藤田 英雄

BACKGROUND: Acute myocardial infarction (AMI) is a fatal cardiovascular disease with varying prognosis. Recent studies suggest a close relationship between cardiovascular disease and metabolic dysfunction-associated fatty liver disease (MAFLD), but because the prognostic value of MAFLD in patients with AMI remains unclear, we investigated the relationship between MAFLD and clinical outcomes in patients with AMI. METHODS AND RESULTS: This retrospective study included 1,142 patients with AMI who underwent percutaneous coronary intervention (PCI) to the culprit lesion of AMI and were classified as MAFLD (n=231) and non-MAFLD (n=911). Hepatic steatosis was diagnosed by a liver-to-spleen attenuation (L/S) ratio <1 on computed tomography. The primary outcome was major adverse cardiovascular events (MACE), which were defined as a composite of all-cause death, non-fatal MI, and readmission for heart failure. Over a median follow-up of 609 days, MACE was less frequently observed in the MAFLD group than in the non-MAFLD group (P=0.015). However, the multivariate Cox hazard analysis showed that MAFLD was not associated with MACE (hazard ratio 0.80, 95% confidence interval 0.564-1.140, P=0.219) after controlling for confounding factors. CONCLUSIONS: We could not show a significant association between MAFLD and MACE in patients with AMI, suggesting the absence of strong association between MAFLD and long-term clinical outcomes in these patients.

Background Accurately predicting left ventricular ejection fraction (LVEF) recovery after percutaneous coronary intervention (PCI) in patients with chronic coronary syndrome (CCS) is crucial for clinical decision-making. Objective This study aimed to develop and compare multiple machine learning (ML) models to predict LVEF recovery and identify key contributing features. Methods We retrospectively analyzed 520 patients with CCS from the Clinical Deep Data Accumulation System database. Patients were categorized into 4 binary classification tasks based on baseline LVEF (≥50% or &lt;50%) and degree of recovery: (1) good recovery, defined as an LVEF increase of &gt;10% compared with ≤0%; and (2) normal recovery, defined as an LVEF increase of 0% to 10% compared with ≤0%. For each task, 3 feature selection strategies (all features, least absolute shrinkage and selection operator [LASSO] regression, and recursive feature elimination [RFE]) were combined with 4 ML algorithms (extreme gradient boosting [XGBoost], categorical boosting, light gradient boosting machine, and random forest), resulting in 48 models. Models were evaluated using 10-fold cross-validation and assessed by the area under the curve (AUC), decision curve analysis, and calibration plots. Results The highest AUCs were achieved by RFE combined with XGBoost (AUC=0.93) for preserved LVEF with good recovery, LASSO combined with XGBoost (AUC=0.79) for preserved LVEF with normal recovery, LASSO combined with XGBoost (AUC=0.88) for reduced LVEF with good recovery, and RFE combined with XGBoost (AUC=0.84) for reduced LVEF with normal recovery. Shapley Additive Explanation analysis identified uric acid, platelets, hematocrit, brain natriuretic peptide, glycated hemoglobin, glucose, creatinine, baseline LVEF, left ventricular end-diastolic internal diameter, heart rate, R wave amplitude in V5, and R wave amplitude in V6 as important predictive factors of LVEF recovery. Conclusions ML models incorporating feature selection strategies demonstrated strong predictive performance for LVEF recovery after PCI. These interpretable models may support clinical decision-making and can improve the management of patients with CCS after PCI.

OBJECTIVES: The association between blood pressure (BP) and the mortality risk may vary depending on the comorbidities. This study was conducted to investigate the subgroup-specific correlation between systolic BP (SBP) and mortality in patients with coronary artery disease undergoing percutaneous coronary intervention (PCI). METHODS: The Clinical Deep Data Accumulation System for PCI (CLIDAS-PCI), a nation-wide multicenter database with seven tertiary medical hospitals in Japan, retrospectively collected data on patients undergoing PCI for acute coronary syndrome or stable coronary artery disease. Cubic spline curves modeled the relationship between SBP and all-cause death in the entire cohort and subgroups stratified by age, sex, diabetes, left ventricular (LV) hypertrophy, renal function and LV systolic function. We assessed the SBP, which minimizes mortality risk. RESULTS: A total of 8384 patients [71 [IQR 64, 78] years, 6494 (77%) male] with SBP at hospital discharge were analyzed. During 2.7 years of median follow-up, 695 deaths occurred. In the overall population, spline analysis demonstrated a nadir range of mortality risk around an SBP of 110-130 mmHg. Subgroup analyses revealed that elderly (age ≥ 80 years), those with renal dysfunction, and those with preserved LV systolic function had higher SBP levels associated with lowest risk. Conversely, patients <80 years, those with better renal function, and those with LV systolic dysfunction exhibited lower SBP levels at lowest risk. CONCLUSION: This study demonstrated differential association between SBP and mortality risk in various subgroups, highlighting the need for personalized BP management in multimorbid patients with coronary artery disease.

BACKGROUND: There is a substantial risk of slow flow during percutaneous coronary intervention (PCI) for the culprit lesion in acute myocardial infarction (AMI), which can lead to adverse outcomes. We hypothesized that single-step long balloon inflation during stent deployment was associated with a more favorable final Thrombolysis in Myocardial Infarction (TIMI) flow grade. This retrospective study aimed to compare both the final TIMI flow grade and the delta TIMI flow grade in intravascular ultrasound (IVUS)-guided PCI for AMI between patients with long balloon inflation and those with conventional inflation. METHODS AND RESULTS: Long inflation was defined as single-step inflation ≥60 s at stent deployment. The primary endpoints were achievement of the final TIMI flow grade 3 and the delta TIMI flow grade, defined as the difference between the initial and final grades. We analyzed 336 AMI patients with attenuation plaque on IVUS, dividing them into a long inflation group (n=50) and a conventional inflation group (n=286). Despite a significantly higher TIMI thrombus grade in the long inflation group (P<0.001), the rate of the final TIMI 3 flow was similar (90% vs. 88.5%; P=1.00). However, the delta TIMI flow grade was significantly greater in the long inflation group (P=0.028). CONCLUSIONS: Single-step long balloon inflation may be a simple and feasible method to achieve optimal final TIMI flow in IVUS-guided PCI for AMI.

