Background:Phase-contrast cine-magnetic resonance imaging (PC-CMR) of the coronary sinus (CS) is a promising approach for quantifying coronary sinus flow (CSF) and global coronary flow reserve ...(G-CFR). We evaluated the prognostic value of G-CFR using PC-CMR in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS).Methods and Results:The study prospectively enrolled 116 NSTE-ACS patients who underwent uncomplicated urgent PCI within 48 h of symptom onset. Post-PCI (median, 20 days) PC-CMR images of the CS were acquired to assess absolute CSF at rest and during maximum hyperemia. The association of G-CFR with major adverse cardiac events (cardiac death, nonfatal myocardial infarction, late revascularization, or hospitalization for congestive heart failure) was investigated. Rest and maximal hyperemic CSF and corrected G-CFR were 1.27 interquartile range, 0.79–1.73 mL/min/g, 2.95 2.02–3.84 mL/min/g, and 2.42 1.69–3.34, respectively. At a median follow-up of 17 months, cardiac event-free survival was significantly worse in patients with a corrected G-CFR <2.33 (log-rank χ2=19.5, P<0.001). Cox proportional-hazards analysis showed that corrected G-CFR (hazard ratio, 0.434, 95% CI, 0.270–0.699, P<0.001) and NT-pro BNP at admission (hazard ratio, 1.0001, 95% CI, 1.0000–1.0001, P=0.007) were independent predictors of adverse cardiac events during follow-up.Conclusions:In NSTE-ACS patients successfully revascularized within 48 h of onset, post-PCI PC-CMR-derived G-CFR provided significant prognostic information independent of infarct size and conventional risk scores.
Background:Fractional flow reserve (FFR) is an important physiological measure of intermediate coronary artery stenosis. Pressure signal drift (PD) is widely recognized but has largely been ignored ...in FFR measurements. We sought to determine the effect of PD on FFR-derived decision-making.Methods and Results:We analyzed 1,218 FFR measurements for intermediate stenosis in 940 patients, in which the pullback maneuver confirmed PD ≤3 mmHg. The primary objectives were to determine the frequency and magnitude of PD and its effect on decision-making on the basis of an FFR cutoff of 0.80. In all, 479 (39.3%) measurements showed PD. PD was significantly associated with age, hypertension, reference diameter, left anterior descending artery lesion location, and read-out FFR values. Classification discordance between read-out and PD-corrected FFR values was detected in 44 (3.6%) measurements in total and in 9.2% of PD cases. The decision changed from FFR ≤0.80 to FFR >0.80 in 40 (3.3%) and vice versa in 4 (0.3%) measurements. PD showed no effect on decision-making when the FFR read-out value was ≤0.76 or ≥0.83.Conclusions:PD is not uncommon, and its effect on FFR-based decision-making was not negligible in the range between 0.77 and 0.82 where reclassification occurred in 18.7% of FFR measurements. (Circ J 2016; 80: 1812–1819)
Systemic low-grade inflammation has been shown to be associated with left ventricular hypertrophy (LVH). However, the relationship between pericoronary adipose tissue attenuation (PCATA) and both LVH ...and regional physiological indices remains unknown. This study aimed to evaluate the association of PCATA with LVH and regional physiological indices in stable coronary artery disease (CAD) patients with preserved systolic function. A total of 114 CAD patients who underwent coronary CT angiography (CTA) and invasive physiological tests showing ischemia due to a single de novo lesion were included in the study. On proximal 40-mm segments of all three major coronary vessels on CTA, PCATA was assessed by the crude analysis of the mean CT attenuation value − 190 to − 30 Hounsfield units HU) and the culprit vessel PCATA was used for the analysis. Regional physiological indices were invasively obtained by pressure–temperature sensor-tipped wire. The patients were divided into three groups by culprit vessel PCATA tertiles, and clinical, CTA-derived, and physiological indices were compared. Univariable and multivariable analyses were further performed to determine the predictors of LVH. Angiographic stenosis severity, culprit lesion locations, culprit vessel fractional flow reserve, coronary flow reserve, index of microcirculatory resistance, total and target vessel coronary calcium score, and biomarkers including high-sensitivity C-reactive protein were not different among the groups. The left ventricular (LV) mass, LV mass index (LVMI), and LV mass at risk were all significantly different in the three groups with the greatest values in the highest tertile group (all,
P
< 0.05). On multivariable analysis, male gender, NT-proBNP, and PCATA were independent predictors of LVMI. Culprit vessel PCATA was significantly associated with LVMI, but not with regional physiology in CAD patients with functionally significant lesions and preserved systolic function. Our results may offer insight into the pathophysiological mechanisms linking pericoronary inflammation and LVH to worse prognosis.
•Thin-cap fibroatheroma (TCFA) was associated with subsequent neoatherosclerosis.•Low-density lipoprotein cholesterol (LDL-C) was related to neoatherosclerosis.•LDL-C and TCFA incrementally predict ...very late neoatherosclerosis.
