bluuebunny/crossref_metadata_2025 huggingface dataset:
Statins bring the prognostic impact only in peripheral artery disease patients with elevated c-reactive proteins -subanalysis from multicenter registry-
Authors: Shibahashi E , Jujo K , Ueshima D , Fujimoto Y , Shimazaki K , Tanaka T , Murata T , Miyazaki T , Matsumoto M , Tokuyama H , Shimura T , Higashitani M
Published: November 2020

Introduction

Recent trials demonstrated favorable effects of statins on the clinical prognosis, partly through anti-inflammatory properties, in patients with coronary artery disease. However, this favorable effect has not been fully verified in patients with peripheral arterial disease (PAD). We hypothesized that statins exert different prognostic effects depending on the degrees of inflammation at the time of endovascular therapy (EVT).

Methods

This study is a subanalysis from the Toma-Code Registry that is a Japanese prospective cohort of 2,321 consecutive patients with PAD treated by endovascular therapy in hospitals from 2014 to 2016. After the exclusion of patients without information of C-reactive protein (CRP) at the time of index EVT, 2,039 patients including 1,039 statin users and 1,000 statin non-users were ultimately analyzed. The patient enrolled were divided into 4 categories depending on CRP level at the time of EVT; Low-CRP (<0.1 mg/dL), Intermediate-low-CRP (0.1–0.3 mg/dL), Intermediate-High-CRP (0.3–1.0 mg/dL), and High-CRP (>1.0 mg/dL). A composite of death, stroke, myocardial infarction, and major amputation as the primary endpoint of this study was compared between statin users and non-users in each CRP category.

Results

The composite endpoint occurred in 255 patients during the observation period. Overall, statin users had a significantly lower event rate than non-users (Log-rank test: P<0.001). However, there were no significant difference in the event rates between statin users and non-users in the Low-, and Intermediate-Low-CRP categories. Only in the Intermediate-High- and the High-CRP categories, statin users showed a significantly lower event rates than non-users (P=0.02 and P=0.008, respectively, Figures). Additionally, multivariate Cox regression analysis in the High-CRP group revealed that statin use was independently associated with the primary endpoint (adjusted hazard ratio: 0.67 [95% confidence interval: 0.45–0.99]), even after the adjustment of covariants.

Conclusion

Statins may exert a favorable prognostic effect in PAD patients with highly elevated CRP, but not in those with low to moderate CRP level.

Event free survival

Funding Acknowledgement

Type of funding source: None
The predictors of clinical outcome after endovascular intervention for lower extremity peripheral arterial disease
Authors: Kim B , Kim B.G , Seo J.K , Kim G.S , Lee H.Y , Byun Y.S
Published: November 2020

Background

Patients with peripheral arterial disease (PAD) have a higher mortality rate than age-matched patients without PAD. Also more than half of patients with symptomatic PAD have polyvascuar disorder including coronary artery disease (CAD).

Purpose

This study aimed to identify the predictors of mortality outcomes in patients with peripheral artery disease undergoing lower extremity endovascular intervention.

Methods

We studied 300 consecutive patients admitted for symptomatic low extremity arterial disease. A total of 196 patients without angina and prior coronary revascularization (72±10 years, 156 men) who underwent lower extremity endovascular intervention (claudication, n=74; critical limb ischemia, n=122) were retrospectively analyzed. All patients underwent coronary angiography but not simultaneous coronary revascularization. CAD was defined as angiographically significant (≥50%) stenosis of coronary arteries and severity was classified as none, 1-, 2-, or 3-vessel disease (VD). All-cause mortality and major adverse cardiac and cerebrovascular event (MACCE) rate were compared between the patients with CAD and those without CAD. MACCE included any of the following adverse events: cardiac death, cerebrovascular death, acute myocardial infarction, stroke, and congestive heart failure.

Results

Mean duration of follow-up was 3 years. All-cause mortality and MACCE were 16.3% and 19.8%, respectively. The independent risk factors for all-cause mortality were old age (HR=1.05, P=0.043), lower body mass index (HR=0.83, P=0.016), critical limb ischemia (HR=3.74, P=0.033) and the presence of CAD (HR=2.85, P=0.027). This variable surpassed all classical risk factors (including smoking and history of hypertension or diabetes mellitus). Of the 196 patients, 101 patients (52%) had asymptomatic CAD; 1-VD (n=35, 18%); 2-VD (n=32, 16%); 3-VD (n=28, 14%). Patients with CAD had significantly higher all-cause mortality (19% vs. 11%, P=0.018) and higher MACCE rate (26% vs. 8%, P=0.001) compared to those without CAD. Furthermore, the severity of CAD had graded associations with the all-cause mortality and MACCE rate (Figure). Independent predictors of CAD were critical limb ischemia (CLI) (OR = 2.43, P=0.018) and presence of the below-the-knee lesions (OR = 2.04, P=0.019). In addition, CAD was more prevalent in the patients with lower BMI (61% vs. 41%, p=0.007).

Conclusion

Asymptomatic coronary artery disease (CAD) was found in half of the patients undergoing endovascular intervention for lower extremity arterial disease and associated with higher mortality and MACCE rate. Therefore, detection of CAD might be important for risk stratification for these patients, especially with lower body mass index or critical limb ischemia.

Funding Acknowledgement

Type of funding source: None
Upper extremities deep vein thrombosis and DOAC treatment: a prospective cohort study
Authors: Vedovati M.C , Tratar G , Mavri A , Pierpaoli L , Agnelli G , Becattini C
Published: November 2020

Background

Data on the use of direct oral anticoagulants (DOACs) in patients with upper extremities deep vein thrombosis (UEDVT) are limited.

