Background This study aimed to evaluate the prognostic value of hyperemic coronary sinus flow (h-CSF) and global coronary flow reserve (g-CFR) obtained by phase-contrast cine-magnetic resonance ...imaging in patients with acute myocardial infarction (MI). Methods and Results This retrospective study analyzed patients with acute MI (n=523) who underwent primary (ST-segment-elevation MI) or urgent (non-ST-segment-elevation MI) percutaneous coronary intervention. Absolute coronary sinus blood flow (CSF) at rest and during vasodilator stress hyperemia was quantified at 30 days (24-36 days) after the index infarct-related lesion percutaneous coronary intervention and revascularization of functionally significant non-infarct-related lesions. We used Cox proportional hazards regression modeling to examine the association between h-CSF, g-CFR, and major adverse cardiac events defined as all-cause death, nonfatal MI, hospitalization for congestive heart failure, and stroke. Finally, 325 patients with ST-segment-elevation MI (62.1%) and 198 patients with non-ST-segment-elevation MI (37.9%) were studied over a median follow-up of 2.5 years. The rest CSF, h-CSF, and g-CFR were 0.94 (0.68-1.26) mL/min per g, 2.05 (1.42-2.73) mL/min per g, and 2.17 (1.54-3.03), respectively. Major adverse cardiac events occurred in 62 patients, and Cox proportional hazards analysis showed that h-CSF and g-CFR were independent predictors of major adverse cardiac events (h-CSF: hazard ratio HR, 0.64; 95% CI, 0.47-0.88;
=0.005; g-CFR: HR, 0.62; 95% CI, 0.47-0.82;
=0.001). When stratified by h-CSF and g-CFR, cardiac event-free survival was the worst in patients with concordantly impaired h-CSF (<1.6 mL/min per g) and g-CFR (<1.7) (
<0.001). Conclusions Global coronary sinus flow quantification using phase-contrast cine-magnetic resonance imaging provided significant prognostic information independent of infarction size and conventional risk factors in patients with acute MI undergoing revascularization.
Recent retrospective investigations have suggested that optical coherence tomography (OCT) enables the diagnosis of underlying acute coronary syndrome (ACS) causes such as plaque rupture, plaque ...erosion, and calcified nodule. The relationships of these etiologies with clinical outcomes, and the clinical utility of OCT-guided primary percutaneous coronary intervention (PCI) are not systematically studied in real-world ACS treatment settings.
The TACTICS registry is an investigator-initiated, prospective, multicenter, observational study to be conducted at 21 hospitals in Japan. A total of 700 patients with ACS (symptom onset within 24 h) undergoing OCT-guided primary PCI will be enrolled. The primary endpoint of the study is to identify the underlying causes of ACS using OCT-defined morphological assessment of the culprit lesion. The key secondary clinical endpoints are hazard ratios of the composite of cardiovascular death, non-fatal myocardial infarction, heart failure, or ischemia-driven revascularization in patients with underlying etiologies at the 12- and 24-month follow-ups. The feasibility of OCT-guided primary PCI for ACS will be assessed by the achievement rates of optimal post-procedural results and safety endpoints.
The TACTICS registry will provide an overview of the underlying causes of ACS using OCT, and will reveal any difference in clinical outcomes depending on the underlying causes. The registry will also inform on the feasibility of OCT-guided primary PCI for patients with ACS.
The TACTICS (Tokyo, Kanagawa, Chiba, Shizuoka, and Ibaraki active OCT applications for ACS) registry.
ACS, acute coronary syndrome; OCT, optical coherence tomography; PCI, percutaneous coronary intervention. Display omitted
•TACTICS is an investigator-initiated prospective multicenter observational study.•Optical coherence tomography (OCT)-guided primary percutaneous coronary intervention (PCI) will be performed.•The primary endpoint is to identify the underlying causes of acute coronary syndrome (ACS).•Clinical outcomes and feasibility of OCT-guided PCI will be clarified.