BACKGROUND: Primary percutaneous coronary intervention (PCI) has improved the prognosis of patients with ST-segment elevation myocardial infarction (STEMI). However, radiation skin damage is one of serious complications in primary PCI. The purpose of this study was to identify the determinants of the excess radiation dose in primary PCI. METHODS: We included 1126 patients with STEMI and divided them into an excess radiation group (n = 61; peak skin dose ≥2 Gy) and a standard radiation group (n = 1065; peak skin dose <2 Gy). Univariate and multivariate logistic regression analyses were performed to find patient or procedural factors associated with excess radiation. RESULTS: In patient factors, body mass index (BMI) was significantly associated with excess radiation [odds ratio (OR) 1.09, 95 % confidence interval (CI) 1.01-1.18, P = 0.022] after controlling for confounding factors. In procedural factors, use of intra-aortic balloon pumping (OR 2.12, 95 % CI 1.05-4.27, P = 0.035), number of used guidewire (OR 1.70, 95 % CI 1.26-2.31, P < 0.001), number of used balloon (OR 1.50, 95 % CI 1.18-1.92, P = 0.001), total length of stents (OR 1.25, 95 % CI 1.09-1.44, P = 0.002), use of microcatheters (OR 2.18, 95 % CI 1.13-4.21, P = 0.02) and thrombus aspiration (OR 3.86, 95 % CI 2.07-7.20, P < 0.001) were significantly associated with excess radiation after controlling for confounding factors. CONCLUSIONS: In primary PCI for STEMI, high BMI and using many devices were significantly associated with excess radiation. We should pay special attention to patients with high BMI and complex lesions which require many devices to prevent excess skin radiation.

BACKGROUND: There are few data verifying the utility of the CHADS-P2A2RC score in comparison with the CHADS2 score for estimating net adverse clinical events (NACE) in chronic coronary syndrome (CCS) patients without atrial fibrillation (AF) in real-world settings. METHODS: We performed analysis for a total of 3985 CCS patients without AF who underwent percutaneous coronary intervention (PCI) between April 2013 and March 2019 for whom information was obtained from the CLIDAS (Clinical Deep Data Accumulation System)-PCI database. The primary endpoint was NACE defined as the composite of 3-point major adverse cardiovascular events (3P-MACE) (cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke) and GUSTO moderate/severe bleeding events. RESULTS: Kaplan-Meier analysis showed that both the CHADS-P2A2RC and CHADS2 scores stratified the risks. The incidences of NACE were stratified well by the very-high-risk category, which was uniquely defined as a CHADS-P2A2RC score of ≥6 (hazard ratio: 2.38, 95 % CI = 1.91-2.97, p-value <0.001). The area under the curve (AUC) in estimating NACE within 3 years was higher when the CHADS-P2A2RC score was used than when the CHADS2 score was used (0.67 vs. 0.62, p = 0.003). This was mainly due to the accuracy in estimating bleeding events (0.66 vs. 0.60, p = 0.006). CONCLUSIONS: The accuracy in estimating NACE after PCI for CCS patients without AF was higher when the CHADS-P2A2RC score was used than when the CHADS2 score was used, mainly due to the accuracy in predicting bleeding risk. Higher incidences of endpoints were well-stratified by a very-high-risk category defined as a CHADS-P2A2RC score of ≥6.

The prevalence of malignancies in patients undergoing percutaneous coronary intervention (PCI) is increasing with aging. Active malignancy is a significant contributor to high bleeding risk. For cancer patients requiring oral anticoagulant (OAC) therapy, the choice between direct oral anticoagulants (DOAC) and warfarin is critical. The aim of this study was to investigate long-term bleeding events in patients with malignancy undergoing PCI. The CLIDAS (Clinical Deep Data Accumulation System) multicenter database includes data from seven tertiary medical hospitals in Japan. This retrospective analysis included 6451 patients who underwent PCI between April 2013 and March 2019 and completed 3-year follow-up. The patients were divided into two groups; No malignancy (n = 5787) and Malignancy group (n = 664). Malignancy was defined by a history of cancer treatment. These groups were further subcategorized based on OAC therapy; (1) No malignancy without OAC (n = 5134), (2) No malignancy with DOAC (n = 261), (3) No malignancy with warfarin (n = 392), (4) Malignancy without OAC (n = 589), (5) Malignancy with DOAC (n = 38), and (6) Malignancy with warfarin (n = 37). The primary outcome was the incidence of bleeding events, defined according to the Global Use of Streptokinase and t-PA for Occluded Coronary Arteries classification of moderate and severe bleeding. The secondary outcomes were major adverse cardiac events (MACE) and net adverse clinical events (NACE). Multivariable Cox regression analysis showed that the malignancy with warfarin group had a significantly higher risk of bleeding events compared to the malignancy without OAC group (hazard ratio [HR], 3.64; 95% confidence interval [CI], 1.38-9.61, p value = 0.009). No significant differences were observed for MACE (HR, 1.39; 95% CI 0.59-3.25, p value = 0.454) or NACE (HR, 1.62; 95% CI, 0.80-3.29; p value = 0.184). Malignancy patients receiving warfarin were associated with a higher risk of bleeding events. DOACs may represent a preferable alternative to warfarin with regard to bleeding risk in patients with malignancy undergoing PCI.

In-stent protrusion is sometimes observed after the stent implantation to the culprit lesion of ST-segment elevation myocardial infarction (STEMI). However, it remains unclear whether additional interventions are necessary for non-obstructive in-stent protrusions. The purpose of this retrospective study was to compare clinical outcomes of patients with STEMI between with and without angiographically visible in-stent protrusions, and to evaluate the association between angiographically visible in-stent protrusions and long-term clinical outcomes in patients with STEMI. We included 639 patients with STEMI who underwent stent implantation and divided them into the protrusion group (n = 59) and the clear stent group (n = 580). In-stent protrusion was defined as an angiographically visible in-stent contrast filling defect at final angiography. The primary endpoint was major adverse cardiovascular events (MACE), which were defined as the composite of all cause death, non-fatal myocardial infarction, and ischemia-driven target vessel revascularization. During the median follow-up duration of 620 (213-1379) days, MACE were more frequently observed in the protrusion group than in the clear stent group (p = 0.002). The multivariate Cox hazard analysis revealed that in-stent protrusion was significantly associated with MACE after controlling for multiple confounding factors (HR 2.373, 95% CI 1.311-4.294, p = 0.004). In conclusion, angiographically visible in-stent contrast filling defect at final angiography is a marker for worse clinical outcomes in primary PCI. When interventional cardiologists recognize visible irregular protrusion after stent implantation for STEMI, additional intervention or careful clinical follow up may be needed.

