To evaluate the feasibility of spectral imaging with dual-layer spectral detector computed tomography (CT) for the diagnosis of acute coronary syndrome. We identified 30 consecutive patients who ...underwent cardiac CT using dual-layer spectral detector CT and were diagnosed with acute ischemic syndrome by an invasive coronary angiography. We reconstructed 120 kVp images and generated virtual monochromatic images (VMIs; 40–200 keV in 10 keV increments), iodine concentration maps, and effective atomic number (
Z
) maps. We calculated the contrast and contrast-to-noise ratio (CNR) between myocardial normal and hypo-perfusion and chose the VMIs with the best CNR for quantitative analysis. We compared the image noise, contrast, and CNR of 120 kVp images and the best VMIs, CT value, iodine concentration, and effective
Z
between myocardial normal and hypo-perfusion with the paired t test. As the X-ray energy decreased, venous attenuation, contrast, and CNR gradually increased. The 40 keV image yielded the best CNR. The contrast and CNR between myocardial normal and hypo-perfusion were significantly higher in 40 keV images than those in 120 kVp images. The iodine concentration and the effective
Z
were significantly higher in normal myocardium than those in hypo-perfused myocardium. Spectral imaging with dual-layer spectral detector CT is a feasible technique to detect the hypo-perfused area of acute ischemic syndrome.
It remains unclear whether clopidogrel is better suited than aspirin as the long-term antiplatelet monotherapy following dual antiplatelet therapy (DAPT) after percutaneous coronary intervention ...(PCI).
This study compared clopidogrel monotherapy following 1 month of DAPT (clopidogrel group) with aspirin monotherapy following 12 months of DAPT (aspirin group) after PCI for 5 years.
STOPDAPT-2 (Short and Optimal Duration of Dual Antiplatelet Therapy 2) is a multicenter, open-label, adjudicator-blinded, randomized clinical trial conducted in Japan. Patients who underwent PCI with cobalt-chromium everolimus-eluting stents were randomized in a 1-to-1 fashion either to clopidogrel or aspirin groups. The primary endpoint was a composite of cardiovascular outcomes (cardiovascular death, myocardial infarction, stroke, or definite stent thrombosis) or major bleeding (TIMI major or minor bleeding).
Among 3,005 study patients (age: 68.6 ± 10.7 years; women: 22.3%; acute coronary syndrome: 38.3%), 2,934 patients (97.6%) completed the 5-year follow-up (adherence to the study drugs at 395 days: 84.7% and 75.9%). The clopidogrel group compared with the aspirin group was noninferior but not superior for the primary endpoint (11.75% and 13.57%, respectively; HR: 0.85; 95% CI: 0.70-1.05; Pnoninferiority < 0.001; Psuperiority = 0.13), whereas it was superior for the cardiovascular outcomes (8.61% and 11.05%, respectively; HR: 0.77; 95% CI: 0.61-0.97; P = 0.03) and not superior for major bleeding (4.44% and 4.92%, respectively; HR: 0.89; 95% CI: 0.64-1.25; P = 0.51). By the 1-year landmark analysis, clopidogrel was numerically, but not significantly, superior to aspirin for cardiovascular events (6.79% and 8.68%, respectively; HR: 0.77; 95% CI: 0.59-1.01; P = 0.06) without difference in major bleeding (3.99% and 3.32%, respectively; HR: 1.23; 95% CI: 0.84-1.81; P = 0.31).
Clopidogrel might be an attractive alternative to aspirin with a borderline ischemic benefit beyond 1 year after PCI.
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It can be difficult to diagnose coronary artery disease in patients with acute coronary syndrome if coronary angiography does not identify stenosis. Coronary inflammation, which can contribute to the ...pathogenesis of coronary artery disease and acute coronary syndrome, can be quantified using the perivascular fat attenuation index. Furthermore, the perivascular fat attenuation index is a marker for all-cause mortality, cardiac-related mortality and impaired global coronary flow reserve.
Here we report a case of a patient presenting with symptoms of acute coronary syndrome. The patient had hypokinesis of the lateral-posterior wall of the left ventricle, decreased myocardial perfusion in the posterior wall myocardium and elevated myocardial troponin-T and creatine phosphokinase levels. However, coronary computed tomography angiography did not identify arterial stenosis. The patient did have an increased perivascular fat attenuation index, indicating coronary inflammation. Moreover, the fat attenuation index was higher around the left circumflex artery than around the right coronary artery or left anterior descending artery. Intravascular ultrasonography identified an intramural haematoma, leading to a diagnosis of type 3 spontaneous coronary artery dissection in the left circumflex artery.