Purpose

To assess the effectiveness and safety of DOACs in the treatment of UEDVT.

Methods

Data on patients with an objective diagnosis of acute UEDVT treated with DOACs were merged from prospective cohorts of patients with venous thromboembolism (VTE). Study outcomes were recurrent VTE and major bleeding (MB) occurring during DOAC treatment.

Results

Overall, 132 patients were included: mean age was 47.7±18.0 years (range 18 to 97), males were 42.4%. Twenty-seven percent of patients had 2 or more risk factors for VTE, 29.5% had UEDVT complicating a central venous line or after pacemaker implantation (Table). Ninety-two patients (70%) were managed as outpatients. Increased age (OR 1.03, 95% CI 1.0–1.05) and anemia (OR 1.35, 95% CI 1.07–1.70) were associated with in-patient management. Among patients treated with apixaban (40) or rivaroxaban (85) loading dose was used in 72%; in patients treated with dabigatran (5) or edoxaban (2) mean heparin pre-treatment was 8 days. DOACs were started after 1 month from UEDVT diagnosis in 12.9% of patients; active cancer was a main predictor for delayed initiation (OR 22.2, 95% CI 5.8–84.4). Mean treatment duration in patients with a scheduled stop was 4.9 months, while mean followup in those who continued DOACs was 9.3 months. No recurrence of VTE nor MBs occurred during DOAC treatment; one patient had acute limb ischemia (1.38% patient-year), 7 clinically relevant non-MBs (3 genital, 2 epistaxis, 1 gingival, 1 genital bleeding plus epistaxis; 10.51% patient-year), 5 deaths (4 cancer, 1 advanced age; 9.69% patient-year).

Conclusions

Our data support the effectiveness and safety of DOACs for the treatment of acute UEDVT. Further studies are required to confirm these findings.

Funding Acknowledgement

Type of funding source: None
Cardiac troponin I and incident stroke in European cohorts – insights from the BiomarCaRE project
Authors: Camen S , Palosaari T , Kuulasmaa K , Soederberg S , Palmieri L , Ferrario M.M , Blankenberg S , Niiranen T , Tunstall-Pedoe H , Peters A , Zeller T , Linneberg A , Salomaa V , Iacoviello L , Schnabel R.B
Published: November 2020

Background

Stroke is a common cause of death and a leading cause of disability and morbidity. Stroke risk assessment remains a challenge but circulating biomarkers may improve risk prediction. Controversial evidence is available on the predictive ability of troponin concentrations and the risk of stroke in the community. Furthermore, reports on the predictive value of troponin concentrations for different stroke subtypes (ischemic and hemorrhagic) are scarce.

Methods

High-sensitivity cardiac troponin I (hsTnI) concentrations were assessed in 82,881 individuals (median age 50.7 years, 49.7% men) free of stroke or myocardial infarction at baseline from nine prospective European community cohorts. Multiple imputations were used to handle missing data. We used Cox proportional hazards regression to determine relative risks, followed by measures of discrimination and reclassification using 10-fold cross-validation to control for over-optimism. Follow-up was based upon linkage with national hospitalization registries and causes of death registries.

Results

Over a median follow-up of 12.7 years, 3,033 individuals were diagnosed with incident non-fatal or fatal stroke (N=1,654 ischemic strokes, N=612 hemorrhagic strokes, N=767 indeterminate strokes). In multivariable regression models hsTnI concentrations were associated with overall stroke (hazard ratio (HR) per one standard deviation increase 1.16, 95% confidence interval (CI) 1.10–1.21), ischemic stroke (HR 1.15, 95% CI 1.09–1.21) and hemorrhagic stroke (HR 1.10, 95% CI 1.01–1.21). Adding hsTnI concentrations to classical cardiovascular risk factors (C-indices 0.808, 0.840 and 0.735 for overall, ischemic and hemorrhagic stroke, respectively) increased the C-index significantly, but modestly. In individuals with an intermediate ten-year risk (5–20%) the net reclassification improvement for overall stroke was 0.039 (p=0.010).

Conclusions

Elevated hsTnI concentrations are associated with an increased risk of incident stroke in the community, irrespective of stroke subtype. Adding hsTnI concentrations to classical risk factors only modestly improved estimation of 10-year risk of stroke in the overall cohort, but might be of some value in individuals at an intermediate risk.

Funding Acknowledgement

Type of funding source: Public grant(s) – EU funding. Main funding source(s): The BiomarCaRE Project is funded by the European Union Seventh Framework Programme (FP7/2007-2013) under grant agreement no.HEALTH-F2-2011-278913. This project has received further funding from the European Research Council (ERC) under the European Union's Horizon 2020 research and innovation programme (grant agreement No 648131).
Men who live alone have high risk of NOAC discontinuation
Authors: Binding C , Olesen J.B , Lee C , Sindet-Petersen C , Pedersen C.T , Gislason G , Bonde A
Published: November 2020

Background/Introduction

Patients with atrial fibrillation (AF), who are considered at risk of stroke, are treated with oral anticoagulants (OACs), and non-vitamin K antagonist oral anticoagulants (NOACs) are preferred over vitamin K antagonists in recent guidelines. Poor NOAC compliance among patients with AF could result in an increased risk of thromboembolism and major bleeding, however, it has yet to be evaluated how cohabitant status and gender affects compliance with NOAC treatment among patients with AF.

