Gillian Balbir Singh

Combined Usefulness of the Platelet-to-Lymphocyte Ratio and the Neutrophil-to-Lymphocyte Ratio in Predicting the Long-Term Adverse Events in Patients Who Have Undergone Percutaneous Coronary Intervention with a Drug-Eluting Stent

Objectives The aim of this study was to investigate the combined usefulness of platelet-to-lymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR) in predicting the long-term adverse events in patients who have undergone percutaneous coronary intervention (PCI) with a drug-eluting stent (DES). Methods 798 patients with stable angina, unstable angina and non-ST elevated myocardial infarction (NSTEMI) who underwent elective successful PCI with DES were consecutively enrolled. The value of PLR and NLR in predicting adverse coronary artery disease (CAD) events and the correlations between these markers and adverse events (all-cause mortality, cardiac death, and nonfatal myocardial infarction) were analyzed. Results The follow-up period was 62.8 ± 28.8 months. When patients were classified into four groups according to the optimal cut-off values for the PLR and NLR on receiver operating characteristic analysis, patients with a high PLR (>128) and high NLR (>2.6) had the highest occurrence of adverse events among the groups. On Cox multivariate analysis, the NLR >2.6 [hazard ratio (HR) 2.352, 95% confidence interval (CI) 1.286 to 4.339, p = 0.006] and the PLR >128 (HR 2.372, 95% CI 1.305 to 3.191, p = 0.005) were independent predictors of long-term adverse events after adjusting for cardiovascular risk factors. Moreover, both a PLR >128 and a NLR >2.6 were the strongest predictors of adverse events (HR 2.686, 95% CI 1.452 to 4.970, p = 0.002). Conclusion High pre-intervention PLR and NLR, especially when combined, are independent predictors of long-term adverse clinical outcomes such as all-cause mortality, cardiac death, and myocardial infarction in patients with unstable angina and NSTEMI who have undergone successful PCI with DES.

Fractional flow reserve-guided paclitaxel-coated balloon treatment for de novo coronary lesions.

To assess the safety and efficacy of fractional flow reserve (FFR) guided paclitaxel‐coated balloon (PCB) treatment for de novo coronary artery lesions. Background: There is limited data on PCB treatment for de novo lesions especially of major epicardial coronary arteries.

Anatomical and Physiological Changes after Paclitaxel-Coated Balloon for Atherosclerotic De Novo Coronary Lesions: Serial IVUS-VH and FFR Study.

Aims To assess the serial changes of de novo coronary lesions treated with paclitaxel-coated balloon (PCB) using intravascular ultrasound virtual histology (IVUS-VH) and fractional flow reserve (FFR). Method and Results This prospective observational study enrolled 27 patients with coronary artery disease treated with PCB who underwent coronary angiography, IVUS-VH and FFR before, immediately after intervention and at 9 months. 28 de novo lesions were successfully treated with PCB. Angiographic late luminal loss was 0.02 ± 0.27mm. Mean vessel and lumen areas showed increase at 9 months (12.0 ± 3.5mm2 to 13.2 ± 3.9mm2, p <0.001; and 5.4 ± 1.2mm2 to 6.5 ± 1.8mm2, p <0.001, respectively). Although mean plaque area was unchanged (6.6 ± 2.6mm2 to 6.6 ± 2.4mm2, p = 0.269), percent atheroma volume decreased significantly (53.4 ± 7.9% to 49.5 ± 6.4%, p = 0.002). The proportion of plaque compositions including fibrous, fibrofatty, dense calcium and necrotic core by IVUS-VH was unchanged at 9 months. The FFR of the treated lesion was 0.71 ± 0.13 pre-procedure, 0.87 ± 0.06 post-procedure and 0.84 ± 0.06 at follow-up. Conclusions De novo coronary lesions treated with PCB showed persistent anatomical and physiological patency with plaque redistribution and vessel remodeling without chronic elastic recoil or plaque compositional change during follow-up.

