藤田 英雄

PURPOSE: Dipeptidyl peptidase-4 (DPP-4) inhibitors increase endothelial progenitor cells (EPCs) in peripheral blood circulation. However, the underlying mechanisms and effects on vascular endothelial function remain unclear. We evaluated whether the DPP-4 inhibitor teneligliptin increases circulating EPCs by inhibiting stromal-derived factor-1α (SDF-1α) and improves flow-mediated vascular dilatation (FMD) in type 2 diabetes mellitus patients with acute coronary syndrome (ACS) or its risk factors. PATIENTS AND METHODS: This single-center, open-label, prospective, randomized controlled trial evaluated 17 patients (hemoglobin A1c ≤7.5% and peak creatinine phosphokinase <2000 IU/mL) with ACS or a history of ACS or multiple cardiovascular risk factors. Metabolic variables of glucose and lipids, circulating EPCs, plasma DPP-4 activity, and SDF-1α levels, and FMD were evaluated at baseline and 28 ± 4 weeks after enrollment. Patients were randomly assigned to either the teneligliptin (n = 8) or control (n = 9) groups. RESULTS: The DPP-4 activity (∆-509.5 ± 105.7 vs ∆32.8 ± 53.4 μU/mL) and SDF-1α levels (∆-695.6 ± 443.2 vs ∆11.1 ± 193.7 pg/mL) were significantly decreased after 28 weeks in the teneligliptin group than those in the control group. The number of EPCs showed an increasing trend in the teneligliptin treated group; albeit this did not reach statistical significance. Glucose and lipid levels were not significantly different between the groups before and after 28 weeks. However, FMD was significantly improved in the teneligliptin group when compared to the control group (∆3.8% ± 2.1% vs ∆-0.3% ± 2.9%, P=0.006). CONCLUSION: Teneligliptin improved FMD through a mechanism other than increasing the number of circulating EPCs.

BACKGROUND: Epidemiological studies reported that acute myocardial infarction (AMI) occurs more often in winter season or days with low temperatures. However, most of these studies did not distinguish ST-elevation myocardial infarction (STEMI) from AMI. The purpose of this study was to investigate the relationship between temperature and the occurrence of STEMI. METHODS: We reviewed all daily temperature in Saitama City between January 2015 and December 2021 (2557 days) and divided them into days in which our institution received STEMI (days with STEMI) and days in which our institution did not receive STEMI (days without STEMI). RESULTS: The daily maximum temperature was significantly lower in days with STEMI than in days without STEMI [20.0 °C (68.0 °F) versus 21.2 °C (70.2 °F), p = 0.001]. The maximum temperature was significantly lower in days with STEMI than in days without STEMI in the elderly [19.9 °C (67.8 °F) versus 21.1 °C (70.0 °F), p = 0.003], whereas this trend was weaker in the non-elderly [20.2 °C (68.4 °F) versus 20.9 °C (69.6 °F), p = 0.171]. Furthermore, the maximum temperature was significantly lower in days with STEMI than in days without STEMI in male [20.0 °C (68.0 °F) versus 21.1 °C (70.0 °F), p = 0.002], whereas this trend was weaker in females [20.0 °C (68.0 °F) versus 20.9 °C (69.6 °F), p = 0.169]. CONCLUSIONS: The daily temperatures were significantly lower in days with STEMI than in days without STEMI, and this relationship was pronounced in elderly or male patients.

AIMS: Complex and high-risk intervention in indicated patients (CHIP) is an emerging concept in the contemporary percutaneous coronary intervention (PCI). CHIP is known to consist three factors, namely, (1) patient factors, (2) complicated heart disease, and (3) complex PCI. However, it remains unclear whether additional CHIP factors further increase the incidence of complications in complex PCI. Thus, in this study, we aim to compare the incidence of complications among definite CHIP, possible CHIP, and non-CHIP in terms of complex PCI and to further investigate the association between CHIP and complications. METHODS: The primary aim of this study was to determine the major complications in PCI. We included 989 PCI lesions and divided those into definite CHIP (n=140), possible CHIP (n=397), and the non-CHIP groups (n=452). RESULTS: The incidence of major complications was noted to be the highest in the definite CHIP, followed by the possible CHIP, and lowest in the non-CHIP (p=0.001). The multivariate logistic regression analysis using a generalized estimating equation revealed definite CHIP (versus non-CHIP: odds ratio (OR) 2.099, 95% confidence interval (CI) 1.062-4.150, p=0.033) was significantly associated with major complications after controlling for confounding factors. Another multivariate logistic regression analysis revealed immunosuppressive drugs (OR 3.040, 95% CI 1.251-7.386, p=0.014), unstable hemodynamics (OR 5.753, 95% CI 1.217-27.201, p=0.027), and frailty (OR 2.039, 95% CI 1.108-3.751, p=0.022) were significantly associated with major complications among CHIP factors. CONCLUSIONS: The incidence of major complications in complex PCI was determined to be the highest in the definite CHIP, followed by the possible CHIP and lowest in the non-CHIP. Thus, more attention should be given to the three components of CHIP to prevent major complications in complex PCI.

