Daigo Hiraya

Coronary high-intensity plaque on T1-weighted magnetic resonance imaging and its association with myocardial injury after percutaneous coronary intervention

AIMS Non-contrast T1-weighted imaging (T1WI) has emerged as a novel non-invasive imaging for vulnerable coronary plaque showing a high-intensity plaque (HIP). However, the association between HIP and percutaneous coronary intervention (PCI) has not been evaluated. We investigated the association between the presence of HIP and the incidence of myocardial injury after PCI. METHODS AND RESULTS A total of 77 patients with stable angina were imaged with non-contrast T1WI by using a 1.5 T magnetic resonance system (HIP and non-HIP group, N = 31 and 46 patients, respectively). We defined HIP as a coronary plaque to myocardium signal intensity ratio (PMR) of ≥1.4. High-sensitive cardiac troponin-T (hs-cTnT) was measured at baseline and 24 h after PCI. Percutaneous coronary intervention-related myocardial injury (PMI) was defined as an elevation of hs-cTnT >5× 99th percentile upper reference limit. High-intensity plaque was associated with the characteristics of ultrasound attenuation and positive remodelling on intravascular ultrasound. Although baseline hs-cTnT was similar between the groups, increase in hs-cTnT was significantly greater in the HIP vs. non-HIP group (0.065 [0.023-0.304] vs. 0.017 [0.005-0.026], P < 0.001). Percutaneous coronary intervention-related myocardial injury occurred more frequently in the HIP than non-HIP group (58.1 vs. 10.9%, P < 0.001), and the cut-off value of PMR found to be 1.44 for predicting PMI (sensitivity 78.3% and specificity 81.5%). In multivariate analysis, a PMR of ≥1.4 was a significant predictor of PMI (odds ratio 5.63, 95% confidence interval 1.28-24.7, P = 0.022). CONCLUSION High-intensity plaque on non-contrast T1WI was characterized as vulnerable coronary plaque on IVUS and was associated with higher incidence of PMI.

Preventive effect of statin pretreatment on contrast-induced acute kidney injury in patients undergoing coronary angioplasty: Propensity score analysis from a multicenter registry

BACKGROUND The prophylactic benefit of statins in reducing the incidence of contrast-induced acute kidney injury (CI-AKI) has been investigated in several studies with conflicting results. We sought to investigate whether statin pretreatment prevents CI-AKI in coronary artery disease (CAD) patients undergoing percutaneous coronary intervention (PCI). METHODS A total of 2198 CAD patients who underwent PCI, except for those undergoing dialysis or who died within 7 days after angioplasty, were analyzed from the ICAS (Ibaraki Cardiovascular Assessment Study) multicenter registry. Analyzed subjects were divided into 2 groups according to statin pretreatment: statin pretreatment (n=839) and non-statin pretreatment (n=1359). Selection bias of statin pretreatment was adjusted by propensity score-matching method: pretreatment statin (n=565) and non-statin pretreatment (n=565). CI-AKI was defined as an increase in serum creatinine of ≥ 25% or 0.5mg/dl from baseline within 1 week of contrast medium exposure. RESULTS A total of 192 (8.7%) patients developed CI-AKI. No significant differences were observed in baseline patient characteristics between the statin and non-statin pretreatment groups after propensity score matching. In the propensity score-matched groups, the incidence of CI-AKI was significantly lower in patients with statin pretreatment than in those without statin pretreatment (3.5% vs.10.6%, odds ratio [OR]: 0.31, 95% confidence interval [CI]: 0.18-0.52, P<0.001). Multivariate logistic regression analysis showed that statin pretreatment remained an independent negative predictor of CI-AKI (OR: 0.31, 95% CI: 0.18-0.53, P<0.001) among propensity score-matched subjects. CONCLUSIONS Statin pretreatment was associated with a significant decrease in the risk of CI-AKI in CAD patients undergoing PCI in the ICAS Registry.