Purpose

The aim of this study was to evaluate the risk of NOAC discontinuation among patients with AF according to cohabitant status and gender.

Methods

Using the Danish national registries we identified and included patients with AF aged 40–90 years in treatment with NOAC. The study period was from 2013 to 2017, and patients were followed for two years, or until death, outcome or emigration. The main outcome was discontinuation of NOAC-treatment for at least 30 days. Absolute risks were calculated as cumulative incidences using the Aalen Johansen estimator, and multiple covariate adjusted Cox regressions were used to calculate hazard ratios (HR).

Results

We included 32,380 patients with AF in NOAC treatment, where 16.8% were men living alone (median age 72 years), 25.8% were women living alone (median age 79 years), 37.2% were men living with a partner (median age 70 years), and 20.2% were women living with a partner (median age 79 years). Absolute two-year risk of NOAC discontinuation was highest among men living alone (Cumulative Incidence (CI) 0.19; 95% CI: 0.17 to 0.20), followed by men living with a partner (CI 0.18; 0.17 to 0.19), women living with a partner (CI 0.16; 0.15 to 0.17), and women living alone (CI 0.13; 0.12 to 0.14). After adjustment, living alone was associated with an increased risk of NOAC discontinuation among men (HR 1.15, 95% CI: 1.05 to 1.26), but not among women (HR 1.04, 95% CI: 0.93 to 1.15, interaction p=0.32). In an analysis evaluating gender, we found that being male was associated with a significantly higher risk of NOAC-discontinuation (HR 1.18, CI: 1.10 to 1.25) compared to women.

Results were similar when we used 60 days discontinuation instead of 30 days discontinuation as outcome.

Conclusion

Gender and cohabitant status was significantly associated with risk of NOAC discontinuation. Male gender and living alone was associated with a higher risk of NOAC discontinuation among patients with AF in a nationwide population.

Adjusted relative two-year risks

Funding Acknowledgement

Type of funding source: None
Structural and functional atrial remodelling after transcatheter closure of patent foramen ovale
Authors: Molnar A.A , Abraham P , Gulyas G , Meszaros H , Straub E , Nardai S , Merkely B
Published: November 2020

Introduction

Patent foramen ovale (PFO) is a common abnormality affecting more than 20% of the adult population. For most people they are accidental findings; however, in some the PFO can open widely enabling paradoxical embolisation. Randomised controlled trials have demonstrated in patients with cryptogenic stroke that transcatheter closure of PFO with a septal occluder device is associated with reduced rates of recurrent stroke. However, the impact of atrial septal closure on left atrial (LA) and right atrial (RA) structural and functional remodelling is less known.

Methods

We prospectively enrolled 53 patients with cryptogenic ischemic stroke and PFO eligible for transcatheter PFO closure (mean age 46±11 years, 44% females). National Institute of Health Stroke Score (NIHSS), and the modified Rankin score (mRS) were calculated as markers of clinical severity of the index stroke. Presence of any shunt, atrial volumes and functional parameters were evaluated including LA reservoir, conduit and contraction function before PFO closure and 12 months after procedure. Beyond conventional transthoracic echocardiography (Philips Epiq CVx Ultrasound), two dimensional speckle tracking method was used to assess body surface area-indexed LA maximal volume (LAVmaxi), LA minimal volume (LAVmini), LA volume before left atrial contraction (LApreAi), LA ejection fraction (LAEF), LA reservoir strain (LASres), LA conduit strain (LAScond), LA contraction strain (LAScontr), LA peak systolic strain rates (LASRs), LA peak early diastolic strain rate (LASRe) and LA peak late diastolic strain rate (LASRa) using dedicated software on separate workstation (Cardiac Performance; TomTec Imaging, Unterschleissheim, Germany).

Results

The index stroke was modest and non-disabling, with an NIHSS 3.37±2.63 and mRS 1.67±1.06. Baseline LA, RA volumes and dimensions were in normal range (LAVi 25.5±9.6 ml/m2; LA length 37.6±6.2 mm; LA width 40.4±7.1 mm; RA length 36.6±6.7 mm; RA width 39.5±8.6 mm). Thirty-seven patient had 12 month clinical follow-up examinations revealing no significant differences (all p values >0.05) in atrial volumes, ejection fraction and strain parameters. LASRa was significantly lower after 12 month (p=0.03; baseline LASRa −1.7±0.7 s–1 vs follow-up LASRa −1.3±0.9 s–1) No new cerebral ischaemic events, aortic erosions, atrial fibrillation, significant residual shunts or device thrombosis and displacement were recorded during the follow-up.

Conclusion

PFO-associated strokes in young individuals are mainly non-disabling. Our study suggests that transcatheter interatrial closure is effective without promoting unfavourable atrial anatomical remodelling during short-term follow-up, however, it may affect active atrial contraction. Long-term follow-up examinations are needed to investigate the potential late impact of occluders on atrial anatomical, functional remodelling.

Funding Acknowledgement

Type of funding source: None
Left atrial appendage closure with zero fluoroscopic exposure via intracardiac echocardiographic guidance
Authors: Du X.F , Chu H.M , Shen C.J , He B
Published: November 2020

Background

Percutaneous left atrial appendage closure (LAAC) is currently guided by fluoroscopy and transesophageal echocardiography (TEE).

Objective

We report an LAAC technique using intracardiac echocardiography (ICE) and electroanatomic mapping system (EAMS) under local anesthesia without fluoroscopy exposure.