BACKGROUND AND AIMS: Intravascular ultrasound (IVUS) often allows us to observe reverberations behind calcification in percutaneous coronary intervention (PCI) to heavily calcified lesions. However, clinical significance of reverberations remains unknown. The aim of this study was to assess the impact of reverberations on stent expansion and clinical outcomes after PCI with rotational atherectomy (RA) to heavily calcified lesions. METHODS: We considered 250 calcified lesions that underwent IVUS-guided PCI with RA. According to the number of reverberations (NR), those lesions were divided into the high NR (≥3) group (n = 36) and the low NR (≤2) group (n = 214). Stent expansion and the cumulative incidence of ischemia-driven target lesion revascularization (ID-TLR) were compared between the high and low NR groups. RESULTS: The high NR group showed significantly smaller stent expansion rate than the low NR group (67.7% vs. 75.9%, respectively, p=0.02). The multivariate logistic regression analysis showed that high NR and calcified nodule were significantly associated with stent underexpansion. The incidence of ID-TLR was significantly higher in the high NR group than in the low NR group (p=0.03). In multivariate Cox hazard analysis, high NR and acute coronary syndrome were significantly associated with ID-TLR. CONCLUSIONS: High NR was significantly associated with stent underexpansion and ID-TLR. When high NR was detected by IVUS, the PCI strategy was be planned carefully to avoid stent underexpansion. The follow-up program of the patients with high NR might need to be scheduled prudently because of the high risk of TLR.

Some patients admitted to intensive care units (ICU) would develop delirium, which is associated with poor prognosis. The purpose of this retrospective study was to identify factors associated with ICU delirium in patients with acute myocardial infarction (AMI). We included 753 AMI and divided those into the ICU-delirium group (n = 110) and the non-ICU-delirium group (n = 643) according to the presence of ICU delirium. The ICU delirium was evaluated by confusion assessment method for the intensive care unit. Patient characteristics and clinical outcomes were compared between the 2 groups, and factors associated with ICU delirium were sought by multivariate analysis. The prevalence of female sex was significantly higher in the ICU-delirium group (43.6%) than in the non-ICU-delirium group (20.2%) (p < 0.001). The incidence of in-hospital death was significantly higher in the ICU-delirium group (17.3%) than in the non-ICU-delirium group (0.5%) (p < 0.001). The multivariate logistic regression analysis revealed that age [every 10 years increase: odds ratio (OR) 1.439, 95% confidence interval (CI) 1.127-1.837, p = 0.004], female sex (OR 2.237, 95%CI 1.300-3.849, p = 0.004), triple vessel disease (OR 2.317, 95%CI 1.365-3.932, p = 0.002), body mass index < 18.5 kg/m2 (OR 2.910, 95%CI 1.410-6.008, p = 0.004), use of mechanical support (OR 2.812, 95%CI 1.500-5.270, p = 0.001), respiratory failure (OR 5.342, 95%CI 3.080-9.265, p < 0.001), and use of continuous renal replacement therapy (OR 5.901, 95%CI 2.520-13.819, p < 0.001) were significantly associated with ICU delirium. In conclusion, ICU delirium was associated with in-hospital death. Older age, female sex, triple vessel disease, leanness, use of mechanical support, respiratory failure, and continuous renal replacement therapy were significantly associated with the occurrence of ICU delirium.

OBJECTIVES: This study aimed to investigate the relationship between immediate incomplete stent apposition (ISA) detected by intravascular ultrasound (IVUS) and midterm stent failure. BACKGROUND: Stent failure is one of serious clinical events related to percutaneous coronary intervention (PCI). The previous studies using optical coherence tomography showed that ISA could be associated with stent thrombosis. However, the association between immediate ISA detected by IVUS and stent failure has not been fully investigated. METHODS: We included 396 lesions that underwent elective PCI, and divided those into the appropriate stent apposition (ASA) group (n = 290) and the ISA group (n = 106). The primary endpoint was stent failure, which was defined as a composite of ischemia-driven target lesion revascularization and stent thrombosis. We compared clinical and lesion characteristics between the two groups, and performed a multivariate COX hazard analysis to investigate the association between immediate ISA and stent failure. RESULTS: The median follow-up duration was 1296 days. The Kaplan-Meier curves revealed the higher incidence of stent failure in the ISA group than in the ASA group (p < 0.001). The multivariate stepwise COX hazard analysis showed that immediate ISA (hazard ratio 4.97, 95% confidence interval 1.31-18.82, p = 0.018) was significantly associated with stent failure. When we set the cut-off value of the immediate ISA distance as 0.25 mm, the distance ≥ 0.25 mm had 68.8% sensitivity and 85.0% specificity to predict stent failure. CONCLUSIONS: Immediate ISA detected by IVUS was associated with midterm stent failure. We should pay attention to reduce immediate ISA for improving the midterm outcomes.

AIMS: Coronary calcification detected by coronary angiography is a simple risk marker for long-term clinical outcomes in stable coronary artery disease. However, the significance of angiographic coronary calcification in the culprit lesion of acute myocardial infarction (AMI) has not been fully discussed. The purpose of this retrospective study was to assess the usefulness of angiographic coronary calcification as a risk marker for long-term clinical outcomes following percutaneous coronary intervention to the culprit lesions of AMI. METHODS: We included 1209 patients with AMI and divided them into the none-mild calcification group (n=923) and the moderate-severe calcification group (n=286) according to angiographic coronary calcification in the culprit lesion of AMI. The primary endpoint was the occurrence of major adverse cardiac events (MACE), which was defined as a composite of all-cause death, nonfatal MI, readmission for heart failure, and ischemia-driven target vessel revascularization. RESULTS: The median follow-up duration was 542 (Q1: 182, Q3: 990) days. A total of 345 MACE were observed during the study period. The occurrence of MACE was significantly greater in the moderate-severe calcification group than in the none-mild calcification group (43.4% vs. 23.9%, p＜0.001). In the multivariate Cox hazard model, moderate-severe calcification was significantly associated with MACE (hazard ratio 1.302, 95% confidence interval 1.011-1.677, p=0.041) after controlling multiple confounding factors. CONCLUSIONS: Angiographically moderate to severe calcification in AMI culprit lesion was associated with long-term worse clinical outcomes. Angiographic coronary calcification can be a simple risk marker in patients after AMI.

