Clinical impact of angiographic restenosis after bare-metal stent implantation on long-term outcomes in patients with coronary artery disease.

BACKGROUND: In-stent restenosis (ISR) after bare-metal stent (BMS) implantation is thought to be clinically benign, although this notion remains controversial. The long-term clinical outcomes of ISR with BMS have not been established. METHODS AND RESULTS: Among 983 consecutive patients (1,227 lesions) implanted with a BMS between 1999 and 2004 at the authors' institution, 746 underwent routine follow-up angiography. Angiographic ISR (ISR group) was evident in 215 patients (28.8%) and 136 of them underwent repeat revascularization. The incidence of major adverse cardiac events (MACE), acute coronary syndrome (ACS), target lesion revascularization and all-cause death were evaluated between patients with and without ISR (non-ISR group). Patients in the ISR group were older and more likely to have diabetes. The median follow-up period was 2,031 days. The rates of MACE and ACS were significantly higher in the ISR group compared with the non-ISR group (33.5% vs. 13.7%, P<0.0001 and 11.2% vs. 7.0%, P<0.05, respectively). Multivariate Cox regression analysis demonstrated that ISR was significantly associated with clinical outcomes (adjusted hazard ratio [HR] for MACE, 2.81; 95% confidence interval [CI]: 2.01-3.94, P<0.01; adjusted HR for ACS, 1.84; 95%CI: 1.08-3.13, P<0.05). CONCLUSIONS: ISR with BMS was significantly associated with long-term adverse clinical outcomes. Risk of future cardiovascular events due to ISR must be carefully considered.

Gender-based outcomes among patients with diabetes mellitus after percutaneous coronary intervention in the drug-eluting stent era.

Diabetes mellitus has a greater effect on mortality rates due to coronary artery disease in women than in men. Although women undergoing coronary intervention in general have a higher frequency of adverse outcomes than men, the effect of gender among diabetic patients on clinical outcomes after percutaneous coronary intervention (PCI) has not been well established in the drug-eluting stent (DES) era. We have investigated the impact of gender on long-term clinical outcome in these high risk populations. We enrolled 404 consecutive patients (74 women and 330 men) with diabetes mellitus who underwent elective PCI (85% with DES). We evaluated the incidence of major adverse cardiac events (MACE), which is a composite of total all-cause death, acute coronary syndrome (ACS), and target lesion revascularization (TLR) during a period of 4 years after coronary intervention. The women were significantly older, more likely to have dyslipidemia, and had significantly higher systolic blood pressure and LDL-C values than men. The use of insulin and angiotensin receptor blockers was more frequent among the women (32.4% versus 21.0%, P = 0.04 and 60.8% versus 39.8%, P < 0.01, respectively). The angiographic profiles of both were comparable. At four-year clinical follow-up, cumulative incidence of MACE was identical between the women and the men (16.2% versus 15.5%, P = 0.90; adjusted HR 1.23, 95% CI 0.61-2.50, P = 0.56). Although the baseline characteristics of the women were worse, clinical outcomes did not significantly differ between women and men among diabetic patients after elective PCI.

Ultrasound-guided puncture reduces bleeding-associated complications, regardless of calcified plaque, after endovascular treatment of femoropopliteal lesions, especially using the antegrade procedure: A single-center study.

BACKGROUND: A common complication of endovascular treatment for femoropopliteal lesions is bleeding at the vascular access site. Although risk factors of bleeding-associated complications at the approach site have been reported, the results have been inconclusive. Hence, this study aimed to assess the predictors of bleeding-associated complications at the approach site in patients undergoing endovascular treatment for femoropopliteal lesions. METHODS: This retrospective, single-center, observational study included consecutive patients who underwent endovascular treatment (n = 366, 75% male, 72.4±9.9 year) for peripheral arterial disease with claudication and critical limb ischemia in our hospital from January 2010 to December 2017. We divided the patients into bleeding and non-bleeding groups, depending on whether bleeding-associated complications occurred at the approach site. Bleeding-associated complications were defined according to the Bleeding Academic Research Consortium criteria types 2, 3, and 5. RESULTS: Altogether, 366 endovascular treatment procedures and 404 arterial accesses were performed for femoropopliteal lesions in 335 peripheral arterial disease patients with claudication and 69 critical limb ischemia patients. We recorded 35 postprocedural bleeding-associated complications at the approach site (9%), all of which were hematomas. The predictors of increased bleeding-associated complications were age ≥ 80 years (bleeding vs. non-bleeding group, 43% vs. 25%, p<0.05) and antegrade cannulation of the common femoral artery (48% vs. 69%, p<0.05). Ultrasound-guided puncture reduced bleeding-associated complications (odds ratio, 0.28; 95% confidence interval, 0.004-0.21; p<0.05). In contrast, there was no significant difference in puncture site calcification between the groups (bleeding vs. non-bleeding groups, 29% vs. 21%, p = 0.29). CONCLUSION: Ultrasound-guided puncture is associated with a decrease in bleeding-associated complications at the approach site, regardless of the presence of calcified plaque. It is particularly effective and should be more actively used in patients aged ≥80 years and for antegrade cannulation of the common femoral artery.

