Soe Hee Ann

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.

Remote ischemic preconditioning in hemodialysis: a pilot study

Hemodialysis (HD)-induced myocardial ischemia is associated with an elevated cardiac troponin T, and is common in asymptomatic patients undergoing conventional HD. Remote ischemic preconditioning (RIPC) has a protective effect against myocardial ischemia–reperfusion injury. We hypothesized that RIPC also has a protective effect on HD-induced myocardial injury. Chronic HD patients were randomized to the control group or the RIPC group. RIPC was induced by transient occlusion of blood flow to the arm with a blood-pressure cuff for 5 min, followed by 5 min of deflation. Three cycles of inflation and deflation were undertaken before every HD session for 1 month (total 12 times). The primary outcome was the change in cardiac troponin T (cTnT) level at day 28 from baseline. Demographic and baseline laboratory values were not different between the control (n = 17) and the RIPC groups (n = 17). cTnT levels tended to decrease from day 2 in the RIPC group through to 28 days, in contrast to no change in the control group. There were significant differences in the change of cTnT level at day 28 from baseline [Control, median; −0.002 ng/ml (interquartile range −0.008 to 0.018) versus RIPC, median; −0.015 ng/ml (interquartile range −0.055 to 0.004), P = 0.012]. RIPC reduced cTnT release in chronic conventional HD patients, suggesting that this simple, cheap, safe, and well-tolerated procedure has a protective effect against HD-induced ischemia.

Validation of magnetocardiography versus fractional flow reserve for detection of coronary artery disease

BACKGROUND Although magnetocardiography (MCG) has been proposed as a non-invasive technique with high accuracy for functional diagnosis of myocardial injury, the validation of MCG against fractional flow reserve FFR in diagnosing coronary artery disease (CAD) has not yet been established. The goal of the study was to determine the diagnostic accuracy of MCG versus invasively determined FFR in patients with suspected or known CAD. METHODS Forty seven patients with suspected CAD (35 men; mean age 69 years) who underwent coronary angiography and FFR measurement were enrolled. FFR ≤ 0.8 was considered to indicate significant myocardial ischemia. The change of ST-segment fluctuation score from rest to stress was calculated from the MCG. In addition, two blinded cardiologists assessed MCG images that were visualized by post-processing method, bulls-eye mapping. RESULTS The best cut-off value of the percent change of ST-segment fluctuation score was -39.0% with sensitivity of 86.7% and specificity of 73.9%. Sensitivity, specificity, diagnostic accuracy, and the area under the receiver-operator characteristics curve of bulls-eye mapping for the detection of significant CAD were 90.5%, 92.3%, 91.5%, and 0.914 on a patient basis and 90.0%, 93.8%, 92.3%, and 0.919 by coronary territory, respectively. CONCLUSIONS MCG accurately detects functionally significant CAD as defined by using FFR, provides an assessment of ischemic status in agreement with the change of ST-segment fluctuation score, and accurately localizes the ischemic territory in bulls eye mapping. Therefore, MCG may provide an incremental value for prediction of myocardial ischemia non-invasively and safely in clinical practice with fast examination time.

Better inflation time of stent balloon for second-generation drug-eluting stent expansion and apposition: an optical coherence tomography study.

OBJECTIVES We tried to determine the effect of stent balloon inflation time on stent expansion and apposition using optical coherence tomography. BACKGROUND Second-generation drug-eluting stents (DES) have thin struts; however, inflation times for optimal stent expansion and apposition are unknown in vivo. METHODS Subjects included 17 patients (18 de novo coronary artery lesions), in whom Resolute Integrity → (n = 9) and Xience Prime → (n = 9) DES were deployed. All stents were inflated 3 times to the nominal inflation pressure (8.9 ± 0.6 atm) using the stent delivery balloon. The first inflation continued until the stent was angiographically fully expanded; the other 2 lasted 15 and 30 seconds, respectively. RESULTS After the first, second, and third inflation of stent balloon, stent area (5.94 ± 1.7, 6.69 ± 1.8, 7.05 ± 1.8 mm(2) , P < 0.001) and stent volume (146.94 ± 59.40, 166.78 ± 69.55, 177.25 ± 69.19 mm(3) , P < 0.001) increased significantly. The number of malapposed struts (18.0 ± 17.0, 7.9 ± 10.2, 7.4 ± 10.8, P < 0.001) and the mean depth of malapposed struts (188.9 ± 75.6, 120.3 ± 101.4, 95.4 ± 86.8 µm, P < 0.001) decreased. Malapposed stent area (0.62 ± 0.32, 0.52 ± 0.21 mm(2) , P < 0.05) and the malapposed stent volume (15.03 ± 7.78, 12.64 ± 5.16 mm(3) , P < 0.05) decreased significantly following the second inflation; the third inflation gave no additional benefits to these parameters. There was no adverse clinical outcome after each stent balloon inflation. CONCLUSIONS Additional 15 seconds of inflation after the angiographically full expansion of the stent balloon allows better stent expansion and apposition even though the inflation pressure is nominal pressure.

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

Gender differences in risk factors and clinical outcomes in young patients with acute myocardial infarction.

Background There are limited data on the influence of gender on risk factors and clinical outcomes in young patients with acute myocardial infarction (AMI). Methods This prospective study stratified outcomes according to gender in patients of age ≤50 years with a diagnosis of AMI, and who were enrolled in the nationwide registry of the Korea Working Group of Myocardial Infarction. The end point was the incidence of major adverse cardiovascular events (MACEs) defined as the composite of cardiac death, recurrent myocardial infarction (MI), and repeat revascularisation at 30 days and 1 year after admission. Results The registry enrolled 30 001 patients with AMI, of whom 5200 met the study inclusion criteria; 4805 patients were male and 395 were female. Current smoking was significantly higher in men, while hypertension and diabetes mellitus were significantly more common in women. Women underwent less coronary revascularisation, and were less likely to be on optimal medical therapy compared with men despite having a higher Killip class at presentation and higher risk angiographic findings. Although women had higher rates of MACEs (3.8% vs 1.8%, p=0.018 at 30 days and 7.8% vs 4.7%, p=0.004 at 1-year follow-up) compared with men, female gender was not an independent predictor of MACEs after adjusting for propensity score. Conclusions There were significant gender differences in the risk factors for coronary artery disease and the short-term and long-term clinical outcomes of young patients with AMI. Continued preventive strategies should be focused on gender-different risk factor reduction in these young patients.