Direct Oral Anticoagulants Affect Activated Clotting Time During and Bleeding Events After Percutaneous Coronary Intervention.

Inappropriately high activated clotting time (ACT) during percutaneous coronary intervention (PCI) is associated with an increased risk of bleeding events. However, whether the prescription of direct oral anticoagulants (DOACs) affects ACT kinetics during heparin use and adverse clinical events in patients who underwent PCI remains unclear. We aimed to evaluate the relations between ACT changes during and adverse clinical events after PCI in patients who were prescribed DOAC. This observational study included 246 patients who underwent PCI at the 2 cardiovascular centers who were not receiving warfarin and whose ACT was recorded immediately before and 30 minutes after injection of unfractionated heparin. Patients were divided into 2 groups according to DOAC prescription at the time of the index PCI: DOAC users (n = 31) and nonusers (n = 215). Any bleeding and systemic thromboembolic events were investigated until 30 days after PCI. The average age of this population was 70.5 years, and 66.3% were male. Average ACT was significantly higher in DOAC users than nonusers both before and 30 minutes after unfractionated heparin induction (157.2 ± 30.1 vs 131.8 ± 25.1 seconds, p <0.001; 371.1 ± 122.2 vs 308.3 ± 82.2 seconds, p <0.001; respectively). The incidence of systemic thromboembolism after PCI was low and comparable between the 2 groups (0% vs 3.7%, p = 0.60). However, the rate of any bleeding event was significantly higher in DOAC users than in nonusers (16.1% vs 4.7%, p = 0.028). Patients receiving DOAC have higher ACT during PCI and higher incidence of bleeding events than those not receiving DOAC.

Calcium Fracture After Intravascular Lithotripsy as Assessed With Optical Coherence Tomography.

BACKGROUND: Plaque characteristics associated with effective intravascular lithotripsy (IVL) treatment of calcification have not been investigated. This study identified calcified plaque characteristics that favor the use of IVL.Methods and Results: Optical coherence tomography (OCT) was performed in 16 calcified lesions in 16 patients treated with IVL and coronary stenting. Cross-sectional OCT images in 262 segments matched across pre-IVL, post-IVL, and post-stenting time points were analyzed. After IVL, 66 (25%) segments had calcium fracture. In multivariable analysis, calcium arc (odds ratio [OR] 1.22; 95% confidence interval [CI] 1.13-1.32; P<0.0001), superficial calcification (OR 6.98; 95% CI 0.07-55.57; P=0.0182), minimum calcium thickness (OR 0.66; 95% CI 0.51-0.86; P=0.0013), and nodular calcification (OR 0.24; 95% CI 0.08-0.70; P=0.0056) were associated with calcium fracture. After stenting, stent area was larger for segments with fracture (8.0 [6.9-10.6] vs. 7.1 [5.2-8.9] mm2; P=0.004). CONCLUSIONS: Post-IVL calcium fracture is more likely in calcified lesions with lower thickness, a larger calcium arc, superficial calcification, and non-nodular calcification, leading to a larger stent area.

Outcomes of Elderly Patients With Acute Myocardial Infarction and Heart Failure Who Undergo Percutaneous Coronary Intervention.

Background: As life expectancy rises, percutaneous coronary intervention (PCI) is being performed more frequently, even in elderly patients with acute myocardial infarction (AMI). This study evaluated outcomes of elderly patients with AMI complicated by heart failure (AMIHF), as defined by Killip Class ≥2 at admission, who undergo PCI. Methods and Results: We retrospectively analyzed 185 patients with AMIHF aged ≥80 years (median age 85 years) who underwent PCI between 2009 and 2019. The median follow-up period was 572 days. The rates of in-hospital major bleeding (Bleeding Academic Research Consortium Type 3 or 5) and in-hospital all-cause mortality were 20.5% and 25.9%, respectively. The proportion of frail patients increased during hospitalization, from 40.6% at admission to 59.2% at discharge (P<0.01). The cumulative incidence of all-cause mortality was 36.3% at 1 year and 44.1% at 2 years. After adjusting for confounders, advanced age, Killip Class 4, final Thrombolysis in Myocardial Infarction flow grade <3, and longer door-to-balloon time were associated with higher mortality, whereas higher left ventricular ejection fraction and cardiac rehabilitation were associated with lower mortality (all P<0.05). Progression of frailty during hospitalization was an independent risk factor for long-term mortality in hospital survivors (P<0.01). Conclusions: The management of patients with AMIHF aged ≥80 years who undergo PCI remains challenging, with high rates of in-hospital major bleeding, frailty progression, and mortality.

Rate Pressure Products Affect the Relationship between the Fractional Flow Reserve and Instantaneous Wave-Free Ratio.

