems were identified in 66.2% of the patients. Patients with oral health problems had high prevalence of decreased physical function, undernutrition, and cognitive impairment. A reduction in the Barthel Index, as an indicator of activities of daily living during hospitalization, was significant in the enrolled patients. The Barthel Index decreased more in patients with oral health problems than those with normal oral health. Furthermore, the revised oral assessment guide score on admission was found to be the only independent predictor of changes in the Barthel Index during hospitalization in the multivariate analyses. CONCLUSIONS: Oral assessment using the revised oral assessment guide during hospitalization could provide useful information for the management of elderly heart failure patients.

Two-step changes in paced QRS morphology suggest capturing at different levels of posterior fascicle fibers during left bundle branch area pacing: A case report.

Two-step changes in paced QRS morphology during the left bundle branch area pacing threshold test. It suggests that capturing occurs at multiple sites of the left bundle branch-Purkinje system.

Impact of right coronary artery dominance on the long-term mortality in the patients with acute total/subtotal occlusion of unprotected left main coronary artery.

BACKGROUND: Patients with a right dominant coronary artery anatomy account for a significant proportion of acute myocardial infarction cases, and this condition is associated with a better prognosis. However, there are limited data on the impact of coronary dominance on patients with acute total/subtotal occlusion of unprotected left main coronary artery (ULMCA). METHODS: This study aimed to assess the impact of right coronary artery (RCA) dominance on long-term mortality in patients with acute total/subtotal occlusion of the ULMCA. From a multicenter registry, 132 cases of consecutive patients who had undergone emergent percutaneous coronary intervention (PCI) due to acute total/subtotal occlusion of the ULMCA were reviewed. RESULTS: Patients were classified into two groups according to the size of their RCA (dominant RCA group, n = 29; non-dominant RCA group, n = 103). Long-term outcomes were examined according to the presence of dominant RCA. Cardiopulmonary arrest (CPA) occurred in 52.3 % of patients before revascularization. All-cause death was significantly lower in the dominant RCA group than in the non-dominant RCA group. In the Cox regression model, dominant RCA was an independent predictor of all-cause death, as well as total occlusion of ULMCA, collateral from RCA, chronic kidney disease, and CPA. Patients were further analyzed according to the degree of stenosis of the ULMCA; patients with non-dominant RCA and total occlusive ULMCA had the worst outcome compared with the other groups. CONCLUSIONS: A dominant RCA might improve long-term mortality in patients with acute total/subtotal occlusion of the ULMCA who were treated with PCI.

Differences in clinical outcomes between octogenarian and nonagenarian patients with acute heart failure.

AIM: The number of hospitalized super-elderly patients with heart failure (HF) has increased with aging of the population. These patients are associated with poor clinical outcomes with the advance of age; however, few reports regarding acute HF have compared the clinical outcomes of nonagenarians with those of octogenarians. METHODS: This study enrolled 683 patients aged ≥80 years who were admitted to our institution for acute HF between 2016 and 2020. The outcomes of interest were the 1-year all-cause mortality, incidence of cardiac events (cardiac-related death or HF-related readmission), and physical function during hospitalization of patients with survival-to-discharge. Physical function was evaluated using the Barthel index. RESULTS: Post-discharge all-cause mortality, particularly non-cardiac mortality, was significantly higher in nonagenarians than octogenarians. Conversely, the incidence of cardiac death or rehospitalization for HF after discharge was comparable between the two groups. On admission, the Barthel index score was significantly lower in nonagenarians than octogenarians, and further decreased during hospitalization. Nonagenarians required social support at discharge more often than octogenarians (67.4% vs. 44.4%; P < 0.001). CONCLUSIONS: The current study demonstrated that nonagenarians have poorer non-cardiac outcomes and were more vulnerable regarding physical activities than octogenarians among patients with acute HF. Holistic medical care, including palliative care and social support, will be increasingly required with increasing age. Geriatr Gerontol Int 2023; 23: 227-233.

Long-term outcomes of percutaneous revascularization for internal mammary artery-left anterior descending artery bypass failure.

