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Wang A, Tian X, Zuo Y, Zhang X, Wu S, Zhao X. Association between the triglyceride-glucose index and carotid plaque stability in nondiabetic adults. Nutr Metab Cardiovasc Dis 2021; 31:2921-2928. [PMID: 34353702 DOI: 10.1016/j.numecd.2021.06.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 06/10/2021] [Accepted: 06/25/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS The rupture of an unstable atherosclerotic plaque is one of the major causes of thrombosis. However, there was limited evidence on the relationship of triglyceride-glucose (TyG) index, a simple surrogate marker of insulin resistance, with the carotid plaque stability. This study aimed to investigate the association between the TyG index and carotid plaque stability in nondiabetic adults. METHODS AND RESULTS The study included 4748 nondiabetic participants from the Asymptomatic Polyvascular Abnormalities Community study. Carotid plaque stability was assessed using ultrasonography. The TyG index was calculated as ln [fasting triglyceride (mg/dL) × fasting glucose (mg/dL)/2]. Logistic regression was used to evaluate the association of the TyG index with carotid plaque stability by calculating odds ratio (OR) and 95% confidence interval (CI). Of the 4748 participants, 1192 (25.11%) participants had stable carotid plaque, and 1247 (26.26%) had unstable carotid plaque. The prevalence of unstable carotid plaque substantially increased with increasing TyG index tertile (P for trend <0.0001). In the fully adjusted model, the OR comparing participants in the highest versus the lowest tertile of the TyG index was 1.31 (95% CI, 1.09-1.57). The optimal cutoff point for the TyG index in case of unstable carotid plaque was 8.56. However, we did not observe a statistically significant association between the TyG index and stable carotid plaque. CONCLUSIONS Elevated the TyG index was significantly associated with the prevalence of unstable carotid plaque in nondiabetic adults.
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Affiliation(s)
- Anxin Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xue Tian
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing, China
| | - Yingting Zuo
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing, China
| | - Xiaoli Zhang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shouling Wu
- Department of Cardiology, Kailuan Hospital, North China University of Science and Technology, China.
| | - Xingquan Zhao
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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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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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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Wang A, Wu L, Liu X, Su Z, Luo Y, Chen S, Li H, Liu X, Tao L, Guo J, Zhang F, Cao Y, Zhao X, Wu S, Guo X. The prevalence of carotid plaque with different stability and its association with metabolic syndrome in China: The Asymptomatic Polyvascular Abnormalities Community study. Medicine (Baltimore) 2016; 95:e4619. [PMID: 27559957 PMCID: PMC5400324 DOI: 10.1097/md.0000000000004619] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Few studies have investigated the prevalence of carotid plaque with different stability in Chinese. As is well known, carotid atherosclerosis is tightly associated with metabolic syndrome (MetS); however, the data about the association between the presence of carotid plaque with different stability and MetS was limited. The aim of our study was to investigate the prevalence of carotid plaque with different stability and its potential association with MetS in general Chinese population.The Asymptomatic Polyvascular Abnormalities Community study is a community-based study to investigate the epidemiology of asymptomatic polyvascular abnormalities in Chinese adults. A total of 5393 participants were finally eligible and included in this study. The carotid plaque and its stability were assessed using ultrasonography. The MetS was defined using the criteria from US National Cholesterol Education Program-Adult Treatment Panel III. Data were analyzed with multivariate logistic regression models.Of the 5393 subjects, 1397 (25.9%) participants had stable carotid plaque, 1518 (28.1%) had unstable carotid plaque in participants, and 1456 (27.0%) had a MetS. MetS was, respectively, significantly associated with the prevalence of carotid plaque (odds ratio [OR]: 1.25; 95% confidence interval [CI]: 1.07, 1.47), stable carotid plaque (OR: 1.23; 95% CI: 1.02,1.48), and unstable carotid plaque (OR: 1.27; 95% CI: 1.03,1.56) after adjusting for age, gender, level of education, income, smoking, drinking, physical activity, body mass index, low-density lipoprotein, and high-sensitivity C-reactive protein. With the number of MetS components, the prevalence of carotid plaque, stable carotid plaque, and unstable carotid plaque significantly increased (P for trend <0.0001), respectively.In summary, the prevalence of carotid plaque was 54.1%, stable carotid plaque was 25.9%, and unstable carotid plaque was 28.1%. Our study revealed that the prevalence of carotid plaque, stable carotid plaque, and unstable carotid plaque was, respectively, significantly associated with MetS in the general population.