The rate pressure product (RPP) is an index of myocardial metabolism that correlates closely with myocardial hemodynamics. The relationship between the RPP and the fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) is not known. In this study, we investigated the effects of the RPP on the FFR and iFR. We retrospectively enrolled 195 patients (259 lesions) who had undergone invasive coronary angiography and both the iFR and FFR examinations between 2012 and 2017. The RPP was defined as systolic blood pressure multiplied by the heart rate, measured prior to the iFR evaluation. The study population was divided into the low-RPP (n = 129, mean RPP: 6981 ± 1149) and high-RPP (n = 130, mean RPP: 10391 ± 1603) groups according to the median RPP. Correlations and biases between the iFR and FFR were compared. The diagnostic performance of the iFR in the groups was calculated, using FFR as the gold standard. The correlation between the iFR and FFR was higher in the high-RPP group than in the low-RPP group. The bias between the iFR and FFR in the high-RPP group was smaller than that in the low-RPP group. The best cutoff value of the iFR for predicting an FFR of 0.8 was 0.90 for all lesions, 0.93 for the low-RPP group, and 0.82 for the high-RPP group. The iFR and RPP showed a weak but a statistically significant negative correlation (R = 0.14; p = 0.029). This was not observed for the relationship between the FFR and RPP. In conclusion, the RPP affects the relationship between the FFR and iFR. With FFR as the gold standard, the iFR may underestimate and overestimate the functionality of ischemia in the low- and high-RPP groups, respectively.

Outcomes of Renal Transplant Recipients after Percutaneous Coronary Intervention.

Renal transplantation (RT) can improve life expectancy in hemodialysis (HD) patients. However, little is known about the outcomes of renal transplant recipients after percutaneous coronary intervention (PCI). This study aimed to elucidate the effect of RT on clinical outcomes after PCI. Renal transplant recipients who underwent PCI from 2002 to 2017 were enrolled. To evaluate the effectiveness of RT, we retrospectively reviewed HD patients who underwent PCI. Propensity-score matching was performed using logistic regression to control for differences in baseline characteristics. The primary outcome was the incidence of major adverse cardiac events. After propensity matching, patients were classified into the RT (n = 50) group and HD (n = 50) group. Kaplan-Meier analysis revealed that the incidence of major adverse cardiac events was significantly lower in the RT group than in the HD group (p < 0.0001). Moreover, RT was associated with a lower risk for all-cause death (odds ratio 0.04; 95% confidence interval 0.002 to 0.03; p = 0.0054) and target vessel revascularization (OR 0.27; 95% CI 0.07 to 0.79; p = 0.015). RT may improve clinical outcomes after PCI, and it is encouraged for HD patients to increase life expectancy and reduce the occurrence of adverse events after PCI. Further research would be warranted to support this finding.

Hemodynamic and Lesion Characteristics Associated with Discordance between the Instantaneous Wave-Free Ratio and Fractional Flow Reserve.

BACKGROUND: The instantaneous wave-free ratio (iFR) is an invasive coronary physiological index that is not inferior to fractional flow reserve- (FFR-) guided revascularization. The indexes of iFR and FFR are similar and closely correlated, but there are a few key differences. Previous studies suggested that patient characteristics and lesion severity could induce discordance between iFR and FFR. This study aimed to clarify the hemodynamics and lesion characteristics that influence discordance between iFR and FFR. METHODS: In this retrospective study, we enrolled 225 patients (304 lesions) who underwent clinically indicated invasive coronary angiography and both iFR and FFR examinations between 2012 and 2017. We included only patients who underwent right heart catheterization and had blood pressure and heart rates recorded immediately prior to iFR and FFR. RESULTS: Discordance (iFR ≤0.89 and FFR >0.8 or iFR >0.89 and FFR ≤0.8) was observed in 80 lesions (26.3%). The heart rate, rate-pressure product, and cardiac index tended to be higher in the iFR ≤0.89 group than in the iFR >0.89 group. These trends were not seen between the FFR ≤0.8 group and FFR >0.8 group. A multivariate analysis showed that independent predictors of iFR ≤0.89 and FFR >0.8 discordance were female sex and higher rate-pressure product. iFR >0.89 and FFR ≤0.8 discordance was rare in hemodialysis patients. CONCLUSION: Even if iFR is functionally significant in intermediate stenosis, additional FFR evaluations should be considered for women, especially those with a high rate-pressure product, to avoid unnecessary percutaneous coronary intervention. If iFR is not functionally significant with intermediate stenosis in hemodialysis patients, then further FFR evaluations are unnecessary.

Safety and Efficacy of Low-Dose Prasugrel as Part of Triple Therapy With Aspirin and Oral Anticoagulants in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention　- From the TWMU-AF PCI Registry.

BACKGROUND: Using the standard maintenance dose of prasugrel (10 mg/day) as part of triple therapy with aspirin and an oral anticoagulant (OAC) is not recommended in the current guidelines because it increases the risk of bleeding compared with clopidogrel. However, the safety and efficacy of low-dose prasugrel (3.75 mg/day) as part of triple therapy has not been reported. Methods and Results: We registered 816 consecutive patients with atrial fibrillation (AF) who underwent percutaneous coronary intervention (PCI) from January 2011 to June 2016 at 8 hospitals in Japan. We examined the clinical outcomes of patients who received either low-dose prasugrel (n=57) or clopidogrel (n=451) as part of triple therapy after PCI. The incidences of bleeding (TIMI major and minor) and major adverse cerebrocardiovascular events (MACCE; all-cause death, nonfatal myocardial infarction, stent thrombosis, unplanned revascularization, and stroke) were evaluated. The cumulative 1-year incidence of bleeding was not significantly different (prasugrel 5.6% vs. clopidogrel 8.1%, log-rank P=0.55). In addition, the cumulative 1-year incidence of MACCE was also not significantly different (prasugrel 11.5% vs. clopidogrel 12.3%, log-rank P=0.88). CONCLUSIONS: Low-dose prasugrel, as part of triple therapy, did not increase the risk of bleeding compared with clopidogrel. Therefore, it can be an alternative to clopidogrel for patients with AF undergoing PCI.