Tomoyuki Ota

Impact of Sirolimus-Eluting Stent Fracture on 4-Year Clinical Outcomes

Background—Although stent fracture (SF) after sirolimus-eluting stent (SES) implantation has been recognized as one of the predisposing factors of in-stent restenosis, it remains uncertain whether SF can increase the risk of major adverse cardiac events (MACE), especially beyond 1 year after SES implantation. The aim of this study was to assess the impact of SF relative to non-SF on 4-year clinical outcomes after treatment with SES of comparable unselected lesions. Methods and Results—A total of 874 lesions in 793 patients undergoing SES implantation and subsequent angiography 6 to 9 months after index procedure were analyzed. At 6- to 9-month angiographic follow-up, SF was identified in 70 of 874 lesions (8.0%). In-stent late loss was significantly higher in SF lesions versus non-SF lesions (0.42±0.59 mm versus 0.13±0.49 mm, P<0.001), resulting in a significantly higher in-stent restenosis rate (21.4% versus 4.1%, P<0.001). At 4 years, SF versus non-SF was associated with a significantly higher MACE rate (23.2% versus 12.6%, P=0.014), mainly driven by significantly higher target-lesion revascularization (18.8% versus 10.2%, P=0.029) rate. Adverse effects of SF on clinical outcomes occurred mostly within the first year (17.4% versus 6.6%, P=0.001), with similar MACE rate between 1 and 4 years (5.8% versus 5.9%, P=0.611). No significant differences between SF versus non-SF patients were observed in the cumulative frequency of very late stent thrombosis (2.9% versus 1.4%, P=0.281), death (0% versus 2.1%, P=0.252), or myocardial infarction (5.8% versus 2.9%, P=0.165). Conclusions—SF of SES was associated with higher MACE rate up to 1 year, mainly driven by higher target-lesion revascularization, whereas no significant association was evident between years 1 and 4.

Impact of coronary stent designs on acute stent recoil

BACKGROUND Acute stent recoil has been often observed following stent delivery balloon deflation in coronary arteries and the recoil rate varies by stent design. Accordingly, the purpose of the present study was to evaluate the impact of stent designs on acute stent recoil after new generation drug-eluting stent implantation. METHODS AND RESULTS A total of 154 lesions [56 treated with biolimus-eluting stent (BES), 46 with cobalt chromium everolimus-eluting stent (CoCr-EES), and 52 with platinum chromium everolimus-eluting stent (PtCr-EES)] were evaluated. Quantitative coronary angiography was used to measure the minimal lumen diameter (MLD). MLD1 was defined as a MLD of complete expansion of the last stent delivery balloon at the highest pressure. MLD2 was defined as a MLD immediately after the last stent delivery balloon deflation. Acute stent recoil was determined by the calculation as (MLD1-MLD2)/MLD1. Acute stent recoil was significantly higher in the CoCr-EES group versus the BES group and PtCr-EES group (10.1 ± 6.9%, 6.7 ± 5.5%, and 6.5 ± 4.8%, respectively, p = 0.01). Multivariate linear regression analysis demonstrated that the use of CoCr-EES and the number of stent delivery balloon inflations were independent predictors of acute stent recoil (r = 0.26, β = 0.21, p = 0.01 and r = -0.51, β = -0.58, p < 0.01, respectively). CONCLUSION Acute stent recoil occurred more frequently with the CoCr-EES compared with both BES and PtCr-EES. Strategies with multiple balloon inflation might be needed to overcome this recoil phenomenon.

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.

The role of angiographic follow-up after percutaneous coronary intervention

In the early days of coronary angioplasty, follow-up coronary angiography was often performed to assess restenosis. Angiographic restenosis has been shown to be associated with worse clinical outcomes, though the exact causality has yet to be determined. Numerous studies have repeatedly demonstrated that routine follow-up coronary angiography increases the incidence of target lesion revascularization without a clear reduction in mortality or myocardial infarction. Despite the lack of proven benefit of angiographic follow-up, routine follow-up coronary angiography is still being performed in certain countries and facilities. There are several factors that might explain the lack of benefit of angiographic follow-up: 1) lower incidence of stent failure in the current drug-eluting stent era has attenuated the net clinical benefit of follow-up angiography. 2) Angiographic restenosis might not lead to myocardial ischemia. 3) Patients that do have functionally significant restenosis are often referred for coronary angiography due to clinical indications such as intractable angina. 4) Absence of restenosis at the time of follow-up angiography does not exclude future restenosis. The absence of proven benefit in unselected populations does not necessarily preclude the presence of benefit in selected population, and there may be a subgroup of patients who can benefit from angiographic follow-up such as those with a large myocardial ischemic territory or those at very high risk of restenosis. Until there is more clinical evidence with respect to follow-up angiography, the decision of whether or not to perform it routinely in selected high-risk population should entail an in-depth discussion with the patient.

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.

Subtle myocardial damage associated with diagnostic coronary angiography alone

AIMS To evaluate the frequency, predictors and prognostic significance of elevation in cardiac troponin I (cTnI) after coronary angiography (CAG). METHODS AND RESULTS A series of 296 consecutive patients with normal pre-procedural cTnI levels and undergoing elective CAG at our centre were prospectively analysed. Positive cTnI elevation was defined as >0.06 ng/ml. Positive cTnI elevation was observed in 44 patients (14.8%), but CK-MB was elevated in only four patients (1.3%) after the procedure. The risk of cTnI elevation was independently associated with left ventricular hypertrophy (odds ratio [OR] 5.52; 95% confidence interval [CI], 2.54 to 12.02; P<0.001), inexperienced operator (OR 10.83; 95% CI, 2.47 to 47.43; P=0.002) and the amount of contrast agent (OR 1.12; 95% CI, 1.03 to 1.23; P=0.009 for each 10 ml increase), whereas it was not associated with the severity of coronary artery disease. At one year, however, postprocedural elevation of cTnI was not associated with an increased risk of death (2.3% vs. 0.8%, P=0.384) or myocardial infarction (2.3% vs. 2.0%, P=0.623). CONCLUSIONS A minor elevation of cTnI is observed commonly after CAG, which might be associated with left ventricular hypertrophy, operators experience and the amount of contrast used; however, it does not influence 1-year events rates.

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.