AIMS: Calcified nodule (CN) has been known as the advanced stage of coronary calcification. However, clinical outcomes following percutaneous coronary intervention (PCI) to CN remain unknown. This study aimed to compare clinical outcomes, including target lesion revascularization (TLR), between calcified coronary lesions with and without CN. METHODS: Two hundred forty-nine lesions undergoing intravascular ultrasound-guided PCI with rotational atherectomy (RA) were enrolled and divided into the CN group (n=100) and the non-CN group (n=149) according to the presence of CN. The cumulative incidence of clinically driven TLR (CD-TLR) and the reasons for CD-TLR were compared between the CN and non-CN groups. RESULTS: The incidence of CD-TLR was significantly higher in the CN group than in the non-CN group. In the landmark analysis at 1 year, the CN group showed a significantly higher incidence of CD-TLR within 1 year. However, the incidence of CD-TLR beyond 1 year was numerically lower in the CN group than in the non-CN group. In the multivariate Cox hazard model, CN was significantly associated with CD-TLR. In the CN group, in-stent CN was the major reason for CD-TLR (52%) and was observed mainly within 1 year (90%). CONCLUSIONS: In the heavily calcified lesions requiring RA, CN was the factor associated with the higher rate of CD-TLR especially within 1 year. The timing of CD-TLR in lesions with CN may indicate that the process of CN protruding through the struts was progressed monthly.

In-hospital mortality of acute myocardial infarction (AMI) complicated with cardiogenic shock (CS) remains high. Also, in-hospital mortality of AMI complicated with cardiac arrest (CA) has been reported to be highest among any AMI. However, there were few reports that compared in-hospital mortality directly between AMI complicated with CS and complicated with CA. The purpose of this study was to compare in-hospital outcomes between AMI complicated with CS and complicated with CA. We retrospectively included 195 AMI patients complicated by CS or CA, and divided those into the CA group (n = 109) and the CS group (n = 86). We also subdivided the CA group into CA with persistent CS (n = 83) and CA without persistent CS (n = 26). One-third of the study population died during the index admission. In-hospital death was more frequently observed in the CA group (45.0%) than in the CS group (20.9%) (p < 0.001). In-hospital mortality was highest in the CA with persistent CS group (68.7%), followed by the CS group (20.9%), and least in the CA without persistent CS group (11.5%) (p < 0.001). Favorable neurological function was more frequently observed in the CA without persistent CS group (76.9%) and the CS group (74.4%) than in the CA with persistent CS group (27.7%) (p < 0.001). In conclusion, in-hospital mortality was higher in AMI patients with CA than in those with CS. However, when we divided AMI patients with CA into those with and without persistent CS, in-hospital mortality was lowest in CA without persistent CS, followed by CS, and highest in CA with persistent CS.

BACKGROUND: Percutaneous coronary intervention (PCI) to the calcified bifurcation lesion is still a challenging issue even for experienced interventional cardiologists. In such bifurcation lesions, side branch compromise caused by carina-shift or plaque shift just following stent implantation or balloon dilatation is one of the most important complications. It remains unclear whether rotational atherectomy (RA) to the main vessel reduces the incidence of side branch compromise in the calcified bifurcation lesions. The aim of this retrospective study was to compare the incidence of side branch compromise/occlusion between PCI with versus without RA. METHODS: This was a retrospective, single-center study. Side branch compromise/occlusion was defined as final Thrombolysis in Myocardial Infarction flow grade of side branch ≤2/≤1. We included 302 calcified bifurcation lesions, and divided those into the RA group (n = 140) and the non-RA group (n = 162) according to use of RA to the main vessel. RESULTS: The incidence of side branch compromise/occlusion was significantly less in the RA group than in the non-RA group (compromise: 6.4 % versus 14.2 %, p = 0.038; occlusion: 3.6 % versus 10.5 %, p = 0.017). RA was inversely associated with the incidence of side branch compromise [odds ratio (OR) 0.272, 95 % confidence interval (CI) 0.096-0.772, p = 0.014] and occlusion (OR 0.175, 95 % CI 0.049-0.628, p = 0.008). CONCLUSIONS: RA to the main vessel was associated with a lower incidence of side branch compromise/occlusion. RA to the main vessel only may be a reasonable approach to reduce the risk of side branch compromise/occlusion in calcified bifurcation lesions.

BACKGROUND: Low ankle-brachial index (ABI) is an established risk factor for long-term cardiovascular outcomes in patients with acute myocardial infarction (AMI), and brachial-ankle pulse wave velocity (ba-PWV) may also be a risk factor. However, there is a significant overlap between low ABI and high ba-PWV. The purpose of this retrospective study was to examine whether increased ba-PWV was associated with long-term clinical outcomes in AMI patients with normal ABI. METHODS: We included 932 AMI patients with normal ABI and divided them into the high PWV group (≥1,400 cm/s; n=646) and the low PWV group (<1400 cm/s; n=286) according to the ba-PWV values measured during the AMI hospitalisation. The primary endpoint was the major adverse cardiovascular events (MACE) defined as the composite of all-cause death, nonfatal myocardial infarction, and hospitalisation for heart failure. RESULTS: During the median follow-up duration of 541 days (Q1: 215 days-Q3: 1,022 days), a total of 154 MACE were observed. The Kaplan-Meier curves showed that MACE was more frequently observed in the high PWV group than in the low PWV group (p<0.001). The multivariate Cox hazard analysis revealed that high ba-PWV was significantly associated with MACE (hazard ratio [HR] 1.587; 95% CI 1.002-2.513; p=0.049) after controlling multiple confounding factors. CONCLUSIONS: High ba-PWV was significantly associated with long-term adverse events in AMI patients with normal ABI. Our results suggest the usefulness of PWV as a prognostic marker in AMI with normal ABI.

