Objectives We sought to assess whether hyperinsulinemia is associated with percentage lipid and coronary plaque burden in nondiabetic patients with acute coronary syndromes (ACS). Background ...Hyperinsulinemia carries an increased risk of cardiovascular disease even in pre-diabetic patients, but the precise mechanisms of its effects remain unclear. Methods Nonculprit coronary lesions associated with mild-to-moderate stenosis in 82 nondiabetic patients with ACS were examined by integrated backscatter intravascular ultrasound (IB-IVUS), using a 40-MHz intravascular catheter. Conventional IVUS and IB-IVUS measurements from the worst 10-mm segment (1-mm intervals) were calculated. All patients underwent a 75-g oral glucose tolerance test (OGTT) to calculate the area under the insulin concentration-time curve (AUC insulin) from 0 to 120 min. Results Patients in the high tertile of AUC insulin had a significantly greater percentage lipid area and absolute lipid volume than did patients in the intermediate and low tertiles (tertile 3 vs. tertile 2 vs. tertile 1; 37.6 ± 16.6% vs. 25.8 ± 11.9% vs. 27.5 ± 14.7%, p < 0.01 by analysis of variance ANOVA, and 29.9 ± 22.6 mm3 vs. 15.3 ± 12.6 mm3 vs. 17.7 ± 12.7 mm3 , p < 0.01 by ANOVA, respectively) and a smaller percentage fibrosis area (55.0 ± 11.5% vs. 61.7 ± 9.4% vs. 60.7 ± 9.4%, p = 0.03 by ANOVA). Multiple regression analysis showed that the high tertile of AUC insulin was independently associated with an increased percentage lipid area (p < 0.05). On conventional IVUS analysis, external elastic membrane cross-sectional area was significantly increased with greater plaque volume in patients in the high tertile of AUC insulin (both p < 0.05 by ANOVA). Conclusions Hyperinsulinemia is associated with an increased lipid content and a greater plaque volume of nonculprit intermediate lesions in nondiabetic patients with ACS, suggesting that plaque vulnerability is increased in this subgroup of patients.
Summary Background Although there has been an intense debate whether concomitant use of proton-pump inhibitors (PPIs) attenuates the antiplatelet effects of thienopyridine derivatives, the drug–drug ...interaction remains unclear in Japanese patients with coronary artery disease. Methods and results Platelet function test was performed in 461 patients who were scheduled for or had undergone stent implantation, treated with 100 mg/day of aspirin and a thienopyridine (200 mg/day of ticlopidine or 75 mg/day of clopidogrel) for at least 14 days. Adenosine diphosphate-induced platelet aggregation was evaluated with screen filtration pressure method, and the upper quartile of high platelet reactivity was defined as high on-treatment platelet reactivity (HPR). PPI use was at physician's discretion. Patients taking a thienopyridine plus a PPI ( n = 166) were older and had a higher incidence of acute coronary syndromes on admission compared with patients taking a thienopyridine without a PPI ( n = 295). The rate of HPR was higher in patients taking a thienopyridine plus a PPI than in patients taking a thienopyridine without a PPI (31% vs 21%, p = 0.01). On multivariate logistic regression analysis, independent predictors of HPR were concomitant PPI use odds ratio (OR): 1.66, 95% confidence interval (CI): 1.03–2.68, diabetes mellitus (OR: 1.76, CI: 1.11–2.81), and calcium channel blockers use (OR: 1.93, CI: 1.18–3.18). However, there was no significant difference in the rate of extremely high platelet reactivity 58 patients (12.5%) with PATI < 4.0 μM between patients treated with a thienopyridine plus a PPI and those without a PPI (14% vs 11%, NS). Conclusion HPR was frequently observed in Japanese patients treated with thienopyridines plus PPIs compared to those without PPIs. Further prospective studies are needed to estimate the risk of adverse cardiovascular events associated with concomitant use of PPIs and thienopyridines.