Objective Angiotensin-converting enzyme inhibitors (ACEis), angiotensin receptor blockers (ARBs), and beta-blockers (BBs) are commonly prescribed for patients with non-ST-segment elevation myocardial infarction (NSTEMI). However, the target blood systolic pressure (SBP) or pulse rate (PR) in these patients has not been established. This study aimed to assess the association between SBP/PR control at discharge and the clinical outcomes in patients with NSTEMI. Methods We retrospectively analyzed 596 patients with NSTEMI who received both ACEis/ARBs and BBs at discharge. Patients were categorized into a good control group (SBP ≤130 mmHg and PR ≤80 bpm, n=379) and poor control group (SBP >130 mmHg or PR >80 bpm, n=217). The primary endpoint was major cardiovascular events (MACEs), defined as the composite of all-cause death, non-fatal myocardial infarction, and heart failure readmission. Results During a median follow-up of 1,267 days, 205 MACEs occurred. Kaplan-Meier curves showed higher MACE rates in the poor control group than in the good control group (p=0.003). A multivariate Cox hazard analysis revealed that the good control group was inversely associated with MACEs (hazard ratio 0.748, 95% confidence interval: 0.561-0.997, p=0.048) after controlling for confounding factors. Conclusion Good control of SBP and PR was inversely associated with long-term adverse events in patients with NSTEMI who received both ACEis/ARBs and BBs. This study highlights the significance of optimizing medication titrations at discharge.

INTRODUCTION: In-stent calcification is recognized as a significant contributor to unfavorable clinical outcomes. Understanding the various types and underlying mechanisms of in-stent calcification can help interventional operators to make decisions. AREAS COVERED: This review will describe the distinct types of in-stent calcification, which are categorized into in-stent smooth calcification and in-stent calcified nodule. The mechanisms and characteristics of in-stent smooth calcification and calcified nodule will be summarized. Given the differences between these two types, treatment approaches will be discussed. This review will focus on histopathology and intracoronary imaging. For the purpose of this review, evidence was gathered from electronic literature searches via PubMed, with a particular focus on primary evidence published in the last 5 years. EXPERT OPINION: Several treatment devices are available such as conventional balloon, modified balloon, atherectomy device, and intravascular lithotripsy. In-stent smooth calcification and calcified nodule might result in different clinical courses after repeated target lesion revascularization. Understanding the mechanisms with the various types of in-stent calcification may assist operators in selecting appropriate treatment strategies.

BACKGROUND: An artificial intelligence algorithm-guided electrocardiogram (AI-ECG) has been developed to detect atrial fibrillation (AF) in patients with sinus rhythm (SR). However, its utility for population-based screening remains unclear in Japan. METHOD AND RESULTS: In this prospective cohort study, "SPAFS" (Stroke Prevention by Early Detection of AF in Shimizu), participants who underwent health examinations at the Shimizu Medical Association Examination Center from January 2022 to July 2023 were enrolled, with known AF excluded. ECGs were categorized by AI as low-, moderate-, or high risk: non-SR were labeled as non-applicable (NA). All participants underwent 7-day single-lead ECG monitoring. Among 362 participants (61.1 ± 10.5 years, 38% male, CHADS2 score 0.49 ± 0.70), AF was newly detected in 3.0% (n = 11), with increasing prevalence across AI risk categories. The non-low-risk group (moderate, high, and NA) had a significantly higher AF detection rate than the low-risk group (OR 9.36, 95% CI 1.99-44.01). Subgroup analysis in those aged ≥65 years showed a similar trend (OR 8.09 [95%CI 1.63-39.7]). When the NA group (not eligible for AI) was excluded, similar trends were observed, although statistical significance was attenuated (OR 4.89 [95% CI 0.88-27.1] in the total, 5.09 [95% CI 0.89-29.0] in those aged ≥65 years). In the total cohort, AI-ECG showed higher discriminative ability than the CHADS2 score ≥1 in both the total cohort (AUC 0.75 vs. 0.68) and participants aged ≥65 years (AUC 0.73 vs. 0.61). CONCLUSIONS: AI-ECG risk determination correlated with AF detection in a Japanese healthy cohort, especially in the aged population, supporting its utility as a population-based screening tool.

Slow flow is the most common complication of rotational atherectomy (RA). Compared with long single sessions, short single sessions may reduce the incidence of slow flow just after RA. This study aimed to compare the incidence of slow flow just after RA between short single session and long single session strategies. This multicenter, 1:1 randomized clinical trial was conducted at 3 hospitals in Japan. The short single session strategy was defined as repeating short single sessions (up to 15 s) of RA, whereas the long single session strategy was defined as repeating long single sessions (20-30 s) until the burr crossed the target lesion. The primary outcome was slow flow just after RA, which was defined as [(initial TIMI-frame count before RA) × 1.1 minus (TIMI-frame count just after RA)] less than 0. During the study period, 266 patients were included in the final study population and were randomly assigned to the Short single session group (n = 132) or the long single session group (n = 134). The protocol adherence rate was equally high in both groups (Short single session: 98.5% versus long single session 94.8%, p = 0.172). The incidence of slow flow just after RA was similar between the 2 groups (short single session:14.4% versus long single session: 14.9%, p > 0.999). In conclusion, this randomized trial did not show a benefit of the short single session strategy compared with the long single session strategy in RA with respect to the prevention of slow flow (Unique identifier: UMIN000047231).