BACKGROUND: As severity of acute myocardial infarction (AMI) varies widely, several risk stratifications for AMI have been reported. We have introduced a novel AMI risk stratification system linked to a rehabilitation program (novel AMI risk stratification; nARS), which stratified AMI patients into low (L)-, intermediate (I)-, and high (H)-risk groups. The purpose of this retrospective study was to compare the long-term clinical outcomes in patients with AMI among L-, I-, H-risk groups.Methods and Results: This study included 773 AMI patients, and assigned them into the L-risk group (n=332), the I-risk group (n=164), and the H-risk group (n=277). The primary endpoint was major cardiovascular events (MACE), defined as the composite of all-cause death, readmission for heart failure, non-fatal myocardial infarction, and target vessel revascularization after the discharge of index admission. The median follow-up duration was 686 days. MACE was most frequently observed in the H-risk group (39.4%), followed by the I-risk group (23.2%), and least in the L-risk group (19.9%) (P<0.001). The multivariate Cox hazard analysis revealed that the H-risk was significantly associated with MACE (HR 2.166, 95% CI 1.543-3.041, P<0.001) after controlling for multiple confounding factors. CONCLUSIONS: H-risk according to nARS was significantly associated with long-term adverse events after hospital discharge for patients with AMI. These results support the validity of nARS as a risk marker for long-term outcomes.

Patients with acute myocardial infarction (AMI) with chronic total occlusion (CTO) in nonculprit arteries had worse prognosis than patients with AMI without CTO in nonculprit arteries. However, the reason was not clearly explained. This retrospective study aimed to compare the clinical outcomes between patients with AMI with CTO versus those with severe stenosis (90% to 99% stenosis) in nonculprit arteries, which would help to elucidate the role of CTO in nonculprit arteries. We included 643 patients with AMI and divided those into the CTO group (n = 188) and 90% to 99% stenosis group (n = 455). The primary end point was the major adverse cardiovascular events (MACE) defined as the composite of all-cause death, nonfatal myocardial infarction, and readmission for heart failure. During the median follow-up duration of 431 days (Q1:178 days to Q3:950 days), a total of 189 MACE was observed. The Kaplan-Meier curves showed that MACE was more frequently observed in the CTO group than in the 90% to 99% stenosis group (p <0.001). The multivariate Cox hazard analysis revealed that CTO in nonculprit arteries (vs 90% to 99% stenosis) was significantly associated with MACE (hazard ratio 1.410, 95% confidence interval 1.042 to 1.907; p = 0.026) after controlling known confounding factors. In conclusion, patients with AMI with CTO in nonculprit arteries had worse clinical outcomes than those with 90% to 99% stenosis in nonculprit arteries. Patients with AMI with CTO could be recognized as a high-risk group rather than those with 90% to 99% stenosis and should be carefully managed to prevent cardiovascular events.

Intravascular ultrasound (IVUS) can provide useful information in patients undergoing complex percutaneous coronary intervention with rotational atherectomy (RA). The association between IVUS findings and slow flow following rotational atherectomy (RA) has not been investigated, although slow flow has been shown to be an unfavorable sign with worse outcomes. The aim of this study was to determine the IVUS-factors associated with slow flow just after RA. We retrospectively enrolled 290 lesions (5316 IVUS-frames) with RA, which were divided into the slow flow group (n = 43 with 1029 IVUS-frames) and the non-slow flow group (n = 247 with 4287 IVUS-frames) based on the presence of slow flow. Multivariate regression analysis assessed the IVUS-factors associated with slow flow. Slow flow was significantly associated with long lesion length, the maximum number of reverberations [odds ratio (OR) 1.49; 95% confidence interval (CI) 1.07-2.07, p = 0.02] and nearly circumferential calcification at minimal lumen area (MLA) (≥ 300°) (OR, 2.21; 95% CI 1.13-4.32; p = 0.02). According to the maximum number of reverberations, the incidence of slow flow was 2.2% (n = 0), 11.9% (n = 1), 19.5% (n = 2), 22.5% (n = 3), and 44.4% (n = 4). In conclusion, IVUS findings such as longer lesion length, the maximum number of reverberations, and the greater arc of calcification at MLA may predict slow flow after RA. The operators need to pay more attention to the presence of reverberations to enhance the procedure safety.

Coronary collateral flow is an important prognostic marker in percutaneous coronary intervention (PCI) for chronic total occlusion. However, the role of collateral flow to the culprit lesion of acute myocardial infarction (AMI) has not been fully established yet. The purpose of this retrospective study was to examine the association between collateral flow and long-term clinical outcomes in patients with AMI. We included 937 patients with AMI, and divided those into the no-collateral group (n = 704) and the collateral group (n = 233) according to the presence or absence of collateral flow to the culprit lesion of AMI. The primary endpoint was the incidence of major adverse cardiac events (MACE), which was defined as a composite of all-cause death, non-fatal MI, re-admission for heart failure, and ischemia driven target vessel revascularization. The median follow-up duration was 473 days (Q1: 184 days- Q3: 1027 days), and a total of 263 MACE was observed during the study period. The incidence of MACE was significantly greater in the no-collateral group than in the collateral group (29.8% vs. 22.3%, p = 0.027). In the multivariate COX hazard model, the presence of collateral flow was inversely associated with MACE (HR 0.636, 95% CI 0.461-0.878, p = 0.006) after controlling multiple confounding factors. In conclusion, the presence of collateral flow to the culprit lesion of AMI was inversely associated with long-term adverse outcomes. Careful observation of collateral flow may be important in emergent coronary angiography to stratify a high-risk group among various patients with AMI.

