Naohiro Osugi

Relation Between Paradoxical Decrease in High-Density Lipoprotein Cholesterol Levels After Statin Therapy and Adverse Cardiovascular Events in Patients With Acute Myocardial Infarction

Statin therapy moderately increases high-density lipoprotein cholesterol (HDL-C) levels. Contrary to this expectation, a paradoxical decrease in HDL-C levels after statin therapy is seen in some patients. We evaluated 724 patients who newly started treatment with statins after acute myocardial infarction (AMI). These patients were divided into 2 groups according to change in HDL-C levels between baseline and 6 to 9 months after initial AMI (ΔHDL). In total, 620 patients had increased HDL-C levels and 104 patients had decreased HDL-C levels. Both groups achieved follow-up low-density lipoprotein cholesterol levels <100 mg/dl. Adverse cardiovascular events (a composite of all-cause death, myocardial infarction, and stroke) have more frequently occurred in the decreased HDL group compared with the increased HDL group (15.4% vs 7.1%, p = 0.01). Multivariate analysis showed that decreased HDL, onset to balloon time, and multivessel disease were the independent predictors of adverse cardiovascular events (hazard ratio [HR] 1.95, 95% confidence interval [CI] 1.08 to 3.52; HR 1.05, 95% CI 1.01 to 1.09; and HR 2.08, 95% CI 1.22 to 3.56, respectively). In conclusion, a paradoxical decrease in serum HDL-C levels after statin therapy might be an independent predictor of long-term adverse cardiovascular events in patients with AMI.

Association of Estimated Glomerular Filtration Rate and Proteinuria With Lipid-Rich Plaque in Coronary Artery Disease.

BACKGROUND Estimated glomerular filtration rate (eGFR) and proteinuria are both important determinants of the risk of cardiovascular disease and mortality. The aim of the present study was to investigate the independent and combined effects of eGFR and proteinuria on tissue characterization of the coronary plaques of culprit lesions. METHODSANDRESULTS Conventional intravascular ultrasound and 3-D integrated backscatter intravascular ultrasound (IB-IVUS) were performed in 555 patients undergoing elective percutaneous coronary intervention. They were divided into 2 groups according to the absence or presence of proteinuria (dipstick result ≥1+). Patients with proteinuria had coronary plaque with significantly greater percentage lipid volume compared with those without (43.6±14.8% vs. 48.6±16.1%, P=0.005). Combined analysis was done using eGFR and absence or presence of proteinuria. Subjects with eGFR 45-59 ml/min/1.73 m2 and proteinuria were significantly more likely to have higher percent lipid volume compared with those with eGFR >60 ml/min/1.73 m2 without proteinuria. After multivariate adjustment for confounders, the presence of proteinuria proved to be an independent predictor for lipid-rich plaque (OR, 1.85; 95% CI: 1.12-3.06, P=0.016). CONCLUSIONS The addition of proteinuria to eGFR level may be of value in the risk stratification of patients with coronary artery disease.

Correlations between geriatric nutritional risk index and peripheral artery disease in elderly coronary artery disease patients.

Malnutrition is associated with the development of atherosclerosis and an increased risk of cardiovascular mortality in elderly patients. The present study aimed to investigate the association between the Geriatric Nutritional Risk Index (GNRI), a simple nutritional assessment tool, and the prevalence of peripheral artery disease (PAD) in elderly coronary artery disease patients.

Impact of Airflow Limitation on Carotid Atherosclerosis in Coronary Artery Disease Patients

Background: Both airflow limitation and smoking are established cardiovascular risk factors. However, their interaction as risk factors for the development of atherosclerosis in coronary artery disease patients remains unclear. Objectives: To evaluate the effect of the interaction between airflow limitation and smoking status on the severity of carotid atherosclerosis. Methods: We categorized the 234 enrolled patients with coronary artery disease into four groups: never-smokers with normal pulmonary function (group A), never-smokers with airflow limitation (group B), ever-smokers with normal pulmonary function (group C), and ever-smokers with airflow limitation (group D). Results: The prevalence of airflow limitation in the enrolled patients was 23.1% (ever-smokers: 15.8%, never-smokers: 7.3%). The prevalence of severe carotid atherosclerosis was 28.2, 29.4, 41.3, and 45.9%, respectively, in the four groups (group D vs. group A, p = 0.035). Even after multivariate adjusting for confounding factors, ever-smokers with airflow limitation were independently associated with severe carotid atherosclerosis (odds ratio 2.89, 95% confidence interval, 1.19-7.00, p = 0.019). Conclusions: Ever-smokers with airflow limitation were significantly associated with severe carotid atherosclerosis among patients with coronary artery disease. These findings also provide additional insight into the correlation between airflow limitation and poor cardiovascular clinical outcomes.

Impact of diabetic retinopathy on late cardiac events after percutaneous coronary intervention

BACKGROUND Diabetic retinopathy has been identified as a predictor of cardiovascular events and heart failure in patients with diabetes mellitus (DM). This study aimed to assess the impact of diabetic retinopathy on the incidence of late cardiac events following percutaneous coronary intervention. METHODS We enrolled 88 consecutive DM patients who underwent elective percutaneous coronary intervention and whose ophthalmologic records were available. Patients were divided into 2 groups: those with diabetic retinopathy (DR+ group; n=47), and those without diabetic retinopathy (DR- group; n=41). We examined the incidence of major adverse cardiac events (MACE) including cardiac death, myocardial infarction, and acute heart failure requiring emergency admission over a period of up to 5 years. RESULTS Patients in the DR+ group were likely to have a lower estimated glomerular filtration rate. Kaplan-Meier analysis showed that the event-free survival rates for all MACE, myocardial infarction, and heart failure were significantly lower in the DR+ group than in the DR- group (p=0.002, p=0.025, and p=0.022, respectively). Multivariate Cox proportional hazards analysis indicated that the presence of DR was a significant predictor of MACE (hazard ratio: 8.7; 95% CI: 1.1-69.8, p=0.042). CONCLUSION The presence of DR might be a useful predictor of late cardiac events following percutaneous coronary intervention.

