Mineok Chang

Impact of the Stent Length on Long-Term Clinical Outcomes Following Newer-Generation Drug-Eluting Stent Implantation

Stent length has been considered an important predictor of adverse events after percutaneous coronary intervention, even with the first-generation drug-eluting stents (DESs). The introduction of newer-generation DES has further reduced the rates of adverse clinical events such as restenosis, myocardial infarction, and stent thrombosis. The aim of this study was to compare the impact of stent length on the long-term clinical outcomes between first- and newer-generation DESs. The effects of stent length (≥32 vs <32 mm) on the clinical outcomes were evaluated in 8,445 patients who underwent percutaneous coronary intervention using either a first-generation DES (sirolimus- and paclitaxel-eluting stents, n = 6,334) or a newer-generation DES (everolimus- and zotarolimus-eluting stents, n = 2,111) from January 2004 to December 2009. The 3-year adverse outcomes (composite of all-cause death, nonfatal myocardial infarction, target vessel revascularization, and stent thrombosis) were compared using the inverse probability of treatment-weighted method according to the stent length. After adjustment for differences in the baseline risk factors, a stent length of ≥32 mm was significantly associated with higher cumulative rates of target vessel revascularization and stent thrombosis in the patients treated with a first-generation DES (adjusted hazard ratio 1.875, 95% confidence interval 1.531 to 2.297, p <0.001; adjusted hazard ratio 2.964, 95% confidence interval 1.270 to 6.917, p = 0.012), but it was not associated with the clinical outcomes in patients treated with a newer-generation DES. In conclusion, stent length might not be associated with long-term clinical outcomes in newer-generation DES era, whereas stent length might be associated with long-term clinical outcomes in the first-generation DESs.

Comparison of Stenting Versus Bypass Surgery According to the Completeness of Revascularization in Severe Coronary Artery Disease: Patient-Level Pooled Analysis of the SYNTAX, PRECOMBAT, and BEST Trials

OBJECTIVESnThe aim of this study was to compare long-term survival between patients with severe coronary artery disease undergoing coronary artery bypass grafting (CABG) and those undergoing percutaneous coronary intervention (PCI) achieving complete revascularization (CR) or incomplete revascularization.nnnBACKGROUNDnThe importance of CR in decision making regarding revascularization strategy in patients with severe coronary artery disease is unknown.nnnMETHODSnData were pooled from the SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery), PRECOMBAT (Premier of Randomized Comparison of Bypass Surgery Versus Angioplasty Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease), and BEST (Randomized Comparison of Coronary Artery Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients With Multivessel Coronary Artery Disease) trials. Thexa0primary outcome was death from any cause and was compared in an as-treated analysis.nnnRESULTSnThe rate of CR was 61.7% (57.2% with PCI and 66.8% with CABG). During a median 4.9-year follow-up period (interquartile range: 4.5 to 5.0 years), compared with patients undergoing CABG with CR, those undergoing PCI with incomplete revascularization had a higher risk for death from any cause (adjusted hazard ratio [aHR]: 1.43; 95% confidence interval [CI]: 1.03 to 2.00; pxa0= 0.036) and the composite of death, myocardial infarction, and stroke (aHR: 1.48; 95% CI: 1.14 to 1.92; pxa0= 0.003). However, there was no significant difference between patients undergoing CABG with CR and those undergoing PCI with CR regarding the risk for death from any cause (aHR: 1.16; 95% CI: 0.83 to 1.63; pxa0= 0.39) and the composite of death, myocardial infarction, and stroke (aHR: 1.14; 95% CI: 0.87 to 1.48; pxa0= 0.35). Subgroup analysis of multivessel coronary disease, high SYNTAX score (>32), and diabetes showed consistent findings.nnnCONCLUSIONSnFor the treatment of left main or multivessel coronary artery disease, PCI resulting in CR was associatedxa0with a similar long-term survival rate to CABG resulting in CR. Therefore, the ability to achieve CR should enterxa0into the decision algorithm for choice of revascularization strategy.

Status of hypertension and coronary stenosis in asymptomatic type 2 diabetic patients: Analysis from Coronary Computed Tomographic Angiography Registry

