Daisuke Hachinohe

Value of Early Risk Stratification Using Hemoglobin Level and Neutrophil-to-Lymphocyte Ratio in Patients With ST-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

Complete blood count is the most widely available laboratory datum in the early in-hospital period after ST-elevation myocardial infarction (STEMI). We assessed the clinical utility of the combined use of hemoglobin (Hb) level and neutrophil-to-lymphocyte ratio (N/L) for early risk stratification in patients with STEMI. We analyzed 801 consecutive patients with STEMI treated with primary percutaneous coronary intervention (PCI) within 12 hours of onset of symptoms. Patients with cardiogenic shock or underlying malignancy were excluded, and 739 patients (63 ± 13 years, 74% men) were included in the final analysis. Patients were categorized into 3 groups using the median value of N/L (3.86) and the presence of anemia (Hb <13 mg/dl in men and <12 mg/dl in women); group I had low N/L and no anemia (n = 272), group II had low N/L and anemia, or high N/L and no anemia (n = 331), and group III had high N/L and anemia (n = 136). There were significant differences on clinical outcomes during 6-month follow-up among the 3 groups. Prognostic discriminatory capacity of combined use of Hb level and N/L was also significant in high-risk subgroups such as patients with advanced age, diabetes mellitus, multivessel coronary disease, low ejection fraction, and even in those having higher mortality risk based on Thrombolysis In Myocardial Infarction risk score. In a Cox proportional hazards model, after adjusting for multiple covariates, group III had higher mortality at 6 months (hazard ratio 5.6, 95% confidence interval 1.1 to 27.9, p = 0.036) compared to group I. In conclusion, combined use of Hb level and N/L provides valuable timely information for early risk stratification in patients with STEMI undergoing primary PCI.

Role of Intravascular Ultrasound in Patients with Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention

Stent thrombosis and restenosis remain drawbacks of drug-eluting stents in patients with acute myocardial infarction (AMI). Intravascular ultrasound (IVUS) guidance for stent deployment helps optimize its results in stable patients. The aim of this study was to examine the utility of routine IVUS guidance in patients with AMI undergoing percutaneous coronary intervention (PCI). Employing data from Korea Acute Myocardial Infarction Registry (KAMIR), we analyzed 14,329 patients with AMI from April 2006 through September 2010. Patients with cardiogenic shock and rescue PCI after thrombolysis were excluded. Clinical outcomes of 2,127 patients who underwent IVUS-guided PCI were compared to those of 8,235 patients who did not. Mean age was 63.6 ± 13.5 years and 72.3% were men. Patients undergoing IVUS-guided PCI were younger, more often men, more hyperlipemic, and had increased body mass index and left ventricular ejection fraction. Number of treated vessels and stents used, stent length, and stent diameter were increased in the IVUS-guided group. Multivessel involvement was less frequent and American College of Cardiology/American Heart Association type C lesion was more frequent in the IVUS-guided group. Drug-eluting stents were more frequently used compared to bare-metal stents in the IVUS group. There was no significant relation of stent thrombosis between the 2 groups. Twelve-month all-cause death was lower in the IVUS group. After multivariate analysis and propensity score adjustment, IVUS guidance was not an independent predictor for 12-month all-cause death (hazard ratio 0.212, 0.026 to 1.73, p = 0.148). In conclusion, this study does not support routine use of IVUS guidance for stent deployment in patients who present with AMI and undergo PCI.

Management of Non–ST-Segment Elevation Acute Myocardial Infarction in Patients With Chronic Kidney Disease (from the Korea Acute Myocardial Infarction Registry)

The aim of this study was to compare clinical outcomes among early invasive (EI), deferred invasive (DI), and conservative strategies in patients with acute non-ST-segment elevation myocardial infarction (NSTEMI) and chronic kidney disease (CKD). High-risk patients with NSTEMI are believed to fare better with an EI strategy, but the optimal treatment for patients with NSTEMI and CKD is not known. In total 5,185 patients with acute NSTEMI were enrolled from the Korea Acute Myocardial Infarction Registry and followed for 1 year. Patients were divided into EI, DI, and conservative treatment groups and classified into 4 stages using references from the National Kidney Foundation. The invasive EI and DI groups were compared to the conservative groups, and the EI and DI groups were compared according to each renal function stage. At 1-year follow-up, mortality rates in the conservative group were significantly higher than in the invasive groups except for the severe CKD group. The benefit of the EI over the DI strategy, although there were no significant differences between the 2 groups, tended to decrease as renal function decreased. In conclusion, in the management of NSTEMI, an invasive strategy decreased mortality compared to a conservative strategy except for severe CKD. In the timing of an invasive strategy, the EI strategy was observed to be superior to the DI strategy in patients with mild CKD; however, this tendency reversed as renal function decreased. When patients with NSTEMI have severe CKD, a conservative or DI strategy with prescription of cardioprotective medications and prevention of further deterioration in renal function should be considered.

