Associations between different types of hypoglycemic agents and the clinical outcome of percutaneous coronary intervention in diabetic patients-From the FU-Registry

Differences in lesion characteristics and patient background associated with the medium-term clinical outcomes of bare-metal and first-, second- and third-generation drug-eluting stents

We investigated the lesion characteristics and patient background factors associated with the medium-term incidence of major adverse cardiac events (MACEs) for bare-metal stents (BMS) and 1st-, 2nd- and 3rd-generation drug-eluting stents (DES) using the PCI-Registry (FU-Registry). Between January 2003 and March 2016, 2967 cases/3508 lesions for which percutaneous coronary intervention was performed at Fukuoka University Hospital and related facilities were enrolled. Patients were divided into BMS and 1st-, 2nd- and 3rd-generation drug-eluting stent (DES) groups. The incidence of MACEs in the BMS group (26.2%) was significantly higher than those in the 1st, 2nd and 3rd DES groups (18.0%, 12.5%, and 11.0%, respectively). The incidence of MACEs in the BMS group was strongly associated with insulin use, hemodialysis, low high-density lipoprotein cholesterol, stent minimum lesion diameter, stent length, severe calcification and a small vessel diameter of less than 2.5 mm. Some of these factors showed no association with MACEs among the drug-elution groups, and only hemodialysis, arteriosclerosis obliterans and severe calcification showed a strong correlation in the 2nd DES group. In the 3rd DES group, none of the factors considered were associated with MACEs. In conclusion, in stent implantation, the number of factors associated with MACEs has gradually decreased as the stent generation increased.

Atherosclerotic Coronary Artery Disease in Patients With Cardiometabolic Syndrome

Major risk factors for cardiovascular disease (CVD) include aging, gender, smoking, family history and cardiometabolic syndrome. The relative residual risks for CVD after statin treatment for primary and secondary prevention have been reported by several large-scale randomized clinical trials. Statin treatment appears to prevent one-third of the onset and progression of CVD, but not the remaining two-thirds. There are three major problems regarding the residual risk of CVD: 1) Insufficient reduction of low-density lipoprotein cholesterol levels; 2) Low levels of high-density lipoprotein cholesterol and elevated triglyceride; and 3) Insufficient control of other risk factors (high blood pressure, obesity, metabolic syndrome, type 2 diabetes, etc.). Thus, a multifaceted preventive approach should be needed to prevent CVD after statin treatment.

Sex difference between target levels of cholesterol-related parameters and post-PCI long-term clinical outcomes: From the FU-Registry

BACKGROUND

Since single lipid parameters are too weak to predict the risk of coronary artery disease, we examined whether the allocation of patients into four groups based on achievement of the target levels set by the Japan Atherosclerosis Guidelines at the time of percutaneous coronary intervention (PCI) would reveal different long-term (5 years) clinical outcomes in males and females.

METHODS

The results of a 5-year follow-up study are summarized as FU-Registry, Long-Term Clinical Outcome Results. The subjects consisted of 1158 patients who underwent elective PCI. The male and female patients were separately allocated into four groups: (1) high-density lipoprotein cholesterol (HDL-C≥40mg/dl as well as low-density lipoprotein-cholesterol (LDL-C)≥100mg/dl); (2) HDL-C≥40mg/dl as well as LDL-C<100mg/dl; (3) HDL-C<40mg/dl as well as LDL-C≥100mg/dl; (4) HDL-C<40mg/dl as well as LDL-C<100mg/dl, for a comparison of both patient as well as lesion characteristics and the endpoint of major adverse cardiac events (MACEs).

RESULTS

Regarding lesion characteristics, significant differences (p<0.05) were detected in the usage rate of a drug-eluting stent (DES) as well as the bend, stent reference diameter, and stent minimum lumen diameter in females by ANOVA, and in severe calcification, the bend, and usage rate of DES (p<0.001) in males. In females, significant differences (p<0.05) were observed in MACEs and target lesion revascularization-PCI. In contrast, among males, the four groups had nearly equivalent outcomes. Uni- and multivariate analyses revealed that HDL-C as well as LDL-C in females were associated with MACEs [OR 3.29 (95% CI 1.05-8.57, p=0.04)], while no association was observed in male multivariate analysis.