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Affiliation(s)
- Anxin Wang
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University
- China National Clinical Research Center for Neurological Diseases
- Center of Stroke, Beijing Institute for Brain Disorders
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing
| | - Lingyun Wu
- North China University of Science and Technology
| | - Xiaoxue Liu
- Department of Cardiology, Tangshan People's Hospital, North China University of Science and Technology, Tangshan
| | - Zhaoping Su
- Department of Epidemiology and Health Statistics, Academy of Public Health and Management, Weifang Medical University, Weifang
| | - Yanxia Luo
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University
- Beijing Municipal Key Laboratory of Clinical Epidemiology, Capital Medical University, Beijing
| | - Shuohua Chen
- Department of Cardiology, Kailuan Hospital, North China University of Science and Technology, Tangshan, China
| | - Haibin Li
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University
- Beijing Municipal Key Laboratory of Clinical Epidemiology, Capital Medical University, Beijing
| | - Xiangtong Liu
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University
- Beijing Municipal Key Laboratory of Clinical Epidemiology, Capital Medical University, Beijing
| | - Lixin Tao
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University
- Beijing Municipal Key Laboratory of Clinical Epidemiology, Capital Medical University, Beijing
| | - Jin Guo
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University
- Beijing Municipal Key Laboratory of Clinical Epidemiology, Capital Medical University, Beijing
| | - Feng Zhang
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University
- Beijing Municipal Key Laboratory of Clinical Epidemiology, Capital Medical University, Beijing
| | - Yibin Cao
- Department of Neurology, Tangshan Gongren Hospital
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University
- China National Clinical Research Center for Neurological Diseases
- Center of Stroke, Beijing Institute for Brain Disorders
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing
- Correspondence: Xiuhua Guo, Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing 100069, China (e-mail: ); Shouling Wu, Department of Cardiology, Kailuan Hospital, North China University of Science and Technology, Tangshan 063000, China (e-mail: ); Xingquan Zhao, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China (e-mail: )
| | - Shouling Wu
- Department of Cardiology, Kailuan Hospital, North China University of Science and Technology, Tangshan, China
- Correspondence: Xiuhua Guo, Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing 100069, China (e-mail: ); Shouling Wu, Department of Cardiology, Kailuan Hospital, North China University of Science and Technology, Tangshan 063000, China (e-mail: ); Xingquan Zhao, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China (e-mail: )
| | - Xiuhua Guo
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University
- Beijing Municipal Key Laboratory of Clinical Epidemiology, Capital Medical University, Beijing
- Correspondence: Xiuhua Guo, Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing 100069, China (e-mail: ); Shouling Wu, Department of Cardiology, Kailuan Hospital, North China University of Science and Technology, Tangshan 063000, China (e-mail: ); Xingquan Zhao, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China (e-mail: )
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Cakar MA, Sahinkus S, Aydin E, Vatan MB, Keser N, Akdemir R, Gunduz H. Relation between the GRACE score and severity of atherosclerosis in acute coronary syndrome. J Cardiol 2013; 63:24-8. [PMID: 24012333 DOI: 10.1016/j.jjcc.2013.06.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Revised: 05/13/2013] [Accepted: 06/27/2013] [Indexed: 12/22/2022]
Abstract
BACKGROUND Patients with non-ST-elevation acute coronary syndrome are heterogeneous in terms of clinical presentation and immediate- and long-term risk of death or non-fatal ischemic events. The aim of the present study was to evaluate the relationship between the Global Registry of Acute Coronary Events (GRACE) score and severity of coronary artery disease angiographically evaluated by Gensini score in patients with non-ST-elevation acute coronary syndrome. METHODS A total of 245 patients with non-ST-elevation acute coronary syndrome were enrolled to the study. Based on the GRACE risk score classification system, the patients were divided into low- (n=97, 39.6%), intermediate- (n=84, 34.3%), and high- (n=64, 26.1%) risk groups. All patients underwent coronary angiography within five days after admission. RESULTS The Gensini scores were 26±29 in the low-risk group, 29±19 in the intermediate-risk group, and 38±23 in the high-risk group (p=0.016). The low-risk group was significantly different from the high-risk group (p=0.013), and the difference from the intermediate-risk group almost reached significance. Normal, noncritical, one and two, or multivessel disease were identified in 15 (6.1%), 31 (12.7%), 75 (30.6%), and 124 (50.6%) patients, respectively. The prevalence of multivessel disease was 28% in the low-risk group, 30% in the intermediate-risk group, and 42% in the high-risk group. The high-risk group was significantly different from the low-risk group (p<0.01). CONCLUSION Our study demonstrates that the GRACE score has significant value for assessing the severity and extent of coronary artery stenosis in patients with non-ST-elevation acute coronary syndrome.