BACKGROUND: Among various mechanical support devices, veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is the last resort for acute myocardial infarction (AMI) patients complicated with refractory cardiogenic shock or cardiac arrest. The purpose of this study was to investigate the V-A ECMO-related complications in AMI patients who underwent percutaneous coronary intervention (PCI), and to find the association between complications and in-hospital death in that population. METHODS: We retrospectively included 101 AMI patients who received V-A ECMO and underwent PCI to the culprit lesion, and divided them into the survivor group (n=43) and the in-hospital death group (n=58). We compared the clinical characteristics and outcomes including complications between the 2 groups, and performed multivariate logistic regression analysis to find factors associated with in-hospital death and major bleeding. RESULTS: The incidence of major bleeding including V-A ECMO site bleeding and intracranial hemorrhage was higher in the in-hospital death group (34.5%) than in the survivor group (7%) (p=0.001). Multivariate logistic regression analysis revealed that final thrombolysis in myocardial infarction (TIMI) flow grade ≤2 (OR 4.453, 95% CI1.427-13.894, p=0.010) and major bleeding (OR 4.986, 95% CI1.277-19.466, p=0.021) were significantly associated with in-hospital death. Out-of-hospital cardiac arrest (OHCA) was significantly associated with major bleeding (OR 3.881, 95% CI 1.358-11.089, p=0.011). CONCLUSIONS: In AMI patients who received V-A ECMO and underwent PCI, final TIMI flow grade ≤2 and major bleeding were associated with in-hospital death. OHCA was closely associated with major bleeding.

Slow flow during primary percutaneous coronary intervention (PCI) is a common complication. Our group showed that the stent (or post-balloon) diameter-to-vessel diameter ratio was inversely associated with slow flow phenomenon. We advocated the utility of modest stent expansion strategy, which was defined as the stent (or post-balloon) diameter-to-culprit vessel diameter ratio < 0.71, for prevention of slow flow phenomenon. This study aimed to compare the long-term outcomes in patients with acute myocardial infarction (AMI) between the modest stent expansion strategy and the aggressive stent expansion strategy (the stent diameter-to-culprit vessel diameter ratio ≥ 0.71). We included 584 AMI patients, which were divided 177 patients in the modest stent expansion group and 146 patients in the aggressive stent expansion group. The primary endpoint was major adverse cardiac events (MACE), which was defined as a composite of cardiac death, ischemia driven target vessel revascularization, and stent thrombosis. The slow flow after stent deployment was more frequently observed in the aggressive stent expansion group (24.0%) than in the modest stent expansion group (4.0%) (P < 0.001). The Kaplan-Meier curves revealed that MACE was comparable between the two groups (P = 0.64). The multivariate COX hazard model showed the non-significant association between the modest stent expansion strategy and MACE (vs. aggressive stent expansion: hazard ratio 1.005, 95% confidence interval 0.619-3.242, P = 0.41). In conclusion, the modest stent expansion strategy was not associated with long-term MACE. Therefore, the modest stent expansion strategy may be a good choice for the culprit lesion of AMI.

The medical expenses for patients with acute myocardial infarction (AMI) has become enormous burden for global healthcare system. In AMI patients, total admission cost for patients with off-hours visit may be higher than those with on-hours visit, because of additional cost for emergent care during off-hours. This study aimed to compare total medical cost in AMI patients between on-hours visit versus off-hours visit. We retrospectively included 368 AMI patients who underwent PCI to the culprit lesion, and divided them into the on-hours group (n = 173) and the off-hours group (n = 195). We compared clinical characteristics, total admission cost, and clinical outcomes between the two groups. The prevalence of Killip class 3/4 was significantly greater in the off-hours group than in the on-hours group. Length of ICU and hospital stay were significantly longer in the off-hours group than in the on-hours group. Total admission cost was significantly higher in the off-hours group [\1,570,400 (\1,271,550-\2,117,090)] than in the on-hours group [\1,356,270 (\1,100,990-\1,957,225)] (P < 0.001). However, multivariate analysis revealed off-hours visit itself was not associated with high total admission cost after adjusting confounding factors. In conclusion, total admission cost was higher in AMI patients with off-hours visit than in those with on-hours visit. However, multivariate logistic regression analysis revealed that the off-hours visit itself was not associated with the highest total admission cost. Off-hours visit itself did not result in higher cost, but severer conditions in AMI patients with off-hours visit resulted in higher cost.

The situation around primary percutaneous coronary intervention (PCI) has dramatically changed since coronavirus disease 2019 (COVID-19) pandemic. The impact of COVID-19 pandemic on clinical outcomes as well as door-to-balloon time (DTBT), which is known as one of the indicators of early reperfusion, has not been fully investigated in patients with ST-elevation acute myocardial infarction (STEMI). The purpose of this study was to compare DTBT and in-hospital outcomes in patients with STEMI between before versus after COVID-19 pandemic. The primary interest was DTBT and the incidence of in-hospital outcomes including in-hospital death. We included 330 patients with STEMI who underwent primary PCI, and divided them into the pre COVID-19 group (n = 209) and the post COVID-19 group (n = 121). DTBT was significantly longer in the post COVID-19 group than in the pre COVID-19 group (p < 0.001), whereas the incidence of in-hospital death was comparable between the 2 groups (p = 0.238). In the multivariate logistic regression analysis, chest CT before primary PCI (OR 4.64, 95% CI 2.58-8.34, p < 0.001) was significantly associated with long DTBT, whereas chest CT before primary PCI (OR 0.76, 95% CI 0.29-1.97, p = 0.570) was not associated with in-hospital death after controlling confounding factors. In conclusion, although DTBT was significantly longer after COVID-19 pandemic than before COVID-19 pandemic, in-hospital outcomes were comparable between before versus after COVID-19 pandemic. This study suggests the validity of the screening tests including chest CT for COVID-19 in patients with STEMI who undergo primary PCI.

