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Suzuki K, Niida T, Yuki H, Kinoshita D, Fujimoto D, Lee H, McNulty I, Takano M, Nakamura S, Kakuta T, Mizuno K, Jang I. Coronary Plaque Characteristics and Underlying Mechanism of Acute Coronary Syndromes in Different Age Groups of Patients With Diabetes. J Am Heart Assoc 2023; 12:e031474. [PMID: 38014673 PMCID: PMC10727321 DOI: 10.1161/jaha.123.031474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/17/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND High cardiovascular mortality has been reported in young patients with diabetes. However, the underlying pathology in different age groups of patients with diabetes has not been studied. METHODS AND RESULTS The aim of this study was to investigate the plaque characteristics and underlying pathology of acute coronary syndrome in different age groups of patients with or without diabetes in a large cohort. Patients who presented with acute coronary syndrome and underwent preintervention optical coherence tomography imaging were included. Culprit plaque was classified as plaque rupture, plaque erosion, or calcified plaque and stratified into 5 age groups. Plaque characteristics including features of vulnerability were examined by optical coherence tomography. Among 1394 patients, 482 (34.6%) had diabetes. Patients with diabetes, compared with patients without diabetes, had a higher prevalence of lipid-rich plaque (71.2% versus 64.8%, P=0.016), macrophage (72.0% versus 62.6%, P<0.001), and cholesterol crystal (27.6% versus 19.7%, P<0.001). Both diabetes and nondiabetes groups showed a decreasing trend in plaque erosion with age (patients with diabetes, P=0.020; patients without diabetes, P<0.001). Patients without diabetes showed an increasing trend with age in plaque rupture (P=0.004) and lipid-rich plaque (P=0.018), whereas patients with diabetes had a high prevalence of these vulnerable features at an early age that remained high across age groups. CONCLUSIONS Patients without diabetes showed an increasing trend with age in plaque rupture and lipid-rich plaque, whereas patients with diabetes had a high prevalence of these vulnerable features at an early age. These results suggest that atherosclerotic vascular changes with increased vulnerability start at a younger age in patients with diabetes. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifiers: NCT04523194, NCT03479723. URL: https://www.umin.ac.jp/ctr/. Unique identifier: UMIN000041692.
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Affiliation(s)
- Keishi Suzuki
- Cardiology DivisionMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Takayuki Niida
- Cardiology DivisionMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Haruhito Yuki
- Cardiology DivisionMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Daisuke Kinoshita
- Cardiology DivisionMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Daichi Fujimoto
- Cardiology DivisionMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Hang Lee
- Biostatistics CenterMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Iris McNulty
- Cardiology DivisionMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Masamichi Takano
- Cardiovascular CenterNippon Medical School Chiba Hokusoh HospitalInzai, ChibaJapan
| | - Sunao Nakamura
- Interventional Cardiology UnitNew Tokyo HospitalChibaJapan
| | - Tsunekazu Kakuta
- Department of CardiologyTsuchiura Kyodo General Hospital, TsuchiuraIbarakiJapan
| | | | - Ik‐Kyung Jang
- Cardiology DivisionMassachusetts General HospitalHarvard Medical SchoolBostonMA
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Çakır MO, Gören MT. Comparison of Atherosclerotic Plaque Compositions in Diabetic and Non-diabetic Patients. Cureus 2023; 15:e45721. [PMID: 37745746 PMCID: PMC10513476 DOI: 10.7759/cureus.45721] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2023] [Indexed: 09/26/2023] Open
Abstract
INTRODUCTION Diabetes mellitus is one of the major risk factors for coronary artery disease. Intravascular ultrasound (IVUS) imaging has an important role in the evaluation of atherosclerotic coronary artery disease. The aim of the study was to investigate the potential link between diabetes mellitus and plaque vulnerability in patients with coronary artery disease. METHODS In total, 26 patients with acute coronary syndrome (eight with diabetes mellitus) and 34 with stable angina pectoris (16 with diabetes mellitus) constituted the study population. Patients underwent IVUS ultrasound and virtual histology (VH)-IVUS imaging during routine diagnostic catheterization procedures. A total of 70 plaques in 60 patients were examined. RESULTS Patients with diabetes mellitus had a significantly greater percentage of fibrofatty components in the minimal lumen area (MLA) (17 ± 12 in diabetics; 12 ± 6 in non-diabetics; p=0.06). Thin-cap fibroatheromas were more frequent in patients with diabetes mellitus (72% versus 45%; p=0.012). There was a positive correlation between the presence of attenuated plaque and hemoglobin A1C (HbA1c) levels as well (7.09 ± 1.66 versus 6.02 ± 1.00; p=0.011). Patients with HbA1C ≥7.5% also had the highest prevalence of attenuated plaque. CONCLUSION As shown by VH-IVUS, the prevalence of vulnerable plaques in patients with diabetes mellitus was much higher than that in non-diabetic patients. The presence of attenuated plaque detected in grayscale intravascular ultrasonography was associated with high HbA1C levels in diabetic patients. Diabetes mellitus may cause cardiovascular vulnerability by changing the plaque morphology.