Clinical impact of thrombus aspiration during primary percutaneous coronary intervention: Results from Korea Acute Myocardial Infarction Registry

BACKGROUNDnThe role of thrombus aspiration (TA) as an adjunct to primary percutaneous coronary intervention (PPCI) remains a matter of controversy.nnnMETHODS AND RESULTSnA total of 2105 patients enrolled in the nationwide prospective Korea Acute Myocardial Infarction Registry, a cohort of 745 (35.4%) patients who underwent TA during PPCI was compared with 1360 (64.6%) patients who underwent conventional PCI without TA. Clinical outcomes at 12-months of overall enrolled patients and subgroups according to key variables were assessed using Cox regression models adjusted by propensity score. Although there was no significant difference among overall patients, in subgroup analyses, administration of glycoprotein (GP) IIb/IIIa inhibitor during PPCI [adjusted hazard ratio (HR) 0.329, 95% confidence interval (CI) 0.126-0.860, p=0.023] and left anterior descending (LAD) as a culprit lesion (adjusted HR 0.516, 95% CI 0.275-0.971, p=0.040) were the settings, in which TA was associated with a lower major adverse cardiac events (MACE) rate compared with non-TA.nnnCONCLUSIONSnAlthough TA does not improve clinical outcomes in overall patients who underwent PPCI, TA for LAD occlusion improves 12-month MACE. Furthermore, use of GP IIb/IIIa inhibitor with TA has a synergistic effect on clinical outcomes.

Prognostic Impact of Baseline High-Sensitivity C-Reactive Protein in Patients With Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention Based on Body Mass Index

Background and Objectives Serum high sensitivity C-reactive protein (hs-CRP) is a marker of inflammation and may lead to the development of atherosclerosis, adversely affecting mortality. The aim of this study was to evaluate the relationship between baseline hs-CRP level and 12-month clinical outcomes in patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI) according to their body mass index (BMI) status. Subjects and Methods Using data from the Korea Acute Myocardial Infarction Registry from November 2005 to September 2008, a total of 8174 consecutive AMI patients were studied. Cox proportional hazard model revealed that higher baseline levels of hs-CRP was associated with 12-month all-cause mortality (p=0.045). To further understand this association, patients were divided into 3 groups based on their body mass index: 1) overweight/obese, 2) normal weight, and 3) underweight patients. Then each group was stratified into quartiles based on their hs-CRP. Results In overweight/obese patients, Cox model showed significant association of hs-CRP with 12-month mortality when adjusted for age and gender (p<0.001), however, after adjustment with multiple covariates, mortality was highest in the 4th quartile {HR 2.382, (1.079-5.259), p=0.032} though statistically insignificant (p=0.172). We observed no significant association of serum hs-CRP with 12-month mortality in normal weight (p=0.681) and underweight (p=0.760) patients. Conclusion Higher baseline hs-CRP level (≥4.08 mg/dL) in overweight/obese AMI patients showed significant association with 12-month all-cause mortality independent of other prognostic markers.

Effects of ramiprilat-coated stents on neointimal hyperplasia, inflammation, and arterial healing in a porcine coronary restenosis model.

Background and Objectives The renin-angiotensin-aldosterone system has been implicated in the pathogenesis of neointimal hyperplasia, and a role for angiotensin II in the migration and proliferation of vascular smooth muscle cells in restenotic lesions has been proposed. The aim of this study was to determine the anti-proliferative and anti-inflammatory effects of ramiprilat-coated stents in a porcine coronary overstretch restenosis model. Subjects and Methods Pigs were randomized into two groups in which the coronary arteries {16 pigs (16 coronaries in each group)} had a 3.0×17 mm ramiprilat-coated MAC stent or a 3.0×17 mm control MAC stent (AMG, Munich, Germany) implanted with oversizing (stent-to-artery ratio, 1.3 : 1) in porcine coronary arteries, and histopathologic analysis was assessed 28 days after stenting. Results There were no significant differences in the injury and inflammation scores between the two groups (1.20±0.43 vs. 1.23±0.57, p=0.8; and 1.21±0.39 vs. 1.25±0.49, p=0.6, respectively). Within the neointima, most inflammatory cells were lymphohistiocytes. Significant positive correlations existed between inflammatory cell counts and the neointima areas (r=0.567, p<0.001), and between inflammatory cell counts and the percent area stenosis (r=0.478, p<0.001). There was no significant difference in the inflammatory cell counts normalized to the injury (110±89 vs. 123±83, p=0.4) and fibrin scores (0.15±0.06 vs. 0.17±0.07, p=0.8) between the 2 groups. There were trends toward a smaller neointima area (1.06±0.51 mm2 vs. 1.28±0.35 mm2, p=0.083) and a smaller percent area stenosis (18.9±8.7% vs. 21.8±7.2%, p=0.088) in the ramiprilat-coated stent group. Conclusion Although the ramiprilat-coated stent did not show significant inhibitory effects on neointimal hyperplasia, the ramiprilat-coated stent showed good effects on the inflammatory reaction and arterial healing similar to the control stent in a porcine coronary restenosis model.

