Yuki Kakefuda

Impact of coronary plaque composition on cardiac troponin elevation after percutaneous coronary intervention in stable angina pectoris: a computed tomography analysis.

OBJECTIVES The authors used multidetector computed tomography (MDCT) to study the relation between culprit plaque characteristics and cardiac troponin T (cTnT) elevation after percutaneous coronary intervention (PCI). BACKGROUND Percutaneous coronary intervention is often complicated by post-procedural myocardial necrosis manifested by elevated cardiac biomarkers. METHODS Stable angina patients (n = 107) with normal pre-PCI cTnT levels underwent 64-slice MDCT before PCI to evaluate plaque characteristics of culprit lesions. Patients were divided into 2 groups according to presence (group I, n = 36) or absence (group II, n = 71) of post-PCI cTnT elevation ≥3 times the upper limit of normal (0.010 ng/ml) at 24 h after PCI. RESULTS Computed tomography attenuation values were significantly lower in group I than in group II (43.0 [26.5 to 75.7] HU vs. 94.0 [65.0 to 109.0] HU, p < 0.001). Remodeling index was significantly greater in group I than in group II (1.20 ± 0.18 vs. 1.04 ± 0.15, p < 0.001). Spotty calcification was observed significantly more frequently in group I than in group II (50% vs. 11%, p < 0.001). Multivariate analysis showed presence of positive remodeling (remodeling index >1.05; odds ratio: 4.54; 95% confidence interval: 1.36 to 15.9; p = 0.014) and spotty calcification (odds ratio: 4.27; 95% confidence interval: 1.30 to 14.8; p = 0.016) were statistically significant independent predictors for cTnT elevation. For prediction of cTnT elevation, the presence of all 3 variables (CT attenuation value <55 HU; remodeling index >1.05, and spotty calcification) showed a high positive predictive value of 94%, and their absence showed a high negative predictive value of 90%. CONCLUSIONS MDCT may be useful in detecting which lesions are at high risk for myocardial necrosis after PCI.

Association of contrast-induced acute kidney injury with long-term cardiovascular events in acute coronary syndrome patients with chronic kidney disease undergoing emergent percutaneous coronary intervention☆

BACKGROUND The association between contrast-induced acute kidney injury (CI-AKI) and chronic kidney disease (CKD) in patients with acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI) has not been fully reported. We evaluated the association of CI-AKI on cardiovascular events in ACS patients with CKD. METHODS A total of 1059 ACS patients who underwent emergent PCI in our multicenter registry were enrolled (69±12 years, 804 men, 604 STEMI patients). CKD was defined as at least stage 3 CKD, and CI-AKI was defined as an increase of at least 0.5 mg/dL and/or an increase of at least 25% of pre-PCI to post-PCI serum creatinine levels within 1 week after the procedure. Primary endpoints included cardiovascular death, myocardial infarction, and cerebrovascular disorder (stroke or transient ischemic attack). RESULTS In our study, 368 (34.7%) patients had CKD. During follow-up periods (435±330 days), CI-AKI and primary endpoints occurred in 164 (15.5%) patients and 106 (10.0%) patients, respectively. Multivariate Cox proportional hazards model revealed that age, female gender, peak creatinine kinase>4000, IABP use, CI-AKI (hazard ratio [HR], 2.17; 95% confidential interval [CI], 1.52 to 4.00; P<0.001), and CKD (HR, 1.66; 95% CI, 1.01 to 2.72; P=0.046) were independent predictors of primary endpoints. Kaplan-Meier analysis showed that occurrence of primary endpoints increased significantly with an increase in CKD stage, and CI-AKI yielded worse long-term prognosis at every stage of CKD (P<0.001). CONCLUSIONS CI-AKI was revealed to be a significant incremental predictor of cardiovascular events at each stage of CKD in ACS patients.