Comparison of Paclitaxel-Coated Balloon Treatment and Plain Old Balloon Angioplasty for De Novo Coronary Lesions

Purpose This study compared the angiographic outcomes of paclitaxel-coated balloon (PCB) versus plain old balloon angioplasty (POBA) treatment for de novo coronary artery lesions. At present, there is no available data comparing the efficacy of PCB versus POBA for the treatment of de novo coronary lesions. Materials and Methods This multicenter retrospective observational study enrolled patients with de novo coronary lesions with a reference vessel diameter between 2.5 mm and 3.0 mm and lesion length ≤24 mm who were successfully treated with PCB or POBA. Angiographic measurements and quantitative coronary analysis were performed before and after the procedure, and at 9 months follow-up. Results A total of 72 patients (49 receiving PCB and 23 receiving POBA) were enrolled in this study. Late luminal loss was -0.12±0.30 mm in the PCB group and 0.25±0.50 mm in the POBA group (p<0.001). There was a higher percentage of binary restenosis (diameter stenosis ≥50%) in POBA, compared to PCB (30.4%, n=7 vs. 4.1%, n=2, p<0.001). Target vessel revascularization was higher in the POBA group (13.0%, n=3 vs. 0%, p=0.033). Conclusion PCB treatment of de novo coronary lesions showed better 9-month angiographic outcomes than POBA treatment alone.

Prognostic Utility of Neutrophil-to-Lymphocyte Ratio on Adverse Clinical Outcomes in Patients with Severe Calcific Aortic Stenosis.

Background Inflammation is an important factor in the pathogenesis of calcific aortic stenosis (AS). We aimed to evaluate the association between an inflammatory marker, neutrophil-to-lymphocyte ratio (NLR) and major adverse cardiovascular events (MACE) in patients with severe calcific AS. Methods A total of 336 patients with isolated severe calcific AS newly diagnosed between 2010 and 2015 were enrolled in this study. Using Cox proportional hazards (PH) regression models, we investigated the prognostic value of NLR adjusted for baseline covariates including logistic European System for Cardiac Operative Risk Evaluation score (EuroSCORE-I) and undergoing aortic valve replacement (AVR). We also evaluated the clinical relevance of NLR risk groups (divided into low, intermediate, high risk) as categorized by NLR cutoff values. MACE was defined as a composite of all-cause mortality, cardiac death and non-fatal myocardial infarction during the follow-up period. Results The inflammatory marker NLR was an independent prognostic factor most significantly associated with MACE [hazard ratio (HR), 1.06; 95% confidence interval (CI), 1.04–1.09; p-value <0.001]. The goodness-of-fit and discriminability of the model including EuroSCORE-I and AVR (loglikelihood difference, 15.49; p-value <0.001; c-index difference, 0.035; p-value = 0.03) were significantly improved when NLR was incorporated into the model. The estimated Kaplan-Meier survival rates at 5 years for the NLR risk groups were 84.6% for the low risk group (NLR ≤ 2), 67.7% for the intermediate risk group (2 < NLR ≤ 9), and 42.6% for the high risk group (NLR > 9), respectively. Conclusion The findings of the present study demonstrate the potential utility of NLR in risk stratification of patients with severe calcific AS.

Serial Morphological Changes of Side-Branch Ostium after Paclitaxel-Coated Balloon Treatment of De Novo Coronary Lesions of Main Vessels