Perivascular fat attenuation index may be a useful tool to help identify and localise disease-causing lesions, and to direct further testing to confirm a diagnosis of spontaneous coronary artery dissection in acute coronary syndrome patients without significant arterial stenosis.
Abstract
Sodium-glucose cotransporter 2 inhibitors could reduce cardiovascular events in patients with heart failure irrespective of diabetes status. In this prespecified sub-analysis of ...randomised-controlled trial, we investigated the efficacy of luseogliflozin (2.5 mg daily), a sodium–glucose cotransporter 2 inhibitor, with that of voglibose (0.6 mg daily), an alpha-glucosidase inhibitor, on high-risk lipid profile and inflammatory markers in patients with type-2 diabetes and heart failure. Among the 157 patients studied, there were no significant differences in the mean malondialdehyde LDL or small-dense LDL cholesterol levels between the luseogliflozin and voglibose groups (percent change: 0.2% vs. − 0.6%, p = 0.93; − 1.7% vs. − 8.6%, p = 0.21) after 12 weeks in comparison to levels at the baseline. No significant difference was observed between the two groups in the adiponectin and high-sensitivity C-reactive protein levels after 12 weeks compared to the baseline levels (percent change, − 1.6% vs. − 4.0% and 22.5% vs. 10.0%; p = 0.52 and p = 0.55, respectively). In conclusion, in patients with type-2 diabetes and heart failure, compared to voglibose, luseogliflozin did not significantly improve the high-risk lipoprotein profile including malondialdehyde LDL and small-dense LDL cholesterol or the levels of inflammatory markers, including adiponectin and high-sensitivity C-reactive protein.
Trial registration:
Trial number: UMIN-CTR, UMIN000018395; Registered 23 July 2015; URL:
https://www.umin.ac.jp/ctr/index.htm
.
Assessment of myocardial viability in patients with myocardial infarction is critical to identify residual ischemic tissue in areas of reduced function and to determine the need for ...revascularization. We present the case of an 80-year-old man with chest pain and a history of hypertension. Initial evaluation revealed abnormal electrocardiogram findings, and subsequent studies suggested chronic anteroseptal myocardial infarction with reduced cardiac function. Dual-energy cardiac computed tomography was performed to evaluate the coronary arteries and myocardium. Late iodine enhancement images obtained by dual-energy computed tomography showed mixed plaques and severe proximal left anterior descending artery stenosis. Conventional late iodine enhancement imaging was inconclusive, prompting extracellular volume fraction analysis using iodine density imaging. Extracellular volume fraction assessment indicated viable anterior myocardium, leading to successful coronary revascularization. Follow-up demonstrated improved wall motion and ejection fraction. Our study highlights the utility of late iodine enhancement with dual-energy computed tomography in assessing myocardial viability as a noninvasive alternative to magnetic resonance imaging, particularly in patients with contraindications to magnetic resonance imaging. This approach aids in treatment planning, evaluation of efficacy and determination of prognosis in cases of ischemic heart disease.
Background Effects of sodium-glucose cotransporter 2 inhibitors on reducing hospitalization for heart failure have been reported in randomized controlled trials, but their effects on patients with ...heart failure with preserved ejection fraction (HFpEF) are unknown. This study aimed to evaluate the drug efficacy of luseogliflozin, a sodium-glucose cotransporter 2 inhibitor, in patients with type 2 diabetes mellitus and HFpEF. Methods and Results We performed a multicenter, open-label, randomized, controlled trial for comparing luseogliflozin 2.5 mg once daily with voglibose 0.2 mg 3 times daily in patients with type 2 diabetes mellitus suffering from HFpEF (left ventricular ejection fraction >45% and BNP B-type natriuretic peptide concentrations ≥35 pg/mL) in a 1:1 randomization fashion. The primary outcome was the difference from baseline in BNP levels after 12 weeks of treatment between the 2 drugs. A total of 173 patients with diabetes mellitus and HFpEF were included. Of these, 83 patients were assigned to receive luseogliflozin and 82 to receive voglibose. There was no significant difference in the reduction in BNP concentrations after 12 weeks from baseline between the 2 groups. The ratio of the mean BNP value at week 12 to the baseline value was 0.79 in the luseogliflozin group and 0.87 in the voglibose group (percent change, -9.0% versus -1.9%; ratio of change with luseogliflozin versus voglibose, 0.93; 95% CI, 0.78-1.10;
=0.26). Conclusion In patients with type 2 diabetes mellitus and HFpEF, there is no significant difference in the degree of reduction in BNP concentrations after 12 weeks between luseogliflozin and voglibose. Registration URL: https://www.umin.ac.jp/ctr/index.htm; Unique identifier: UMIN000018395.
