Demographic Trends and Changes in the Pre- and In-Hospital Medical Management of Acute Myocardial Infarction During the First 12 Months of the COVID-19 Pandemic in Mie Prefecture　- Report From the Mie ACS Registry.

Background: Even though hospital admissions for acute myocardial infarction (AMI) decreased globally during the COVID-19 pandemic in early 2020, limited information is available on subsequent demographic trends in the number of cases and management of AMI through the first 12 months of the COVID-19 pandemic. Methods and Results: We assessed demographic trends, patient characteristics, and AMI outcomes (n=730) during the first 12 months of the COVID-19 pandemic and compared them with corresponding months during the control period (February 2016-January 2020; n=2,742) using data from the Mie ACS Registry. Although a 25.8% reduction in hospitalizations for AMI was observed in the 3 months following the declaration of a state of emergency (47.7 vs. 64.3/month; P=0.002), the total number of AMI patients was similar between the 12-month COVID-19 and control periods (60.8 vs. 57.2/month; P=0.58). The number of patients requiring direct ambulance transport was lower in the first half of the COVID-19 than control period (44.4% vs. 51.5; P=0.028). In-hospital mortality was higher in the second half of the COVID-19 than control period (8.9% vs. 5.8%; P=0.032). Conclusions: Through the first 12 months of the COVID-19 pandemic, the number of AMI cases was similar to that in previous years. The COVID-19 pandemic changed the behavior of AMI patients and both pre- and in-hospital medical management, which significantly affected the severity and prognosis of AMI.

Mechanisms and prediction of short-term natriuretic effect of sodium-glucose cotransporter 2 inhibitor in heart failure patients coexisting type 2 diabetes mellitus.

The mechanisms of the diuretic effect of sodium-glucose cotransporter 2 (SGLT2) inhibitor and its predictors in heart failure (HF) patients with coexisting type 2 diabetes mellitus (T2DM) remain under investigation. A total of 40 hospitalized HF patients with T2DM (68 ± 13 years old, male gender 63%) were prospectively enrolled and received ipragliflozin at a dose of 50 mg once daily after breakfast for at least 4 consecutive days. They underwent first-morning blood and urine tests, and 24-h urine tests before and after short-term ipragliflozin therapy. Daily urine volume significantly increased from 1365 ± 511 mL/day on day 0 to 1698 ± 595 mL/day on day 3 (P < 0.001), which resulted in significant decreases in body weight and plasma brain natriuretic peptide level. Changes in 24-h urine volume were strongly and independently correlated with changes in 24-h urine sodium excretion (r = 0.80, P < 0.001), but was not significantly correlated with those in 24-h urine sugar excretion (r = 0.29, P = 0.07). Lower concentration of first-morning urine sodium and higher loop diuretic dosage before ipragliflozin therapy were associated with urine volume increment with ipragliflozin therapy, and former retained its independent predictor (Odds ratio 0.96, 95% CI 0.93-0.99, P = 0.02). First-morning urine sodium ≤ 53 mEq/L and baseline loop diuretics ≥ 20 mg/day predicted increased urine volume on day 3 with high diagnostic accuracy. Ipragliflozin has acute natriuretic activity, and first-morning urine sodium and baseline dosage of loop diuretics strongly predicted the diuretic effects. Ipragliflozin therapy may restore responsiveness to loop diuretics in symptomatic HF patients with T2DM.

Clinical usefulness of instantaneous wave-free ratio for the evaluation of coronary artery lesion with prior myocardial infarction: A multi-center study.

BACKGROUND: Fractional flow reserve (FFR) is useful for assessing the functional significance of coronary artery stenosis, even in lesions with prior myocardial infarction (pMI). Instantaneous wave-free ratio (iFR) is a vasodilator-free alternative for the physiological assessment of coronary artery stenosis. In addition, iFR shows good diagnostic agreement with FFR and an iFR-guided revascularization strategy was non-inferior to an FFR-guided revascularization strategy. However, the clinical usefulness of iFR for the evaluation of a coronary artery lesions with pMI has not been evaluated. METHODS AND RESULTS: A total of 200 lesions from 200 patients (44 pMI territories lesions and 156 non-pMI coronary artery lesions) were analyzed retrospectively. Major adverse cardiac events (MACE) were defined as cardiovascular death, non-fatal MI, unstable angina pectoris, fatal arrhythmia and heart failure during 12 months follow-up after the physiological assessment of coronary artery stenosis. iFR was closely correlated with FFR in pMI and non-pMI lesions (r = 0.81 and 0.72; P < 0.001, respectively). In pMI lesions, an iFR cut-off of 0.89 was optimal against a clinical FFR cut-off of 0.80 according to receiver operating characteristics (ROC) curve analysis, whereas in non-pMI lesions, the iFR cut-off value was 0.92 without statistical significance. In addition, the event rate of MACE was similar between pMI and non-pMI patients during follow-up even in the presence or absence of an PCI procedure. CONCLUSIONS: iFR may be a useful alternative method compared with FFR for clinical decision-making even in pMI patients.