Despite the excellent long-term results of internal mammary artery (IMA)-left anterior descending (LAD) bypass, percutaneous revascularization of IMA is sometimes required for IMA-LAD bypass failure. However, its clinical outcomes have not been fully elucidated. The aim of this study was to investigate the long-term clinical outcomes, including target lesion revascularization (TLR) following contemporary percutaneous revascularization of failed IMA bypass graft. We examined data of 59 patients who had undergone percutaneous revascularization of IMA due to IMA-LAD bypass failure at nine hospitals. Patients with IMA graft used for Y-composite graft or sequential bypass graft were excluded. The incidence of TLR was primarily examined, whereas other clinical outcomes including cardiac death, myocardial infarction, and target vessel revascularization were also evaluated. Mean age of the enrolled patients was 67.4 ± 11.3 years, and 74.6% were men. Forty patients (67.8%) had anastomotic lesions, and 17 (28.8%) underwent revascularization within three months after bypass surgery. Procedural success was achieved in 55 (93.2%) patients. Stent implantation was performed in 13 patients (22.0%). During a median follow-up of 1401 days (interquartile range, 282-2521 days), TLR was required in six patients (8.5% at 1, 3, and 5 years). Patients who underwent percutaneous revascularization within 3 months after surgery tended to have a higher incidence of TLR. Clinical outcomes of IMA revascularization for IMA-LAD bypass failure were acceptable.

A Comparative Study of Three Nutritional Risk/Screening Indices for Predicting Cardiac Events and Physical Functioning Among Patients with Acute Heart Failure.

Undernutrition is very common among patients with heart failure (HF). This study evaluated the prognostic values of three nutritional risk/screening indices among patients with acute HF. We retrospectively calculated scores for 465 patients with acute HF using the Controlling Nutritional Status (CONUT) tool, the Geriatric Nutritional Risk Index (GNRI), and the Mini-Nutritional Assessment Short Form (MNA-SF). The outcomes of interest were the 1-year rate of cardiac events (cardiac-related death or HF-related readmission) and the Barthel index as an index of physical function during hospitalization. The CONUT, GNRI, and MNA-SF scores were significantly correlated, although the proportions of a normal nutritional state varied (CONUT: 18.3%, GNRI: 32.9%, and MNA-SF: 43.9%). Kaplan-Meier estimates revealed that cardiac events were more common among patients with undernutrition based on the CONUT score, and multivariable regression analysis revealed that only the CONUT score independently predicted poor outcomes. Furthermore, changes in the Barthel index during hospitalization were significantly correlated with the CONUT score but not with the GNRI and MNA-SF scores. In receiver operating characteristic analyses, the CONUT score had the most powerful predictive values on both the postdischarge incidence of cardiac events and the decline of physical function during hospitalization compared with the GNRI and the MNA-SF. These results indicate that the CONUT score might provide useful information for predicting poor outcomes in patients with acute HF.

Incidence and predictors of frailty progression among octogenarians with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention.

BACKGROUND: Frailty is one of the most serious health problems in older individuals with cardiovascular disease. Moreover, frailty progression is associated with subsequent adverse outcomes; therefore, the prevention of frailty progression is an important clinical issue. However, the incidence and predictors of frailty progression following acute myocardial infarction have not yet been fully elucidated. METHODS: The present study is a sub-analysis of an observational multicenter registry retrospectively evaluating clinical outcomes of 288 octogenarians who underwent primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) between January 2014 and December 2016 at five hospitals. We identified 244 patients who survived until discharge and evaluated frailty at baseline and discharge using the Clinical Frailty Scale (CFS). We defined frailty progression as an increase of at least one level in the CFS score at discharge from baseline and assessed the predictors of frailty progression. RESULTS: Frailty progression was observed in 29.5% of patients. Patients with frailty progression were older, had more severe conditions with a higher prevalence of Killip 4 status and mechanical circulatory support use, more frequently experienced in-hospital events such as stroke (4/72, 6% vs. 0/172, 0%, p = 0.007), and had longer hospital stays than those without frailty progression [19 (11-35) vs. 13 (9-19) days, p<0.01]. Multivariate analysis showed that age (odds ratio 1.08, 95% confidence interval 1.00-1.17, p = 0.046) and Killip 4 status at baseline (odds ratio 3.34, 95% confidence interval 1.26-8.85, p = 0.01) were significant predictors of frailty progression. CONCLUSIONS: In-hospital frailty progression was commonly observed in octogenarians with STEMI who underwent primary PCI and survived until discharge, and was associated with more severe clinical conditions.