Methods

Seven non-valvular atrial fibrillation (NVAF) patients with high risk of stroke and bleeding (male 5/7, aged 71.7±8.8 years, mean CHA2DS2-VASc score 5.1±2.1; mean HAS-BLED score 3.0±1.2) were enrolled. ICE probe was advanced into left atrium (LA) navigated by the EAMS. LAA sizing and LAmbreTM device implantation were guided by ICE following the orthogonal tri-axial algorithm (Axis-X: from left pulmonary veins [LPVs] to LAA; Axis-Y: from right PV ostium to LAA; Axis-Z: from lower LA to LAA).

Results

There were two cauliflower-like, two chicken-wing-like and three cactus-like LAAs. The mean diameters of ostia and landing zone were 21.4±3.9mm and 20.4±4.2mm, respectively. LAmbre devices with a mean umbrella diameter of 23.7±4.2mm and cover disc diameter of 29.4±3.6mm were successfully implanted and acute complete LAA sealing without peri-device leak (PDL) were achieved in all cases. The mean procedural duration was 73.0±21.4min. No fluoroscopy exposure nor contrast consumption were recorded. No procedure-related complications were documented. The PDL at 45-day follow-up was 1.7±0.8mm. No stroke or thromboembolic events were documented.

Conclusions

The fluoroscopic exposure could be minimized, even to zero, in the ICE-guided LAAC procedures feasibly and safely using LAmbre devices. The orthogonal tri-axial assessment is considered efficacious and safe for the procedures.

Orthogonal tri-axial algorithm

Funding Acknowledgement

Type of funding source: None
Genetically determined atrial fibrillation and risk of stroke: a Mendelian randomization study
Authors: Fill J , Fokina A , Klappacher G
Published: November 2020

Background

Based on observational evidence, atrial fibrillation is a well-established risk factor of stroke to be considered for antithrombotic treatment in presence of additional clinical conditions derived from multivariate risk models. Although biologically plausible, it however still is unknown whether this association is causal and confined to the embolic stroke subtype.

Purpose

Our objective was to explore whether genetically determined manifestation of atrial fibrillation was associated with stroke and its etiologic subtypes by conducting a 2-sample Mendelian randomization (MR) study on publicly available summary statistics from GWAS consortia.

Methods

Genetic instruments for atrial fibrillation were obtained from the AFGen Consortium comprising 17,931 cases and 115,142 controls. Their associations with stroke and stroke subtypes were evaluated in the MEGASTROKE genome-wide association study data set (67 162 cases; 454 450 controls) applying inverse variance–weighted meta-analysis, weighted-median analysis, Mendelian randomization–Egger regression, and multivariable Mendelian randomization. The dataset of Nielsen et al. comprising a total of 60,620 cases with atrial fibrillation and 970,216 controls of European ancestry from six contributing studies was used as an independent validation sample. Genetic instruments for atrial fibrillation were further tested for association with etiologically related traits by using publicly available genome-wide association study data.

Results

Genetic predisposition to atrial fibrillation was associated with higher risk of any stroke (beta coefficient [b] ± standard error [se] = 0.22±0.04; P=0.0001), any ischemic stroke (b ± se = 0.24±0.05; P=0.0003), and cardioembolic stroke (b ± se = 0.76±0.10; P<0.0001), but not with small-vessel stroke or large artery stroke, see figure. Analyses in the validation sample showed similar associations (any stroke: b ± se = 0.19±0.04; P<0.0001; any ischemic stroke: b ± se = 0.21±0.04; P<0.0001; cardioembolic stroke: b ± se = 0.82±0.13; P<0.0001). Genetically determined atrial fibrillation was further weakly associated with chronic kidney disease (b ± se = 0.10±0.04; P=0.0261), but not with coronary artery disease and myocardial infarction or any other available phenotype.

Conclusions

Genetic predisposition to atrial fibrillation is associated with higher risk of any stroke, mainly driven by the ischemic and cardioembolic subtypes. In contrast, large artery and small-vessel strokes did not exhibit a causal relationship with atrial fibrillation.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Medical University of Vienna, Austria
Global risk factors of contrast-induced acute kidney injury: systematic review and meta-analysis
Authors: Liu L , Liu Y , Chen S , Chung E.Y.M , Lei L , He Y , Lun Z , Chen L , Zhang H , Zhuang X , Song F , Sun G , Chen G , Chen J.Y , Tan N
Published: November 2020

Background

Administration of iodinated contrast is common but may be associated with contrast-induced acute kidney injury (CI-AKI), particularly in at-risk patients. There is no recent systematic review of potentially modifiable risk factors.

Methods

We searched MEDLINE, Embase and the Cochrane Database of Systematic Reviews (to 30 th June 2019) for observational studies assessing risk factors associated with CI-AKI. Twelve potentially modifiable risk factors were finally included in this thematic review and meta-analysis. Random or fixed meta-analysis was performed to derive the adjusted odds ratio (aOR), and the population attributable risk (PAR) was calculated for each risk factor globally and by region.

Findings

We included 157 studies (2,297,863 participants). The global incidence of CI-AKI was 5.4%. The potentially modifiable risk factors included high contrast volume (PAR 33%), eight cardiovascular risk factors (diuretic use, multivessel coronary artery disease, acute coronary syndrome, hypertension, hypotension, heart failure, reduced left ventricular ejection fraction and intra-aortic balloon pump use) (combined PAR 76.2%) and three noncardiovascular risk factors (renal dysfunction, diabetes mellitus and anaemia) (combined PAR 47.4%) with geographical differences.