BACKGROUND: The causal relationship between hyperuricemia and cardiovascular diseases is still unknown. We hypothesized that hyperuricemic patients after percutaneous coronary intervention (PCI) had a higher risk of major adverse cardiovascular events (MACE). METHODS: This was a large-scale multicenter cohort study. We enrolled patients with chronic coronary syndrome (CCS) after PCI between April 2013 and March 2019 using the database from the Clinical Deep Data Accumulation System (CLIDAS), and compared the incidence of MACE, defined as a composite of cardiovascular death, myocardial infarction, and hospitalization for heart failure, between hyperuricemia and non-hyperuricemia groups. RESULTS: In total, 9,936 patients underwent PCI during the study period. Of these, 5,138 patients with CCS after PCI were divided into two group (1,724 and 3,414 in the hyperuricemia and non-hyperuricemia groups, respectively). The hyperuricemia group had a higher prevalence of hypertension, atrial fibrillation, history of previous hospitalization for heart failure, and baseline creatinine, and a lower prevalence of diabetes than the non-hyperuricemia group, but the proportion of men and age were similar between the two groups. The incidence of MACE in the hyperuricemia group was significantly higher than that in the non-hyperuricemia group (13.1 vs. 6.4%, log-rank P < 0.001). Multivariable Cox regression analyses revealed that hyperuricemia was significantly associated with increased MACE [hazard ratio (HR), 1.52; 95% confidential interval (CI), 1.23-1.86] after multiple adjustments for age, sex, body mass index, estimated glomerular filtration rate, left main disease or three-vessel disease, hypertension, diabetes mellitus, dyslipidemia, history of myocardial infarction, and history of hospitalization for heart failure. Moreover, hyperuricemia was independently associated with increased hospitalization for heart failure (HR, 2.19; 95% CI, 1.69-2.83), but not cardiovascular death or myocardial infarction after multiple adjustments. Sensitive analyses by sex and diuretic use, B-type natriuretic peptide level, and left ventricular ejection fraction showed similar results. CONCLUSION: CLIDAS revealed that hyperuricemia was associated with increased MACE in patients with CCS after PCI. Further clinical trials are needed whether treating hyperuricemia could reduce cardiovascular events or not.

Periprocedural myocardial infarction (PMI) following percutaneous coronary intervention (PCI) is more frequently observed in true bifurcation lesions such as Medina (1,1,1) and (0,1,1). The aim of this study is to compare the incidence of PMI in elective PCI between Medina (1,1,1) and (0,1,1) bifurcation lesions. This was a retrospective, single-center study. We included 162 true bifurcation lesions, which were divided into the (1,1,1) group (n = 85) and the (0,1,1) group (n = 77). We compared the incidence of PMI between the two groups and performed multivariate logistic regression analysis using PMI as a dependent variable. The incidence of PMI was similar in the (1,1,1) group and the (0,1,1) group (12.9% versus 15.6%, P = 0.658). The final TIMI flow grade of the side branches and that of the main branches were also similar in the two groups. In multivariate logistic regression analysis, Medina classification (1,1,1) was not associated with PMI (odds ratio (OR), 0.996; 95% confidence interval (CI), 0.379-2.621; P = 0.994), but the angle of the side branch < 45° (OR, 3.569; 95% CI, 1.320-9.654; P = 0.012), lesion length in a main vessel (per 10-mm increase) (OR, 1.508; 95% CI, 1.104-2.060; P = 0.010), and absence of side branch protection (OR, 3.034; 95% CI, 1.095-8.409; P = 0.033) were significantly associated with PMI. In conclusion, the Medina (1,1,1) bifurcation lesions did not increase the incidence of PMI as compared to Medina (0,1,1). However, the narrow side branch angle, diffuse long lesion, and absence of side branch protection were significantly associated with PMI. We should pay attention to these high-risk features in the treatment of true bifurcation lesions.

In percutaneous coronary intervention (PCI) to the culprit lesion of acute myocardial infarction (AMI), unsuccessful guidewire crossing causes immediate poor outcomes. It is important to determine the factors associated with unsuccessful guidewire crossing in AMI lesions. The purpose of this study was to find factors associated with difficulty in crossing the culprit lesion of AMI. We defined the difficult group when the guidewire used to cross the culprit lesion was a polymer jacket type guidewire or a stiff guidewire. We included 937 patients, and divided those into the non-difficult group (n = 876) and the difficult group (n = 61). Proximal reference diameter was significantly smaller in the difficult group than in the non-difficult group (p < 0.001), and degree of calcification was severer in the difficult group than in the non-difficult group (p < 0.001). In the multivariate stepwise logistic regression analysis, proximal reference diameter [odds ratio (OR) 0.313, 95% confidence interval (CI) 0.185-0.529, p < 0.001)], previous PCI (OR 3.065, 95% CI 1.612-5.830, p = 0.001), moderate-severe calcification (OR 4.322, 95% CI 2.354-7.935, p < 0.001), blunt type obstruction (OR 12.646, 95% CI 6.805-23.503, p < 0.001), and the presence of collateral to the culprit lesion (OR 2.110, 95% CI 1.145-3.888, p = 0.017) were significantly associated with difficulty in crossing the culprit lesion. In conclusion, previous PCI, calcification, blunt type obstruction, and the presence of collateral were associated with difficulty in crossing the culprit lesion, whereas proximal reference diameter was inversely associated with difficulty. Our study provides a reference to recognize the difficulty in crossing the culprit lesions of AMI for PCI operators, especially junior operators.