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Affiliation(s)
- Mustafa Ozan Çakır
- Department of Cardiology, Bulent Ecevit University Faculty of Medicine, Zonguldak, TUR
| | - Mustafa Taner Gören
- Department of Cardiology, Istanbul University School of Medicine, Istanbul, TUR
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3
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Malaiapan Y, Leung M, White AJ. The role of intravascular ultrasound in percutaneous coronary intervention of complex coronary lesions. Cardiovasc Diagn Ther 2020; 10:1371-1388. [PMID: 33224763 DOI: 10.21037/cdt-20-189] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Intravascular ultrasound (IVUS) is a catheter-based coronary imaging technique. It utilises the emission & subsequent detection of reflected high frequency (30-60 MHz) sound waves to create high resolution, cross-sectional images of the coronary artery. IVUS has been the cornerstone of intracoronary imaging for more than two decades. When compared to the invasive coronary angiogram which studies only the silhouette of the contrast-filled artery lumen, IVUS also crucially images the vessel wall. Because of this capability, IVUS has greatly facilitated understanding of the coronary atherosclerosis process. Such insights from IVUS reveal how commonly and extensively plain angiography underestimates the true extent of coronary plaque, the characteristics of plaques prone to rupture and cause acute coronary syndromes (lipid rich, thin cap atheroma), and a realisation of the widespread occurrence of vessel remodelling in response to atherosclerosis. Similarly, IVUS has historically provided salutary mechanistic insights that have guided many of the incremental advances in the techniques of percutaneous coronary intervention (PCI). Examples include mechanisms of in-stent restenosis, and the importance of high-pressure post-dilatation of stents to ensure adequate stent apposition and thereby reduce the occurrence of stent thrombosis. IVUS also greatly facilitates the choice of correct diameter and length of stent to implant. Overall, a compelling body of evidence indicates that use of intravascular ultrasound in PCI helps to achieve optimal technical results and to mitigate the risk of adverse cardiac events. In this review, the role of intravascular ultrasound as an adjunct to PCI in complex coronary lesions is explored. The complex coronary situations discussed are the left main stem, ostial stenoses, bifurcation stenoses, thrombotic lesions, the chronically occluded coronary artery, and calcified coronary artery disease. By thorough review of the available evidence, we establish that the advantages of IVUS guidance are particularly evident in each of these complex CAD subsets. In particular, some consider the use of IVUS to be almost mandatory in left main PCI. A comparison with other intracoronary imaging techniques is also explored.
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Affiliation(s)
- Yuvaraj Malaiapan
- Monash Heart, Monash Medical Centre, Clayton, VIC, Australia.,Department of Medicine, Monash University, Clayton, VIC, Australia
| | - Michael Leung
- Monash Heart, Monash Medical Centre, Clayton, VIC, Australia.,Department of Medicine, Monash University, Clayton, VIC, Australia
| | - Anthony J White
- Monash Heart, Monash Medical Centre, Clayton, VIC, Australia.,Department of Medicine, Monash University, Clayton, VIC, Australia
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Hou F, Zhou Y, Liu W, Yang S, Wang Z, Ma X, Du Y, Li Y, Guan J. Characteristics of culprit lesions in young patients with metabolic syndrome and classic cardiovascular risk factors. Exp Ther Med 2020; 19:2766-2772. [PMID: 32256759 DOI: 10.3892/etm.2020.8484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 01/06/2020] [Indexed: 01/23/2023] Open
Abstract
The association between cardiovascular risk factors (CVRFs) and characteristics of coronary plaque in young patients has remained to be fully elucidated. Therefore, the present study sought to determine the association between CVRFs and phenotypes of culprit coronary plaques revealed by optical coherence tomography (OCT) in young patients with stable coronary heart disease (CHD) and acute coronary syndrome (ACS). OCT imaging pullback was performed at corresponding sites on 123 lesions in 123 young patients (age, 36±7 years), including those with stable CHD and ACS. Patients with analyzable OCT images were classified as having thin-cap fibroatheromas (TCFAs), plaque rupture, macrophage accumulation, calcified nodule, vasa vasorum, cholesterol crystal and erosion. TCFAs were more prevalent in patients with metabolic syndrome (MetS) than in those without MetS (P=0.020). Plaque rupture was more common in smokers than in non-smokers (P=0.002). Multivariate analysis indicated that MetS was independently associated with TCFAs (P=0.041) and smoking was independently associated with plaque rupture (P=0.006). Young patients with MetS were demonstrated to have more extensive TCFAs and young smokers had a higher prevalence of culprit plaque rupture.