Bubble chart of the 12 risk factors

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): National Science Foundation of China
A prospective, randomized, comparison of the coronary vasomotion associated with drug-coated balloon versus drug-eluting stent
Authors: Kawai T , Yamada T , Watanabe T , Morita T , Furukawa Y , Tamaki S , Kawasaki M , Kikuchi A , Seo M , Nakamura J , Kayama K , Kawahira M , Fukunami M
Published: November 2020

Background

It is widely known that even new-generation drug-eluting stent (DES) induce coronary vasomotion abnormality. On the other hand, recent studies reported that drug-coated balloon (DCB) for native coronary artery was non-inferior to DES in medium term outcomes. However, there is no available information about vasomotion after treatment with DCB.

Purpose

The aim of this study was to prospectively compare coronary vasomotion in patients treated with DCB versus new-generation DES.

Methods

Twenty-seven patients were randomly treated with angioplasty with DCB (n=12) versus implantation of bioabsorbable polymer everolimus-eluting stent (BP-EES, n=15) after successful predilation. At 8 months after treatment, endothelium-dependent and -independent vasomotion were evaluated by intracoronary infusion of incremental doses of acetylcholine (for right coronary artery: low-dose 5μg, high-dose 50μg and for left coronary artery: low-dose 10μg, high-dose 100μg) and nitroglycerine (200μg). Mean luminal diameter of the distal segments, beginning 5 mm and ending 15 mm distal to the edge of the treated segment was quantitatively measured by angiography.

Results

Clinical and procedural characteristics were not different between two groups. Vasoconstriction after acetylcholine infusion was less pronounced in the DCB group than the BP-EES group (low-dose: 4±13% vs −4±14%, p=0.158, high-dose: −2±14% vs −28±30%, p=0.013). The response to nitroglycerin was not different between two groups (17±13% vs 18±24%, p=0.838).

Conclusion

Vasoconstriction after acetylcholine infusion in the peri-treated region was more pronounced in the BP-EES group than in the DCB group, which suggests that endothelial function of coronary vessel treated by DCB can be more preserved than new-generation DES.

Figure 1

Funding Acknowledgement

Type of funding source: None
Radial versus femoral access for coronary angiography and interventions: a systematic review and meta-analysis of randomized trials
Authors: Chiarito M , Cao D , Nicolas J , Roumeliotis A , Power D , Chandiramani R , Goel R , Claessen B.E , Ferrante G , Stefanini G.G , Mehran R , Dangas G
Published: November 2020

Background

The presence of any benefits associated with radial or femoral access among patients undergoing coronary angiography and percutaneous coronary interventions (PCI) is still debated.

Purpose

Our aim is to provide a comprehensive quantitative appraisal of the effects of access site on the risks of stroke, myocardial infarction, and major bleeding in patients undergoing coronary angiography with or without PCI.

Methods

In January 2020, we searched PubMed, Embase, and meeting abstracts for randomized trials comparing radial versus femoral access for coronary angiography with or without subsequent PCI. Odds ratios (OR) were used as metric of choice for treatment effects with random-effects models. Co-primary efficacy endpoints were stroke and myocardial infarction. Primary safety endpoint was major bleeding. Secondary endpoints were all cause mortality and vascular complications. Heterogeneity was assessed with the I-squared index. This study is registered with PROSPERO.

Results

We identified 31 trials, including 30,414 patients. Risks of stroke (OR 1.11, 95% CI 0.76–1.64, I2=0%) and myocardial infarction (OR 0.90, 95% CI 0.79–1.03, I2=0%) were comparable between radial and femoral access. Radial access was associated with a reduction for the risk of major bleeding as compared to femoral access (OR 0.53, 95% CI 0.42–0.67, I2=3.3%) with a number needed to treat of 92. Findings were consistent regardless clinical features and procedure performed, with the only exception of an increased benefit of the radial access in patients with chronic coronary syndrome (p forinteraction=0.005). The risk for all-cause mortality (OR 0.73, 95% CI 0.61–0.89, I2=0%) and vascular complication (OR 0.32, 95% CI 0.23–0.44, I2=16.7%) was significantly lower in the radial compared to femoral access group.

Conclusions

In patients undergoing coronary angiography with or without PCI, radial compared to femoral access did not reduce the risk of stroke and myocardial infarction, with no impact on the effect estimates of clinical presentation, age, gender, or subsequent PCI. Whereas, radial access is associated with a significant risk reduction of major bleeding as compared to femoral access. The benefit favoring radial access is of important clinical relevance in view of the relatively low number needed to treat to prevent a major bleeding and the significant impact on mortality.

Funding Acknowledgement

Type of funding source: None
Side branch long lesion with main vessel vulnerable plaques by optical coherence tomography predict target-vessel myocardial infarction after provisional stenting in patients with coronary bifurcation
Authors: Chen S.L
Published: November 2020

Background

Provisional side branch (SB) stenting is correlated with target-vessel myocardial infarction (TVMI) in patients with coronary bifurcation lesions. However, the underlying mechanisms remain unknown.

Objectives

We aimed to determine the correlation of SB lesion length with vulnerable plaques using optical coherence tomography (OCT) and TVMI in patients with coronary bifurcation lesions treated by a provisional approach.