Gender differences in the association between serum uric acid and prognosis in patients with acute coronary syndrome

BACKGROUND Increased levels of uric acid (UA) have been associated with cardiovascular disease. This association is generally stronger in women than men. However, gender differences in the prognostic value of UA in patients with acute coronary syndrome (ACS) are unknown. We investigated gender differences in the relationship between UA level and the prognosis in patients with ACS. METHOD This was an observational analysis of patients with ACS undergoing percutaneous coronary intervention enrolled in the Ibaraki Cardiac Assessment Study (ICAS) registry. We analyzed 1380 patients (330 women, 1050 men) with ACS who had information on UA. We assessed the association between UA and the incidence of major cardiovascular adverse events (MACE), defined as all-cause death, congestive heart failure, reinfarction, and stroke. Patients were divided according to gender-specific UA quartile. RESULTS The mean UA level in women was significantly lower than that in men (4.9mg/dl vs 5.9mg/dl, p<0.001). After a median duration of follow-up period of 437 days (interquartile range 222-801 days), MACE had occurred in 186 (13%) patients [56 (17%) events in women; 130 (12%) events in men]. Kaplan-Meier analysis for MACE-free survival demonstrated that a higher quartile of UA was associated with MACE in both women and men (p<0.001, p=0.002, respectively). Multivariate Cox regression analysis revealed that the highest quartile of UA, as compared with the lowest quartile of UA, was an independent predictor of MACE in women [hazard ratio (HR), 2.84; 95% CI, 1.19-6.77; p=0.018] but not in men (HR, 1.32; 95% CI, 0.66-2.64; p=0.422). CONCLUSIONS An increased level of UA was associated with MACE more strongly in women than in men with ACS. These results suggest that there are gender differences in the association of UA level with the prognosis in patients with ACS.

Effect of the Mehran risk score for the prediction of clinical outcomes after percutaneous coronary intervention.

BACKGROUND The association of Mehran risk score (MRS) with long-term prognosis in patients treated with percutaneous coronary intervention (PCI) has not been fully reported. We investigated the association between MRS and clinical outcomes in patients who underwent PCI. METHODS Study subjects comprised 2198 patients treated with PCI from the Ibaraki Cardiovascular Assessment Study multicenter registry, excluding patients receiving hemodialysis or who died within 7 days. We categorized them into 4 groups according to MRS (low-risk: ≤5; medium-risk: 6-10; high-risk: 11-16; and very high-risk: ≥16). Contrast-induced acute kidney injury (CI-AKI) was defined as an increase of 0.5mg/dL or 25% in pre-PCI serum creatinine within 1-week post procedure. We evaluated CI-AKI and major adverse cardiac and cerebrovascular events (MACCE), and defined as all-cause death, myocardial infarction, congestive heart failure, or cerebrovascular disorder (stroke or transient ischemic attack). RESULTS A total of 192 (8.7%) patients developed CI-AKI. At multivariate analysis, odds ratio for CI-AKI was 4.09 (95% CI: 1.72-9.17, p=0.002) in the very high-risk group, 1.49 (95% CI: 0.89-2.42, p=0.120) in the high-risk group, and 1.08 (95% CI: 0.74-1.54, p=0.693) in the medium-risk group, as compared with the low-risk group. MACCE in the very high-risk group was more than 5-fold higher [hazard ratio (HR) 5.40, 95% CI: 2.96-9.28, p<0.001] compared with the low-risk group and was also increased in the high-risk (HR 3.72, CI: 2.59-5.32, p<0.001) and medium-risk groups (HR 1.97, CI: 1.45-2.69, p<0.001). Kaplan-Meier analysis showed that increasing risk for MACCE was seen across the groups as MRS increased (p<0.001). CONCLUSION MRS might provide potentially useful information for prediction of CI-AKI and clinical outcomes after PCI.