Prognostic Value of Myocardial Contrast Delayed Enhancement With 64-Slice Multidetector Computed Tomography After Acute Myocardial Infarction

OBJECTIVES This study evaluated the clinical value of myocardial contrast delayed enhancement (DE) with multidetector computed tomography (MDCT) for predicting clinical outcome after acute myocardial infarction (AMI). BACKGROUND Although some studies have described the use of MDCT for assessment of myocardial viability after AMI, clinical experience remains limited. METHODS In 102 patients with first AMI, 64-slice MDCT without iodine reinjection was performed immediately following successful percutaneous coronary intervention (PCI). We measured the size of myocardial contrast DE on MDCT and compared it with clinical outcome. Primary composite cardiac events were cardiac death or hospitalization for worsening heart failure. RESULTS Among the 102 patients (24 ± 10 months follow-up), 19 patients experienced primary composite cardiac events (cardiac death, n = 7; heart failure, n = 12). Kaplan-Meier analysis showed higher risk of cardiac events for patients in the third tertile of myocardial contrast DE size (≥ 36 g) than for those in the other 2 tertiles (p < 0.0001). Multivariable Cox proportional hazards regression analysis indicated that myocardial contrast DE size (adjusted hazard ratio [HR] for tertile 3 vs. 1: 16.1, 95% confidence interval [CI]: 1.45 to 72.4, p = 0.022; HR for tertile 3 vs. 2: 5.06, 95% CI: 1.25 to 22.7, p = 0.039) was a significant independent predictor for cardiac events after adjustment for Thrombolysis In Myocardial Infarction risk score, left ventricular ejection fraction, total defect score on single-photon emission CT with technetium tetrofosmin, and transmural extent of myocardial contrast DE on MDCT. CONCLUSIONS Myocardial contrast DE size on MDCT immediately after primary PCI may provide promising information for predicting clinical outcome in patients with AMI.

Preventive effect of statin pretreatment on contrast-induced acute kidney injury in patients undergoing coronary angioplasty: Propensity score analysis from a multicenter registry

BACKGROUND The prophylactic benefit of statins in reducing the incidence of contrast-induced acute kidney injury (CI-AKI) has been investigated in several studies with conflicting results. We sought to investigate whether statin pretreatment prevents CI-AKI in coronary artery disease (CAD) patients undergoing percutaneous coronary intervention (PCI). METHODS A total of 2198 CAD patients who underwent PCI, except for those undergoing dialysis or who died within 7 days after angioplasty, were analyzed from the ICAS (Ibaraki Cardiovascular Assessment Study) multicenter registry. Analyzed subjects were divided into 2 groups according to statin pretreatment: statin pretreatment (n=839) and non-statin pretreatment (n=1359). Selection bias of statin pretreatment was adjusted by propensity score-matching method: pretreatment statin (n=565) and non-statin pretreatment (n=565). CI-AKI was defined as an increase in serum creatinine of ≥ 25% or 0.5mg/dl from baseline within 1 week of contrast medium exposure. RESULTS A total of 192 (8.7%) patients developed CI-AKI. No significant differences were observed in baseline patient characteristics between the statin and non-statin pretreatment groups after propensity score matching. In the propensity score-matched groups, the incidence of CI-AKI was significantly lower in patients with statin pretreatment than in those without statin pretreatment (3.5% vs.10.6%, odds ratio [OR]: 0.31, 95% confidence interval [CI]: 0.18-0.52, P<0.001). Multivariate logistic regression analysis showed that statin pretreatment remained an independent negative predictor of CI-AKI (OR: 0.31, 95% CI: 0.18-0.53, P<0.001) among propensity score-matched subjects. CONCLUSIONS Statin pretreatment was associated with a significant decrease in the risk of CI-AKI in CAD patients undergoing PCI in the ICAS Registry.

Triple Antithrombotic Therapy Is the Independent Predictor for the Occurrence of Major Bleeding Complications Analysis of Percent Time in Therapeutic Range

Background—Triple antithrombotic therapy increases the risk of bleeding events in patients undergoing percutaneous coronary intervention. However, it remains unclear whether good control of percent time in therapeutic range is associated with reduced occurrence of bleeding complications in patients undergoing triple antithrombotic therapy. Methods and Results—This study included 2648 patients (70±11 years; 2037 men) who underwent percutaneous coronary intervention with stent in the Ibaraki Cardiovascular Assessment Study registry and received dual antiplatelet therapy with or without warfarin. Clinical end points were defined as the occurrence of major bleeding complications (MBC), major adverse cardiac and cerebrovascular event, and all-cause death. Among these 2648 patients, 182 (7%) patients received warfarin. After a median follow-up period of 25 months (interquartile range, 15–35 months), MBC had occurred in 48 (2%) patients, major adverse cardiac and cerebrovascular event in 484 (18%) patients, and all-cause death in 206 (8%) patients. Multivariable Cox regression analysis revealed that triple antithrombotic therapy was the independent predictor for the occurrence of MBC (hazard ratio, 7.25; 95% confidence interval, 3.05–17.21; P<0.001). The time in therapeutic range value did not differ between the patients with and without MBC occurrence (83% [interquartile range, 50%–90%] versus 75% [interquartile range, 58%–87%]; P=0.7). However, the mean international normalized ratio of prothrombin time at the time of MBC occurrence was 3.3±2.1. Triple antithrombotic therapy did not have a predictive value for the occurrence of all-cause death (P=0.1) and stroke (P=0.2). Conclusions—Triple antithrombotic therapy predisposes patients to an increased risk of MBC regardless of the time in therapeutic range.