Clinical implications of severe sarcopenia in Japanese patients with acute heart failure.

AIM: Sarcopenia is a geriatric condition characterized by progressive loss of skeletal muscle mass and function. The definition and diagnosis of sarcopenia is inconsistent between different populations and is still evolving. Herein, we investigated the prevalence and clinical implications of severe sarcopenia using the Asian Working Group for Sarcopenia (AWGS) 2019 criteria in Japanese patients with acute heart failure (HF). METHODS: Overall, 272 patients admitted for acute HF were evaluated for sarcopenia using the AWGS 2019 criteria. RESULTS: There were 46 patients with severe sarcopenia, accounting for approximately 75% of patients who were diagnosed as having sarcopenia. A Kaplan-Meier analysis showed that patients with severe sarcopenia had a higher incidence of cardiac death or rehospitalization for HF 1 year post-discharge than those with non-severe sarcopenia or without sarcopenia (log-rank P = 0.006). A multivariate Cox regression analysis showed that severe sarcopenia was independently correlated with the occurrence of cardiac death or rehospitalization for HF after adjusting for other prognostic factors (hazard ratio 2.580, 95% confidence interval: 1.404-4.740, P = 0.002). CONCLUSIONS: Severe sarcopenia constituted most sarcopenia diagnoses using the AWGS 2019 cut-off values, and was independently associated with 1-year incidence of cardiac death or rehospitalization for HF post-discharge in Japanese patients with acute HF. The assessment of sarcopenia may provide useful information for HF management. Geriatr Gerontol Int 2022; 22: 477-482.

Association between serum urate level and carotid atherosclerosis: an insight from a post hoc analysis of the PRIZE randomised clinical trial.

OBJECTIVES: Elevated serum urate (SU) levels are associated with arterial atherosclerosis and subsequent cardiovascular events. However, an optimal therapeutic target SU level for delaying atherosclerotic progression in patients with hyperuricaemia remains uncertain. The aim of this analysis was to assess an association between changes in SU level and carotid intima-media thickness (IMT) to examine whether an optimal SU concentration exists to delay atherosclerotic progression. METHODS: This was a post hoc analysis of the PRIZE (programme of vascular evaluation under uric acid control by xanthine oxidase inhibitor, febuxostat: multicentre, randomised controlled) study of Japanese adults with asymptomatic hyperuricaemia. The primary endpoint of this analysis was an association between changes in SU levels and mean common carotid artery IMT (CCA-IMT) after 24 months of febuxostat treatment. RESULTS: Among subjects treated with febuxostat (n=239), a total of 204 who had both data on SU and mean CCA-IMT at baseline and 24 months were included in this analysis. The mean baseline SU level was 7.7±1.0 mg/dL, and febuxostat treatment significantly reduced SU concentrations at 24 months (estimated mean change ‒3.051 mg/dL, 95% CI ‒3.221 to ‒2.882). A multivariable linear regression analysis revealed that a reduction in SU level was associated with changes in mean CCA-IMT values at 24 months (p=0.025). In contrast, the achieved SU concentrations were not associated with changes in mean CCA-IMT at 24 months. CONCLUSION: A greater reduction in SU, but not its achieved concentrations, may be associated with delayed progression of carotid IMT in patients with asymptomatic hyperuricaemia treated with febuxostat. TRIAL REGISTRATION NUMBER: UMIN000012911.

＜Editors' Choice＞ Prevalence of acute coronary syndrome during the pandemic of COVID-19 in the Tokai Region of Japan.