Mother-and-child technique using 4-Fr inner catheter for stent delivery during provisional stenting

Provisional stenting is the most common strategy in the treatment of bifurcated lesions. However, such a situation as the failure in additional stent deployment to the side branch through the stent strut is occasionally encountered. In this paper, we report on two cases, in which we managed to successfully cross an additional stent to the angulated side branch through the stent strut using the four-in-six system after failed attempts using conventional techniques. This system will allow us to perform provisional stenting more easily.

Comparison of Drug-Eluting Stents in Acute Myocardial Infarction Patients with Chronic Kidney Disease

Background/Aims To determine which drug-eluting stents are more effective in acute myocardial infarction (MI) patients with chronic kidney disease (CKD). Methods This study included a total of 3,566 acute MI survivors with CKD from the Korea Acute Myocardial Infarction Registry who were treated with stenting and followed up for 12 months: 1,845 patients who received sirolimus-eluting stents (SES), 1,356 who received paclitaxel-eluting stents (PES), and 365 who received zotarolimus-eluting stents (ZES). CKD was defined as an estimated glomerular filtration rate < 60 mL/min/1.73 m2 calculated by the modification of diet in renal disease method. Results At the 12-month follow-up, patients receiving ZES demonstrated a higher incidence (14.8%) of major adverse cardiac events (MACEs) compared to those receiving SES (10.1%) and PES (12%, p = 0.019). The ZES patients also had a higher incidence (3.9%) of target lesion revascularization (TLR) compared to those receiving SES (1.5%) and PES (2.4%, p = 0.011). After adjusting for confounding factors, ZES was associated with a higher incidence of MACE and TLR than SES (adjusted hazard ratio [HR], 0.623; 95% confidence interval [CI], 0.442 to 0.879; p = 0.007; adjusted HR, 0.350; 95% CI, 0.165 to 0.743; p = 0.006, respectively), and with a higher rate of TLR than PES (adjusted HR, 0.471; 95% CI, 0.223 to 0.997; p = 0.049). Conclusions Our findings suggest that ZES is less effective than SES and PES in terms of 12-month TLR, and has a higher incidence of MACE due to a higher TLR rate compared with SES, in acute MI patients with CKD.

Clinical impact of non-high density lipoprotein-cholesterol and apolipoprotein B on clinical outcomes in metabolic syndrome patients with acute myocardial infarction undergoing percutaneous coronary intervention.

Background and Objectives Non-high density lipoprotein-cholesterol (non-HDL-C) and apolipoprotein B (ApoB) are markers of atherosclerotic risk and predictors of cardiovascular events. The aim of this study was to evaluate clinical impact of non-HDL-C and ApoB on clinical outcomes in metabolic syndrome (MS) patients with acute myocardial infarction (AMI) undergoing percuatneous coronary intervetion. Subjects and Methods We analyzed 470 MS patients (64.4±12.0 years, 53.6% male) with AMI who were followed-up for 12-month after percutaneous coronary intervention (PCI) from December 2005 to January 2008 in a single center. These patients were divided into 2 groups based on median values of non-HDL-C and ApoB. We studied their baseline and follow-up relation with 12-month clinical outcomes, all-cause death and major adverse cardiac events (MACE). Results Mean values of baseline non-HDL-C and ApoB were 141.2±43.1 mg/dL and 99.3±29.0 mg/dL respectively. During 12-month follow-up 32 MACE (6.8%) and 12 deaths (2.5%) occurred. We observed significant correlation between non-HDL-C and ApoB. Twelve-month MACE and all-cause death after PCI showed no significant relation as non-HDL-C or ApoB levels increased. Follow-up patients (n=306, rate 65%) also did not show significant relation with clinical outcomes. Twelve-month MACE decreased as non-HDL-C and ApoB reduction rates increased. Conclusion There was no significant association between higher non-HDL-C or ApoB and 12-month clinical outcomes in MS patients with AMI undergoing PCI. ApoB was found to be a better predictor of 12-month MACE than non-HDL-C based on their reduction rates.

Rotational atherectomy and new-generation drug-eluting stent implantation

The aim of this study was to evaluate the clinical outcomes of rotational atherectomy (RA) followed by new‐generation drug‐eluting stent (DES) implantation in patients with an extensive amount of calcified and fibrotic plaque.