Duration and clinical outcome of dual antiplatelet therapy after percutaneous coronary intervention: a retrospective cohort study using a medical information database from Japanese hospitals

Low-Dose Prasugrel vs. Standard-Dose Clopidogrel for Patients Undergoing Percutaneous Coronary Intervention

BACKGROUND

Low-dose prasugrel (3.75 mg) is used as maintenance therapy for percutaneous coronary intervention; however, data on long-term outcomes are scarce.

METHODS AND RESULTS

We analyzed 5,392 participants in the KiCS-PCI registry who were administered low-dose prasugrel or clopidogrel at discharge between 2008 and 2018 and for whom 2-year follow-up data were available. We adjusted for confounders using matching weight analyses and multiple imputations. Similarly, we used inverse probability- and propensity score-weighted analyses. We also performed instrumental variable analyses. The primary outcomes were acute coronary syndrome (ACS) and bleeding requiring readmission. Secondary outcomes were all-cause death and a composite outcome of ACS, bleeding, heart failure, stroke, coronary bypass requiring admission, and all-cause death. In this cohort, 12.2% of patients were discharged with low-dose prasugrel. Compared with clopidogrel, low-dose prasugrel was associated with a reduced risk of ACS (hazard ratio [HR] 0.58; 95% confidence interval [CI] 0.39-0.85), bleeding (HR 0.62; 95% CI 0.40-0.97), and the composite outcome (HR 0.71; 95% CI 0.59-0.86). Inverse probability-weighted analysis yielded similar results; however, matching weight analysis without multiple imputations and propensity score-matched analyses showed similar outcomes in both groups. Instrumental variable analyses showed reduced risks of ACS and composite outcome for those on low-dose prasugrel. All-cause mortality did not differ in all analyses.

CONCLUSIONS

Low-dose prasugrel demonstrates comparable outcomes to clopidogrel in terms of ACS and bleeding.

Pharmacological and Device-Based Intervention for Preventing Heart Failure After Acute Myocardial Infarction - A Clinical Review

In patients with acute myocardial infarction (MI), heart failure (HF) is one of the most common complications that is associated with a significant burden of mortality and healthcare resources. The clinical benefits of key HF drugs, the so-called "4 pillars" or "fantastic 4", namely β-blockers, mineralocorticoid receptor antagonists, angiotensin receptor-neprilysin inhibitor, and sodium-glucose cotransporter 2 inhibitors, have been established in patients with HF with reduced ejection fraction, whereas the effects of these drugs are not comprehensively appreciated in patients with acute MI. This review summarizes current evidence on pharmacological and device-based interventions for preventing HF after acute MI.

Long-term clinical outcomes of drug-coated balloon angioplasty for de novo coronary lesions in patients with diabetes mellitus

BACKGROUND

We investigated whether drug-coated balloon (DCB) treatment is effective for all de novo cases of coronary artery disease (CAD) in patients with diabetes mellitus. Furthermore, we also investigated the relationship between the degree of diabetes mellitus and clinical outcomes after DCB treatment.

METHODS

In this study, we included 516 consecutive patients with de novo CAD who were treated with DCB. The patients were divided into the diabetic and non-diabetic groups. Patients with diabetes mellitus were further classified into non-insulin-treated diabetes mellitus (NITDM) and insulin-treated diabetes mellitus (ITDM). The primary endpoints were major adverse cardiovascular ischemic events (MACE) and clinically driven target lesion revascularization (CD-TLR).

RESULTS

Within a mean clinical follow-up period of 2.5 years, the incidence of MACE among patients with diabetes mellitus (22.1%) was almost twice that of non-diabetic patients (11.9%) with a relative risk of 1.86 (95% CI 1.24-2.79, p = 0.002). The 3-year CD-TLR occurred in 28 patients with diabetes mellitus (10.6%) and 13 non-diabetic patients (5.1%, p = 0.02). ITDM patients had a significantly higher rate of MACE compared with non-diabetic patients with a relative risk of 2.86 (95% CI 1.76-4.63, p = 0.0002). ITDM remained an independent predictor of 3-year MACE with an odd ratio of 1.96 (95% CI 1.00-3.83, p = 0.05).

CONCLUSION

In patients undergoing DCB, the presence of DM was associated with a higher risk of MACE and CD-TLR. Particularly in DCB, treatment was still inadequately effective for ITDM patients.

Advances in Technology and Technique in Percutaneous Coronary Intervention: A Clinical Review

Percutaneous coronary intervention (PCI) has become the standard procedure for patients with angina and acute coronary syndrome. From the perspective of technology and technique, PCI has advanced over the last four decades, resulting in considerably improved clinical outcomes in patients with coronary artery disease in the current era. In this review article, we summarize recent advances, promising technologies, and areas for research in the field of PCI.

Relationship between body mass index and clinical events in patients with atrial fibrillation undergoing percutaneous coronary intervention

BACKGROUND

It is still unclear whether body mass index (BMI) affects bleeding and cardiovascular events in patients requiring oral anticoagulants (OAC) for atrial fibrillation (AF) and antiplatelet agents after percutaneous coronary intervention (PCI) for coronary artery disease (CAD). The aim of this study was to evaluate the relationship between BMI and clinical events in patients who underwent PCI under OAC therapy for AF.