BACKGROUND: The below the knee (BTK) arteries of legs with peripheral artery disease (PAD) frequently exhibit medial calcification and chronic thrombus. However, the relationship between chronic thrombus and medial calcification remains poorly understood. AIMS: This study aimed to evaluate the association between chronic thrombus and medial calcification in the BTK arteries of patients with PAD using optical frequency domain imaging (OFDI). METHODS: OFDI frames were analyzed in legs with PAD undergoing OFDI-guided endovascular therapy. Data regarding thrombus, medial calcification, and the type and extent of calcification were collected. The multivariate logistic regression analysis was used to find the OFDI factors significantly associated with chronic thrombus. The causes of chronic thrombus were examined. RESULTS: A total of 5293 frames from 21 legs in 19 patients were analyzed. Among all frames, medial calcification and chronic thrombus were observed in 51% and 23%, respectively. The multivariate logistic regression analysis showed that medial calcification and the degree of arc-quadrant of medial calcification were significantly associated with chronic thrombus. Medial calcification-related thrombus was the most common cause of chronic thrombus (57%), followed by lipidic atherosclerosis (35%), calcified nodule (3%) and distal emboli (3%). The prevalence of chronic thrombus related to medial calcification increased as the degree of arc-quadrant of medial calcification increased. CONCLUSIONS: Chronic thrombus was significantly associated with medial calcification in the BTK arteries. The major cause of chronic thrombus was medial calcification-related thrombus. This study proposed a potential mechanism by which medial calcification can induce chronic thrombus in the BTK lesions.

The impact of mid-range (mr) ejection fraction (EF) on long-term clinical outcomes has been reported in patients with heart failure but remains unclear in patients with ST-segment elevation myocardial infarction (STEMI). The purpose of this study was to compare the long-term clinical outcomes among STEMI patients with preserved EF (pEF), mrEF, and reduced EF (rEF), and to evaluate the significance of mrEF as a prognostic factor for patients with STEMI. We included 705 patients with STEMI and divided them into rEF group (n = 155), mrEF group (n = 155), and pEF group (n = 395) according to the pre-discharge EF. The primary endpoint was the major adverse cardiovascular events (MACE), which were defined as the composite of all-cause death, re-admission for heart failure, and non-fatal myocardial infarction (MI). The median follow-up duration was 906 days (Q1:349.5-Q3:1479). The Kaplan-Meier curves showed that MACE and re-admission for heart failure were more frequently observed in the rEF group, followed by the mrEF group, and least in the pEF group (p < 0.001). The multivariate Cox hazard analysis revealed that mrEF as well as rEF were significantly associated with MACE after controlling for confounding factors [rEF: hazard ratio (HR) 2.333, 95% confidence interval (CI) 1.350-4.034, p = 0.002, mrEF:HR1.852, 95%CI 1.139-3.010, p = 0.013]. Mid-range EF as well as rEF was significantly associated with MACE and re-admission for heart failure in patients with STEMI. Our results suggest that mrEF is an important prognostic factor in patients with STEMI.

Background: Peripheral arterial disease (PAD) is associated with cardiovascular events in patients with acute myocardial infarction (AMI). However, there are limited reports regarding the association between PAD and bleeding events. In this study, we aimed to evaluate whether PAD is independently associated with an increased risk of major bleeding events, in addition to major adverse cardiovascular events (MACEs), in patients with AMI undergoing percutaneous coronary intervention (PCI). Methods: We included 1391 patients with AMI who underwent PCI and divided them into the PAD group (n = 210) and the non-PAD group (n = 1181). The primary endpoint was total bleeding events, defined as Bleeding Academic Research Consortium type 3/5. The secondary endpoint was MACE, defined as the composite of all-cause death, non-fatal myocardial infarction, and hospitalization for heart failure. Results: The median follow-up duration was 653 days. Total bleeding events were more frequently observed in the PAD group than in the non-PAD group (24.8% vs. 11.3%, p < 0.001). The multivariate Cox hazard analysis confirmed that PAD was significantly associated with total bleeding events (HR 1.509; 95% CI 1.056-2.156, p = 0.024) as well as MACEs (HR 2.152; 95% CI 1.510-3.066, p < 0.001) after controlling for confounding factors. Conclusions: PAD was independently associated with a higher risk of major bleeding and cardiovascular events in patients with AMI undergoing PCI. These findings suggest that PAD should be recognized as a critical factor in risk stratification for AMI and may affect individualized bleeding risk management strategies in patients with AMI.

BACKGROUND: In pulmonary vein isolation (PVI) for atrial fibrillation (AF), intraoperative defibrillation is often required. Intracardiac defibrillation catheters (ICDCs) are most effective when positioned to enclose the heart between the coronary sinus (CS) and right atrium (RA) (CS/RA configuration). However, achieving this positioning via the inferior vena cava (IVC) can be challenging, and alternative configurations remain underexplored. METHODS: This study included patients with paroxysmal or persistent AF who underwent cryoballoon ablation followed by intracardiac cardioversion using an ICDC via the IVC. The catheter was initially positioned with distal electrodes in the CS and proximal electrodes in the IVC (CS-only configuration). If cardioversion failed, the catheter was repositioned to place distal electrodes in the superior vena cava (SVC configuration). A maximum of 30 J of energy was used for all cardioversion attempts. RESULTS: A total of 81 patients were included. Cardioversion in the CS-only configuration restored sinus rhythm in 11% (9/81) of patients. Repositioning to the SVC configuration achieved successful cardioversion in 93.1% (67/72) of the remaining cases without complications. Patients requiring the SVC configuration had a significantly higher prevalence of persistent AF (33.3% vs. 80.6%; p = 0.045). No adverse events were observed following cardioversion in the SVC configuration. CONCLUSIONS: While the CS-only configuration offers ease of placement, its efficacy is limited. Repositioning to the SVC configuration significantly enhances cardioversion success and represents a safer, more effective alternative for ICDC use during AF ablation.