The outbreak of coronavirus disease 19 (COVID-19) has had a great impact on medical care. During the COVID-19 pandemic, the rate of hospital admissions has been lower and the rate of in-hospital mortality has been higher in patients with acute coronary syndrome (ACS) in Western countries. However, in Japan, it is unknown whether the COVID-19 pandemic has affected the incidence of ACS. In the study, eleven hospitals in the Tokai region participated. Among enrolled hospital, we compared the incidence of ACS during the COVID-19 pandemic (April and May, 2020) with that in equivalent months in the preceding year as the control. During the study period; April and May 2020, 248 patients with ACS were admitted. Compared to April and May 2019, a decline of 8.1% [95% confidence interval (CI) 5.2-12.1; P = 0.33] in admissions for ACS was observed between April and May 2020. There was no significant difference in the strategy for revascularization and in-hospital deaths between 2019 and 2020. In conclusion, the rate of admission for ACS slightly decreased during the COVID-19 pandemic, compared to the same months in the preceding year. Moreover, degeneration of therapeutic procedures for ACS did not occur.

Initiation and long-term use of tolvaptan for patients with worsening heart failure through hospital and clinic cooperation.

Worsening heart failure (WHF) has a negative impact on the prognosis of patients with heart failure. Adequate management of non-hospitalized episodes of WHF, regarded as "outpatient WHF", may reduce the frequency of emergent/urgent hospitalization for acute heart failure; thus, the patients' cardiac parameters return to their clinical baseline. This study aimed to investigate the efficacy of tolvaptan initiation during planned hospitalization of patients with "outpatient WHF" through hospital and clinic cooperation. The data from 28 patients with outpatient WHF referred by general practitioners to hospital were assessed. Tolvaptan administration was initiated during planned hospitalization and continued in the clinics. Patients were followed-up for 12 months. None of the patients required withdrawal of tolvaptan due to adverse effects. During the follow-up period, the loop diuretic dosage significantly decreased. There were significant favorable changes in the levels of serum creatinine, estimated glomerular filtration rate, natriuretic peptide and body weight. Kaplan-Meier survival analysis revealed that the cardiac death- and HF-related hospitalization-free survival rates were significantly higher among the patients who were administered tolvaptan for the outpatient WHF than the propensity score-matched patients who were administered tolvaptan for acute heart failure requiring emergent/urgent hospitalization. In conclusion, tolvaptan may be safe and effective for the long-term management of outpatient WHF through hospital and clinic cooperation.

Clinical Outcomes Following Emergent Percutaneous Coronary Intervention for Acute Total/Subtotal Occlusion of the Left Main Coronary Artery.

BACKGROUND: Data regarding the clinical features, outcomes and prognostic factors in patients presenting with acute total/subtotal occlusion of the unprotected left main coronary artery (LMCA) remain limited.Methods and Results:From a multi-center registry, 134 patients due to acute total/subtotal occlusion of the unprotected LMCA were reviewed. Emergency room (ER) status classification was defined according to the presence of cardiogenic shock and cardiopulmonary arrest (CPA) in the ER (class 1=no cardiogenic shock; class 2= cardiogenic shock but not CPA; and class 3=CPA). In-hospital mortality and cerebral performance category (CPC) as the endpoints were evaluated. One-half (67/134) of the enrolled patients presented with total occlusion of the unprotected LMCA. Regarding ER status classification, class 1, 2, and 3 were observed in 30.6%, 45.5%, and 23.9% of the patients, respectively. In-hospital mortality occurred in 73 (54.5%) patients; of the remaining patients, 52 (85.3%) could be discharged with a CPC 1 or 2. ER status classification (odds ratio 4.4 [95% confidence interval: 2.33-10.67]; P<0.001) and total occlusion of the unprotected LMCA (odds ratio 8.29 [95% confidence interval 2.93-23.46]; P<0.001) were strong predictors of in-hospital mortality. CONCLUSIONS: Acute total/subtotal occlusion involving the unprotected LMCA appeared to be associated with high in-hospital mortality. ER status classification and initial flow in the unprotected LMCA were significant predictive factors of in-hospital mortality.

Improved Renal Function After Percutaneous Coronary Intervention in Non-Dialysis Patients With Acute Coronary Syndrome and Advanced Renal Dysfunction.