Effect of individual proton pump inhibitors on cardiovascular events in patients treated with clopidogrel following coronary stenting: results from the Ibaraki Cardiac Assessment Study Registry.

Objectives: The aim of this study was to evaluate whether combination therapy of clopidogrel and proton pump inhibitors (PPIs) causes higher numbers of cardiovascular events than clopidogrel alone in Japanese patients. Background: PPIs are often prescribed in combination with clopidogrel following coronary stenting. PPIs are reported to diminish the effect of clopidogrel because both are metabolized by CYP2C19. However, no reports address the effects of PPIs on cardiovascular events following coronary stenting in the Japanese population. Methods: A total of 1,887 patients treated with clopidogrel following coronary stenting were enrolled in the Ibaraki Cardiac Assessment Study (ICAS) registry. All subjects were classified into two groups according to treatment without (n = 819) or with (n = 1,068) PPI. Propensity score analysis matched 1:1 according to treatment without PPI (n = 500) or with PPI (n = 500). Primary endpoint was the composite of all‐cause death or myocardial infarction. Results: No significant difference was observed in the primary endpoint between the group without PPI and the group with PPI (4.6% vs. 4.6%, P = 0.77). In contrast, a significant difference was found between the group without PPI and with PPI in regard to the incidence of gastrointestinal bleeding at the end of the follow‐up period and the specific PPI prescribed (2.4% vs. 0.8%, adjusted HR = 0.30, 95% Confidence interval 0.08‐0.87, P = 0.026) after propensity score matching. Conclusions: No significant association between PPI use and primary endpoint was observed in the Japanese population, whereas PPI use resulted in a significant reduction in the rate of gastrointestinal bleeding.

Gender differences in the association between serum uric acid and prognosis in patients with acute coronary syndrome

BACKGROUND Increased levels of uric acid (UA) have been associated with cardiovascular disease. This association is generally stronger in women than men. However, gender differences in the prognostic value of UA in patients with acute coronary syndrome (ACS) are unknown. We investigated gender differences in the relationship between UA level and the prognosis in patients with ACS. METHOD This was an observational analysis of patients with ACS undergoing percutaneous coronary intervention enrolled in the Ibaraki Cardiac Assessment Study (ICAS) registry. We analyzed 1380 patients (330 women, 1050 men) with ACS who had information on UA. We assessed the association between UA and the incidence of major cardiovascular adverse events (MACE), defined as all-cause death, congestive heart failure, reinfarction, and stroke. Patients were divided according to gender-specific UA quartile. RESULTS The mean UA level in women was significantly lower than that in men (4.9mg/dl vs 5.9mg/dl, p<0.001). After a median duration of follow-up period of 437 days (interquartile range 222-801 days), MACE had occurred in 186 (13%) patients [56 (17%) events in women; 130 (12%) events in men]. Kaplan-Meier analysis for MACE-free survival demonstrated that a higher quartile of UA was associated with MACE in both women and men (p<0.001, p=0.002, respectively). Multivariate Cox regression analysis revealed that the highest quartile of UA, as compared with the lowest quartile of UA, was an independent predictor of MACE in women [hazard ratio (HR), 2.84; 95% CI, 1.19-6.77; p=0.018] but not in men (HR, 1.32; 95% CI, 0.66-2.64; p=0.422). CONCLUSIONS An increased level of UA was associated with MACE more strongly in women than in men with ACS. These results suggest that there are gender differences in the association of UA level with the prognosis in patients with ACS.