Methods

A total of 405 patients with 405 bifurcation lesions who underwent pre-PCI OCT imaging of both main vessel (MV) and SB was prospectively enrolled. Patients were defined as Long-SB lesion (SB lesion length ≥10 mm) and Short-SB lesion (SB lesion length <10 mm) groups according to quantitative coronary analysis and were also stratified by the presence of vulnerable plaques based on OCT findings. The primary endpoint was the occurrence of TVMI after provisional stenting at one-year follow-up.

Results

178 (43.9%) patients had long SB lesions. Vulnerable plaques predominantly localized in the main vessel (MV) and more frequently in the Long-SB lesion group (42.7%) compared to 24.2% in the Short-SB lesion group (p<0.001). At one-year follow-up after provisional stenting, there were 31 (8.1%) TVMIs, with 11.8% in the Long-SB lesion group and 4.4% in the Short-SB lesion group (p=0.009), leading to significant difference in target lesion failure between two groups (15.2% vs. 6.6%, p=0.007). The rate of cardiac death, revascularization, and stent thrombosis was comparable between study groups. By multivariate regression analysis, long SB lesion length (p=0.011), presence of vulnerable plaques in the polygon of confluence (p=0.001), and true coronary bifurcation lesions (p=0.004) were three independent factors of TVMI.

Conclusions

Long-SB lesion length with MV vulnerable plaques predict increased TVMI after provisional stenting in patients with true coronary bifurcation lesions. Further study is warranted to identify the better stenting techniques for coronary bifurcation lesions with long lesion in the SB

Kaplan-Meier survival curve

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): NSFC
Differential diagnosis and intervention for braid-like coronary artery – case series analysis based on intracoronary artery imaging
Authors: Leng W.X , Gao L.J
Published: November 2020

Background

Case reports on braid-like coronary arteries, often diagnosed as Woven Coronary Artery, are accumulating. However, the diversity of manifestation of such lesions has caused great confusion.

Methods

Consecutive patients admitted to Fuwai hospital with braid-like lesions on coronary angiography (CAG) were included. Intracoronary optical coherence tomography (OCT) was performed to verify the lesion nature. Major cardiovascular events were recorded in 12 months when a control CAG was recommended.

Results

From January 2018 to June 2019, braid-like lesions were identified in 6 patients (5 male) with average age of 45.3 years. All patients were transferred from lower-level hospitals. Five patients were current heavy smokers, and 4 patients had an old anterior myocardial infarction history. The braid-like segments were found in right coronary artery of 4 patients and in left anterior descending artery of the other 2 patients. Of these 6 braid-like lesions, 3 were culprit of coronary adverse events, and the other 3 lacked relevant history or documented inducible ischemia. The OCT images of all lesions were consistent with recanalization of organized thrombi, which consisted of septa that divided the lumen into multiple small cavities communicating with each other with significant stenosis. These structures had smooth inner borders with traces of intraluminal thrombi, but no separate 3-layered structure could be defined. Drug eluting stents were successfully implanted in all braid-like lesions. All patients were event free for 12 months, and 3 patients received control CAGs which showed stents patent.

Conclusions

Most cases of braid-like coronary artery may be recanalization of organized thrombi rather than Woven Coronary Artery. Smoking may be a potential risk factor. Percutaneous stent implantation may be challenging but benificial in selected patients. The underlying cause of the forming of such thrombotic lesions remained unclear.

Imagings before and after intervention

Funding Acknowledgement

Type of funding source: None
Similar degree of intimal coverage and apposition among drug-eluting stents with persistent, absorbable or without polymer at 1 and 6 months after implantation
Authors: Calvo Fernandez A , Negrete A , Tizon-Marcos H , Millan R , Salvatella N , De La Torre J.M , Diez J.L , Ivern C , Gomez-Lara J , Vaquerizo B
Published: November 2020

Background

Despite technological advances in drug-eluting stents (DES) design, delayed vascular healing is still a problem, triggered by the polymers among others. This may induce restenosis and thrombosis. The development of biodegradable polymers and DES without polymer is thought to improve the vascular response and enhance earlier neointimal healing. Optical coherence tomography (OCT) is the best intracoronary imaging tool to evaluate endothelial coverage after stent implantation.

Purpose

We aimed to quantitatively assess the differences on intimal coverage between biodegradable-polymer, durable-polymer and without-polymer DES at 1 and 6-month follow-up OCT.

Methods

A total of 94 patients with de novo coronary lesions were treated with DES: 26% were treated with Biolimus A9 (BA9) stent without polymer, 30% were treated with Everolimus DES with biodegradable polymer (EESb) and 44% with Everolimus DES with persistent polymer (EESp). OCT analysis was performed blindly at an independent Core Lab at three stages: implantation, after one month and after six months.

The primary endpoint was to compare neointimal coverage and apposition of these three different types of DES with OCT at one and six months after implantation.

Results

A total of 16034 struts were analysed (24% BA9, 29% EESb and 47% EESp). No significant differences were found among the groups regarding baseline clinical characteristics. When studying the strut coverage, it is remarkable the relatively low percentage of early neointimal coverage with no significant differences among stents one month after implantation (84–87%). After six months, there was better coverage in the three stent groups compared with one month (p<0.001). The stents without polymer had better neointimal coverage at six months compared with the stents with persistent polymer (99% vs 92%, p=0.0002). No significant differences were found in the strut apposition after one or six months among the three stent types. However, the rate of apposition was higher after six months compared with one month in all stent groups (p=0,001). No significant differences were found in the neointimal hyperplasia at one month among the three stent groups. At six months there was a higher hyperplasia in the stent without polymer compared to the stent with persistent polymer (164μm vs 92μm, p=0,003). The degree of hyperplasia after six months was higher compared to one month in all groups (p=0,001).