Abstract Background The clinical significance of the extent of tissue prolapse (TP) after percutaneous coronary intervention (PCI) for long-term outcomes remains undetermined. This study investigated ...the relationship between the quantities of TP immediately after PCI and neointimal hyperplasia (NIH) at follow-up on serial optical coherence tomography (OCT) examination. Methods We evaluated 145 native coronary lesions (89 lesions with stable angina pectoris SAP and 56 with acute coronary syndrome ACS). OCT was performed to examine pre-PCI plaque morphologies at the narrowest culprit sites, post-PCI TP area in each cross-sectional area (CSA) and TP volume throughout the stented segments, 9-month follow-up NIH area in each CSA and NIH volume throughout the stented segments. We investigated the relationships between the quantities of TP and NIH and their differences according to clinical presentation. Results ACS lesions had a larger TP area at the narrowest culprit sites (0.39 0.14–0.85 vs. 0.11 0.00–0.32 mm2 , P < 0.001) and at the most protruding sites (0.51 0.24–1.08 vs. 0.21 0.10–0.52 mm2 , P < 0.001) compared with SAP lesions. In ACS lesions, TP area was correlated with NIH area at the culprit sites ( r = 0.283, P = 0.042) and at the most protruding sites ( r = 0.288, P = 0.038). In SAP lesions, TP area was correlated with NIH area at the most protruding sites ( r = 0.244, P = 0.030), but not at the culprit sites. Conclusions The extent of TP immediately after PCI was quantitatively related to the degree of NIH at 9-month follow-up on serial OCT examination. The quantities of TP might influence long-term stent outcomes.
Non-obstructive angioscopy has become a novel method of evaluating atheromatous plaques of the aortic intimal wall. A 77-year-old man with coronary artery disease underwent percutaneous coronary ...intervention in the left descending artery. We subsequently used non-obstructive angioscopy to identify aortic atheromatous plaques and incidentally diagnosed an aortic dissecting aneurysm. Non-obstructive angioscopy demonstrated a great fissure in severe atheromatous plaques at the entry site of the aortic dissection identified by enhanced computed tomography. This is the first report to describe the aortic intimal findings of an aortic dissecting aneurysm in vivo by using trans-catheter angioscopy.
Background Sex difference in fractional flow reserve (FFR) and resting index has not been fully clarified. We sought to investigate the impact of sex on the discordance of revascularization decision ...making between FFR and diastolic pressure ratio during the diastolic wave-free period (dPR
). Methods and Results A total of 759 angiographically intermediate lesions with 30% to 80% diameter stenosis by quantitative coronary angiography in 577 patients in whom FFR and dPR
were measured were investigated. dPR
was measured during the wave-free window of 5 heart cycles at an independent core laboratory. FFR ≤0.80 and dPR
≤0.89 were considered positive studies. A total of 164 vessels in 126 women (21.6%) and 595 vessels in 451 men (78.4%) were included. In lesions with negative dPR
, positive FFR was less frequently observed in women (13 of 73; 17.8%) than in men (97 of 286; 33.9%) (
=0.009). In lesions with positive dPR
, the frequency of negative FFR was observed in 22 of 91 vessels (24.2%) in women and 51 of 309 vessels (16.5%) in men, which did not reach statistical significance (
=0.098). In multivariable analyses, female sex was independently associated with FFR-dPR
discordance both in negative dPR
cohort (odds ratio, 0.44; 95% CI, 0.21-0.98;
=0.036) and in positive dPR
cohort (odds ratio, 2.41; 95% CI, 1.17-4.96;
=0.017) after adjustment for age, weight, quantitative coronary angiography data, and baseline physiological indexes. Conclusions The frequency of FFR-dPR
discordance was significantly associated with sex, which may indicate potential shift of optimal threshold of either FFR or dPR
, or both of them, according to sex.
Background Seasonal variations in acute coronary syndromes (ACS) have been reported, with incidence and mortality peaking in the winter. However, the underlying pathophysiology for these variations ...remain speculative. Methods and Results Patients with ACS who underwent optical coherence tomography were recruited from 6 countries. The prevalence of the 3 most common pathologies (plaque rupture, plaque erosion, and calcified plaque) were compared between the 4 seasons. In 1113 patients with ACS (885 male; mean age, 65.8±11.6 years), the rates of plaque rupture, plaque erosion, and calcified plaque were 50%, 39%, and 11% in spring; 44%, 43%, and 13% in summer; 49%, 39%, and 12% in autumn; and 57%, 30%, and 13% in winter (
=0.039). After adjusting for age, sex, and other coronary risk factors, winter was significantly associated with increased risk of plaque rupture (odds ratio OR, 1.652; 95% CI, 1.157-2.359;
=0.006) and decreased risk of plaque erosion (OR, 0.623; 95% CI, 0.429-0.905;
=0.013), compared with summer as a reference. Among patients with rupture, the prevalence of hypertension was significantly higher in winter (
=0.010), whereas no significant difference was observed in the other 2 groups. Conclusions Seasonal variations in the incidence of ACS reflect differences in the underlying pathobiology. The proportion of plaque rupture is highest in winter, whereas that of plaque erosion is highest in summer. A different approach may be needed for the prevention and treatment of ACS depending on the season of its occurrence. Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT03479723.