Purpose The effects on the side-branch (SB) ostium, following paclitaxel-coated balloon (PCB) treatment of de novo coronary lesions of main vessels have not been previously investigated. This study was aimed at evaluating the serial morphological changes of the SB ostium after PCB treatment of de novo coronary lesions of main vessels using optical coherence tomography (OCT). Materials and Methods This prospective, single-center observational study enrolled patients with de novo lesions, which were traversed by at least one SB (≥1.5 mm) and were treated with PCB. The SB ostium was evaluated with serial angiographic and OCT assessments pre- and post-procedure, and at 9-months follow-up. Results Sixteen main vessel lesions were successfully treated with PCB, and 26 SBs were included for analysis. Mean SB ostial lumen area increased at 9-months follow-up (0.92±0.68 mm2 pre-procedure, 1.03±0.77 mm2 post-procedure and 1.42±1.18 mm2 at 9-months). The SB ostial lumen area gain was 0.02±0.24 mm2 between pre- and post-procedure, 0.37±0.64 mm2 between post-procedure and 9-months, and 0.60±0.93 mm2 between pre-procedure and 9-months. The ostial lumen area increased by 3.9% [interquartile range (IQR) of -33.3 to 10.4%] between pre- and post-procedure, 52.1% (IQR of -0.7 to 77.3%) between post-procedure and 9-months and 76.1% (IQR of 18.2 to 86.6%) between pre-procedure and 9-months. Conclusion PCB treatment of de novo coronary lesions of main vessels resulted in an increase in the SB ostial lumen area at 9-months.

Remote Ischemic Preconditioning for the Prevention of Contrast-Induced Acute Kidney Injury in Diabetics Receiving Elective Percutaneous Coronary Intervention

Objective Remote ischemic preconditioning (RIPC) induces transient episodes of ischemia by the occlusion of blood flow in non-target tissue, before a subsequent ischemia-reperfusion injury. When RIPC is applied before percutaneous coronary intervention (PCI), the kidneys may be protected against ischemia-reperfusion injury and subsequently contrast-induced acute kidney injury (CI-AKI). The aim of this study was to evaluate the efficacy of RIPC for the prevention of CI-AKI in patients with diabetes with pre-existing chronic kidney disease (CKD) undergoing elective PCI. Methods This randomized, double-blind, sham-controlled study enrolled patients with diabetes scheduled for elective PCI with eGFR ≤60 ml/min/1.73 m2 or urinary albumin creatinine ratio of >300 mg/g to receive either RIPC or the sham ischemic preconditioning. Results One hundred and two patients (68.9 ± 8.2 years old, 47.1% men) were included. Baseline eGFR, creatinine and serum NGAL was similar between RIPC and control groups (48.5 ± 12 ml/min vs. 46.6 ± 10 ml/min, p = 0.391; 1.42 ± 0.58 mg/dl vs. 1.41 ± 0.34 mg/dl, p = 0.924; and 136.0 ± 45.0 ng/ml vs. 137.6 ± 43.3 ng/ml, p = 0.961, respectively). CI-AKI occurred in 13.7% (14/102) of the total subjects, with both RIPC and control groups having an equal incidence of 13.7% (7/51). No significant differences were seen in creatinine, NGAL, cardiac enzymes (troponin T, CKMB) and hs-CRP between the groups post-procedure. Conclusions In this study, RIPC applied prior to elective PCI was not effective in preventing CI-AKI in patients with diabetes with pre-existing CKD. Trial Registration ClinicalTrials.gov NCT02329444

Serum Phosphorus Concentration and Coronary Artery Calcification in Subjects without Renal Dysfunction

Serum phosphorus (P) concentration is associated with coronary artery calcification (CAC) as well as cardiovascular events in patients with chronic kidney disease. It has been suggested that this relationship is extended to subjects without renal dysfunction, but further explorations in diverse races and regions are still needed. We performed a cross-sectional study of 2,509 Korean subjects (Far Eastern Asian) with an estimated glomerular filtration rate of ≥60 ml/min/1.73m2 and who underwent coronary computerized tomography. Serum P concentration was divided into pre-determined 4 categories: ≤3.2, 3.2< to ≤3.6, 3.6< to ≤4.0 and >4.0 mg/dL. Agatston score (AS), an index of CAC, was divided into 3 categories: 0, 0< to ≤100, and >100. A multinomial logit model (baseline outcome: AS = 0) was applied to estimate the odds ratio (OR) for each serum P category (reference: ≤3.2mg/dL). Mean age of subjects was 53.5±9.1 years and 36.9% were female. In the adjusted model, serum P concentration of 3.6< to ≤4.0 mg/dL and >4.0 mg/dL showed high ORs for AS of >100 [OR: 1.58, 95% confidence interval (CI): 1.04–2.40 and OR: 2.11, 95% CI: 1.34–3.32, respectively]. A unit (mg/dL) increase in serum P concentration was associated with 50% increase in risk of AS >100 (OR: 1.50, 95% CI: 1.16–1.94). A higher serum P concentration, even within a normal range, may be associated with a higher CAC in subjects with normal renal function.