BACKGROUNDnLimited data exist regarding the prevalence of coronary artery disease (CAD) as well as clinical outcomes in asymptomatic diabetic patients with normotension, controlled hypertension, and uncontrolled hypertension.nnnMETHODSnWe enrolled 935 consecutive asymptomatic type 2 diabetic patients without known CAD. Coronary computed tomography angiography was used to evaluate the prevalence and severity of CAD. Blood pressure was measured at baseline. Patients were assigned to one of the three groups: normotension (n=314), controlled hypertension (systolic blood pressure (SBP)< 140 mm Hg with treatment, n=458), or uncontrolled hypertension (SBP ≥ 140 mm Hg with or without treatment, n=163).nnnRESULTSnObstructive CAD (≥ 50% stenosis) increased from the prevalence in normotensive patients (33%) to that in patients with controlled (40%) or uncontrolled hypertension (52%) (p=0.003). The incidence of obstructive CAD in multivessel or left main CAD also increased across the three groups (13%, 21%, 32%, respectively, p<0.001). A multivariate logistic regression analysis showed that uncontrolled hypertension was an independent predictor of obstructive CAD (adjusted odds ratio, 2.13; 95% confidence interval (CI), 1.42 to 3.21, p<0.001). During a median follow-up of 3.1 years, uncontrolled hypertension was associated with increased risk of cardiac death or myocardial infarction compared to the risk in normotensive patients (hazard ratio, 6.11; 95% CI, 1.65 to 22.6, p=0.007).nnnCONCLUSIONnIn asymptomatic type 2 diabetic patients, uncontrolled hypertension was associated with increased risk of CAD and poor clinical outcomes.

Comparison of Outcome of Coronary Artery Bypass Grafting Versus Drug-Eluting Stent Implantation for Non–ST-Elevation Acute Coronary Syndrome

There is limited data comparing effectiveness of coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) with drug-eluting stents in patients with non-ST-elevation acute coronary syndromes (NSTE-ACS). We compared the long-term outcomes of the 2 revascularization strategies in 1,246 patients presented with NSTE-ACS for left main or multivessel coronary artery disease. Data were pooled from the Randomized Comparison of Coronary Artery Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients with Multivessel Coronary Artery Disease (BEST) trial, the Premier of Randomized Comparison of Bypass Surgery versus Angioplasty Using Sirolimus-Eluting Stent in Patients with Left Main Coronary Artery Disease (PRECOMBAT) trial, and the Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) trial. The primary outcome was a composite of death from any causes, myocardial infarction, or stroke. The baseline characteristics were similar between the 2 study groups. During the median follow-up of 60xa0months, the rate of the primary outcome was significantly lower with CABG than with PCI (hazard ratio [HR] 0.74; 95% confidence interval [CI] 0.56 to 0.98; pxa0= 0.036). This difference was mainly attributed to a significant reduction in the rate of myocardial infarction (HR 0.50; 95% CI 0.31 to 0.82, pxa0= 0.006). The superiority of CABG over PCI was consistent across the major subgroups. The individual risks of death from any causes or stroke were not different between the 2 groups. In contrast, the rate of repeat revascularization was significantly lower in the CABG group than in the PCI group (HR 0.56; 95% CI 0.41 to 0.75, p <0.001). In this study, among patients with NSTE-ACS for left main or multivessel coronary artery disease, CABG significantly reduces the risk of death from any causes, myocardial infarction, or stroke compared with PCI with drug-eluting stents.

Impact of Multivessel Coronary Artery Disease With Versus Without Left Main Coronary Artery Disease on Long-Term Mortality After Coronary Bypass Grafting Versus Drug-Eluting Stent Implantation.

Limited data are available on the impact of concomitant left main coronary artery disease (CAD) on mortality after revascularization of multivessel coronary artery disease (MVD) alone or multivessel plus left main coronary artery disease (MVLMD). This study compared long-term mortality between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) with drug-eluting stents in 2,887 patients with MVD or MVLMD. Data were pooled from the BEST, PRECOMBAT, and SYNTAX trials. The primary outcome was death due to any cause. Of the 2,887 patients, 1,975 (68.4%) were classified as having MVD and 912 (31.6%) as having MVLMD. The median follow-up duration was 60.2xa0months. In the patients with MVD, primary outcome rate after CABG was significantly lower than after PCI (hazard ratio [HR] 0.66; 95% confidence interval [CI] 0.49 to 0.89; pxa0= 0.007). In the patients with MVLMD, however, CABG and PCI showed similar primary outcome rates (HR 0.98; 95% CI 0.67 to 1.43; pxa0= 0.896). Among those who underwent CABG, primary outcome rate was lower in the patients with MVD than in those with MVLMD (HR 0.66; 95% CI 0.46 to 0.95; pxa0= 0.024). Kaplan-Meier analysis showed a clear separation between the patients with MVD and those with MVLMD 2.5xa0years after the index surgery. The risk of death due to any cause was significantly lower after CABG than after PCI with drug-eluting stents in patients with MVD but not in those with MVLMD. The advantage of CABG over PCI for multivessel CAD was significantly attenuated if concomitant left main CAD was present.

Effect of Beta Blockers and Renin-Angiotensin System Inhibitors on Survival in Patients With Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention.