Objective: Endovascular treatment (EVT) for lower-limb peripheral artery disease patients reduces blood pressure (BP) and improves prognosis. This study retrospectively examined hemodynamics during ...EVT to clarify the mechanism.Materials and Methods: Systemic vascular resistance (SVR) was measured using a noninvasive continuous cardiac output monitoring system during EVT. Furthermore, ankle brachial index was measured before and after EVT.Results: The study included 88 lesions of 56 patients (hypertension in 98%). SVR significantly decreased from 2409.1±746.8 dynes·s·cm−5 to 2033.7±635.0 dynes·s·cm−5 (p<0.0001). The difference in SVR before and after EVT was significantly greater in the Fontaine IV group than in the Fontaine IIa group (554.7±406.6 dynes·s·cm−5 vs. 312.9±245.7 dynes·s·cm−5, p=0.0151). The change in SVR was correlated with a change in mean BP in the upper limb (p=0.0026). When the change in pressure gradient between the upper limb and the diseased lower limb was large, mean BP of the upper limb significantly decreased (p=0.0022).Conclusion: EVT can reduce SVR and BP by canceling the pressure gradient between central BP and diseased lower-limb BP.
Tolvaptan, a vasopressin type 2 receptor antagonist, does not affect kidney circulation or cause worsening of renal function (WRF) in patients with acute decompensated heart failure (ADHF). ...Bioelectrical impedance analysis (BIA) can be used to evaluate intravascular volume by calculating the ratio of extracellular water (ECW) to intracellular water (ICW). There have been no reports examining the mechanisms of tolvaptan-induced diuresis using BIA. We investigated whether tolvaptan decreases excess volume while maintaining intravascular volume in ADHF patients.Study patients included 29 ADHF patients (age 48-95, men 69%) diagnosed between April 2013 and May 2016 and who underwent BIA before and after treatment. Fifteen patients were treated with tolvaptan in addition to conventional diuresis therapy (tolvaptan group), and 14 patients were treated with conventional diuresis therapy only (control group). In the control group, the numerical value of serum creatinine (Cre) significantly increased from 0.89 ± 0.22 mg/ dL to 1.07 ± 0.29 mg/dL (P = 0.004), and the ECW/ICW significantly decreased from 0.696 ± 0.036 to 0.673 ± 0.032 (P = 0.004). These values were not significantly different from those obtained for the tolvaptan group. Furthermore, regression analysis showed a negative correlation between ΔCre and ΔECW/ICW, which are the differences between values before and after treatment (ΔCre = -0.002-5.668 × ΔECW/ICW, r2 = 0.306, P = 0.002).Our findings suggest that WRF is caused by a reduction in intravascular volume and that tolvaptan treatment can decrease the excess volume while maintaining intravascular volume.
Background: We aimed to assess the relationships of pentraxin-3 (PTX3) with coronary plaque components and myocardial perfusion after percutaneous coronary intervention (PCI) in order to clarify the ...mechanisms underlying the prognostic function of PTX3 in ST-elevation acute myocardial infarction (STEMI) patients. Methods and Results: We enrolled 75 STEMI patients who underwent pre-PCI virtual histology (VH)-intravascular ultrasound. Relationships of the systemic pre-PCI PTX3 level with coronary plaque components and post-PCI myocardial blush grade (MBG) were evaluated. Lesions with elevated pre-PCI PTX3 (median ≥3.79ng/ml) had higher frequencies of VH-derived thin-cap fibroatheroma (65.8% vs. 24.3%, P<0.0001), plaque rupture (63.2% vs. 24.3%, P=0.001), and post-PCI MBG (0–1) (65.8% vs. 40.5%, P=0.03) than those with PTX3 <3.79ng/ml. In multivariate analysis, pre-PCI PTX3 level was independently related to post-PCI MBG (0–1) (odds ratio, 11.385; 95% confidence interval (CI), 1.346–96.289; P=0.026). At 9-month follow-up, cardiac event-free survival was poorer for patients with post-PCI MBG (0–1) (log-rank test χ2=8.6; P=0.003). Cox proportional-hazards analysis showed post-PCI MBG (0–1) (hazard ratio, 4.109; 95% CI, 1.372–12.309; P=0.012) and Killip class >2 on admission (hazard ratio, 5.356; 95% CI, 1.409–20.359; P=0.014) as independent predictors of adverse cardiac events during follow-up. Conclusions: Systemic pre-PCI PTX3 was associated with high-risk plaque components and impaired post-PCI myocardial perfusion. Thus, PTX3 may be a reliable predictor of outcome in STEMI patients. (Circ J 2014; 78: 159–169)
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