Yosuke Tatami

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.

Nutrition Status Predicts Severity of Vascular Calcification in Non-Dialyzed Chronic Kidney Disease

BACKGROUND Vascular calcification is a major complication in chronic kidney disease (CKD) that increases the risk of adverse clinical outcomes. Geriatric nutritional risk index (GNRI) is a simple nutritional assessment tool that predicts poor prognosis in elderly subjects. The purpose of the present study was to evaluate the correlation between GNRI and severity of vascular calcification in non-dialyzed CKD patients.Methods and Results:We enrolled 323 asymptomatic CKD patients. To evaluate abdominal aortic calcification (AAC), we used aortic calcification index (ACI) determined on non-contrast computed tomography. The patients were divided into three groups according to GNRI tertile. Median ACI significantly decreased with increasing GNRI tertile (15.5%, 13.6%, and 7.9%, respectively; P=0.001). On multivariate regression analysis GNRI was significantly correlated with ACI (β=-0.15, P=0.009). We also investigated the combination of GNRI and C-reactive-protein (CRP) for predicting the severity of AAC. Low GNRI and high CRP were significantly associated with severe AAC, compared with high GNRI and low CRP (OR, 4.07; P=0.004). CONCLUSIONS GNRI was significantly associated with AAC in non-dialyzed CKD patients.

Impact of Geriatric Nutritional Risk Index on cardiovascular outcomes in patients with stable coronary artery disease

BACKGROUND The association between malnutrition and cardiovascular prognosis in patients with stable coronary artery disease remains unclear. The aim of this study was to evaluate the association between Geriatric Nutritional Risk Index (GNRI), a simple tool to assess nutritional risk, and long-term outcomes after elective percutaneous coronary intervention (PCI). METHODS This study consisted of 802 patients (age, 70±10 years, male, 69%) who underwent elective PCI. GNRI was calculated at baseline as follows: GNRI=[14.89×serum albumin (g/dl)+[41.7×(body weight/body weight at body mass index of 22)]]. Patients were then divided into three groups as previously reported: GNRI <92, 92 to ≤98, and >98. The endpoint of this study was the composite of cardiac death or non-fatal myocardial infarction. RESULTS During a median follow-up period of 1568 days, 56 cardiac events occurred. Using Kaplan-Meier analysis, the 4-year event-free rates were found to be 79% for GNRI <92, 90% for GNRI 92 to ≤98, and 97% for GNRI >98 (log-rank test p<0.001). GNRI <92 and GNRI 92 to ≤98 showed 6.76-fold [95% confidence interval (CI) 3.13-14.56, p<0.001] and 3.03-fold (HR 3.03, 95%CI 1.36-6.78, p=0.007) increase in the incidences of cardiac death or non-fatal myocardial infarction compared with GNRI >98 after adjusting for confounding factors. CONCLUSION GNRI significantly associated with cardiac events after elective PCI. Further studies should be performed to establish appropriate therapeutic strategies for this vulnerable patient group.

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.

Impact of Renal Functional/Morphological Dynamics on the Calcification of Coronary and Abdominal Arteries in Patients with Chronic Kidney Disease

Aim: Fast-progressing vascular calcification (VC) is accompanied by renal atrophy and functional deterioration along with atherosclerosis in patients with chronic kidney disease (CKD). However, the relationship between VC progression and renal functional and/or morphological changes remains unclear. Methods: We included 70 asymptomatic patients with CKD without hemodialysis in our study. To identify temporal variations, the coronary artery calcification score (CACS), abdominal aortic calcification index (ACI), and renal parenchymal volume index (RPVI) were determined via spiral computed tomography scans taken during the study. We investigated significant factors related to annualized variations of CACS (ΔCACS/y) and ACI (ΔACI/y). Results: During the follow-up period (4.6 years), median values of CACS [in Agatston units (AU)] and ACI increased from 40.2 to 113.3 AU (p = 0.053) and from 13.2 to 21.7% (p = 0.036), respectively. Multivariate analysis revealed that CACS at baseline (p < 0.001) and diabetes mellitus (DM) status (p = 0.037) for ΔCACS/y and ACI at baseline (p = 0.017) and hypertension (HT) status (p = 0.046) for ΔACI/y were significant independent predictors. Furthermore, annualized RPVI variation was significantly related to both ΔCACS/y and ΔACI/y (R = −0.565, p < 0.001, and R = −0.289, p = 0.015, respectively). On the other hand, independent contributions of the estimated glomerular filtration rate (eGFR) and annualized eGFR variation to VC progression were not confirmed. Conclusion: The degree of VC at baseline, DM, HT, and changes in renal volume, but not eGFR, had a strong impact on VC progression in patients with CKD.

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.

Decreased Serum Albumin Predicts Bleeding Events in Patients on Antiplatelet Therapy After Percutaneous Coronary Intervention

BACKGROUND Antiplatelet therapy (APT) after percutaneous coronary intervention (PCI) prevents ischemic events with increased risk of bleeding. Little is known about the relationship between hypoalbuminemia and bleeding risk in patients receiving APT after PCI. This study investigated the association between serum albumin level and bleeding events in this population.Methods and Results:We enrolled 438 consecutive patients who were prescribed dual APT (DAPT; aspirin and thienopyridine) beyond 1 month after successful PCI without adverse events. The patients were divided into 3 groups according to serum albumin tertile: tertile 1, ≤3.7 g/dL; tertile 2, 3.8-4.1 g/dL; and tertile 3, ≥4.2 g/dL. Adverse bleeding events were defined as Bleeding Academic Research Consortium criteria types 2, 3, and 5. During the median follow-up of 29.5 months, a total of 30 adverse bleeding events were observed. Median duration of DAPT was 14 months. The tertile 1 group had the highest risk of adverse bleeding events (event-free rate, 83.1%, 94.3% and 95.8%, respectively; P<0.001). On Cox proportional hazards modeling, serum albumin independently predicted adverse bleeding events (HR, 0.10, 95% CI: 0.027-0.39, P=0.001, for tertile 3 vs. tertile 1). CONCLUSIONS Decreased serum albumin predicted bleeding events in patients with APT after PCI.

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.

Balance between angiogenic and anti-angiogenic isoforms of VEGF-A is associated with the complexity and severity of coronary artery disease

INTRODUCTION Assessing the complexity of coronary artery disease (CAD) is clinically important. Vascular endothelial growth factor A (VEGF-A) is a powerful and the most important regulator of angiogenesis. It has been reported that the anti-angiogenic isoform of VEGF-A (VEGF-A165b) inhibits angiogenesis. The purpose of this study was to evaluate the relationship between the complexities of CAD using the Syntax score (SS) and the levels of circulating total VEGF-A or VEGF-A165b. METHODS A total of 268 patients who underwent percutaneous coronary intervention (PCI) were enrolled. Of these, 73 patients without acute coronary syndrome or previous revascularization were included in this study. These subjects were divided into two groups according to the SS. Circulating total VEGF-A and VEGF-A165b levels were measured using an enzyme-linked immunosorbent assay. RESULTS Circulating levels of total VEGF-A were significantly higher in the SS>22 (high SS) group than in the SS≤22 (low SS) group (p=0.018). Moreover, the ratio of VEGF-A165b to total VEGF-A was significantly lower for the high SS group (p=0.004). The levels of total VEGF-A independently predicted high SS after adjusting for other significant variables among patients who underwent PCI (odds ratio, 1.004; 95% CI, 1.001 to 1.006; p=0.01). CONCLUSIONS These data indicated that high SS was associated with circulating levels of total VEGF-A and the ratio of VEGF-A165b to total VEGF-A in patients with complex CAD.