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Affiliation(s)
- Mehmet Akif Cakar
- Cardiology Department, Sakarya University Faculty of Medicine, 54100 Sakarya, Turkey.
| | - Salih Sahinkus
- Cardiology Department, Sakarya University Faculty of Medicine, 54100 Sakarya, Turkey
| | - Ercan Aydin
- Cardiology Department, Sakarya University Faculty of Medicine, 54100 Sakarya, Turkey
| | - Mehmet Bulent Vatan
- Cardiology Department, Sakarya University Faculty of Medicine, 54100 Sakarya, Turkey
| | - Nurgul Keser
- Cardiology Department, Sakarya University Faculty of Medicine, 54100 Sakarya, Turkey
| | - Ramazan Akdemir
- Cardiology Department, Sakarya University Faculty of Medicine, 54100 Sakarya, Turkey
| | - Huseyin Gunduz
- Cardiology Department, Sakarya University Faculty of Medicine, 54100 Sakarya, Turkey
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Kunimura A, Amano T, Uetani T, Harada K, Yoshida T, Suzuki A, Shimbo Y, Kitagawa K, Harada K, Kato B, Kato M, Takashima H, Ando H, Matsubara T, Ishii H, Murohara T. Prognostic impact of concurrence of metabolic syndrome and chronic kidney disease in patients undergoing coronary intervention: Involvement of coronary plaque composition. J Cardiol 2012. [PMID: 23182943 DOI: 10.1016/j.jjcc.2012.10.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND PURPOSE Metabolic syndrome (MetS) and chronic kidney disease (CKD) have both been reported as risk factors for cardiovascular events. The aim of this study was to assess the synergistic effect of MetS and CKD on atherosclerotic plaque and cardiovascular outcomes. METHODS AND SUBJECTS A total of 545 consecutive patients who underwent percutaneous coronary intervention (PCI) were divided into 4 groups based on the presence or absence of MetS and CKD. MetS was defined using the criteria of the Adult Treatment Panel III of the US National Cholesterol Education Program. CKD was defined as an estimated glomerular filtration rate of <60ml/min/1.73m(2). We analyzed the incidence of major adverse cardiac events (MACE), including cardiovascular death, nonfatal myocardial infarction, target lesion revascularization, and revascularization for new lesions. We also assessed coronary plaque characteristics of 204 patients using integrated backscatter intravascular ultrasound (IB-IVUS). RESULTS MACE occurred more frequently in patients with both MetS and CKD (51.4%) than in the other groups, during the follow-up period (log-rank p<0.001). In the IB-IVUS analyses, patients with both MetS and CKD exhibited greater plaque burden (p=0.003) with higher lipid content (p=0.048) compared to the other groups. In Cox analysis, both MetS and CKD proved to be independent predictors of MACE even after adjustment for confounding factors (p=0.018). CONCLUSIONS Comorbidity of MetS and CKD is an independent predictor of adverse cardiovascular outcomes in patients undergoing coronary intervention, an effect that may be attributed to coronary plaque instability.
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Affiliation(s)
- Ayako Kunimura
- Department of Cardiology, Chubu Rosai Hospital, Nagoya, Japan
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