Neoatherosclerosis (NA) is recognized as an important contributing factor to very late stent failure. The aim of this study was to investigate whether preprocedural underlying plaque morphology is associated with the development of NA using optical coherence tomography (OCT).
One-hundred thirteen stents 25 bare metal stents, 22 first-generation drug-eluting stents (DES), 66 second-generation DES from 98 patients who underwent percutaneous coronary intervention with pre-percutaneous coronary intervention (PCI) OCT and very late OCT examination >3 years after stenting were retrospectively studied. In OCT analysis, NA was defined as a neointima with lipid or calcification. In-stent lipid volume index was defined as the in-stent averaged lipid arc multiplied by in-stent lipid length.
In all, 28 stents were implanted to the culprit lesions of acute coronary syndrome (ACS) and 85 stents were in stable lesions. NA was observed in 29 stents (25.7%) and the median duration from PCI to remote OCT examination was 5.1 (4.0–6.1) years. Multivariable logistic regression analysis revealed that low-density lipoprotein cholesterol (LDL-C) at follow-up OCT odds ratio (OR) 1.03, 95% confidence interval (CI) 1.01–1.04, p<0.001, stent age (OR 2.13, 95% CI 1.36–3.31, p=0.001), and thin-cap fibroatheroma (TCFA) at baseline culprit lesions (OR 14.2, 95% CI 4.6–43.8, p<0.001) were independent predictors for the development of NA. In multiple linear regression analysis, in-stent lipid volume index was significantly correlated with LDL-C at follow-up OCT, stent age, the target lesion of ACS, and OCT-TCFA at baseline.
In addition to the known predictors, underlying plaque characteristics at the time of stenting was significantly associated with the development of NA at approximately 5 years after stent implantation.
Background Although most coronary thromboses occur on the surface of lipid-rich plaque ( LRP ) with plaque rupture ( PR ), previous pathological and optical coherence tomography studies demonstrated ...diversity in the morphological characteristics of culprit plaque underlying the thrombus, including lesions with intact fibrous cap ( IFC ). We investigated the clinical significance of IFC in relation to the presence or absence of LRP observed via optical coherence tomography in culprit lesions of acute coronary syndrome. Methods and Results We investigated 510 patients with acute coronary syndrome who underwent optical coherence tomography for the culprit lesion. Optical coherence tomography analysis included the presence or absence of PR , which were categorized into the PR group and the IFC group, respectively. The IFC group was further categorized on the basis of the presence of LRP . Incidence of major adverse cardiac events ( MACEs ), including cardiac death, myocardial infarction, and clinically driven remote revascularizations, was compared. Culprit lesions were categorized into 328 PR s and 182 IFC s. MACEs occurred in 85 patients (16.7%) during the median follow-up duration of 621 days. LRP was detected in 325 lesions (99%) with PR , whereas 60 (33.0%) of the lesions with IFC did not show LRP . Kaplan-Meier analysis revealed significantly lower MACEs in the IFC group compared with the PR group. Furthermore, the IFC group without LRP showed significantly lower MACEs compared with the IFC group with LRP . Multivariate Cox proportional hazards analysis demonstrated that IFC without LRP was an independent predictor of better prognosis. Conclusions Exclusion of LRP underneath IFC culprit lesions in acute coronary syndrome may predict a lower risk of future MACEs .
Background A previous coronary computed tomography (CT) angiographic study failed to discriminate optical coherence tomography-defined intact fibrous cap culprit lesions (IFC group) from those with ...ruptured fibrous caps (RFC group) in patients with coronary artery disease. This study aimed to evaluate the diagnostic efficacy of preprocedural coronary CT imaging in identifying subsequently performed optical coherence tomography-defined plaque rupture or erosion at culprit lesions in patients with non-ST-segment-elevation acute myocardial infarction. Methods and Results This study used data from 2 recently published studies that tested the hypothesis that coronary CT angiography (CCTA) before percutaneous coronary intervention may provide diagnostic information on the high-risk atherosclerotic burden in patients with non-ST-segment-elevation acute myocardial infarction. In the analysis of 186 patients, optical coherence tomography identified 106 RFC plaques and 80 IFC plaques as the culprit lesions. On CT, the prevalence of low-attenuation plaque, positive remodeling, napkin-ring sign, and spotty calcification were all significantly lower in the IFC group. The culprit vessel pericoronary adipose tissue inflammation and coronary artery calcium scores were significantly lower in the IFC group than in the RFC group. The absence of low-attenuation plaque, napkin-ring sign, zero coronary artery calcium, and low pericoronary adipose tissue inflammation were independent predictors of IFC. When stratified into 5 subgroups according to the number of these 4 CT factors, the prevalence of IFC was 8.3%, 20.8%, 44.6%, 75.6%, and 100% (
<0.001), respectively. Conclusions Preprocedural comprehensive coronary CT imaging, including coronary artery calcium and pericoronary adipose tissue inflammation assessment, can accurately and noninvasively identify optical coherence tomography-defined IFC or RFC culprit lesions.