A Comparison of Peri-Procedural Myocardial Infarction between Paclitaxel-Coated Balloon and Drug-Eluting Stent on De Novo Coronary Lesions

Purpose This study compared the impact of paclitaxel-coated balloons (PCB) or drug eluting stents (DES) on peri-procedural myocardial infarction (PMI) on de novo coronary lesion in stable patients. Materials and Methods In this observational study, we compared the incidence of PMI amongst patients with single vessel de novo coronary lesions who underwent treatment with a PCB or DES. Propensity score-matching analysis was used to assemble a cohort of patients with similar baseline characteristics. PMI was classified as myocardial infarction occurring within 48 hours after percutaneous coronary intervention with a threshold of 5 x the 99th percentile upper reference limit of normal for creatine kinase-myocardial band (CK-MB) or troponin T (TnT). Results One hundred four patients (52 receiving PCB and 52 receiving DES) were enrolled in this study. The peak mean values of CK-MB and TnT were significantly higher in the DES group. There was a significantly higher rate of PMI in the DES group (23.1% vs. 1.9%, p=0.002). Total occlusion of the side-branch occurred in two patients treated with DES, while no patients treated with PCB. In multivariable analysis, DES was the only independent predictor of PMI compared with PCB (odds ratio 42.85, 95% confidence interval: 3.44–533.87, p=0.004). Conclusion Treatment with a PCB on de novo coronary lesion might be associated with a significant reduction in the risk of PMI compared to DES.

Plaque characteristics and inflammatory markers for the prediction of major cardiovascular events in patients with ST-segment elevation myocardial infarction

To investigate the clinical utility of culprit plaque characteristics and inflammatory markers for the prediction of future cardiovascular events in patients with ST-segment elevation myocardial infarction (STEMI) with successful drug-eluting stent (DES) implantation. We evaluated 172 STEMI patients with successful primary percutaneous coronary intervention (PCI) with DES using pre-PCI high-sensitivity C-reactive protein (hs-CRP), neutrophil-to-lymphocyte ratio (NLR) and pre-PCI intravascular ultrasound virtual histology (IVUS-VH) of culprit lesions. The incidence of major adverse cardiovascular events (MACE) including all-cause mortality, non-fatal MI, stroke and late revascularization were recorded during hospitalization and follow-up. During follow-up (median 41 months), the incidence of MACE did not significantly differ among patients with or without all 3 high-risk plaque features on IVUS-VH (15.1 vs. 16.2%; p = 0.39). In contrast, patients with elevated hs-CRP and NLR levels were at significant risk for MACE [32.7 vs. 5.8%; hazard ratio (HR) 7.85; p < 0.001 and 43.9 vs. 6.9%; HR 8.44; p < 0.001, respectively]. High-risk plaque features had no incremental usefulness to predict future MACE. However, the incorporation of hs-CRP and NLR into a model with conventional clinical and procedural risk factors significantly improved the C-statistic for the prediction of MACE (0.76–0.89; p = 0.04). High-risk plaque features identified by IVUS-VH in culprit lesions were not associated with future MACE in patients with STEMI receiving DES. However, elevated hs-CRP and NLR levels were significantly associated with poorer outcomes and had incremental predictive values over conventional risk factors.