METHOD

This was a multicenter, observational cohort study conducted at 15 institutions in Japan. AF patients who underwent PCI with drug-eluting stents for CAD were retrospectively and prospectively included. Patients were divided into the Group 1 (BMI <21.3 kg/m2) and the Group 2 (BMI ≥21.3 kg/m2) according to the first-quartile value of BMI. The primary endpoint was net adverse clinical events (NACE), a composite of major adverse cardiovascular events (MACE) and major bleeding events within one year after index PCI procedure.

RESULTS

In the 720 patients, 180 patients (25.0%) had BMI value <21.3 kg/m2. While the rates of NACE and MACE were significantly higher in the Group 1 than the counterpart (21.1% vs. 11.9%, p = 0.003 and 17.2% vs. 8.9%, p = 0.004), that of major bleeding did not differ significantly between the 2 groups (5.6% vs. 4.3%, p = 0.54). The cumulative rate of NACE and MACE was significantly higher in the Group 1 than the Group 2 (both log-rank p = 0.002), although that of major bleeding events was equivalent between the 2 groups (log-rank p = 0.41). In multivariable Cox regression analyses, while BMI value <21.3 kg/m2 was not associated with major bleeding events, that cut-off value was an independent predictor for increased NACE and MACE.

CONCLUSIONS

Among the patients undergoing PCI for CAD and requiring OAC for AF, BMI value was a useful indicator to predict major adverse clinical events.

Incidence, Predictors, and Outcome Associated With Ventricular Tachycardia or Fibrillation in Patients Undergoing Primary Percutaneous Coronary Intervention for Acute Myocardial Infarction

BACKGROUND

The characteristics and clinical outcomes associated with sustained ventricular tachycardia and fibrillation (VT/VF) in Japanese acute myocardial infarction (AMI) patients remain unknown.

METHODS AND RESULTS

Consecutive AMI patients (n=1,941) transferred to the Hirosaki University Hospital and treated with primary percutaneous coronary intervention (PCI) within 12 h of onset were retrospectively studied. The incidence of VT/VF during hospitalization was 8.3%, and 75% of cases occurred by the end of PCI. Independent predictors associated with VT/VF occurrence by the end of PCI and after PCI, respectively, were identified. Additionally, the differences between patients with VT and VF were examined, which revealed that the characteristics of patients and predictors for VT and VF were clearly different. Additionally, the QRS duration during VT was measured, which demonstrated the possible involvement of Purkinje fibers for VT in the acute phase of AMI. Of the patients with VT/VF, 12% required ECMO support due to refractory VT/VF despite intravenous antiarrhythmic agents such as β-blockers, amiodarone, and nifekalant. Among the patients discharged alive, 1,690 were followed up for a mean of 3.7 years. VT/VF occurrence during hospitalization did not affect the mid-term clinical outcomes even in patients with VT.

CONCLUSIONS

The results clearly indicated that VT/VF is still a serious complications of AMI. We need to identify patients at high risk of developing VT/VF for careful observation and appropriate intervention.

Synthesis & characterization of novel MIP with RAFT polymerization of (2-hydroxy ethyl methacrylate)/chitosan as a nanocarrier for drug delivery applications

The primary function of the drug delivery system is to transfer various drugs to certain parts of the body. The drug is transferred reliably in the molecularity imprinted system, based on adjusting the drug release mechanism to control the drug amount and treatment duration. Molecular Imprinting Technology can provide an efficient polymer system to detect bioactive molecules and has high adsorption capacity as drug delivery carriers. This study developed a nanocarrier of molecular imprinted polymer (MIP) of poly (2-hydroxy ethyl methacrylate)/chitosan nanocomposite and also evaluated their performance for drug loading and release in the buffer blood medium. Nanocarriers were prepared based on the RAFT polymerization technique, and cefixime was applied to evaluate the load and release of drugs in nanocarriers. Crucial parameters such as the ratio of imprinted to functional monomer and also the ratio of functional monomer to cross-link should be assessed to obtain the best performance of the MIP. Each of these parameters was studied for four different ratios. TEM analysis showed that the particle size of optimum MIP was between 15 and 20 nm. The specific surface area of CH-CEMIP (chitosan-cefixime MIP) and CEMIP (cefixime MIP) samples were 7.53 and 6.32 m2/g, respectively. Comparing these amounts and the specific surface area of the (Non-Imprinted) NIP sample (1.87 m2/g) indicated that special diagnostic pores were generated. In the drug loading process, the CH-CEMIP sample with 82 mg/g could link to the drug more than CEMIP and NIP samples due to its high selectivity property. Furthermore, according to the drug release experiments, the CH-CEMIP sample performed better in 250 h as 84 % of cefixime in this duration was released slowly and steadily.