Objective Immediate primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction is closely associated with better clinical outcomes. However, the optimal timing of PCI for the culprit lesion in non-ST-elevation myocardial infarction (NSTEMI) is not fully understood. The aim of this study was to compare clinical outcomes between patients with early and delayed PCI and to investigate whether early PCI within 24 hours of admission can improve long-term clinical outcomes in patients with NSTEMI. Methods This was a single-center, retrospective study. The primary endpoint was major adverse cardiovascular events (MACE), which was defined as the composite of all-cause death, non-fatal MI, and re-admission for heart failure. Results We included 816 patients with NSTEMI and divided them into an early PCI group (n=446) and a delayed PCI group (n=370). The median follow-up period was 856 days. The median age was lower in the early PCI group [73 (65-79) years] than in the delayed PCI group [76 (69-81)] (p<0.001). Shock at admission was more frequently observed in the early PCI group (11.9%) than in the delayed PCI group (3.2%) (p=0.001). The incidence of MACE in the delayed PCI group (40.8%) was higher than that in the early PCI group (28.5%) (P<0.001). However, a multivariate Cox hazard analysis revealed that early PCI was not associated with MACE after controlling for multiple confounding factors (HR 1.005, 95% CI 0.763-1.322, p=0.973). Conclusion The timing of PCI may not be important in hemodynamically stable patients with NSTEMI, as long as primary PCI is performed.

UNLABELLED: Coronary artery dissection is a common complication in percutaneous coronary intervention (PCI). The bailout procedure from coronary artery dissection is relatively simple if a guidewire remains within the true lumen. However, if the guidewire migrates into a dissection cavity separated by a calcified plaque, the bailout procedure is more difficult even for experienced interventional cardiologists. In this case report, we provide a bailout procedure for complicated coronary artery dissection, in which the guidewire was pushed out from the true lumen to the false lumen behind calcified plaque. The knowledge of guidewire bias and intravascular ultrasound-guided PCI was useful and the technique to strengthen the back-up support was necessary for the successful bailout. LEARNING OBJECTIVE: Guidewire migration into the false lumen behind a calcified plaque is a rare complication, but the knowledge of a bailout method using guidewire bias and intravascular ultrasound is important.

The clinical outcomes of percutaneous coronary intervention (PCI) in patients with dialysis are still worse compared with those without dialysis. Among patients with dialysis, those who started dialysis due to diabetic nephropathy (DMN) may have a worse prognosis than those who started dialysis due to non-DMN. This retrospective study aimed to compare the clinical outcomes in dialysis patients who underwent PCI between with and without long-term dialysis due to DMN. We included 303 dialysis patients with PCI. The length of dialysis at the time of PCI was used to stratify the study patients. Patients with DMN and the length of dialysis ≥ 3 years were defined as the long-DMN group (n = 117), and the others were defined as the other group (n = 186). The primary endpoint was the incidence of major adverse cardiac events (MACE), which was defined as a composite of all-cause death, non-fatal myocardial infarction, re-admission for heart failure, and ischemia-driven target vessel revascularization. A total of 165 MACE were observed with the median follow-up of 568 days. The Kaplan-Meier curves showed that MACE was more frequently observed in the long-DMN group than in the other group (p = 0.005). In the multivariate Cox hazard model, long-DMN was significantly associated with MACE (hazard ratio 1.483, 95% confidence interval 1.075-2.046, p = 0.016) after controlling for multiple confounding factors. Among patients with dialysis, the combination of DMN and a long history of dialysis is closely associated with poor clinical outcomes. These patients should be carefully followed up by both cardiologists and nephrologists.

Percutaneous coronary intervention has been developed for patients with coronary artery disease. Calcified lesions are recognized as an unsolved issue where many clinical devices have evolved and some disappeared. Understanding intracoronary imaging of the calcified lesions can help operators to make decisions during the procedure. There are several potential stories of progression of calcification, although a precise mechanism of progression of calcification remains unknown. In the process of a large calcification, it is histologically believed that lipid is replaced by calcification. This process can be observed by intracoronary imaging devices, i.e., intravascular ultrasound and optical coherence tomography. Calcified nodule is a unique type of calcifications. Among the calcified lesions, especially calcified nodule has serious clinical outcomes such as target lesion revascularization (TLR) with stent under-expansion. Additionally, in-stent calcified nodule is a distinctive type of restenosis pattern after stenting to calcified nodule, leading to malignant cycle of repeated TLR. Recently, calcified nodule is divided into two types based on the surface irregularity: (1) eruptive and (2) non-eruptive calcified nodule. Eruptive calcified nodule has higher rate of target vessel revascularization than non-eruptive calcified nodule despite greater stent expansion in eruptive calcified nodule. It is thought that there are differences of component such as the amount of fibrin and the size of calcific nodules between both, although it is common for both to include calcific nodules and fibrin. Histopathological understanding calcified nodule can be helpful to choose the treatment devices during the procedure in the area where there is no correct answer.

Abstract Aims Delayed diagnosis of pulmonary hypertension (PH) is a known cause of poor patient prognosis. We aimed to develop an artificial intelligence (AI) model, using ensemble learning method to detect PH using electrocardiography (ECG), chest X-ray (CXR), and brain natriuretic peptide (BNP), facilitating accurate detection and prompting further examinations. Methods and results We developed a convolutional neural network model using ECG data to predict PH, labelled by ECG from seven institutions. Logistic regression was used for the BNP prediction model. We referenced a CXR deep learning model using ResNet18. Outputs from each of the three models were integrated into a three-layer fully connected multimodal model. Ten cardiologists participated in an interpretation test, detecting PH from patients’ ECG, CXR, and BNP data both with and without the ensemble learning model. The area under the receiver operating characteristic curves of the ECG, CXR, BNP, and ensemble learning model were 0.818 [95% confidence interval (CI), 0.808–0.828], 0.823 (95% CI, 0.780–0.866), 0.724 (95% CI, 0.668–0.780), and 0.872 (95% CI, 0.829–0.915). Cardiologists’ average accuracy rates were 65.0 ± 4.7% for test without AI model and 74.0 ± 2.7% for test with AI model, a statistically significant improvement (P &amp;lt; 0.01). Conclusion Our ensemble learning model improved doctors’ accuracy in detecting PH from ECG, CXR, and BNP examinations. This suggests that earlier and more accurate PH diagnosis is possible, potentially improving patient prognosis.