Predictive Value of Aortic Valve Calcification for Periprocedural Myocardial Injury in Patients Undergoing Percutaneous Coronary Intervention

Aims: Previous studies have shown that aortic valve calcification (AVC) was associated with cardiovascular events and mortality. On the other hand, periprocedural myocardial injury (PMI) in percutaneous coronary intervention (PCI) is a well-known predictor of subsequent mortality and poor clinical outcomes. The purpose of the study was to assess the hypothesis that the presence of AVC could predict PMI in PCI. Methods: This study included 370 patients treated with PCI for stable angina pectoris. AVC was defined as bright echoes > 1 mm on one or more cusps of the aortic valve on ultrasound cardiography (UCG). PMI was defined as an increase in high-sensitivity troponin T level of > 5 times the upper normal limit (> 0.070 ng/ml) at 24 hours after PCI. Results: AVC was detected in 45.9% of the patients (n = 170). The incidence of PMI was significantly higher in the patients with AVC than in those without AVC (43.5% vs 21.0%, p < 0.001). The presence of AVC independently predicted PMI after adjusting for other significant variables (odds ratio 2.26, 95% confidence interval 1.37–3.74, p = 0.002). Other predictors were male sex, age, estimated glomerular filtration rate, and total stent length. Furthermore to predict PMI, adding AVC to the established risk factors significantly improved the area under the receiver operating characteristic curves, from 0.68 to 0.72, of the PMI prediction model (p = 0.025). Conclusion: The presence of AVC detected in UCG could predict the incidence of PMI.

Impact of Paradoxical Decrease in High-density Lipoprotein Cholesterol Levels After Statin Therapy on Major Adverse Cardiovascular Events in Patients with Stable Angina Pectoris

PURPOSE Statin therapy usually increases HDL-C levels. However, a paradoxical decrease in HDL-C levels after statin therapy is often seen in clinical settings. The relationship between a paradoxical decrease in HDL-C levels after statin therapy and adverse cardiovascular events in patients with stable angina pectoris (SAP) is not well understood. The purpose of this study was to analyze the relationship between paradoxical HDL-C decreases after statin therapy and major adverse cardiovascular events (MACEs) in patients undergoing percutaneous coronary intervention (PCI) for SAP. METHODS Between January 2006 and March 2015, 867 patients underwent PCI for SAP. Of them, we enrolled 209 patients who were newly started on statin therapy before PCI. We excluded patients who had started statin therapy earlier than 6 months before PCI, patients who had not started statin therapy after PCI, and patients who were diagnosed with acute coronary syndrome. They were divided into 2 groups according to the change in their HDL-C levels between baseline and 6 to 9 months after the index PCI: decreased HDL group after statin treatment (80 patients) and increased HDL group (129 patients). The primary end points were MACEs defined as a composite of all-cause death, nonfatal acute myocardial infarction, and target vessel revascularization (TVR). FINDINGS Using Kaplan-Meier analysis, the 7-year event rate for composite MACEs in the decreased HDL group was found to be higher than that for the increased HDL group (38% versus 24%, log-rank P = 0.02). TVR occurred more frequently in the decreased HDL group than in the increased HDL group (32% versus 12%, log-rank P = 0.01). With the use of multivariate analysis, changes in HDL-C levels after statin therapy indicated a significant inverse association with the increased risk of MACEs, (hazard ratio [HR] = 0.94; 95% CI, 0.92-0.97; P < 0.01). The incidence of MACEs was more strongly associated with ΔHDL than with ΔLDL. Moreover, BMS usage also independently predicted MACEs (HR = 2.18; 95% CI, 1.14-4.17; P < 0.01). IMPLICATIONS A paradoxical decrease in HDL-C levels after statin therapy might be a risk factor for MACEs, especially TVR, in patients with SAP.

Unfractionated Heparin during the Interruption of Antiplatelet Therapy for Non-cardiac Surgery after Drug-eluting Stent Implantation.

OBJECTIVE Heparin is not recommended to be administered during the interruption of antiplatelet therapy for non-cardiac surgery. However, there are insufficient data to determine the value. The purpose of the present study was to evaluate the clinical results of the administration of unfractionated heparin during the interruption of antiplatelet therapy in non-cardiac surgery patients who had previously undergone drug-eluting stent (DES) implantation. METHODS We retrospectively identified 210 elective non-cardiac surgical procedures that were performed with the administration of unfractionated heparin during interruption of all antiplatelet therapies in patients who had previously undergone DES implantation. Heparin was administered during the perioperative period in accordance with the local practice guideline at out institution. We examined the clinical outcomes within 30 days of surgery. RESULTS The mean number of implanted DESs was 2.1±1.3. No major adverse cardiac events (including cardiac death, definite stent thrombosis, and non-fatal myocardial infarction) occurred in any of the 210 cases within 30 days of surgery. Four of the 210 cases (1.9%) required reoperation for bleeding within 30 days of surgery. CONCLUSION Our data showed the potential for the perioperative management with unfractionated heparin administration in Japanese patients who had previously undergone DES implantation who required non-cardiac surgery with the interruption of all antiplatelet therapies.