Elevated plasma norepinephrine level and sick sinus syndrome in patients with lone atrial fibrillation

Objective Plasma norepinephrine (NE) level can be a guide to mortality in patients with heart failure. This study aimed to evaluate the significance of plasma NE level compared with plasma natriuretic peptides (atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP)) levels in patients with atrial fibrillation (AF). Methods Included in this study were 137 consecutive patients referred for catheter ablation of lone AF (paroxysmal in 90 and persistent in 47 patients). Blood samples for measurements of ANP, BNP and NE were drawn in the supine position before the procedure. Results ANP, BNP and NE levels were greater in patients with persistent AF than in patients with paroxysmal AF (median (25th–75th centile)=28 (18–49) vs 69 (36–106), p<0.0001; 28 (15–50) vs 94 (39–156), p<0.0001; and 315 (223–502) vs 382 (299–517) pg/mL, p=0.04, respectively). NE level correlated weakly with ANP and BNP levels (r=0.28 and r=0.23, respectively, p<0.01 for both). BNP and NE levels differed between patients with and without recurrence of AF (55 (26–135) vs 35 (18–64), p=0.005 and 431 (323–560) vs 302 (225–436) pg/mL, p<0.001, respectively). Of note, only NE level was significantly greater in patients with symptomatic sick sinus syndrome (SSS) (n=21) than in those without SSS (560 (466–632) vs 321 (242–437) pg/mL, p<0.0001). Logistic regression analysis showed NE level to be the only independent discriminator for SSS (OR 1.006, 95% CI 1.002 to 1.010, p=0.001). Conclusions An increase in plasma NE level was observed in patients with AF and SSS. Although this implies a pathophysiological link between clinical manifestation of SSS and the autonomic nervous dysfunction, further studies are needed to clarify the mechanisms for this novel finding.

Drug-eluting versus bare-metal stents in large coronary arteries of patients with ST-segment elevation myocardial infarction: Findings from the ICAS registry

BACKGROUND AND PURPOSE There are a few retrospective subgroup analyses or registries of large-vessel (≥ 3.5mm) stenting. We investigated clinical outcomes of patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI) with drug-eluting stents (DES) and bare-metal stents (BMS) in large coronary vessels. METHODS AND SUBJECTS Of 1100 STEMI patients registered in the Ibaraki Cardiovascular Assessment Study (ICAS) multicenter registry from April 2007 to June 2012 who underwent PCI, we enrolled 454 patients (65.8 ± 12.7 years old, 81% male) with ≥ 3.5-mm stents. We excluded 53 patients with cardiogenic shock or left main trunk lesions. The remaining 401 patients were divided into Group-D, PCI with DES (n = 184), and Group-B, PCI with BMS (n = 217). Propensity score analysis matched 1:1 according to treatment with DES (n = 101) or with BMS (n = 101). We evaluated major adverse cardiac and cerebrovascular events (MACCE) and incidence of stent thrombosis (ST). MACCE was defined as all-cause death, myocardial infarction (MI), target-vessel revascularization (TVR), or cerebrovascular accident (CVA). ESSENTIAL RESULTS During a mean follow-up period of 526 days, all-cause death, MI, CVA, MACCE, and ST were not significantly different in Group-D versus Group-B (all-cause death: 4.35% vs. 4.61%, p = 0.90; MI: 0% vs. 0%; CVA: 2.72% vs. 3.23%, p = 0.76; MACCE: 15.2% vs. 20.3%, p = 0.19; and ST: 0.0% vs. 1.38%, p = 0.11). After adjusting for age, insulin use, multivessel disease, intra-aortic balloon pump use, culprit lesions, and estimated glomerular filtration rate <60 ml/min/1.73 m(2), MACCE was not significantly different between the groups (odds ratio: 0.69; 95% CI: 0.40-1.23; p = 0.21). However, TVR was significantly lower in Group-D than Group-B in Kaplan-Meier analysis (p = 0.048) after propensity score matching. PRINCIPAL CONCLUSION There was no advantage to using a DES in large vessels for preventing a hard endpoint, whereas DES use resulted in a significant reduction in TVR in the patients with STEMI in this registry.