Conclusions

The new-generation DES with biodegradable-polymer or without polymer showed relatively poor early neointimal coverage and similar to the last generation durable-polymer EES. According to these results, DAPT may not be shortened in any of the three DES types studied.

Funding Acknowledgement

Type of funding source: None
Differential impact of target vessel on the diagnostic performance of resting full-cycle ratio as non-hyperemic physiological assessment
Authors: Takashima H , Ohashi H , Ando H , Suzuki A , Sakurai S , Nakano Y , Sawada H , Fujimoto M , Naito K , Tanabe S , Suzuki W , Waseda K , Amano T
Published: November 2020

Background

Recently, wire-based resting indices have been recognized as gold standard for evaluating physiological lesion assessment. The resting full-cycle ratio (RFR) is a unique resting index which is calculated as the point of absolutely lowest distal pressure to aortic pressure during entire cardiac cycle. It is unclear whether the diagnostic performance of RFR for detecting functional coronary artery stenosis is similar in each coronary artery. The aim of this study is to compare the diagnostic performance of RFR based on target coronary vessel.

Method

This study was a prospectively enrolled observational study. A total of 156 consecutive patients with 220 intermediate lesions were enrolled in this study. The RFR was measured after adequately waiting for stable condition, while FFR was measured after intravenous administration of ATP (180mcg/kg/min). Lesions with FFR ≤0.80 were considered functionally significant coronary artery stenosis.

Results

In all lesions, reference diameter, diameter stenosis, lesion length, RFR, and FFR were 3.0±0.7mm, 45±13%, 13.0±8.8mm, 0.90±0.09, and 0.82±0.10, respectively. Functional significance was observed in 88 lesions (40%) of all lesions. RFR showed a significant correlation with FFR in overall lesions (r=0.774, p<0.001). The ROC curve analysis of RFR showed good accuracy for predicting functional significance (AUC 0.87, diagnostic accuracy 81%) in all subjects. Regarding each target vessel, there were similar and significant positive correlation between RFR and FFR (LAD; r=0.733, p<0.001, LCX; r=0.771, p<0.001, RCA; r=0.769, p<0.001, respectively). The prevalence of discordant between RFR and FFR was significantly different among 3 vessels (LAD 26%, LCX 12%, RCA 13%, respectively, p<0.05 for among 3 groups). Regarding the comparison of ROC curves according to lesion location, AUC was significantly lower in LAD than in LCX and RCA (LAD 0.780, LCX 0.947, RCA 0.926, p<0.01 for LAD compared to LCX, p<0.01 for LAD compared to RCA, respectively). Furthermore, the diagnostic accuracy was significantly different according to target vessel (LAD 74%, LCX 88%, RCA 87%, respectively, p<0.05 for among 3 vessels).

Conclusion

RFR demonstrated better diagnostic accuracy for evaluating functional lesion severity. The diagnostic performance of RFR was different based on target vessel. RFR is a unique and useful resting index, and it may detect functionally significant coronary stenosis that cannot be detected with other resting indices in daily practice.

Funding Acknowledgement

Type of funding source: None
The impact of myocardial volume assessed with cardiac computed tomography on the prediction of coronary lesion ischemia
Authors: Matsuda J
Published: November 2020

Background

Angiographical stenosis assessed by quantitative coronary angiography (QCA) is correlated with fractional flow reserve (FFR). However, there is discrepancy between severity assessed by QCA and functional ischemia assessed by FFR in non-negligible proportion.

Purpose

We sought to investigate the incremental predictive value of left ventricular myocardial mass (LVM) assessed by computed tomography (CT) in addition to QCA for a significant ischemia.

Methods

A total of 177 angiographically intermediate lesions which underwent FFR measurement and cardiac CT were investigated. FFR was measured with pressure-sensor wire during the hyperemia. LVM of the subtended territory to the lesion was measured with use of proprietary off-line software. Having FFR≤0.80 was considered a significant ischemia and the predictors of FFR≤0.80 was determined.

Results

FFR ≤0.80 was detected in 83 (46.9%) lesions. Left anterior descending (LAD) lesion (P=0.013), Male (P=0.013), younger age (P<0.001), small diameter stenosis (DS) (P=0.003), long lesion length (LL) (P=0.003), small minimal lesion diameter (MLD) (P<0.001) and large LVM (P<0.001) were associated with FFR ≤0.80. In multivariate analysis, LAD (OR 2.36; 95% CI 1.05–5.32, P<0.001), MLD (OR 0.080; 95% CI 0.030–0.21, P<0.001) and LVM (OR 1.05; 95% CI 1.03–1.08, P<0.001) independently predicted FFR ≤0.80. Receiver-operating characteristics (ROC) analysis showed the area under the curve (AUC) was improved by combining multiple factors (DS alone, AUC = 0.63 vs DS + LAD, AUC = 0.71: P=0.029) (DS + LAD, vs DS + LAD + LVM, AUC = 0.79: P=0.0071) (Figure).

Conclusion

Myocardial volume of subtended region was associated with myocardial ischemia independent of anatomical stenosis and LAD location.