This study aimed to investigate the relationship between the restoration of coronary flow just before stent deployment and the final thrombolysis in myocardial infarction (TIMI) flow grade 3 in patients with ST-segment elevation myocardial infarction (STEMI) whose initial TIMI flow grade ≤ 1. In primary percutaneous coronary intervention (PCI), initial TMI flow grade ≤ 1 is closely associated with suboptimal final TIMI flow grade. We included 466 STEMI patients with initial TIMI flow grade ≤ 1 and divided into a restored flow group or an unrestored flow group according to the TIMI flow grade just before stent deployment. The primary endpoint was the achievement of final TIMI flow grade 3. We compared clinical characteristics between the two groups and performed a multivariate logistic analysis to investigate the association between the coronary flow restoration and the final TIMI flow grade. The prevalence of final TIMI flow grade 3 was significantly higher in the restored flow group than the unrestored flow group. The multivariate logistic regression analysis revealed that the restoration of coronary flow just before stent deployment was significantly associated with final TIMI flow grade 3 (OR 7.771, 95% CI 3.412-17.699, p < 0.001). The restoration of coronary flow just before stent deployment was significantly associated with the achievement of final TIMI flow grade 3 in STEMI patients with initial TIMI flow grade ≤ 1. Interventional cardiologist may pay more attention to the coronary flow restoration just before stent deployment when the initial TIMI flow grade is ≤ 1.

AIM: Coronary artery disease is a major cause of mortality in patients with chronic kidney disease (CKD); however, the actual burden of asymptomatic coronary artery stenosis in patients with advanced-stage CKD remains unclear. We investigated the prevalence and associated factors of significant coronary artery stenosis (≥ 50%) in asymptomatic patients with moderate-to-severe (stage G3-5) CKD. Furthermore, we evaluated the usefulness of carotid maximum intima-media thickness (IMT) in predicting significant coronary artery stenosis in these patients. METHODS: We enrolled 128 patients (men: 68.0%; mean age: 70.3±11.2 years; mean estimated glomerular filtration rate: 37.6±12.9 mL/min/1.73 m2) in a prospective, cross-sectional study. The presence and severity of coronary artery stenosis was evaluated by coronary magnetic resonance angiography. Carotid maximum-IMT was also evaluated by carotid ultrasonography. Factors which were associated with the presence of significant coronary artery stenosis were explored by multivariable logistic regression analysis. The diagnostic accuracy of carotid maximum-IMT for detecting significant coronary artery stenosis was explored by receiver operating characteristic (ROC) curve analysis. RESULTS: Seventy-six patients (60%) had significant coronary artery stenosis. Univariable analyses showed that age, body mass index, high-density lipoprotein cholesterol, glycated hemoglobin, C-reactive protein, and carotid maximum-IMT were associated with the presence of significant coronary artery stenosis. However, multivariable logistic regression analysis revealed that only carotid maximum-IMT (odds ratio: 4.86; P < 0.001) was associated with the presence of significant coronary artery stenosis. The ROC curve of carotid maximum-IMT was significant (P < 0.001), with an area under the curve of 0.788 (cut-off value, 1.5 mm; sensitivity, 0.84; specificity, 0.58). CONCLUSION: The prevalence of significant coronary artery stenosis was high (60%) in patients with moderate-to-severe CKD. Carotid maximum-IMT was the primary factor associated with the presence of significant coronary artery stenosis and might be a surrogate marker for significant coronary artery stenosis in these patients.

Artificial intelligence models reportedly detect a low ejection fraction (EF) with chest radiography (CXR) examinations, which traditionally require a transthoracic echocardiogram (TTE) for evaluation. However, whether coupling a CXR model with an electrocardiogram (ECG) model improves the detection performance remains unclear. This study aimed to evaluate various models and fusion strategies for their detection performance.This study included 7,246 patients who underwent CXR, ECG, and TTE at the University of Tokyo Hospital. Two ECG models were used-a convolutional neural network and masked autoencoder. Two methods for combining CXR and ECG models were tested, early and late fusion. In the early fusion method, the CXR and ECG models were trained simultaneously, whereas in the late fusion method, three ensemble techniques were implemented. The CXR single model achieved an area under the curve (AUC) of 0.798. Both fusion models significantly outperformed the CXR single model. The early fusion model achieved an AUC of 0.937 (P = 0.015), while the late fusion model had an AUC of 0.928 (P = 0.010).Combining the CXR and ECG models significantly improved detection performance. This approach enables more accurate identification of patients with low EF, a condition typically requiring TTE for diagnosis.

BACKGROUND: Heart failure should be diagnosed as early as possible. Although deep learning models can predict one or more echocardiographic findings from electrocardiograms (ECGs), such analyses are not comprehensive. OBJECTIVES: This study aimed to develop a deep learning model for comprehensive prediction of echocardiographic findings from ECGs. METHODS: We obtained 229,439 paired ECG and echocardiography data sets from 8 centers. Six centers contributed to model development and 2 to external validation. We identified 12 echocardiographic findings related to left-sided cardiac abnormalities, valvular heart diseases, and right-sided cardiac abnormalities. These findings were predicted using convolutional neural networks, and a composite label was analyzed using logistic regression. A positive composite label indicated positivity in any of the 12 findings. RESULTS: For the composite findings label, the area under the receiver-operating characteristic curve was 0.80 (95% CI: 0.80-0.81) on hold-out validation and 0.78 (95% CI: 0.78-0.79) on external validation. The composite findings label applying logistic regression had an area under the receiver-operating characteristic curve of 0.80 (95% CI: 0.80-0.81) with accuracy of 73.8% (95% CI: 73.2-74.4), sensitivity of 81.1% (95% CI: 80.5-81.8), and specificity of 60.7% (95% CI: 59.6-61.8). CONCLUSIONS: We have developed convolutional neural network models that predict a wide range of echocardiographic findings, including left-sided cardiac abnormalities, valvular heart diseases, and right-sided cardiac abnormalities from ECGs and created a model to predict a composite findings label by logistic regression analysis. This model has potential to serve as an adjunct for early diagnosis and treatment of previously undetected cardiac disease.