Background The significance of inverted T waves remains unclear in patients with acute pulmonary embolism (PE). Methods and Results The relationship of the number of leads with inverted T waves to ...the severity of PE in 40 patients with acute PE was studied. Patients were classified into 3 groups according to the number of leads with inverted T waves on the admission electrocardiogram (ECG): 15 patients, ≤3 leads (group L); 12 patients, 4-6 leads (group M); and 13 patients, ≥7 leads (group H). In groups L, M and H, the rates of right ventricular dysfunction on echocardiography were 47%, 92% and 100% (p<0.01), respectively, and the rates of in-hospital complicated events (including death or the need for catecholamine support, cardiopulmonary resuscitation or mechanical cardiovascular support because of hemodynamic instability) were 0%, 8% and 46% (p=0.004), respectively. On multivariate analysis, arterial hypotension at presentation (odds ratio (OR) 8.96, p=0.049) and inverted T waves in ≥7 leads on the admission ECG (OR 16.8, p=0.037) were the only independent predictors of in-hospital complicated events. Conclusions The number of leads with inverted T waves may be a useful and simple marker of increased risk for early complications in patients with acute PE. (Circ J 2006; 70: 750 - 755)
Background Experimental studies suggest that statins promote vascular fibrinolysis, so statin treatment before the onset of acute myocardial infarction (AMI) may result in a smaller infarct size. ...Methods and Results The study group comprised 310 patients with AMI who received fibrinolysis within 12 h after symptom onset: 39 had received statin pretreatment (statin group) and 271 had not (non-statin group). Initial Thrombolysis In Myocardial Infarction (TIMI) flow grade did not differ between groups. Among 120 patients with initial TIMI flow grade 0/1, achievement of TIMI flow grade >2 after passing the guidewire through the culprit lesion was more frequent in the statin group (70% vs 35%, P=0.03). The final rate of TIMI flow grade 3 was higher in the statin group (95% vs 86%, P=0.11). Area under the curve (AUC) for creatine kinase (CK) was lower in the statin group (55,972±45,934 vs 84,195±84,276 IU · L-1 · h-1, P=0.04). Multivariate analysis revealed statin pretreatment as an independent negative predictor of larger infarct size as defined by the upper tertile of AUC for CK (odds ratio 0.25, 95% confidence interval 0.07-0.91, P=0.035). Conclusion Statin pretreatment may enhance fibrinolysis and reduce infarct size in patients with AMI. (Circ J 2009; 73: 330 - 335)
Summary A 40-year-old man was referred to our hospital because of an abnormal shadow on the left cardiac border on the chest roentgenogram at the regular medical health examination without any ...symptoms. A giant coronary artery aneurysm of left anterior descending artery with a maximum diameter of approximately 50 mm was detected with computed tomography and coronary angiography. The patient was treated and followed up medically. Four years later, the size of the coronary artery aneurysm became larger. Then resection of the coronary artery aneurysm and coronary artery bypass grafting were successfully performed. Coronary artery aneurysms are rare in adults and are usually found in association with Kawasaki disease, coronary atherosclerosis, and so on. We also review the literature of giant coronary artery aneurysms exceeding 50 mm in diameter.
Background: Secondary prevention in patients with myocardial infarction (MI) is critically important to prevent ischaemic heart failure and reduce social burden. Pioglitazone improves vascular ...dysfunction and prevents coronary atherosclerosis, mainly via anti-inflammatory and antiatherogenic effects by enhancing adiponectin production in addition to antihyperglycemic effects, thus suggesting that pioglitazone attenuates cardiovascular events in patients with mild (HbA1c levels < 6·5%) diabetes mellitus (DM). Therefore, we evaluated the effects of pioglitazone on cardiovascular events in patients with both previous MI and mild DM. Methods: In this multicentre, prospective, randomised, open, blinded-endpoint trial, we randomly assigned 630 patients with mild DM with a history of MI to undergo either DM therapy with (pioglitazone group) or without (control group) pioglitazone. DM was diagnosed using the 75-g oral glucose tolerance test, and mild DM was defined if HbA1c level was <6·5%. The primary endpoint was the composite of cardiovascular death and hospitalisation caused by acute MI, unstable angina, coronary revascularisation (including percutaneous coronary intervention and cardiac bypass surgery), and stroke. Findings: HbA1C levels were 5·9 and 5·8% (p = 0·71) at baseline and 6·0 and 5·8% (p < 0·01) at 2 years for the control and pioglitazone groups, respectively.The primary endpoint was observed in 14·2% and 14·1% patients in the control and pioglitazone groups during two years (95% confidential interval (CI):0.662–1·526, p = 0·98), respectively; the incidence of MI and cerebral infarction was 0·3% and 2·2% (95%CI: 0·786–32·415, p = 0·09) and 1·0% and 0·3% (95%CI: 0·051–3·662, p = 0·44), respectively. Post-hoc analyses of the 7-year observation period showed that these trends were comparable (21·9% and 19·2% in the control and pioglitazone groups, 95%CI: 0.618–1·237, p = 0·45). Interpretation: Pioglitazone could not reduce the occurrence of cardiovascular events in patients with mild DM and previous MI. Keywords: Myocardial infarction, Diabetes mellitus, Pioglitazone, Blood glucose-lowering, Cardiovascular events, PROBE study
The aim of this study was to evaluate the utility of distal protection during percutaneous coronary intervention (PCI) in patients with acute coronary syndromes at high risk for distal embolization.
...The results of previous clinical trials indicated that the routine use of distal protection in patients with ST-segment elevation myocardial infarction did not improve clinical outcomes. However, selective use of distal protection by means of a filter-based distal protection system has not been evaluated.
Two hundred patients with acute coronary syndromes who had native coronary artery lesions and attenuated plaque with longitudinal length ≥5 mm on pre-PCI intravascular ultrasound were randomly assigned to undergo PCI with distal protection or conventional treatment.
The primary endpoint (no-reflow phenomenon) occurred in 26 patients (26.5%) in the distal protection group and 39 patients (41.7%) in the conventional treatment group (p = 0.026), and the corrected TIMI (Thrombolysis In Myocardial Infarction) frame count after revascularization was significantly lower in the distal protection group (23 vs. 30.5; p = 0.0003). The incidence of cardiac death, cardiac arrest, cardiogenic shock after revascularization requiring defibrillation, cardiopulmonary resuscitation, or extracorporeal membrane oxygenation was significantly lower in the distal protection group than in the conventional treatment group (0% vs. 5.2%; p = 0.028).
The use of distal embolic protection applied with a filter device decreased the incidence of the no-reflow phenomenon and was associated with fewer serious adverse cardiac events after revascularization than conventional PCI in patients with acute coronary syndromes with attenuated plaque ≥5 mm in length. (Assessment of Distal Protection Device in Patients at High Risk for Distal Embolism in Acute Coronary Syndrome ACS VAMPIRE3; NCT01460966)
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