AbstractBecause it remains uncertain whether &bgr;-blockers (BBs) and/or renin–angiotensin system inhibitors benefit a broad population of acute myocardial infarction (AMI) patients, we sought to evaluate the effectiveness of these drugs in improving survival for post-AMI patients who underwent a percutaneous coronary intervention (PCI).From the nationwide data of the South Korea National Health Insurance, 33,390 patients with a diagnosis of AMI who underwent a PCI between 2009 and 2013 and survived at least 30 days were included in this study. We evaluated the risk of all-cause death for patients treated with both BB and angiotensin-converting enzyme inhibitor (ACEI)/angiotensin II receptor antagonist (ARB) (nu200a=u200a16,280), only BB (nu200a=u200a3683), and only ACEI/ARB (nu200a=u200a9849), with the drug-untreated patients (nu200a=u200a3578) as the reference.Over a median follow-up of 2.4 years, although treated patients displayed a trend toward improved survival, there were no significant differences in the adjusted risk of all-cause death when patients were treated with both drugs (hazard ratio [HR] 0.86, 95% confidence interval [CI] 0.70–1.06, Pu200a=u200a0.154), BB (HR 0.88, 95% CI 0.68–1.14, Pu200a=u200a0.325), or ACEI/ARB (HR 0.84, 95% CI 0.68–1.04, Pu200a=u200a0.111). No additional benefit was found for the combination therapy compared with either isolated BB (HR 0.98, 95% CI 0.80–1.21, Pu200a=u200a0.856) or ACEI/ARB (HR 1.03, 95% CI 0.89–1.19, Pu200a=u200a0.727) therapy.Treatment with BB and/or ACEI/ARB has limited effect on survival in unselected nonfatal AMI patients who undergo PCI.

Plaque composition and morphologic characteristics in significant left main bifurcation disease; virtual histology intravascular ultrasound study.

ObjectivesAlthough the left main coronary artery (LMCA) is clinically the most important site, little is known about the longitudinal plaque distribution and composition in the significant LMCA disease. MethodsPreprocedure virtual histology intravascular ultrasound data were analyzed in 120 patients with significant LMCA bifurcation lesions (angiographic diameter stenosis>50%) requiring revascularization. Plaque burden and percentage of necrotic core (%NC) at the minimal lumen area site and maximal %NC site were measured in four segments: proximal LMCA, distal LMCA, left anterior descending (LAD) ostium, and proximal LAD. ResultsAngiographically, a significant LMCA and ostial LAD stenosis were observed in 89.2 and 81.7% of patients, respectively. At the minimal lumen area site, the proximal LAD segment showed the smallest lumen [3.5u2009mm2 (2.5–4.7), P<0.001] and the greatest plaque burden [73.2% (63.0–79.3), P<0.001] compared with the other segments. Also, there was a significant downward trend in the number of IVUS-defined lesions toward the proximal LMCA (P=0.001). At the maximal %NC site, the proximal LAD segment carried the largest necrotic core [32.7% (25.7–40.1), P<0.001] and the most frequent virtual histology thin-cap fibroatheroma (67.6%, P<0.001) among the segments, followed by the proximal LMCA [30.3% (22.3–40.0) and 32.9%, respectively]. Most of the plaques carried, at least, one slice of fibroatheroma in every segment; thus, fibroatheroma distributed in a continuous pattern from the proximal LAD to the proximal LMCA. ConclusionIn the significant LMCA bifurcation disease, the proximal LAD segment was found to have the smallest lumen, the largest plaque burden, the highest virtual histology thin-cap fibroatheroma rate, and thus presented the most vulnerable characteristics by virtual histology intravascular ultrasound.

Spontaneous spinal epidural hematoma

A 32-year-old woman was referred to our hospital with the sudden onset of low back and cervical pain during a hemodialysis session at a local hospital. She had been on hemodialysis because of progressive renal failure due to lupus nephritis. There were no external signs of trauma on physical examination. A few hours after admission …

Impact of In-Stent Tissue Type on Periprocedural Myocardial Infarction and 2-Year Clinical Outcomes After Treatment of Coronary Artery Restenosis.

The development of neoatherosclerosis characterized by lipid core, in-stent thin-cap fibroatheroma (TCFA), calcification, and intimal rupture contribute to development of late stent failure [(1,2)][1]. We assessed the impact of optical coherence tomography (OCT)-detected TCFA and intimal rupture on

Outcomes of Coronary Artery Bypass Graft Surgery Versus Drug-Eluting Stents in Older Adults

Little data are available to compare coronary artery bypass graft surgery (CABG) vs percutaneous coronary intervention (PCI) with drug‐eluting stents (DES) in older adults. We evaluate the long‐term outcomes of CABG vs PCI with DES in older adults with left main or multivessel coronary artery disease (CAD).