In vivo evaluation of fibrous cap thickness by optical coherence tomography for positive remodeling and low-attenuation plaques assessed by computed tomography angiography

BACKGROUND Coronary plaques with positive remodeling (PR) and low-attenuation plaques (LAP) by computed tomography angiography (CTA) might be associated with plaque vulnerability. The purpose of this study was to assess the relation between coronary plaques with PR and LAP by CTA and fibrous cap thickness measured by optical coherence tomography (OCT). METHODS We used CTA and OCT to assess 102 coronary plaques in patients with coronary artery disease (unstable angina pectoris, n=24; stable angina pectoris, n=78). Plaque characteristics were divided into three groups: 2-feature-positive plaques (PR and LAP; n=32), 1-feature-positive plaques (PR or LAP; n=20), and 2-feature-negative plaques (neither PR nor LAP; n=50). PR was defined as remodeling index (RI) of >1.05 and LAP was defined as CT density value <50HU. RESULTS There were significant differences between the three plaque groups with respect to fibrous cap thickness measured by OCT: 76±24μm in 2-feature-positive plaques, 154±51μm in 1-feature-positive plaques, and 192±49μm in 2-feature-negative plaques (P<0.001). The RI (1.21±0.06, 1.14±0.05, P=0.011) and the presence of thin cap fibroatheroma (TCFA) (<70-μm thickness) (75%, 15%, P=0.001) were significantly higher in UAP than in SAP patients with 2-feature-positive plaques, whereas fibrous cap thickness (68.9±24.1, 92.1±21.9μm, P<0.001) was lower in the UAP patients. In UAP patients, the presence of ring-like enhancement showed higher accuracy of 88% for detection of TCFA. CONCLUSIONS Coronary PR and LAP by CTA were associated with the degree of fibrous cap thickness measured by OCT. CTA can non-invasively provide promising information on plaque vulnerability by identifying coronary plaque with PR and LAP, especially ring-like enhancement.

Multimodality intracoronary imaging in spontaneous coronary artery dissection: Impacts of intravascular ultrasound, optical coherence tomography, and coronary angioscopy

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome and its etiology and pathogenesis have not been well understood. Intracoronary imaging modalities with intravascular ultrasound and optical coherence tomography would enable a precise diagnosis in this entity. Coronary angioscopy is also a unique tool for allowing direct visualization of the luminal surface of a vessel. We described an interesting case of SCAD documented with multimodality intracoronary imaging showing the presence of superficial lipid plaque nearby the coronary dissection entry point, which might have been associated with fragility of the arterial wall and the subsequent development of SCAD.

Pneumonitis due to an herbal medicine, Otsu-ji-to.

We report a successfully treated case with interstitial pneumonitis due to Otsu-ji-to. Otsu-ji-to contains Ou-gon, an extract of Scuttelaria roots, which is called scullcap in western countries. In Western traditional herbal medicine, scullcap is also utilized for convulsions, hysteria, nervous tension, and epilepsy. A 53-year-old man was admitted for diffuse ground-glass opacity in both lungs noted on a chest X-ray. He had had hemorrhoid 1 month previously, which was successfully treated with surgery. In his postoperative course, he had Otsu-ji-to 7.5 g/day orally. Two weeks after the initiation of the drug, he developed shortness of breath, and was dyspneic at rest. Chest CT showed bilateral diffuse ground-glass opacities in both lungs, but honeycombing and traction bronchiectasis were not observed on it. There was no finding of heart failure or an evidence of pulmonary embolism. The radiological features seemed compatible with acute interstitial pneumonitis. An echocardiogram was normal. Laboratory data showedWBC 10,500/mm, LDH 357 U/L, C-reactive protein 9.46 mg/dl. There was no elevation of antibody titers of Mycolasma, Legionella pneumophilia, and Chlamydia psittaci. Antibiotic treatment was initiated with ciprofloxacin on admission, however, his respiratory status rapidly deteriorated. Suspecting Otsuji-to-induced pneumonitis, it was discontinued and the patient was treated with methylprednisolone (500 mg/day) for 3 days. A lung biopsy was planned but the patients respiratory condition improved

Circulating microRNAs as an emerging biomarker for acute aortic dissection diagnosis—comparing with prior biomarkers

Acute aortic dissection (AAD) is a serious disease with a high mortality rate. The mortality rate for patients with type A AAD who do not get treatment is of 1–2% per hour during the first 24 hours and almost 50% of the patients die within a week (1). The highest mortality associated with AAD occurs in the first 48 hours after onset of symptoms.