Funding Acknowledgement

Type of funding source: None
Characterization of plaque features exhibiting physiological mismatch between fractional flow reserve and resting index: near-infrared spectroscopy imaging analysis
Authors: Murai K , Kataoka Y , Hosoda H , Nakashima T , Honda S , Fujino M , Nakao K , Yoneda S , Otsuka F , Nishihira K , Kanaya T , Asaumi Y , Noguchi T , Yasuda S
Published: November 2020

Background

In addition to fractional flow reserve (FFR), resting indexes (RI) have been shown as another physiological measure to evaluate myocardial ischemia. Despite the clinical usefulness of RI without the use of intravenous vasodilatory agent, discrepancy between FFR and RI infrequently occurs. Whether this physiological mismatch is derived by specific plaque feature remains unknown.

Purpose

To characterize coronary plaques associated with coronary physiological mismatch.

Methods

We analyzed 59 coronary arteries (LAD/RCA/LCX=49/4/6) with FFR≤0.80 in 57 stable CAD subjects receiving PCI. Following measurement of FFR and RI, culprit lesion was evaluated by near-infrared spectroscopy and intravascular ultrasound (NIRS/IVUS). The analyzed vessels were stratified according to FFR and RI values: FFR≤0.75+RI>0.89 (n=6: physiological mismatch), FFR>0.75+RI>0.89 (n=6), FFR≤0.75+RI≤0.89 (n=33) and FFR>0.75+RI≤0.89 (n=14).

Results

The median values of percent diameter stenosis, FFR and RI were 51%, 0.75 and 0.87, respectively. Physiological mismatch was observed in 10.1% (=6/59) of analyzed vessels. On IVUS imaging, maximum percent plaque area was greater than 70% in all groups (p=0.29). Furthermore, there were no significant differences in angiographic and IVUS-derived minimum lumen area across 4 groups (Table). However, culprit lesions exhibiting physiological mismatch contained a substantially larger amount of lipid plaque, reflected by a higher maximum 4-mm lipid-core burned index (maxLCBI4mm: p=0.04) on NIRS imaging (Table). Multivariate analysis demonstrated maxLCBI4mm as the only plaque feature associated with physiological mismatch (odds ratio=1.010, 95% CI: 1.001–1.019, p=0.02).

Conclusion

Plaque feature associated with coronary physiological mismatch was the extent of lipidic materials but not the quantity of coronary atheroma. Since the accumulation of lipidic plaque component is caused by endothelial dysfunction, this vascular substrate could impair baseline vasomotion, thereby causing a lower FFR despite preserved RI value. Evaluation of lipidic burden may be a potential option to avoid unnecessary deferral of revascularization in subjects with normal RI value.

maxLCBI4mm in each group

Funding Acknowledgement

Type of funding source: None
Impact of periprocedural myocardial infarction on 10-year mortality after percutaneous coronary intervention or coronary artery bypass grafting for multivessel or left main coronary artery disease
Authors: Hara H , Takahashi K , Ono M , Gao C , Wang R , Kappetein P , Mohr F , Mack M , Holmes D , Morice M , Davierwala P , Head S , Thuijs D , Onuma Y , Serruys P
Published: November 2020

Background

Periprocedural myocardial infarction (PMI) occurs frequently after both percutaneous coronary intervention (PCI) and bypass grafting surgery (CABG) in patients with complex coronary artery disease (CAD), and PMI has been shown to have a detrimental impact on mortality. On the other hand, long-term impact of PMI on mortality has not been fully evaluated.

Purpose

This study aimed to assess the impact of PMI according to SCAI definition on 10-year all-cause death in patients with complex CAD.

Methods

The SYNTAX Extended Survival (SYNTAXES) study evaluated vital status up to 10 years in 1800 patients with de novo three-vessel disease and/or left main coronary artery disease randomized to treatment with CABG or PCI in the SYNTAX trial. Blood was sampled for creatine kinase (CK) pre- and post-revascularisation, and the cardiac specific MB iso-enzyme (CK-MB) was determined only if the CK ratio ≥2 x the upper limit of normal (ULN). If the CK ratio <2 ULN, CK-MB assessment was not mandated. In this analysis, patients with at least one blood sampling within 48 hours of the procedure were included. PMI was defined as follows; peak CK-MB measured within 48 hours of the procedure ≥10 x ULN, or ≥5 x ULN with new Q-waves in 2 contiguous leads or new persistent left bundle branch block.

Results

Of 1800 patients, 1679 (93.2%) patients were included. Of 877 patients treated with PCI, PMI occurred in 26 patients (3.0%), whereas 14 (1.7%) PMIs were observed in 802 patients treated with CABG. Compared with patients without PMI, patients with PMI presented with unstable angina more frequently (45.0% vs. 28.7, p=0.033), and had a higher rate of bifurcation lesion (87.5% vs. 72.5, p=0.046). PMI was associated with a higher all-cause mortality at 10 years compared with no PMI (55.3% vs. 25.4%; Log-rank p<0.001, Figure), which was mainly driven by a high mortality rate within 1 year. In patients undergoing PCI, the mortality rates were significantly higher in patients with PMI not only within 1 year (Log-rank p<0.001) but also beyond one year (Log-rank p=0.016), compare to patients without PMI (Figure). On the other hand, in patients undergoing CABG, a higher mortality rate in patients with PMI was observed until 1 year (Log-rank p<0.001), but the impact of PMI on mortality beyond one year after CABG subsided (Log-rank p=0.308) (Figure 1).

Conclusion

PMI was associated with a poor prognosis at 10 years. The impact of PMI on mortality was strong within one year. Of note, the impact of PMI on mortality persisted beyond 1 year only in patients undergoing PCI. Patients who were treated with PCI and suffered PMI need careful follow-up beyond one year after revascularization.

Figure 1

Funding Acknowledgement

Type of funding source: None