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Affiliation(s)
- Fangjie Hou
- Department of Cardiology, Qingdao Municipal Hospital, Qingdao, Shandong 266000, P.R. China.,Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, P.R. China
| | - Yujie Zhou
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, P.R. China
| | - Wei Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, P.R. China
| | - Shiwei Yang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, P.R. China
| | - Zhijian Wang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, P.R. China
| | - Xiaoteng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, P.R. China
| | - Yu Du
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, P.R. China
| | - Ya Li
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, P.R. China.,Department of Cardiology, Affiliated Hospital of Hebei University, Baoding, Hebei 071000, P.R. China
| | - Jun Guan
- Department of Cardiology, Qingdao Municipal Hospital, Qingdao, Shandong 266000, P.R. China
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Hou FJ, Zhou YJ, Ma XT, He T, Yan RQ, Geng Q, Wang HY, Ma Y, Ren YQ, Dong FZ. Culprit Lesion Characteristics in Young Patients with Hyperhomocysteinemia. Med Sci Monit 2019; 25:5306-5311. [PMID: 31313754 PMCID: PMC6659466 DOI: 10.12659/msm.914979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background The relationships between culprit coronary plaque characteristics and hyperhomocysteinemia (HHcy) are not fully understood in young patients. In this study we investigated the relationship between culprit atherosclerotic plaque phenotype assessed by optical coherence tomography (OCT) and hyperhomocysteinemia (HHcy) in young patients. Material/Methods We investigated the OCT imaging and HHcy of 123 lesions in 123 young patients (≤45 years of age). According to OCT images, culprit lesions were classified as thin-cap fiber atheroma (TCFA), thrombus, and other. The 123 patients were grouped as: HHcy group (53 cases, HHcy ≥15.5 μmol/l) and control group (70 cases, HHcy <15.5 μmol/l). Results Compared with the control group, the HHcy group had a higher proportion of OCT-TCFA (p=0.03), OCT-vasa vasorum (p=0.013), and OCT-thrombus (p=0.012), and a larger lipid arc (p=0.002). HHcy (P=0.037) and metabolic syndrome (MetS) (P=0.016) remained independent predictors of TCFAs. HHcy (P=0.026) and smoking (P=0.005) remained independent determinants of thrombus. Conclusions HHcy and MetS are associated with TCFAs, and HHcy and smoking are associated with thrombus in young patients with coronary artery disease.
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Affiliation(s)
- Fang-Jie Hou
- Department of Cardiology, 12th Ward, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Beijing, China (mainland).,Department of Cardiology, Qingdao Municipal Hospital, Qingdao, Shandong, China (mainland)
| | - Yu-Jie Zhou
- Department of Cardiology, 12th Ward, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Beijing, China (mainland)
| | - Xiao-Teng Ma
- Department of Cardiology, 12th Ward, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Beijing, China (mainland)
| | - Tao He
- Department of Cardiology, Qingdao Municipal Hospital, Qingdao, Shandong, China (mainland)
| | - Rong-Qiang Yan
- Department of Cardiology, Qingdao Municipal Hospital, Qingdao, Shandong, China (mainland)
| | - Qiang Geng
- Department of Cardiology, Qingdao Municipal Hospital, Qingdao, Shandong, China (mainland)
| | - Hai-Yang Wang
- Department of Cardiology, Qingdao Municipal Hospital, Qingdao, Shandong, China (mainland)
| | - Ying Ma
- Department of Cardiology, Qingdao Municipal Hospital, Qingdao, Shandong, China (mainland)
| | - Yong-Qiang Ren
- Department of Cardiology, Qingdao Municipal Hospital, Qingdao, Shandong, China (mainland)
| | - Fu-Zong Dong
- Department of Cardiology, Qingdao Municipal Hospital, Qingdao, Shandong, China (mainland)
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Liu Z, Xu Y, Hao H, Yin C, Xu J, Li J, Wang Y, Xu D. Efficacy of high intensity atorvastatin versus moderate intensity atorvastatin for acute coronary syndrome patients with diabetes mellitus. Int J Cardiol 2016; 222:22-26. [DOI: 10.1016/j.ijcard.2016.07.140] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 07/08/2016] [Indexed: 10/21/2022]
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Munnur RK, Nerlekar N, Wong DTL. Imaging of coronary atherosclerosis in various susceptible groups. Cardiovasc Diagn Ther 2016; 6:382-95. [PMID: 27500095 DOI: 10.21037/cdt.2016.03.02] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Coronary artery disease (CAD) is the leading cause of death and disability worldwide. Atherosclerosis, which is the primary pathophysiologic mechanism for the development of plaque leading to CAD, is a multifactorial process resulting from a complex interplay between genetic susceptibility and various risk factors such as hypertension (HT), dyslipidaemia, diabetes mellitus (DM) and smoking. In addition, influences from other disease states such as chronic kidney disease (CKD), obesity and the metabolic syndrome as well as gender and ethnic diversity also contribute to the disease process. Insights from pathological observations and advances in cellular and molecular biology have helped us understand the process of plaque formation, progression and rupture leading to events. Several intravascular imaging techniques such as intravascular ultrasound (IVUS), Virtual histology IVUS (VH-IVUS) and optical coherence tomography (OCT) allow in vivo assessment of plaque burden, plaque morphology and response to therapy. In addition, non invasive assessment using coronary artery calcium (CAC) score allows risk stratification and plaque burden assessment whilst computed tomography coronary angiography (CTCA) allows evaluation of luminal stenosis, plaque characterisation and quantification. This review aims to summarise the results of invasive and non-invasive imaging studies of coronary atherosclerosis seen in various high-risk populations including DM, metabolic syndrome, obesity, CKD and, gender differences and ethnicity. Understanding the phenotype of plaques in various susceptible groups may allow potential development of personalised therapies.