An adult case of polysplenia syndrome associated with sinus node dysfunction, dextrocardia, and systemic venous anomalies.

A 54-year-old woman was referred to our hospital for symptomatic sinus bradyarrhythmia with a sinus pause of 8 seconds. She was diagnosed with dextrocardia during childhood and discovered to have heterotaxy syndrome when she had an appendectomy during her teenager years. Chest and abdominal examinations by computed tomography showed multiple spleens located on the right side and abnormal drainages of the superior and inferior vena cava. Left isomerism was diagnosed by bilaterally bilobed lungs. Because of a patent bilateral superior vena cava, pacemaker leads were implanted using the right cephalic vein approach. Her fainting symptoms disappeared after pacemaker implantation.

Increased lysophosphatidic acid levels in culprit coronary arteries of patients with acute coronary syndrome.

BACKGROUND: Lysophosphatidic acid (LPA) is a platelet activator and highly thrombogenic lipid constituent of atherosclerotic plaque. However, whether or not LPA locally released from culprit lesions is associated with acute coronary syndrome (ACS) remains unclear. METHODS: We studied 52 patients with ACS who were treated by emergency percutaneous coronary intervention and thrombectomy. Levels of LPA and other established biomarkers were enzymatically assayed in samples of culprit coronary arterial and systemic peripheral arterial blood. Levels of LPA and lysophosphatidylcholine (LPC) were measured in plasma, and those of autotaxin, soluble CD40 ligand (sCD40L), hs-CRP and Lp-PLA2 were measured in serum. RESULTS: Median LPA levels were significantly higher in coronary (CB) than in peripheral (PB) arterial blood (p = 0.009). Levels of sCD40L were higher in CB than in PB, but the difference did not reach statistical significance (p = 0.177). In contrast, autotaxin and Lp-PLA2 levels were significantly higher in PB than in CB (p = 0.005 and p = 0.038, respectively). Levels of LPC and hs-CRP were also higher in PB than in CB (p = 0.129 and p = 0.121, respectively). Levels of LPA in both CB and PB were positively and significantly associated with those of LPC (r = 0.632, p < 0.01 and r = 0.465, p < 0.001). CONCLUSIONS: Culprit coronary arteries of ACS contained significantly more LPA than the systemic arterial circulation. Higher LPA concentrations might be associated with the pathophysiology of ACS.

Higher lipoprotein-associated phospholipase A2 levels are associated with coronary atherosclerosis documented by coronary angiography.

BACKGROUND: Lipoprotein-associated phospholipase A2 (Lp-PLA2) has been proposed as an inflammatory marker of cardiovascular disease. The present study investigates associations between Lp-PLA2 and other important biomarkers in Japanese patients with coronary artery disease. METHODS: We measured Lp-PLA2 levels in 141 consecutive patients (age 62.6 ± 3.8 years; men 69.2%) with angiographic evidence of coronary artery disease (acute coronary syndrome [ACS]; n = 38), stable angina pectoris (SAP; n = 72) or with angiographically normal coronary arteries (NCA; n = 31). RESULTS: Levels of Lp-PLA2 significantly correlated with low-density lipoprotein-cholesterol (r = 0.302), homocysteine (r = 0.528) and paraoxonase (r = 0.401) in all patients (all P < 0.01). Levels of Lp-PLA2 were significantly higher in patients with coronary atherosclerosis (ACS and SAP) than with NCA (P < 0.05). Levels of highly sensitive C-reactive protein were significantly higher in patients with ACS than with SAP and NCA (both P < 0.05). Multivariate logistic regression analyses revealed that higher Lp-PLA2 levels were independently associated with coronary atherosclerosis (odds ratio: 1.058; 95% confidence interval: 1.012-1.121; P = 0.001). CONCLUSIONS: Higher Lp-PLA2 levels are associated with coronary atherosclerosis independently of traditional coronary risk factors. Thus, Lp-PLA2 is a novel biomarker of coronary atherosclerosis in Japanese patients.

Increased circulating plasma lysophosphatidic acid in patients with acute coronary syndrome.

