藤田 英雄

BACKGROUND: Coronary artery disease (CAD) and aortic valve stenosis (AS) often coexist, with AS exacerbating myocardial ischemia and affecting prognosis. AIMS: To investigate the prognostic impact of AS stratified by peak aortic jet velocity (AV-Vel) in patients undergoing PCI. METHODS AND RESULTS: We conducted retrospective multicenter observational study involving patients who underwent percutaneous coronary intervention (PCI) between April 2013 and March 2019. The patients were divided into non-AS group and AS group. The AS group was further categorized: 2.6 ≤ AV-Vel < 3.0 m/s, mild AS; 3.0 ≤ AV-Vel < 4.0 m/s, moderate AS; and AV-Vel ≥ 4.0 m/s, severe AS. The primary outcome was all-cause mortality, and the secondary outcome was major adverse cardiovascular events (MACE), defined as a composite of all-cause mortality, myocardial infarction, or stroke. Multivariable Cox proportional hazards analysis was performed over 5-year observation period, with landmark analyses conducted at 30 days after PCI and from day 31 after PCI to 5 years. In total, 9,690 patients were analyzed (AS group, n = 361). Over a median follow-up of 2.57 (IQR: 0.89-4.24) years, AS group exhibited higher rates of mortality (HR: 3.06; 95% CI: 2.41-3.90; p < 0.001) and MACE (HR: 2.45; 95%CI: 1.97-3.04; p < 0.001) compared with non-AS group. Subgroup analysis revealed that patients with moderate and severe AS had worse short-term mortality and MACE within 30 days after PCI than the non-AS group, while patients with mild to severe AS showed significantly worse long-term outcomes than the non-AS group. CONCLUSIONS: AV-Vel is independently associated with both short- and long-term outcomes in patients undergoing PCI.

Objective Changes in the left ventricular ejection fraction (LVEF) after an ST-segment elevation myocardial infarction (STEMI) are associated with subsequent ischemic events and mortality. This study aimed to investigate the determinants of a mid-term improvement and deterioration of LVEF in patients with STEMI. Methods We included 585 patients with STEMI who had a modified Simpson EF both at index admission and mid-term (6-12 months) follow-up. We divided the patients into the EF deterioration group (≥10% decrease in EF, n=38), the EF improvement group (≥10% increase in EF, n=127), and the unchanged EF group (<10% change in EF, n=420). Results Baseline EF was significantly associated with an EF deterioration (OR1.472 per 5.0 % increase, 95%CI:1.231-1.761, p<0.001). The hemoglobin levels were inversely associated with an EF deterioration (OR0.760 per 1.0 g/dL increase, 95%CI: 0.632-0.914, p=0.003). The peak creatine kinase levels were significantly associated with an EF deterioration (OR1.034 per 100 U/L increase, 95%CI: 1.019-1.050, p<0.001). A female sex was significantly associated with an EF improvement (OR2.118, 95%CI: 1.222-3.671, p=0.008). The pulse rate was inversely associated with an EF improvement (OR0.887 per 10 bpm increase, 95%CI: 0.791-0.995, p=0.041). Infarct-related artery with LMT-left anterior descending artery was significantly associated with an EF improvement (OR1.661, 95%CI: 1.009-2.734, p=0.046). Time interval between the Baseline EF and follow-up EF was significantly associated with an EF improvement (OR1.008, 95%CI: 1.002-1.013, p=0.006). The peak creatine kinase level (OR0.981 per 100 U/L increase, 95%CI: 0.970-0.992, p<0.001) and baseline EF (OR0.568, 95%CI: 0.500-0.645, p<0.001) was inversely associated with an EF improvement. Conclusion A higher baseline EF, lower hemoglobin levels at admission, and higher peak creatine kinase levels were associated with a mid-term deterioration of LVEF, whereas a female sex, LM-LAD as the infarct-related artery, and the time interval between baseline and follow-up EF were associated with a mid-term improvement in LVEF. Knowledge of these determinants may help to refine the post-STEMI risk stratification and therapeutic strategies.

Percutaneous coronary intervention (PCI) for ostial right coronary artery (RCA) lesions remains challenging and is associated with higher rates of restenosis and target lesion revascularization, even in the contemporary drug-eluting stent era. These unfavorable outcomes are largely attributable to the unique anatomical and histological characteristics of the aorto-ostial junction, including severe calcification, limited vessel compliance, and hinge motion. Intravascular ultrasound (IVUS) studies have identified distinct morphological patterns of ostial RCA lesions, including isolated ostial lesions, diffuse atherosclerotic disease without calcified nodules, and lesions characterized by calcified nodules, which are associated with poorer clinical outcomes. Optimal management of ostial RCA lesions requires careful lesion assessment and tailored therapeutic strategies. For de novo lesions, adequate lesion preparation using high-pressure/scoring balloon dilation, rotational atherectomy (RA), or intravascular lithotripsy is essential to achieve optimal stent expansion. Precise ostial stent placement and intravascular imaging-guided optimization are critical procedural components, and drug-coated balloon (DCB) therapy may be considered in selected cases with a high risk of restenosis. In-stent restenosis (ISR) of the ostial RCA is frequently driven by mechanical factors such as stent underexpansion or fracture. DCBs are the preferred first-line treatment for ISR, while additional lesion modification using high-pressure balloons, RA may be required in cases with significant mechanical constraints. This review summarizes current evidence on the morphology, mechanisms, and contemporary treatment strategies for ostial RCA lesions, with a particular focus on intravascular imaging-guided intervention and practical considerations in clinical practice.

Coronary artery disease (CAD) is a major risk factor for the development of heart failure (HF) with preserved ejection fraction (HFpEF) and is associated with increased mortality. However, an optimal strategy to screen for HFpEF among patients with CAD has not yet been established. The HFpEF-ABA score was introduced to estimate the pretest probability of HFpEF and was shown to predict adverse HF events. This retrospective multicenter cohort study included patients registered in the Clinical Deep Data Accumulation System database who underwent percutaneous coronary intervention from April 2013 to March 2019. Patients with a left ventricular (LV) ejection fraction ≥ 50% and no known history of HF were included. Age, body mass index, and a history of atrial fibrillation were used to calculate the HFpEF-ABA score, and patients were dichotomized at a 50% threshold for descriptive risk stratification. The primary endpoint was a composite of all-cause death and unplanned HF hospitalization. Among 3307 patients, those with high HFpEF-ABA scores were more likely to have hypertension, renal dysfunction, anemia, larger left atrial size, higher LV mass index, and elevated brain natriuretic peptide levels, consistent with an HFpEF phenotype. Over a median follow-up of 721 days, 275 patients experienced the primary endpoint. The HFpEF-ABA score was independently associated with the primary endpoint as both a continuous and a categorical variable (hazard ratio: 1.07 [95% confidence interval: 1.00-1.14], P = 0.043, and 1.37 [1.07-1.76], P = 0.015, respectively). The HFpEF-ABA score identifies CAD patients with an HFpEF phenotype and predicts adverse outcomes.