BACKGROUND: The deterioration of renal function is a strong prognostic predictor in patients with coronary artery disease. Although percutaneous coronary intervention (PCI) has sometimes resulted in improved renal function (IRF) in acute coronary syndrome (ACS) patients, its clinical implications have not been fully elucidated. This study aimed to investigate the prevalence and predictors of IRF after PCI and its relationship with long-term renal outcomes. METHODS: In this retrospective observational cohort study, we examined data from 177 ACS patients with non-dialysis advanced renal dysfunction (estimated glomerular filtration rate [eGFR] < 30 mL/min/1.73 m2) who underwent PCI. Patients with and without IRF were compared in terms of baseline demographic, clinical, and procedural characteristics and renal outcomes. IRF was defined as a 20% increase in eGFR from baseline at 7 or 30 days after the index PCI. RESULTS: IRF was observed in 66 (37.3%) patients. ST-elevation myocardial infarction and shock during PCI were independent predictors of IRF. Patients were followed up for a median of 695 days. Kaplan-Meier analyses demonstrated that patients with IRF had the lower incidence of initiation of permanent dialysis than those without IRF (Log-rank P = 0.015). CONCLUSIONS: IRF was relatively common in non-dialysis patients with ACS and advanced renal dysfunction who underwent PCI. ST-elevation myocardial infarction and shock, which may be indicative of hemodynamic instability during PCI, were independent predictors of IRF. Further, IRF was associated with favorable renal outcomes. Hemodynamic stabilization may be important for improving the short-term and long-term renal outcomes of high-risk patients.

Association between discharge destination and mid-term mortality in octogenarian patients with ST-elevation myocardial infarction.

BACKGROUND: Owing to an increasing aging population, the number of elderly patients undergoing percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) is escalating. The onset of STEMI in elderly patients may lead to increased frailty, resulting in failure of discharge to home despite survival. However, the association of discharge destination with prognosis has not been fully evaluated in this population. METHODS: Between January 2014 and December 2016, a total of 245 octogenarian STEMI survivors who underwent PCI (mean age, 84.4 years; male, 46.5%) were evaluated from a multicenter registry. The 2-year mortalities of the home discharge and non-home discharge groups were compared and analyzed using a Cox regression model. RESULTS: Non-home discharge, which was defined as transfer to another hospital or nursing home after STEMI, was seen in 36 patients. During the 2 years, 37 patients died (home discharge, 27 patients; non-home discharge, 10 patients). The most frequent cause of death was due to infection (21.6%), followed by sudden death (18.9%) and heart failure (16.2%). The cumulative all-cause mortality was significantly higher in the non-home discharge group than in the home discharge group [36.4% vs. 14.8%; hazard ratio (HR), 2.95; 95% confidence interval (CI), 1.43-6.10; p = 0.003]. After multivariate analysis, non-home discharge (adjusted HR, 2.62; 95% CI, 1.20-5.75; p = 0.016) together with left ventricular ejection fraction <40% (adjusted HR, 3.15; 95% CI, 1.57-6.31; p = 0.001), prior heart failure (adjusted HR, 4.88; 95% CI, 1.82-13.13; p = 0.002), target lesion in the left anterior descending artery (adjusted HR, 2.20; 95% CI, 1.12-4.32; p = 0.022), and serum albumin level <3.5 g/dL (adjusted HR, 2.13; 95% CI, 1.06-4.27; p = 0.034) remained significant predictors of all-cause mortality. CONCLUSION: Non-home discharge was associated with an increased risk of mid-term mortality in octogenarian STEMI survivors.

Clinical impacts of cerebral microbleeds in patients with established coronary artery disease.