BACKGROUND: The platelet activator lysophosphatidic acid (LPA) has recently been identified as an ingredient in oxidized LDL and it has been isolated from atherosclerotic plaques. The lysophospholipase D activity of autotaxin produces LPA extracellularly from lysophosphatidylcholine (LPC). The present study determines whether circulating LPA is associated with acute coronary syndrome (ACS). METHODS: We enrolled 141 consecutive patients (age, 62.6±3.8 y; male, 69.2%) with ACS (n=38), stable angina pectoris (SAP; n=72) or angiographically normal coronary arteries (NCA; n=31). The relationships between LPA and other established biomarkers were examined. Concentrations of plasma LPA were determined using an enzymatic assay. RESULTS: Concentrations of LPA significantly correlated with LPC (r=0.549), autotaxin (r=0.370) and LDL-C (r=0.307) (all p<0.01). Lysophosphatidic acid concentrations were significantly higher in patients with ACS than with SAP and NCA (p<0.01), but did not significantly differ between patients with SAP and NCA. Multivariate logistic regression analyses revealed that the highest LPA tertile was independently associated with ACS (odds ratio 1.99, 95% CI: 1.18-3.39, p=0.02). CONCLUSIONS: The present study demonstrated that increased circulating plasma LPA concentrations are significantly associated with ACS.

Long-term effect of metabolic syndrome with and without diabetes mellitus on coronary revascularization in Japanese patients undergoing percutaneous coronary intervention.

BACKGROUND: Metabolic syndrome (MS) plays a crucial role in the long-term prognosis and primary or secondary prevention of coronary artery disease, regardless of the presence or absence of diabetes mellitus (DM). We previously reported that after percutaneous coronary intervention (PCI), patients with MS had worse long-term outcome. However, there is no evidence indicating the importance of MS with and without DM on re-revascularization procedures in Japanese patients undergoing PCI. HYPOTHESIS: We hypothesized that MS patients without DM have an increased risk of re-revascularization following PCI. METHODS: We classified 748 consecutive Japanese patients who had undergone PCI into 4 groups as follows: neither DM nor MS, DM alone, MS alone, and both DM and MS. Post-hoc analyses were conducted using prospectively collected clinical data. Multivariate Cox regression was used to evaluate the risk within each group for subsequent revascularization (repeat PCI and bypass surgery), adjusting for baseline covariates. RESULTS: The progress of 321 (42.9%) patients without DM or MS, 109 (14.6%) patients with DM alone, 129 (17.2%) patients with MS alone, and 189 (25.3%) patients with both DM and MS was followed up for a mean duration of 12.0 ± 3.6 years. Patients with MS alone (hazard ratio: 1.38, 95% confidence interval: 1.01-1.89, P = 0.04) and those with both DM and MS (hazard ratio: 1.36, 95% confidence interval: 1.02-1.81, P = 0.04) had a significantly increased risk for revascularization. CONCLUSIONS: The presence of MS significantly increased the risk for subsequent revascularization among Japanese patients who underwent PCI, regardless of the presence or absence of DM.

Long-term outcomes of women with coronary artery disease following complete coronary revascularization.

BACKGROUND: Although coronary artery disease (CAD) is less prevalent in women than in men, early mortality rate is higher in women with CAD than in men with CAD following coronary revascularization. In terms of the long-term outcomes after coronary revascularization, limited data are available. Especially, in the Japanese CAD population, no data about sex-related differences in long-term outcomes after coronary revascularization exist. The aim of this study was to compare long-term outcomes between men and women following complete revascularization in Japanese patients with CAD. METHODS: We collected data from 1836 consecutive patients who underwent complete revascularization by percutaneous coronary interventions and/or bypass surgeries. All-cause and cardiac mortality and the incidence of stroke were compared between men and women. In addition to the univariate analysis, a multivariate Cox regression was carried out in order to adjust for differences in baseline characteristics. RESULTS: There were 274 female patients (14.9%). They were older, had greater total cholesterol levels, and were more likely to have multivessel disease than men. During follow-up [mean (SD), 11.4 (2.9) years], 412 patients died (including 131 patients who died of cardiac causes), and 130 had a stroke. In the multivariate analysis, female patients did not have a significant risk for all-cause mortality (hazard ratio [HR], 1.01; p=0.993), cardiac mortality (HR, 1.41; p=0.256), or stroke (HR, 0.71; p=0.309). CONCLUSIONS: In the present study involving CAD patients who underwent complete revascularization, we showed that, although women were older and had more unfavorable risk profiles, they did not have a greater risk of long-term all-cause mortality, cardiac mortality, or stroke incidence, compared to men.