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Affiliation(s)
- Ravi Kiran Munnur
- Monash Cardiovascular Research Centre/MonashHEART, Clayton, Victoria, Australia
| | - Nitesh Nerlekar
- Monash Cardiovascular Research Centre/MonashHEART, Clayton, Victoria, Australia
| | - Dennis T L Wong
- Monash Cardiovascular Research Centre/MonashHEART, Clayton, Victoria, Australia
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Andriolo RB, Ponte Jr JR, Gomes Gutierrez E, Andriolo BNG, Ramos LR. Glycaemic control for patients with acute coronary syndrome. Hippokratia 2016. [DOI: 10.1002/14651858.cd010811.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Regis B Andriolo
- Universidade do Estado do Pará; Department of Public Health; Travessa Perebebuí, 2623 Belém Pará Brazil 66087-670
| | | | - Erickson Gomes Gutierrez
- Universidade Federal do Para; Department of Medicine; Avenida Governador Jose Malchar 1192 Belem Para Brazil 660055260
| | - Brenda NG Andriolo
- Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde; Brazilian Cochrane Centre; Rua Borges Lagoa, 564 cj 63 São Paulo São Paulo Brazil 04038-000
| | - Luiz Roberto Ramos
- Escola Paulista de Medicina, Universidade Federal de São Paulo; Department of Preventive Medicine; Rua dos Otonis, 731 Vila Clementino São Paulo São Paulo Brazil 04025-002
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9
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De Servi S, Crimi G, Calabrò P, Piscione F, Cattaneo M, Maffeo D, Toso A, Bartorelli A, Palmieri C, De Carlo M, Capodanno D, Barozzi C, Tomasi L, Della Riva D, Angiolillo DJ, Palmerini T. Relationship between diabetes, platelet reactivity, and the SYNTAX score to one-year clinical outcome in patients with non-ST-segment elevation acute coronary syndrome undergoing percutaneous coronary intervention. EUROINTERVENTION 2016; 12:312-8. [DOI: 10.4244/eijv12i3a51] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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10
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Liu Z, Matsuzawa Y, Herrmann J, Li J, Lennon RJ, Crusan DJ, Kwon TG, Zhang M, Sun T, Yang S, Gulati R, Bell MR, Lerman LO, Lerman A. Relation between fractional flow reserve value of coronary lesions with deferred revascularization and cardiovascular outcomes in non-diabetic and diabetic patients. Int J Cardiol 2016; 219:56-62. [PMID: 27281577 DOI: 10.1016/j.ijcard.2016.05.032] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 05/03/2016] [Accepted: 05/12/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND FFR of deferred PCI lesions can predict future cardiovascular events. However, the prognostic utility of FFR remains unclear in diabetic patients in view of the potential impact of the diffuse nature of vascular disease process. We aimed to study the relation between fractional flow reserve (FFR) values and long-term outcomes of diabetic and non-diabetic patients with deferred percutaneous coronary intervention (PCI). METHODS Patients with FFR assessment and deferred PCI (n=630) were enrolled and stratified according to diabetes mellitus (DM) status and FFR values. Patients were followed over a median of 39months. Cox proportional hazard regression models were used to analyze the association between clinical endpoints and clinical factors such as DM and FFR. RESULTS In non-diabetics (n=450), higher FFR values were associated with less cardiovascular events (hazard ratio (HR) for death and myocardial infarction (MI) [95% confidence interval (CI)], 0.61[0.44 to 0.86] per 0.1 increase in FFR, p=0.007; HR for revascularization [95%CI], 0.66[0.49 to 0.9] per 0.1 increase in FFR, p=0.006). In diabetics (n=180), there was no difference in death and MI across the range of FFR values. Among those patients with an FFR >0.85, diabetics had a more than two-fold higher risk of death and MI than non-diabetics (HR [95% CI], 2.20 [1.19 to 4.01], p=0.015). CONCLUSION Among non-diabetic patients with deferred PCI, a higher FFR was associated with lower rates of death, MI and revascularization. On the contrary in diabetic patients with deferred revascularization, FFR was not able to differentiate the risk of cardiovascular events.
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Affiliation(s)
- Zhi Liu
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA; Division of Cardiology, Xuanwu Hospital Capital Medical University, Beijing 100053, China
| | - Yasushi Matsuzawa
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Joerg Herrmann
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Jing Li
- Division of Cardiology, Xuanwu Hospital Capital Medical University, Beijing 100053, China
| | - Ryan J Lennon
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Daniel J Crusan
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Taek-Geun Kwon
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Ming Zhang
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Tao Sun
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Shiwei Yang
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Rajiv Gulati
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Malcolm R Bell
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Lilach O Lerman
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Amir Lerman
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.