Acute hemodynamic effects of landiolol, an ultra-short-acting beta-blocker, in patients with acute coronary syndrome: Preliminary study

OBJECTIVES We aimed to evaluate acute hemodynamic effects and safety of landiolol in patients with acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI). BACKGROUND Beta-blockers have been proven to be effective for the treatment of ischemic heart disease in both the acute and chronic phases. Landiolol, an ultra-short-acting and highly cardioselective beta-1 blocker, has become available in Japan. In the clinical setting, the hemodynamic response to landiolol administration remains unclear in patients presenting with ACS. METHODS From August 2007 to April 2008, landiolol was administered intravenously immediately before reperfusion procedure in 22 consecutive ACS patients (mean age, 63±9 years; 15 men) with a heart rate (HR) of ≥70 beats/min. The initial intravenous administration dose of landiolol was 20 μg/kg/min in all patients. The maintenance dose was titrated with the aim of reducing HR by 15%. Acute hemodynamic data including HR and systolic and diastolic blood pressure were serially evaluated. RESULTS HR dropped significantly (from 87±11 to 72±8beats/min, p<0.001) 20 min after landiolol initiation. However, systolic and diastolic pressure remained unchanged during administration of landiolol. Although landiolol was discontinued in 2 patients because of sinus bradycardia, no serious complications such as advanced degree atrioventricular block, requiring temporary cardiac pacing, severe hypotension, cardiogenic shock, or deterioration of heart failure were observed in the patients receiving landiolol. CONCLUSIONS Landiolol was safe and effective in reducing oxygen demand of the ischemic heart by reducing only HR without lowering blood pressure in patients with ACS undergoing PCI.

Fatal Ostial Right Coronary Artery Coronary Stent Fracture and Perforation Induced by Mechanical Stress Between the Sternum and Dilated Aortic Root

A 79-year-old woman with a history of open abdominal aortic aneurysm repair presented with worsening angina. Her ECG showed mild ST-segment depression at rest (Figure 1A). Computed tomography coronary angiography revealed a critical stenosis at the right coronary artery ostium without atherosclerotic plaque, which appeared to be induced by extrinsic mechanical compression between the sternum and dilated aortic root (Figure 2 and Movie I in the online-only Data Supplement). Because she refused to undergo cardiac surgery, elective percutaneous coronary intervention for the ostial right coronary artery lesion was performed (Movie II in the online-only Data Supplement). Intravascular ultrasound findings were similar to those observed on computed tomography coronary angiography (Figure 3 and Movie III in the online-only Data Supplement). A Liberte bare metal stent 4.0/12 mm was directly deployed, followed …

Enhancement patterns detected by multidetector computed tomography are associated with microvascular obstruction and left ventricular remodelling in patients with acute myocardial infarction

AIMS This study evaluated the clinical value of myocardial contrast-delayed enhancement (DE) with multidetector computed tomography (MDCT) for detecting microvascular obstruction (MVO) and left ventricular (LV) remodelling revealed by DE magnetic resonance imaging after acute myocardial infarction (AMI). METHODS AND RESULTS In 92 patients with first AMI, MDCT without iodine reinjection was performed immediately following successful percutaneous coronary intervention (PCI). Delayed-enhancement magnetic resonance imaging performed in the acute and chronic phases was used to detect MVO and LV remodelling (any increase in LV end-systolic volume at 6 months after infarction compared with baseline). Patients were divided into two groups according to the presence (n = 33) or absence (n = 59) of heterogeneous enhancement (HE). Heterogeneous enhancement was defined as concomitant presence of hyper- and hypoenhancement within the infarcted myocardium on MDCT. Microvascular obstruction and LV remodelling were detected in 49 (53%) and 29 (32%) patients, respectively. In a multivariable analysis, HE and a relative CT density >2.20 were significant independent predictors for MVO [odds ratio (OR) 13.5; 95% confidence interval (CI), 2.15-84.9; P = 0.005 and OR 12.0; 95% CI, 2.94-49.2; P < 0.001, respectively). The presence of HE and relative CT density >2.20 showed a high positive predictive value of 93%, and the absence of these two findings yielded a high negative predictive value of 90% for the predictive value of MVO. Heterogeneous enhancement was significantly associated with LV remodelling (OR 6.75; 95% CI, 1.56-29.29; P = 0.011). CONCLUSION Heterogeneous enhancement detected by MDCT immediately after primary PCI may provide promising information for predicting MVO and LV remodelling in patients with AMI.