Bioresorbable scaffolds (BRS) were developed as an innovative solution to overcome the limitations of metallic stents. While polymeric BRS initially demonstrated comparable clinical outcomes to drug-eluting stent (DES) in clinical trials, subsequent large-scale studies revealed that patients implanted with polymeric BRS experienced higher rates of scaffold thrombosis (ScT) and target lesion failure compared to those with metallic stents. Resorbable magnesium scaffolds (RMS) have emerged as a promising alternative owing to magnesium's natural degradability and favorable mechanical properties. Learning from the mechanism of polymeric BRS failure and through continuous improvements, recent clinical trials have shown promising clinical performance for RMS technology. However, comparative studies between RMS and DES have continued to highlight the remaining challenges with RMS, particularly in regard to late lumen loss. Recent advancements in third-generation RMS show improvements in strut thickness and homogeneous degradation, which enhances sustained structural integrity throughout the degradation process. Based on encouraging results from a first-in-human trial of the latest version of RMS, a randomized controlled trial has been initiated to compare the outcomes between metallic stents and the latest RMS, with patient enrollment already underway. This review aims to explore the limitations of polymeric BRS and provide an overview of the current developments and future potential of magnesium-based BRS.

Primary percutaneous coronary intervention (PCI) is the cornerstone of treatment for ST-segment elevation myocardial infarction (STEMI). Previous studies suggest that direct transport by ambulance to a primary PCI facility is associated with better clinical outcomes in patients with STEMI. However, those studies included seriously ill patients for whom direct transport is the only option. We included 462 patients with STEMI who were supposed to select either direct transport by ambulance or indirect transport via primary care doctor, and compared the clinical outcomes between the direct transfer group (n = 172) and the indirect transfer group (n = 290). The primary endpoint was major adverse cardiovascular events (MACE), which was defined as the composite of all-cause death, non-fatal myocardial infarction, re-admission for heart failure, and target vessel revascularization. The median follow-up duration was 540 days (86-1266 days). Age was significantly higher in the indirect transfer group [72.0 (64-80) years] than in the direct transfer group [69.5 (58.3-77) years] (p = 0.013). Onset to balloon time was significantly shorter in the direct transport group (p < 0.001). The Kaplan-Meier curves revealed that MACE were similarly observed between the two groups (31.4% vs. 27.2%; p = 0.330). After adjusting for potential confounders, indirect transfer was not associated with MACE (adjusted hazard ratio: 0.740, 95% confidence interval: 0.485-1.128, p = 0.161). In conclusion, indirect transfer was not associated with poor clinical outcomes in patients with STEMI who were supposed to select either direct transport or indirect transport.

Background: It is essential to identify the risk factors for poor clinical outcomes in patients with acute myocardial infarction (AMI). The coronary artery calcium score (CACS) is gathering attention as a predictor for future cardiovascular events. This study aimed to (1) measure CACSs in patients with AMI by non-ECG-gated computed tomography (CT), (2) compare clinical outcomes between patients with a high CACS and a low-intermediate CACS and (3) to elucidate the association between high CACS and clinical outcomes. Methods: We defined the high CACS group as the highest quantile of CACS (Q4) and defined the low-intermediate CACS group as the other quantiles of CACS (Q1-Q3). The primary endpoint was major adverse cardiovascular events (MACE), which were defined as the composite of all-cause death, re-admission for heart failure, non-fatal MI and target vessel revascularization. We included 548 patients with AMI who underwent non-ECG-gated CT and divided them into the high CACS group (CACS ≥ 5346.5, n = 137) and the low-intermediate CACS group (CACS ≤ 5329.3, n = 411). Results: During the median follow-up duration of 535 days, 150 MACE were observed. The Kaplan-Meier curves showed that MACE occurred more frequently in the high CACS group than in the low-intermediate CACS group (p < 0.001). Multivariable Cox hazard analysis revealed that a high CACS was significantly associated with MACE (hazard ratio 1.597, 95% confidence interval 1.081-2.358, p = 0.019) after controlling for multiple confounding factors. Conclusions: Clinical outcomes were worse in AMI patients with a high CACS than in those with a low-intermediate CACS. A high CACS was significantly associated with MACE in multivariate analysis.

The Japanese Society of Hypertension have established a blood pressure (BP) target of 130/80 mmHg for patients with coronary artery disease (CAD). We evaluated the data of 8793 CAD patients in the Clinical Deep Data Accumulation System database who underwent cardiac catheterization at six university hospitals and the National Cerebral and Cardiovascular Center (average age 70 ± 11 years, 78% male, 43% with acute coronary syndrome [ACS]). Patients were divided into two groups based on whether or not they achieved the guideline-recommended BP of <130/80 mmHg. We analyzed the relationship between BP classification and major adverse cardiac and cerebral event (MACCE) separately in two groups: those with ACS and those with chronic coronary syndrome (CCS). During an average follow-up period of 33 months, 710 MACCEs occurred. A BP below 130/80 mmHg was associated with fewer MACCEs in both the overall (hazard ratio [HR] 0.83, 95% confidence interval [CI] 0.70-1.00, p = 0.048) and the ACS group (HR 0.67, 95%CI 0.51-0.88, p = 0.003). In particular, stroke events were also lower among those with a BP below 130/80 mmHg in both the overall (HR 0.69, 95%CI 0.53-0.90, p = 0.006) and ACS groups (HR 0.44, 95%CI 0.30-0.67, p < 0.001). In conclusion, the achievement of BP guidelines was associated with improved outcomes in CAD patients, particularly in reducing stroke risk among those with ACS.

Objective Triple-vessel disease (TVD) is a well-established prognostic factor for patients with acute myocardial infarction (AMI). However, there is a paucity of literature regarding the risk factors for in-hospital death in patients with non-ST-segment elevation myocardial infarction (NSTEMI) and TVD. In this retrospective study, we examined the determinants of in-hospital death in patients with NSTEMI and TVD who underwent percutaneous coronary intervention (PCI) for culprit lesions. Methods The primary objective of this study was to identify the factors associated with in-hospital death using a multivariate analysis. We included 253 patients with NSTEMI and TVD and divided them into a survivor group (n=239) and an in-hospital death group (n=14). Results Systolic blood pressure (SBP) at admission was significantly higher in the survivor group than in the in-hospital death group. The estimated glomerular filtration rate (eGFR) was also higher in the survivor group than in the in-hospital death group. In the multivariate logistic regression analysis, in-hospital death was inversely associated with the SBP at admission (odds ratio [OR] 0.984, 95% confidence interval [CI] 0.970-0.999, p<0.035) and eGFR (OR 0.966, 95% CI 0.939-0.994, p=0.019) and was associated with cardiopulmonary arrest (CPA) before PCI (OR 8.448, 95%CI 1.863-38.309, p=0.006). Conclusion In-hospital death was associated with CPA before PCI and inversely associated with the SBP at admission and eGFR in patients with NSTEMI and TVD who underwent PCI for the culprit lesion. It may be important to recognize these high-risk features in order to improve the clinical outcomes of patients with NSTEMI and TVD.