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Park YM, Han SH, Seo JG, Lee S, Oh PC, Koh KK, Lee K, Suh SY, Kang WC, Ahn T, Choi IS, Shin EK. The role of insulin resistance and metabolic risk factors on culprit coronary plaque. Int J Cardiol 2015; 190:56-62. [DOI: 10.1016/j.ijcard.2015.04.163] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 04/15/2015] [Accepted: 04/18/2015] [Indexed: 11/24/2022]
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12
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Khaliq A, Johnson BD, Anderson RD, Bavry AA, Cooper-DeHoff RM, Handberg EM, Bairey Merz CN, Nicholls SJ, Nissen S, Pepine CJ. Relationships between components of metabolic syndrome and coronary intravascular ultrasound atherosclerosis measures in women without obstructive coronary artery disease: the NHLBI-Sponsored Women's Ischemia Syndrome Evaluation Study. Cardiovasc Endocrinol 2015; 4:45-52. [PMID: 26665010 PMCID: PMC4671302 DOI: 10.1097/xce.0000000000000049] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE In women, metabolic syndrome (MetS) is associated with higher risk of ischemic heart disease-related adverse outcomes versus individual components. We examined the relationship of MetS to subclinical coronary atherosclerosis. METHODS Women (n = 100) undergoing coronary angiography for suspected ischemia but without obstructive coronary artery disease (CAD) underwent intravascular ultrasound (IVUS) of a segment of the left coronary artery. A core lab, masked to other findings, assessed IVUS measures and normalized volume measures to pull-back length. MetS [defined using ATPIII criteria (fasting glucose ≥ 100 mg/dl per revised NCEP guideline)] and its components were entered into multiple regression models to assess associations with IVUS measures. RESULTS Detailed IVUS measurements were available in 87 women. Mean age was 54 ± 10 years, 36% had MetS, and 78% had atheroma. Comparing women with MetS versus without MetS, significant differences were observed for seven IVUS atherosclerosis measures, but were not significant after adjusting for the MetS components. Systolic blood pressure and waist circumference components remained independently positively associated with the IVUS measures after adjusting for age, diabetes, CAD family history, dyslipidemia, smoking, and hormone replacement. CONCLUSION In women with signs and symptoms of ischemia and no obstructive CAD, MetS is associated with coronary atherosclerosis presence and severity. However, these associations appear largely driven by components of waist circumference and systolic blood pressure versus MetS cluster. This supports the concept that MetS is a convenient clustering of risk factors rather than an independent risk predictor, and emphasizes that the critical factors for coronary atherosclerosis are potentially modifiable.
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Affiliation(s)
- Asma Khaliq
- Division of Cardiovascular Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - B. Delia Johnson
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - R. David Anderson
- Division of Cardiovascular Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Anthony A. Bavry
- Division of Cardiovascular Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
- North Florida/South Georgia Veterans Health System, Gainesville, Florida, USA
| | - Rhonda M. Cooper-DeHoff
- Division of Cardiovascular Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Eileen M. Handberg
- Division of Cardiovascular Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - C. Noel Bairey Merz
- Barbra Streisand Women’s Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Stephen J. Nicholls
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Steven Nissen
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Carl J. Pepine
- Division of Cardiovascular Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
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13
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Choy JS, Luo T, Huo Y, Wischgoll T, Schultz K, Teague SD, Sturek M, Kassab GS. Compensatory Enlargement of Ossabaw Miniature Swine Coronary Arteries in Diffuse Atherosclerosis. IJC HEART & VASCULATURE 2015; 6:4-11. [PMID: 25729766 PMCID: PMC4341907 DOI: 10.1016/j.ijcha.2014.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Studies in human and non-human primates have confirmed the compensatory enlargement or positive remodeling (Glagov phenomenon) of coronary vessels in the presence of focal stenosis. To our knowledge, this is the first study to document arterial enlargement in a metabolic syndrome animal model with diffuse coronary artery disease (DCAD) in the absence of severe focal stenosis. Two different groups of Ossabaw miniature pigs were fed a high fat atherogenic diet for 4 months (Group I) and 12 months (Group II), respectively. Group I (6 pigs) underwent contrast enhanced computed tomographic angiography (CCTA) and intravascular ultrasound (IVUS) at baseline and after 4 months of high fat diet, whereas Group II (7 pigs) underwent only IVUS at 12 months of high fat diet. IVUS measurements of the left anterior descending (LAD), left circumflex (LCX) and right coronary (RCA) arteries in Group I showed an average increase in their lumen cross-sectional areas (CSA) of 25.8%, 11.4%, and 43.4%, respectively, as compared to baseline. The lumen CSA values of LAD in Group II were found to be between the baseline and 4 month values in Group I. IVUS and CCTA measurements showed a similar trend and positive correlation. Fractional flow reserve (FFR) was 0.91 ± 0.07 at baseline and 0.93 ± 0.05 at 4 months with only 2.2%, 1.6% and 1% stenosis in the LAD, LCX and RCA, respectively. The relation between percent stenosis and lumen CSA shows a classical Glagov phenomenon in this animal model of DCAD.