Background:The risks of bleeding and cardiovascular events in high bleeding risk (HBR) Japanese patients undergoing percutaneous coronary intervention (PCI) while receiving single-antiplatelet ...therapy (SAPT) remains unknown. We aimed to evaluate the frequency of bleeding and cardiovascular events associated with prasugrel monotherapy after short-term dual-antiplatelet therapy (DAPT) in Japanese HBR patients after PCI.Methods and Results:The PENDULUM mono study was a multicenter, non-interventional, prospective registry (n=1,173). The primary endpoint was the cumulative incidence of clinically relevant bleeding (CRB; Bleeding Academic Research Consortium types 2, 3, and 5) from 1 to 12 months after PCI. Secondary endpoints included major adverse cardiac and cerebrovascular events (MACCE). The proportion of patients who received prasugrel monotherapy at 12 months after PCI was 79.7%, and no cases of stent thrombosis were observed among these patients. The cumulative incidence of CRB was 3.2% from 1 to 12 months after PCI; that of MACCE was 3.8%. Severe anemia, chronic kidney disease, oral anticoagulant use at discharge, and heart failure were significantly associated with CRB.Conclusions:Among HBR patients undergoing PCI who were not suitable for concomitant aspirin and were scheduled for prasugrel monotherapy, most patients were on prasugrel monotherapy after DAPT. Cumulative incidences of CRB and MACCE after periprocedural period were 3.2% and 3.8%, respectively, and no cases of stent thrombosis were reported. SAPT might be a suitable alternative to DAPT.
Previously we briefly reported the effect of 1-month dual antiplatelet therapy (DAPT) for patients with high bleeding risk (HBR) receiving percutaneous coronary intervention (PCI) in the STOPDAPT-2 ...trial, but full analysis data have not been available. We conducted post hoc subgroup analysis regarding the effect of very short DAPT for HBR patients in STOPDAPT-2 trial. The primary endpoint was a 1-year composite of cardiovascular (cardiovascular death, myocardial infarction, definite stent thrombosis, or stroke) and bleeding (TIMI major/minor bleeding) outcomes. Major secondary endpoints were 1-year cardiovascular composite endpoint and bleeding endpoint. HBR was defined by the academic research consortium (ARC) HBR criteria. Among the 3009 study patients, 1054 (35.0%) were classified as HBR and 1955 (65.0%) were as non-HBR. There were no significant interactions between HBR/non-HBR subgroups and the assigned DAPT group on the primary endpoint (HBR; 3.48% vs. 5.98%, HR 0.57, 95% CI 0.32–1.03, and non-HBR; 1.81% vs. 2.36%, HR 0.78, 95% CI 0.42–1.45;
P
for interaction = 0.48), the major secondary cardiovascular endpoint (HBR; 3.07% vs. 4.03%, HR 0.77, 95% CI 0.40–1.48, and non-HBR; 1.41% vs. 1.61%, HR 0.89, 95% CI 0.43–1.84;
P
for interaction = 0.77), and the major secondary bleeding endpoint (HBR; 0.41% vs. 2.71%, HR 0.15, 95% CI 0.03–0.65, and non-HBR; 0.40% vs. 0.85%, HR 0.48, 95% CI 0.14–1.58;
P
for interaction = 0.22). In conclusion, the effects of 1-month DAPT for the primary and major secondary endpoints were consistent in HBR and non-HBR patients without any significant interactions. The benefit of 1-month DAPT in reducing major bleeding was numerically greater in HBR patients.
Clinical trial registration
Short and optimal duration of dual antiplatelet therapy after everolimus-eluting cobalt–chromium stent-2 STOPDAPT-2; NCT02619760.
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