OBJECTIVE: Although cerebral microbleeds predict the occurrence and recurrence of cerebrovascular events in stroke patients, their clinical impacts are unclear in coronary artery disease patients. We aimed to investigate the clinical effect of the presence of cerebral microbleeds in patients with coronary artery disease receiving antithrombotic treatment. METHODS: We included 447 coronary artery disease patients taking at least one thrombotic agent who underwent brain MRI. The association between the presence of cerebral microbleeds and incidence of major adverse cardiac and cerebrovascular events was investigated. RESULTS: Cerebral microbleeds were identified in 18.7% of patients. Median follow-up duration was 1055 (interquartile range, 781-1172) days. Kaplan-Meier survival analysis demonstrated that patients with cerebral microbleeds had a higher incidence of major adverse cardiac and cerebrovascular events than those without (log-rank P = 0.003). A multivariate Cox regression analysis revealed that the presence of cerebral microbleeds was independently correlated with the occurrence of major adverse cardiac and cerebrovascular events after adjusting for other classical risk factors of coronary artery disease (hazard ratio 1.965, 95% confidence interval 1.086-3.556, P = 0.026). Hypertension was associated with the presence of cerebral microbleeds. The cut-off values to maximize the predictive power of SBP and DBP were 132 and 74 mmHg, respectively (P < 0.001). CONCLUSION: The presence of cerebral microbleeds predicts major adverse cardiac and cerebrovascular events in coronary artery disease patients receiving antithrombotic treatment. Evaluation of cerebral microbleeds and hypertension treatment complying with the established guidelines may be beneficial in the management of coronary artery disease patients.

Long-term renal outcomes after elective percutaneous coronary intervention in patients with advanced renal dysfunction.

The aim of the present study was to evaluate the renal outcomes, including the time course of renal function, after elective PCI in patients with advanced renal dysfunction and to assess the predictors of renal dysfunction progression. This is a subanalysis of a previous observational multicenter study that investigated long-term clinical outcomes in patients with advanced renal dysfunction (eGFR < 30 mL/min/1.73 m2), focusing on 151 patients who underwent elective PCI and their long-term renal outcomes. Renal dysfunction progression was defined as a 20% relative decrease in eGFR at 1 year from baseline or the initiation of permanent dialysis within 1 year. Progression of renal dysfunction at 1 year occurred in 42 patients (34.1%). Among patients with renal dysfunction progression, the decrease of renal function from baseline was not observed at 1 month but after 6 months of the index PCI. Baseline eGFR and serum albumin level were significant predictors of renal dysfunction progression at 1 year. Among 111 patients who had not been initiated on dialysis within 1 year, those with renal dysfunction progression had a significantly higher incidence of dialysis initiation more than 1 year after the index PCI than those with preserved renal function (p < 0.001). Among patients with advanced renal dysfunction who underwent elective PCI, 34.1% showed renal dysfunction progression at 1 year. The decrease in renal function was not observed at 1 month but after 6 months of the index PCI in patients with renal dysfunction progression. Furthermore, patients with renal dysfunction progression had poorer long-term renal outcomes.

Clinical outcomes following percutaneous coronary intervention for bifurcation lesions: kissing balloon inflation vs. sequential dilation.

Percutaneous coronary intervention for bifurcation lesions remains challenging, with there being several debatable issues, including the requirement for kissing balloon inflation (KBI). The objective of this study was to assess the clinical outcomes following single crossover stent implantation with KBI or sequential dilation alone. Data were examined for 255 non-left main bifurcation lesions (246 patients) treated with single crossover stent implantation, followed by side branch (SB) strut dilation with KBI (n = 74 lesions) or sequential dilation (n = 181 lesions) in three hospitals. Target lesion revascularization (TLR) was the primary endpoint. There was no significant difference in the pre-procedural reference diameter of both the main vessel (MV) and SB between the KBI and sequential dilation groups. However, MV post-dilation balloon size was smaller with lower pressure and post-procedural minimal lumen diameter was significantly smaller in the KBI group. During the median follow-up period of approximately 3 years, TLR incidence was significantly higher in the KBI group than in the sequential dilation group; in particular, the TLR rate at the distal MV was higher in the former. For bifurcation lesions treated with single crossover stent implantation, the TLR rate was higher after KBI than after sequential dilation; this was mainly due to higher revascularization in the distal MV. For bifurcation lesions treated with KBI, MV post-dilation balloon diameter tended to be smaller with lower pressure, which might lead to poorer stent expansion and a higher TLR rate.