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Affiliation(s)
- Jenny S Choy
- Department of Biomedical Engineering, Indiana University Purdue University Indianapolis, Indianapolis, Indiana
| | - Tong Luo
- Department of Biomedical Engineering, Indiana University Purdue University Indianapolis, Indianapolis, Indiana
| | - Yunlong Huo
- Department of Biomedical Engineering, Indiana University Purdue University Indianapolis, Indianapolis, Indiana
| | - Thomas Wischgoll
- Department of Computer Science and Engineering, Wright State University, Dayton, Ohio
| | - Kyle Schultz
- Department of Cellular and Integrative Physiology, Indiana University, Indianapolis, Indiana
| | - Shawn D Teague
- Department of Radiology, Indiana University, Indianapolis, Indiana
| | - Michael Sturek
- Department of Cellular and Integrative Physiology, Indiana University, Indianapolis, Indiana
| | - Ghassan S Kassab
- Department of Biomedical Engineering, Indiana University Purdue University Indianapolis, Indianapolis, Indiana ; Department of Cellular and Integrative Physiology, Indiana University, Indianapolis, Indiana ; Department of Surgery, Indiana University, Indianapolis, Indiana
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14
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Kedhi E, Généreux P, Palmerini T, McAndrew TC, Parise H, Mehran R, Dangas GD, Stone GW. Impact of coronary lesion complexity on drug-eluting stent outcomes in patients with and without diabetes mellitus: analysis from 18 pooled randomized trials. J Am Coll Cardiol 2014; 63:2111-2118. [PMID: 24632279 DOI: 10.1016/j.jacc.2014.01.064] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 01/04/2014] [Accepted: 01/21/2014] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of this study was to investigate whether baseline lesion complexity affects drug-eluting stent (DES) outcomes according to diabetic status. BACKGROUND Previous studies have reported conflicting results regarding DES safety and efficacy in patients with and without diabetes mellitus (DM). METHODS Patient-level data from 18 prospective randomized trials were pooled. DES treatment outcomes in patients with versus without DM were analyzed in 2 propensity score-matched groups further stratified according to lesion complexity (American College of Cardiology and American Heart Association class A/B1 vs. B2/C). Remaining baseline differences were adjusted for by multivariate analysis. RESULTS DM was present in 3,467 of 18,441 patients (18.8%). DM was a predictor of 1-year repeat revascularization (target lesion revascularization: hazard ratio: 1.34; 95% confidence interval: 1.05 to 1.70; target vessel revascularization: hazard ratio: 1.40; 95% confidence interval: 1.15 to 1.72) and cardiac death or myocardial infarction (hazard ratio: 1.40; 95% confidence interval: 1.09 to 1.81). Rates of target lesion and target vessel revascularization were significantly higher in patients with versus those without DM with type B2/C lesions (8.0% vs. 4.5% and 10.6% vs. 5.9%, respectively, p < 0.0001 for both), but not in patients with only type A/B1 lesions (4.6% vs. 4.8%, p = 0.87, and 7.4% vs. 6.8%, p = 0.47, respectively), with a significant interaction between DM and lesion type observed for both endpoints (p = 0.01 and p = 0.02, respectively). No interaction was observed for death or myocardial infarction (p = 0.28). CONCLUSIONS In the DES era, patients with DM remain at increased risk for cardiac death or myocardial infarction. However, DM is a risk factor for repeat revascularization only in those patients with complex lesions; patients with DM and noncomplex lesions have similar rates of 1-year freedom from repeat revascularization as do patients without DM.
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Affiliation(s)
| | - Philippe Généreux
- New York-Presbyterian Hospital/Columbia University Medical Center, New York, New York; Cardiovascular Research Foundation, New York, New York; Hôpital du Sacré-Coeur de Montréal, Montréal, Québec, Canada
| | - Tullio Palmerini
- Dipartimento Cardiovascolare, Policlinico Sant' Orsola, Bologna, Italy
| | | | - Helen Parise
- Cardiovascular Research Foundation, New York, New York
| | - Roxana Mehran
- Cardiovascular Research Foundation, New York, New York; Icahn School of Medicine at Mount Sinai, New York, New York
| | - George D Dangas
- Cardiovascular Research Foundation, New York, New York; Icahn School of Medicine at Mount Sinai, New York, New York
| | - Gregg W Stone
- New York-Presbyterian Hospital/Columbia University Medical Center, New York, New York; Cardiovascular Research Foundation, New York, New York.