Lysophosphatidylglucoside/GPR55 signaling promotes foam cell formation in human M2c macrophages

Atherosclerosis is a major cause of cerebral and cardiovascular diseases. Intravascular plaques, a well-known pathological finding of atherosclerosis, have a necrotic core composed of macrophages and dead cells. Intraplaque macrophages, which are classified into various subtypes, play key roles in maintenance of normal cellular microenvironment. Excessive uptake of oxidized low-density lipoprotein causes conversion of macrophages to foam cells, and consequent progression/exacerbation of atherosclerosis. G-protein-coupled receptor 55 (GPR55) signaling has been reported to associate with atherosclerosis progression. We demonstrated recently that lysophosphatidylglucoside (lysoPtdGlc) is a specific ligand of GPR55, although in general physiological ligands of GPR55 are poorly understood. Phosphatidylglucoside is expressed on human monocytes and can be converted to lysoPtdGlc. In the present study, we examined possible involvement of lysoPtdGlc/GPR55 signaling in foam cell formation. In monocyte-derived M2c macrophages, lysoPtdGlc/GPR55 signaling inhibited translocation of ATP binding cassette subfamily A member 1 to plasma membrane, and cholesterol efflux. Such inhibitory effect was reversed by GPR55 antagonist ML193. LysoPtdGlc/GPR55 signaling in M2c macrophages was involved in excessive lipid accumulation, thereby promoting foam cell formation. Our findings suggest that lysoPtdGlc/GPR55 signaling is a potential therapeutic target for inhibition of atherosclerosis progression.

Assessment of Nonfatal Bleeding Events as a Surrogate for Mortality in Coronary Artery Disease

Background

Bleeding events are frequently applied as safety end points for randomized controlled trials (RCTs) investigating the effect of antithrombotic agents in patients with coronary artery disease. However, whether a bleeding event is a valid surrogate for death remain uncertain.

Objectives

This study aimed to assess the correlation between the treatment effect on bleeding events and mortality.

Methods

Multiple databases were searched to identify RCTs studying antithrombotic agents for patients with coronary artery disease through August 2022. Major and minor bleeding events were defined in included trials, mostly defined with BARC (Bleeding Academic Research Consortium) or TIMI (Thrombolysis In Myocardial Infarction) criteria. Trial-level correlations between nonfatal bleeding events and mortality were assessed. We performed subgroup analyses by the definitions of bleeding (BARC vs TIMI criteria), study year, and follow-up duration. We used a cutoff with a lower limit of 95% confidence interval of R2 >0.72 as a strong correlation and with an upper limit of 95% confidence interval of R2 <0.50 as a weak correlation.

Results

A total of 48 RCTs with 181,951 participants were analyzed. Overall, trial-level R2 for major and minor bleeding were 0.09 (95% CI: 0.00-0.26) and 0.09 (95% CI: 0.00-0.27) for all-cause or cardiovascular death, respectively. When confined to major bleeding, R2 were 0.03 (95% CI: 0.00-0.13) and 0.01 (95% CI: 0.00-0.05), respectively. All of the subgroup analyses did not show any significant correlations.

Conclusions

We demonstrated a trial-defined bleeding event may not be a valid surrogate for mortality in RCTs investigating the effect of antithrombotic agents for coronary artery disease.

Treatment strategies of acute myocardial infarction: updates on revascularization, pharmacological therapy, and beyond

Owing to recent advances in early reperfusion strategies, pharmacological therapy, standardized care, and the identification of vulnerable patient subsets, the prognosis of acute myocardial infarction has improved. However, there is still considerable room for improvement. This review article summarizes the latest evidence concerning clinical diagnosis and treatment of acute myocardial infarction.

Prognostic Factors of In-Hospital Mortality in Patients with Acute Myocardial Infarction Complicated by Cardiogenic Shock

Among patients with acute myocardial infarction (MI) complicated by cardiogenic shock (CS), in-hospital mortality remains high. In the present study, we aimed to identify factors associated with clinical outcomes of acute MI patients with CS in a contemporary setting. A total of 1102 patients with acute MI undergoing primary percutaneous coronary intervention were included, among whom 196 (17.8%) were complicated by CS. The primary outcome was all-cause death during hospitalization, and factors associated with in-hospital mortality were explored in patients with acute MI and CS. Of the 196 patients with acute MI complicated by CS, 77 (39.3%) died during hospitalization. The rates of non-ST-segment elevation MI (NSTEMI) (33.8% vs. 19.3%, p = 0.02) and culprit lesion in the left main or left anterior descending coronary artery (68.8% vs. 47.9%, p = 0.004) were higher, while left ventricular ejection fraction (LVEF) was lower (24.4 ± 11.7% vs. 39.7 ± 13.8%, p < 0.001) in non-survivors than in survivors. Multivariable analysis identified NSTEMI presentation and lower LVEF as independent predictors of in-hospital death. In conclusion, NSTEMI and low LVEF were identified as factors associated with higher in-hospital mortality. The identification of even higher-risk subsets and targeted therapeutic strategies may be warranted to improve survival of patients with acute MI and CS.