The clinical outcomes in acute myocardial infarction (AMI) patients with Killip class 3 are often inconsistent with those in the literature, and the factors associated with poor outcomes have not been sufficiently investigated. The purpose of this study was to identify factors associated with in-hospital death in AMI patients with Killip class 3. We included 205 AMI patients with Killip class 3, and divided them into a survived group (n = 189) and in-hospital death group (n = 16). The primary objective was to identify factors associated with in-hospital death using multivariate analysis. Age was significantly younger in the survived group than in the in-hospital death group (73.1 ± 11.2 versus 83.2 ± 6.2 years, P < 0.001). Systolic blood pressure (SBP) was significantly higher in the survived group than in the in-hospital death group (150.0 ± 31.2 versus 124.8 ± 25.3 mmHg, P = 0.002). The prevalence of TIMI thrombus grade ≥ 2 was significantly greater in the in-hospital death group than in the survived group (56.3 versus 22.2%, P = 0.005). In multivariate logistic regression analysis, in-hospital death was significantly associated with age [odds ratio (OR) 1.168, 95% confidence interval (CI) 1.061-1.287, P = 0.002] and TIMI thrombus grade ≥ 2 (versus ≤ 1: OR 5.743, 95% CI 1.717-19.214, P = 0.005), and inversely associated with SBP on admission (per 10 mmHg increase: OR 0.764, 95% CI 0.613-0.953, P = 0.017). In conclusion, in-hospital death was associated with age and coronary thrombus burden, and was inversely associated with SBP on admission in patients with Killip class 3. It may be important to recognize these high risk features to improve the clinical outcomes of patients with Killip class 3.

AIMS: Peripheral arterial disease (PAD) is the well-known risk factor for cardiovascular events. Although low ankle-brachial index (ABI) is recognized as a risk factor in general population, low ABI without any symptoms of PAD has not been established as a prognostic marker in patients with acute myocardial infarction (AMI) yet. The purpose of this retrospective study was to examine whether asymptomatic low ABI was associated with long-term clinical outcomes in AMI patients without treatment history of PAD. METHODS: We included 850 AMI patients without a history of PAD and divided them into the preserved ABI (ABI ≥ 0.9) group (n=760) and the reduced ABI (ABI ＜0.9) group (n=90) on the basis of the ABI measurement during the hospitalization. The primary endpoint was the major adverse cardiovascular events (MACE) defined as the composite of all-cause death, non-fatal myocardial infarction, and hospitalization for heart failure. RESULTS: During the median follow-up duration of 497 days (Q1: 219 days to Q3: 929 days), a total of 152 MACE were observed. The Kaplan-Meier curves showed that MACE were more frequently observed in the reduced ABI group than in the preserved ABI group (p＜0.001). The multivariate COX hazard analysis revealed that reduced ABI was significantly associated with MACE (hazard ratio 2.046, 95% confidence interval 1.344-3.144, p=0.001) after controlling confounding factors. CONCLUSIONS: Reduced ABI was significantly associated with long-term adverse events in AMI patients without a history of PAD. Our results suggest the usefulness of ABI as a prognostic marker in AMI patients irrespective of symptomatic PAD.

Introduction: In percutaneous coronary intervention (PCI) to atherosclerotic lesions in the right coronary artery (RCA), coronary artery dissection in the ostium of the RCA is a rare but fatal complication. Stent implantation to the ostium of RCA may be selected for the prevention of aorto-ostial dissection. Aim: To find factors associated with aorto-ostial stent coverage to mild to moderate ostial stenosis during the treatment of severely narrowed non-ostial RCA lesions. Material and methods: The primary interest was to find factors associated with ostial stent coverage using multivariate regression analysis. We included 236 patients who underwent intravascular ultrasound (IVUS)-guided PCI to severely narrowed RCA lesions with mild to moderate ostial stenosis, and divided those into the ostial-coverage group (n = 52) and the non-coverage group (n = 184). Results: The prevalence of continuous ostial plaque detected by intravascular ultrasound (IVUS) was significantly greater in the ostial-coverage group (84.6%) than in the non-coverage group (52.9%) (p < 0.001). Multivariate logistic regression analysis revealed that continuous ostial plaque detected by IVUS (OR = 5.398, 95% CI: 2.322-12.553, p < 0.001) was significantly associated with ostial stent coverage after controlling confounding factors. Ischaemia-driven target vessel revascularization was less frequently observed in the ostial-coverage group than in the non-coverage group, without reaching statistical significance (p = 0.069). Conclusions: Continuous ostial plaque detected by IVUS was significantly associated with ostial stent coverage to the mild to moderate stenosis when PCI to non-ostial, severely narrowed RCA lesions was performed. The use of IVUS may enhance the safety but may increase the total stent length in PCI to RCA.

The rapid introduction of dual antiplatelet therapy (DAPT) is important for patients with acute myocardial infarction (AMI). The risks and benefits of reduced-dose prasugrel (20 mg loading and 3.75 mg maintenance) over clopidogrel have not been fully discussed. The purpose of this study was to compare the 90-days clinical outcomes of AMI between prasugrel-based DAPT and clopidogrel-based DAPT. We included 534 AMI patients and divided them into the clopidogrel group (n = 330) and the prasugrel group (n = 204). The primary endpoint was the total ischemic events and total bleeding events. In all, 52 ischemic events and 35 bleeding events were observed during the study period. The total ischemic events were similar between the clopidogrel and the prasugrel groups (P = 0.385). The total bleeding events were similar between the clopidogrel and the prasugrel groups (P = 0.125). The multivariate Cox hazard analysis showed that prasugrel was not associated with the total ischemic events (hazard ratio (HR) 0.955, 95% confidence interval (CI) 0.499-1.829, P = 0.890) and was not associated with the total bleeding events after controlling confounding factors (HR 0.972, 95% CI 0.528-1.790, P = 0.927). In conclusion, as compared to clopidogrel, the reduced dose of prasugrel was not associated with the excess risk of bleeding or the excess risk of ischemic events. Our real-world data support the current regimen of prasugrel for AMI patients who underwent primary percutaneous coronary intervention.