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15
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A Review of JACC Journal Articles on the Topic of Interventional Cardiology: 2011–2012. J Am Coll Cardiol 2013. [DOI: 10.1016/j.jacc.2013.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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16
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Yonetsu T, Kato K, Uemura S, Kim BK, Jang Y, Kang SJ, Park SJ, Lee S, Kim SJ, Jia H, Vergallo R, Abtahian F, Tian J, Hu S, Yeh RW, Sakhuja R, McNulty I, Lee H, Zhang S, Yu B, Kakuta T, Jang IK. Features of coronary plaque in patients with metabolic syndrome and diabetes mellitus assessed by 3-vessel optical coherence tomography. Circ Cardiovasc Imaging 2013; 6:665-73. [PMID: 23922003 DOI: 10.1161/circimaging.113.000345] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The pathophysiological basis for the association between metabolic syndrome (MetS) and coronary artery disease is not well understood. We sought to characterize coronary plaques in patients with MetS by using optical coherence tomography. METHODS AND RESULTS We identified 451 coronary plaques from 171 subjects who underwent optical coherence tomographic imaging in 3 coronary arteries. Subjects were divided into 3 groups: diabetes mellitus (DM, n=77), MetS (n=35), and a control group (C group, n=59) without DM or MetS. Optical coherence tomographic analysis included the presence of lipid-rich plaque, maximum lipid arc, lipid-core length, lipid index (LI), fibrous cap thickness, and thin-cap fibroatheroma. We defined LI as mean lipid arc multiplied by lipid-core length. Lipid-core length and LI were significantly greater in DM and MetS than in C group (lipid-core length: 7.7 ± 4.0 and 7.0 ± 3.8 versus 5.5 ± 2.4 mm; P<0.001 and P=0.012, and LI: 1164 ± 716 and 1086 ± 693 versus 796 ± 417 mm; P<0.001 and P=0.008). Maximum lipid arc was significantly greater in DM than in C group, whereas no significant difference was observed between MetS and C group (196 ± 45°, 187 ± 42° versus 176 ± 52°; P=0.002 and P=0.182). Fibrous cap thickness and thin-cap fibroatheroma showed no significant difference among the 3 groups. In multivariate analysis, DM and MetS were independently associated with LI, whereas only acute coronary syndrome was the independent predictor for thin-cap fibroatheroma. CONCLUSIONS Compared with control subjects, coronary plaques in MetS contain larger lipid. However, the MetS criteria used in this study could not distinguish the vulnerable features such as thin-cap fibroatheroma, suggesting the necessity of complementary information to identify patients at high risk for cardiovascular events.
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17
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Comparison of nonculprit coronary plaque characteristics between patients with and without diabetes: a 3-vessel optical coherence tomography study. JACC Cardiovasc Interv 2013; 5:1150-8. [PMID: 23174639 DOI: 10.1016/j.jcin.2012.06.019] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Revised: 06/14/2012] [Accepted: 06/21/2012] [Indexed: 01/15/2023]
Abstract
OBJECTIVES The aim of the present study was to compare the characteristics of nonculprit coronary plaques between diabetes mellitus (DM) and non-DM patients using 3-vessel optical coherence tomography (OCT) imaging. BACKGROUND DM patients have a higher recurrent cardiovascular event rate. METHODS Patients who had undergone 3-vessel OCT imaging were identified from the Massachusetts General Hospital OCT Registry. Characteristics of nonculprit plaques were compared between DM and non-DM patients. RESULTS A total of 230 nonculprit plaques were identified in 98 patients. Compared with non-DM patients, DM patients had a larger lipid index (LI) (averaged lipid arc × lipid length; 778.6 ± 596.1 vs. 1358.3 ± 939.2, p < 0.001) and higher prevalence of calcification (48.4% vs. 72.2%, p = 0.034) and thrombus (0% vs. 8.3%, p = 0.047). DM patients were divided into 2 groups based on glycated hemoglobin (A(1C)) levels of ≤7.9% and ≥8.0%. LI was significantly correlated with diabetic status (778.6 ± 596.1 [non-DM] vs. 1,171.5 ± 708.1 [A(1C) ≤7.9%] vs. 1,638.5 ± 1,173.8 [A(1C) ≥8%], p value for linear trend = 0.005), and fibrous cap thickness was inversely correlated with the A(1C) level (99.4 ± 46.7 μm [non-DM] vs. 91.7 ± 29.6 μm [A(1C) ≤7.9%] vs. 72.9 ± 22.7 μm [A(1C) ≥8%], p value for linear trend = 0.014). Patients with A(1C) ≥8% also had the highest prevalence of thin-cap fibroatheroma (TCFA) and macrophage infiltration. CONCLUSIONS Compared with non-DM patients, DM patients have a larger LI and a higher prevalence of calcification and thrombus. The LI was larger and TCFA and macrophage infiltration were frequent in patients with A(1C) ≥8%.