BACKGROUND: The clinical outcomes of ST-segment elevation myocardial infarction (STEMI) due to the occlusion of left coronary artery are worse in patients with proximal occlusion than in those with non-proximal occlusion. However, there are few reports that focus on the comparison of clinical outcomes in patients with STEMI between proximal and non-proximal right coronary artery (RCA) occlusions. METHODS: We included 356 patients with STEMI whose infarct-related artery is RCA and divided them into the proximal group (n = 129) and the non-proximal group (n = 227). We defined segment 1 of RCA as proximal, and segments 2, 3, and 4 as non-proximal according to the reporting system of the American Heart Association. The primary endpoint was major cardiovascular events (MACE), which was defined as the composite of all-cause death, non-fatal myocardial infarction, readmission for heart failure, and ischemia-driven target vessel revascularization. RESULTS: Incidence of shock at admission, requirement for catecholamine during percutaneous coronary intervention (PCI), or mechanical support during PCI tended to be higher in the proximal group (42.6 %) than in the non-proximal group (33.5 %) (p = 0.088). Although the incidence of right ventricular infarction tended to be higher in the proximal group (17.8 %) than in the non-proximal group (10.6 %) without reaching statistical significance (p = 0.072), the incidence of in-hospital death was similar between the 2 groups (1.6 % versus 1.8 %, p = 1.000). The MACE-free survival curves were not different between the 2 groups (p = 0.400). Multivariate Cox hazard analysis revealed that proximal RCA occlusion was not associated with MACE (HR 1.095, 95%CI 0.691-1.737, p = 0.699). CONCLUSIONS: Although the acute phase conditions such as shock or right ventricular infarction tended to be more severe in patients with proximal occlusion, overall clinical outcomes including long-term outcomes were comparable between the proximal and distal RCA occlusions. Furthermore, multivariate analysis showed that the proximal RCA occlusion was not associated with MACE after hospital discharge.

Killip classification has been used to stratify the risk of patients with acute myocardial infarction (AMI). There were many reports that Killip class 3 or 4 is closely associated with poor clinical outcomes. In other words, Killip class 1 or 2 is associated with favorable clinical outcomes in patients with AMI, especially when patients received primary percutaneous coronary intervention (PCI). However, some patients with Killip class 1/2 suffer from serious in-hospital complications. This study aimed to identify factors associated with serious in-hospital complications of ST-segment elevation myocardial infarction (STEMI) in patients with Killip class 1/2. The primary endpoint was serious in-hospital complications defined as the composite of in-hospital death and mechanical complications. We included 809 patients with STEMI, and divided them into the non-complication group (n = 791) and the complication group (n = 18). In-hospital death was observed in 14 patients (1.7%), and mechanical complications were observed in 4 patients (0.5%). Final TIMI flow ≤ 2 was more frequently observed in the complication group (33.3%) than in the non-complication group (5.4%) (p < 0.001). Multivariate logistic regression analysis revealed that serious in-hospital complication was associated with final TIMI flow grade ≤ 2 (Odds ratio 6.040, 95% confidence interval 2.042-17.870, p = 0.001). In conclusion, serious in-hospital complication of STEMI was associated with insufficient final TIMI flow grade in patients with Killip class 1/2. If final TIMI flow grade is suboptimal after primary PCI, we may recognize the potential risk of serious complications even when patients presented as Killip class 1/2.

Although serum troponin level is the gold standard under the universal definition of acute myocardial infarction (AMI), serum creatinine kinase (CK) and creatine kinase-myocardial band (CK-MB) is still measured in clinical practice as the compliment of troponin level. The purpose of this retrospective study is to illustrate the dramatic change of CK-MB/CK ratio by comparing CK-MB/CK ratio in patients with ST-segment elevation myocardial infarction (STEMI) among ≤ 24 h before reaching peak CK, peak CK, ≤ 24 h after reaching peak CK, and 24-48 h after reaching peak CK. We included 502 patients with STEMI. We calculated each average CK-MB/CK ratio at ≤ 24 h before reaching peak CK, peak CK, ≤ 24 h after reaching peak CK, and 24-48 h after reaching peak CK. The average values were compared using Friedman test. The average CK-MB/CK ratio at ≤ 24 h before reaching peak CK, peak CK, ≤ 24 h after reaching peak CK, and 24-48 h after reaching peak CK was 0.096 (9.6% of CK), 0.098 (9.8% of peak CK), 0.076 (7.6% of CK), and 0.028 (2.8% of CK), respectively. The Friedman test suggested that the CK-MB/CK ratio significantly declined after reaching peak CK (p < 0.001). In conclusion, the CK-MB/CK ratio was around 0.1 (10% of CK) until CK-MB and CK reached the peak, but dropped sharply after reaching peak CK. The CK-MB/CK ratio less than 0.1 (10% of CK) cannot be used to rule out the possibility of AMI, when the onset of symptom is unclear or late presentation.

Drug-coated balloons (DCBs) have been widely used in endovascular therapy for femoropopliteal arteries with atherosclerotic lesions. Vascular response after DCBs remains unclear. This mini-review proposes a possible mechanism of restenosis after the DCB strategy. Balloon dilatation including DCBs expands the vascular lumen by producing dissections, which is composed of the original vascular lumen and the cavity surrounded by dissected flaps. The cavity surrounded by dissected flaps is eventually replaced with the thrombus in the healing process after balloon dilatation. However, the thrombus may propagate to the expanded vascular lumen through the entry point of the dissection. Subsequently, the thrombus both in the cavity and the expanded lumen would be organized over time. The vascular lumen in the chronic-phase after DCBs may be influenced by the propagated thrombus from the cavity surrounded by dissected flaps.