Untangling the obesity paradox in patients with acute myocardial infarction after primary percutaneous coronary intervention (detail analysis by age).

BACKGROUND: Obesity is associated with increased morbidity and mortality. However, obesity paradox has been discussed in some patients with cardiovascular disease. OBJECTIVES: We investigated the mechanisms of the obesity paradox in acute myocardial infarction (AMI) patients. METHODS: We evaluated 1634 AMI patients with primary percutaneous coronary intervention (PCI). Patients were divided into 6 subgroups according to baseline body mass index (BMI) (low BMI: <20 kg/m2, normal BMI: 20-24.9 kg/m2, high BMI: ≥25 kg/m2) and age (the younger and elderly groups consisting of patients <70 and ≥70 years old). The primary outcome was defined as all-cause mortality. RESULTS: During the follow-up periods (median, 620 days; range, 344 to 730 days), 8.7% of patients experienced all-cause death. According to the Kaplan-Meier survival analysis, the patients in the younger age group with high BMI demonstrated significantly higher all-cause mortality compared to the other patients in the same age group (P = 0.012). In contrast, patients in the elderly age group with low BMI demonstrated significantly higher all-cause mortality compared to the others in the same age group (P < 0.001). Multivariate cox regression analyses showed that low BMI in the elderly age group (HR 1.69, 95% CI 1.12 to 2.55, P = 0.012) and high BMI in the younger age group (HR 2.77, 95% CI 1.19 to 6.45, P = 0.018) were independent predictors of all-cause mortality. CONCLUSIONS: The obesity paradox was recognized only in patients in the elderly age group and not in the younger age group. The prognostic impact of BMI may differ by age in AMI patients.

Narrowing of the QRS complex, elimination of late gadolinium enhancement and remarkable reverse remodeling achieved by optimal medical treatment in non-ischemic dilated cardiomyopathy.

A 67-year-old woman presented with exertional dyspnea. An electrocardiogram showed complete left bundle branch block. Cardiac magnetic resonance imaging revealed left ventricular (LV) dilatation with reduced ejection fraction, no evidence of myocardial ischemia and late gadolinium enhancement (LGE) in the inferior LV wall. She was diagnosed with decompensated heart failure (HF) secondary to non-ischemic dilated cardiomyopathy. Narrowing of the QRS complex, disappearance of LGE, and remarkable LV reverse remodeling along with improvement in HF symptoms were achieved by combination therapy with angiotensin II receptor blocker, beta-blocker, and mineralocorticoid receptor antagonist. This case highlights the role of triple-blockade therapy in the treatment of HF. .

Optical coherence tomography analysis of the stent strut and prediction of resolved strut malapposition at 3 months after 2nd-generation drug-eluting stent implantation.

Our objective was to clarify whether thrombogenic problems with stent struts are resolved at 3 months after 2nd-generation drug-eluting stent implantation. Twenty-one patients with stable angina pectoris having 28 (22 zotarolimus-eluting, 6 everolimus-eluting) stents with optical coherence tomography (OCT)-guided percutaneous coronary intervention (PCI) were evaluated. Stent strut coverage and malapposition were evaluated by OCT immediately after PCI and at 3-month follow-up. Acute strut malapposition was observed in 26 out of 28 analyzed stents (92.9 %). At 3-month follow-up, 7 (26.9 %) of those 26 stents with strut malapposition were completely resolved, and the mean percentages of uncovered struts and malapposed struts were 8.3 and 2.0 % when analyzed by each individual stent. When analyzing a total of 30,060 struts, 807 struts (2.7 %) demonstrated acute strut malapposition. Among these, 219 struts (27.1 %) demonstrated persistent strut malapposition. On the basis of receiver-operating characteristic curve analysis, a strut-to-vessel (S-V) distance ≤160 µm on post-stenting OCT images was the corresponding cutoff point for resolved malapposed struts (sensitivity 78.1 %, specificity 62.8 %, area under the curve 0.758). The S-V distance of persistent malapposed struts on post-stenting OCT images was longer than that of resolved malapposed struts (235 ± 112 vs. 176 ± 93 µm, p < 0.01). At 3 months after PCI, the prevalence rates of uncovered and malapposed struts were relatively low in 2nd-generation drug-eluting stent. Our results suggest that OCT-guide PCI with an S-V distance ≤160 µm may be recommended especially in patients with planed short-term DAPT.