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18
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Baars T, Konorza T, Kahlert P, Möhlenkamp S, Erbel R, Heusch G, Kleinbongard P. Coronary aspirate TNFα reflects saphenous vein bypass graft restenosis risk in diabetic patients. Cardiovasc Diabetol 2013; 12:12. [PMID: 23305356 PMCID: PMC3560373 DOI: 10.1186/1475-2840-12-12] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Accepted: 01/08/2013] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Patients with diabetes mellitus (DM) have an increased risk for periprocedural complications and adverse cardiac events after percutaneous coronary intervention. We addressed the potential for coronary microvascular obstruction and restenosis in patients with and without DM undergoing stenting for saphenous vein bypass graft (SVG) stenosis under protection with a distal occlusion/aspiration device. METHODS SVG plaque volume and composition were analyzed using intravascular ultrasound before stent implantation. Percent diameter stenosis was determined from quantitative coronary angiography before, immediately after and 6 months after stent implantation. Coronary aspirate was retrieved during stent implantation and divided into particulate debris and plasma. Total calcium, several vasoconstrictors, and tumor necrosis factor (TNF)α in particulate debris and coronary aspirate plasma were determined. RESULTS Patients with and without DM had similar plaque volume, but larger necrotic core and greater particulate debris release in patients with than without DM (20.3±2.7 vs. 12.7±2.6% and 143.9±19.3 vs. 75.1±10.4 mg, P<0.05). The TNFα concentration in particulate debris and coronary aspirate plasma was higher in patients with than without DM (15.9±6.6 vs. 5.1±2.4 pmol/mg and 2.2±0.7 vs. 1.1±0.2 pmol/L, P<0.05), whereas total calcium and vasoconstrictors were not different. Patients with DM had a greater percent diameter stenosis 6 months after stent implantation than those without DM (22.17±5.22 vs. 6.34±1.11%, P<0.05). The increase in TNFα immediately after stent implantation correlated with restenosis 6 months later (r=0.69, P<0.05). CONCLUSION In diabetics, particulate debris and coronary aspirate plasma contained more TNFα, which might reflect the activity of the underlying atherosclerotic process. TRIAL REGISTRATION URL: http://www.clinicaltrials.gov/ct2/results?term=NCT01430884; unique identifier: NCT01430884.
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Affiliation(s)
- Theodor Baars
- Institut für Pathophysiologie, Universitätsklinikum Essen, Hufelandstr 55, 45122 Essen, Germany
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19
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D'Ascenzo F, Agostoni P, Abbate A, Castagno D, Lipinski MJ, Vetrovec GW, Frati G, Presutti DG, Quadri G, Moretti C, Gaita F, Zoccai GB. Atherosclerotic coronary plaque regression and the risk of adverse cardiovascular events: A meta-regression of randomized clinical trials. Atherosclerosis 2013. [PMID: 23206978 DOI: 10.1016/j.atherosclerosis.2012.10.065] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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20
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Epicardial adipose tissue thickness is a predictor for plaque vulnerability in patients with significant coronary artery disease. Atherosclerosis 2013. [DOI: 10.1016/j.atherosclerosis.2012.11.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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21
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Comparison of frequency of periprocedural myocardial infarction in patients with and without diabetes mellitus to those with previously unknown but elevated glycated hemoglobin levels (from the TWENTE Trial). Am J Cardiol 2012; 110:1561-7. [PMID: 22939581 DOI: 10.1016/j.amjcard.2012.07.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Revised: 07/12/2012] [Accepted: 07/12/2012] [Indexed: 11/21/2022]
Abstract
In patients without a history of diabetes mellitus, increased levels of glycated hemoglobin (HbA1c) are associated with higher cardiovascular risk. The relation between undetected diabetes and clinical outcome after percutaneous coronary intervention is unknown. To investigate whether these patients may have an increased risk of periprocedural myocardial infarction (PMI), the most frequent adverse event after percutaneous coronary intervention, we assessed patients of the TWENTE trial (a randomized, controlled, second-generation drug-eluting stent trial) in whom HbA1c data were available. Patients were classified as known diabetics or patients without a history of diabetes who were subdivided into undetected diabetics (HbA1c ≥6.5%) and nondiabetics (HbA1c <6.5%). Systematic measurement of cardiac biomarkers and electrocardiographic assessment were performed. One-year clinical outcome was also compared. Of 626 patients, 44 (7%) were undetected diabetics, 181 (29%) were known diabetics, and 401 (64%) were nondiabetics. In undetected diabetics the PMI rate was higher than in nondiabetics (13.6% vs 3.7%, p = 0.01) and known diabetics (13.6% vs 6.1%, p = 0.11). Multivariate analysis adjusting for covariates confirmed a significantly higher PMI risk in undetected diabetics compared to nondiabetics (odds ratio 6.13, 95% confidence interval 2.07 to 18.13, p = 0.001) and known diabetics (odds ratio 3.73, 95% confidence interval 1.17 to 11.89, p = 0.03). After 1 year, target vessel MI rate was significantly higher in undetected diabetics (p = 0.02) than in nondiabetics, which was related mainly to differences in PMI. Target vessel failure was numerically larger in unknown diabetics than in nondiabetics, but this difference did not reach statistical significance (13.6% vs 8.0%, p = 0.25). In conclusion, undetected diabetics were shown to have an increased risk of PMI.
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Dhawan SS, Corban MT, Nanjundappa RA, Eshtehardi P, McDaniel MC, Kwarteng CA, Samady H. Coronary microvascular dysfunction is associated with higher frequency of thin-cap fibroatheroma. Atherosclerosis 2012; 223:384-8. [DOI: 10.1016/j.atherosclerosis.2012.05.034] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Revised: 05/08/2012] [Accepted: 05/29/2012] [Indexed: 10/28/2022]
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23
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Nicholls SJ. Insights from a virtual world. JACC Cardiovasc Interv 2011; 4:511-2. [PMID: 21596323 DOI: 10.1016/j.jcin.2011.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Accepted: 02/18/2011] [Indexed: 10/18/2022]
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