Recent studies have indicated high rates of future major adverse cardiovascular events in patients with Takotsubo cardiomyopathy (TC), but there is no well-established tool for risk stratification. ...This study sought to evaluate the prognostic value of several artificial intelligence-augmented ECG (AI-ECG) algorithms in patients with TC.
This study examined consecutive patients in the prospective and observational Mayo Clinic Takotsubo syndrome registry. Several previously validated AI-ECG algorithms were used for the estimation of ECG- age, probability of low ejection fraction, and probability of atrial fibrillation. Multivariable models were constructed to evaluate the association of AI-ECG and other clinical characteristics with major adverse cardiac events, defined as cardiovascular death, recurrence of TC, nonfatal myocardial infarction, hospitalization for congestive heart failure, and stroke. In the final analysis, 305 patients with TC were studied over a median follow-up of 4.8 years. Patients with future major adverse cardiac events were more likely to be older, have a history of hypertension, congestive heart failure, worse renal function, as well as high-risk AI-ECG findings compared with those without. Multivariable Cox proportional hazards analysis indicated that the presence of 2 or 3 high-risk findings detected by AI-ECG remained a significant predictor of major adverse cardiac events in patients with TC after adjustment by conventional risk factors (hazard ratio, 4.419 95% CI, 1.833-10.66,
=0.001).
The combined use of AI-ECG algorithms derived from a single 12-lead ECG might detect subtle underlying patterns associated with worse outcomes in patients with TC. This approach might be beneficial for stratifying high-risk patients with TC.
Background Impaired global coronary flow reserve (g-CFR) is related to worse outcomes. Inflammation has been postulated to play a role in atherosclerosis. This study aimed to evaluate the ...relationship between pre-procedural pericoronary adipose tissue inflammation and g-CFR after the urgent percutaneous coronary intervention in patients with first non-ST-segment-elevation acute coronary syndrome. Methods and Results Phase-contrast cine-magnetic resonance imaging was performed to obtain g-CFR by quantifying coronary sinus flow at 1 month after percutaneous coronary intervention in a total of 116 first non-ST-segment-elevation acute coronary syndrome patients who underwent pre-percutaneous coronary intervention computed tomography angiography. On proximal 40-mm segments of 3 major coronary vessels on computed tomography angiography, pericoronary adipose tissue attenuation was assessed by the crude analysis of mean computed tomography attenuation value. The patients were divided into 2 groups with and without impaired g-CFR divided by the g-CFR value of 1.8. There were significant differences in age, culprit lesion location, N-terminal pro-B-type natriuretic peptide levels, high-sensitivity C-reactive protein (hs-CRP) levels, mean pericoronary adipose tissue attenuation between patients with impaired g-CFR and those without (g-CFR, 1.47 1.16, 1.68 versus 2.66 2.22, 3.28;
<0.001). Multivariable logistic regression analysis revealed that age (odds ratio OR, 1.060; 95% CI, 1.012-1.111,
=0.015) and mean pericoronary adipose tissue attenuation (OR, 1.108; 95% CI, 1.026-1.197,
=0.009) were independent predictors of impaired g-CFR (g-CFR <1.8). Conclusions Mean pericoronary adipose tissue attenuation, a marker of perivascular inflammation, obtained by computed tomography angiography performed before urgent percutaneous coronary intervention, but not hs-CRP, a marker of systemic inflammation was significantly associated with g-CFR at 1-month after revascularization. Our results may suggest the pathophysiological mechanisms linking perivascular inflammation and g-CFR in patients with non-ST-segment-elevation acute coronary syndrome.
The prognostic implications of cardiovascular magnetic resonance imaging (CMR)-derived hyperemic myocardial blood flow (MBF) in patients with ST-elevation myocardial infarction (STEMI) are unknown. ...This study sought to investigate the incremental prognostic value of hyperemic MBF over conventional CMR markers to identify patients with high risk of future incidence of patient-oriented composite outcomes (POCO) and major adverse cardiac events (MACE) after STEMI. A total of 237 patients who presented with STEMI were prospectively enrolled. The CMR protocol included left-ventricular ejection fraction (LVEF), late gadolinium enhancement (LGE) and microvascular obstruction (MVO) measurement, and volumetric MBF assessment. During a median follow-up of 2.6 years, 47 patients experienced POCO (primary outcome) and 21 patients had MACE. In a multivariable model, multivessel disease, LGE, MVO, and hyperemic MBF were independently associated with POCO. Addition of hyperemic MBF to the model consisting of GRACE score, multivessel disease, LVEF, LGE, and MVO significantly improved the predictive efficacy (integrated discrimination improvement 0.020,
p
= 0.021). Patients with low hyperemic MBF had significantly higher incidence of MACE compared to those with high hyperemic MBF in propensity score matching analysis (
p
= 0.018). In conclusion, CMR-derived hyperemic MBF could provide independent and incremental prognostic value over LVEF, LGE, and MVO in patients with STEMI.
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