Complications such as slow flow are frequently observed in percutaneous coronary intervention (PCI) with rotational atherectomy (RA). However, it remains unclear whether the high incidence of slow flow results in the high incidence of periprocedural myocardial infarction (PMI), reflecting real myocardial damage. The aim of this study was to compare the incidence of PMI between PCI with versus without RA using propensity score-matching. We included 1350 elective PCI cases, which were divided into the RA group (n = 203) and the non-RA group (n = 1147). After propensity score matching, the matched RA group (n = 190) and the matched non-RA group (n = 190) were generated. The primary interest was to compare the incidence of PMI between the matched RA and non-RA groups. Before propensity score matching, the incidence of slow flow and PMI was greater in the RA group than in the non-RA group. After matching, the incidence of slow flow was still greater in the matched RA group than in the matched non-RA group (16.8% vs. 9.5%, p = 0.048). However, the incidence of PMI was similar between the matched RA and matched non-RA group (7.4% vs. 5.3%, p = 0.528, standardized difference: 0.086). In conclusion, although use of RA was associated with greater risk of slow flow, use of RA was not associated with PMI after a propensity score-matched analysis. The fact that RA did not increase the risk of myocardial damage in complex lesions would have an impact on revascularization strategy for severely calcified coronary lesions.

Percutaneous coronary intervention (PCI) is a standard strategy for non-ST-segment elevation myocardial infarction (NSTEMI) as well as for ST-segment elevation myocardial infarction (STEMI). The device cost for PCI may be more expensive in NSTEMI, because the culprit lesion morphology may be more complex in NSTEMI. This study aimed to compare the total device cost of PCI between STEMI and NSTEMI. We included 504 patients with acute myocardial infraction (AMI) who underwent PCI, and divided those into a STEMI group (n = 286) and a NSTEMI group (n = 218). We compared the total device cost, the number of used devices, and procedure cost between the 2 groups. The total device cost was significantly higher in the NSTEMI group [\371,300 (\320,700-503,350)] than in the STEMI group [\341,200 (\314,200-410,475)] (p = 0.001), whereas the procedure cost was significantly higher in the STEMI group [\343,800 (\243,800-343,800)] than in the NSTEMI group [\220,000 (\216,800-243,800)] (p < 0.001). Drug eluting stent (85.3% vs. 76.1%, p = 0.029) and aspiration catheter (16.8% vs. 2.3%, p < 0.001) were more frequently used in the STEMI group, whereas rotablator (0.7% vs. 8.3%, p < 0.001) were more frequently used in the NSTEMI group. The multivariate logistic regression analysis revealed that NSTEMI was significantly associated with the high device cost (odds ratio 1.899, 95% confidence interval 1.166-3.093, p = 0.01). In conclusion, the total device cost for PCI was significantly higher in the culprit lesions of NSTEMI than in those of STEMI, whereas the procedure cost was significantly higher in the culprit lesions of STEMI than in those of NSTEMI.

Radial access is recommended for primary percutaneous coronary intervention (PCI), because it has fewer bleeding complications than trans-femoral PCI. However, even if trans-radial PCI is chosen, patients with ST-elevation myocardial infarction (STEMI) presenting with anemia on admission might have poor clinical outcomes. The aim of this retrospective study was to investigate whether anemia on admission was associated with mid-term clinical outcomes in patients who underwent trans-radial primary PCI. The primary endpoint was a composite of all-cause death, recurrent acute myocardial infarction, and readmission for heart failure. A total of 288 consecutive patients with STEMI who underwent trans-radial primary PCI were divided into an anemia group (n = 79) and a non-anemia group (n = 209). The median follow-up duration was 301 days. The anemia group was significantly older than the non-anemia group (77.3 ± 11.9 versus 64.4 ± 12.7 years, respectively; P < 0.001). There were significantly more females in the anemia group than in the non-anemia group (36.7% versus 14.4%, respectively; P < 0.001). Kaplan-Meier analysis revealed that the composite outcome-free survival was significantly worse in the anemia group than in the non-anemia group (P < 0.001). Multivariate Cox hazard model analysis revealed that hemoglobin levels on admission were significantly associated with the composite outcome (per 1 g/dL increase: hazard ratio 0.76, 95% confidence interval 0.66-0.88, P < 0.001) after controlling for confounding factors. In conclusion, baseline anemia was significantly associated with poor clinical outcomes. Patients with STEMI presenting with anemia should be managed carefully, even if trans-radial primary PCI is chosen.

The clinical outcomes of patients with non-ST-segment elevation myocardial infarction (NSTEMI) were comparable or even worse than those with ST-segment elevation myocardial infarction (STEMI). Although successful percutaneous coronary intervention (PCI) to the culprit lesions of NSTEMI would improve the clinical outcomes, some PCI require long fluoroscopy time, reflecting the difficulty of PCI. This study aims to find clinical factors associated with long fluoroscopy time in PCI to the culprit lesion of NSTEMI. We included 374 patients and divided those into the conventional fluoroscopy time (n = 302) and long fluoroscopy time (n = 72) groups according to the quintiles of fluoroscopy time. Clinical and angiographic parameters were compared between the two groups. Calcification and tortuosity were significantly more severe in the long fluoroscopy time group than in the conventional fluoroscopy time group. The prevalence of previous coronary artery bypass grafting (CABG) and bifurcation lesions was significantly greater in the long fluoroscopy time group than in the conventional fluoroscopy time group. In the multivariate stepwise logistic regression analysis, previous CABG (odds ratio [OR], 3.368; 95% confidence interval [CI], 1.407-8.064; P = 0.006), bifurcation lesion (OR, 2.407; 95% CI, 1.285-4.506; P = 0.006), excessive tortuosity (versus mild to moderate tortuosity; OR, 4.095; 95% CI, 1.159-14.476; P = 0.029), and moderate to severe calcification (versus none to mild; OR, 5.792; 95% CI, 3.254-10.310; P < 0.001) were significantly associated with long fluoroscopy time. In conclusion, previous CABG, bifurcation, excessive tortuosity, and moderate to severe calcification were associated with long fluoroscopy time. Our study provided a reference for PCI operators to identify the difficulties in PCI to the culprit lesion of NSTEMI.