CONCLUSION

In female patients, HDL-C<40mg/dl and LDL-C≥100mg/dl were even more strongly related to MACEs, whereas the combination of LDL-C and HDL-C was not related to MACEs in male patients.

Association between discordance of LDL-C and non-HDL-C and clinical outcomes in patients with stent implantation: from the FU-Registry

It is not yet clear whether the discordance of low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol (non-HDL-C) predicts the follow-up clinical outcome (major adverse cardiovascular events: MACEs) in patients with coronary stent implantation. Among 2015 patients with coronary stent implantation (Fukuoka University [FU]-Registry), excluding those with acute coronary syndrome or hemodialysis, we selected 801 patients who had undergone successful stent implantation with a follow-up until 18 months, and classified them into 3 groups according to baseline LDL-C and non-HDL-C levels [percentile(P)non-HDL-C more than (P)LDL-C, (P)non-HDL-C equal to (P)LDL-C, and (P)non-HDL-C less than (P) LDL-C]. We found that the discordance of (P)LDL-C and (P)non-HDL-C was not a significant predictor of MACEs. Higher LDL-C level was consistently and independently associated with higher incidences of MACEs after controlling for conventional risk factors and the type of stent used by multivariate Cox regression analyses. In conclusion, LDL-C levels are more important than non-HDL-C levels and the discordance of LDL-C and non-HDL-C levels as predictors of MACEs in patients with stable angina after stent implantation.

Effects of alogliptin on fractional flow reserve evaluated by coronary computed tomography angiography in patients with type 2 diabetes: Rationale and design of the TRACT study

BACKGROUND

Patients with type 2 diabetes are at high risk for developing coronary artery disease (CAD). Noninvasive anatomic assessment by coronary computed tomography angiography (CCTA) is being increasingly used for detecting or excluding CAD. Recently, fractional flow reserve (FFR) using routinely acquired CCTA datasets (FFR_CT) has been developed. Although intensive glycemic control can reduce the risk of microvascular complications, intensive glucose control does not seem to be beneficial in preventing major cardiovascular events when compared with standard therapy. However, it has been reported that dipeptidyl peptidase-4 (DPP-4) inhibitors have anti-atherogenic effects in an animal model. In addition, DPP-4 inhibitors attenuate the progression of carotid intima-media thickness in patients with type 2 diabetes. Therefore, this study will be performed to evaluate the effects of alogliptin, a DPP-4 inhibitor, on coronary atherosclerosis using FFR_CT in patients with type 2 diabetes.

METHODS AND DESIGN

This study will be a prospective, non-randomized, multicenter trial performed in Japan. Patients with type 2 diabetes who have intermediate coronary artery stenosis (diameter stenosis <70%) as evaluated by CCTA will be treated with 25mg/day of alogliptin. After 48 weeks' treatment, CCTA will be repeated. The primary endpoint will be changes in FFR_CT, and the secondary endpoint will be the change in plaque volume from baseline to the 48-week follow-up.

CONCLUSION

This study will be the first multicenter trial to evaluate the effects of alogliptin on coronary atherosclerosis using the newly developed FFR_CT as the primary endpoint, and the findings will clarify the anti-atherogenic effects of alogliptin.

Glycemic Control in Coronary Revascularization

OPINION STATEMENT

Hyperglycemia in the setting of coronary revascularization is associated with increased adverse cardiovascular events in patients with or without diabetes mellitus. Data suggest that acute peri-procedural hyperglycemia causes an increase in inflammation, platelet activity, and endothelial dysfunction and is associated with plaque instability and infarct size. While peri-procedural blood glucose level is an independent predictor of adverse outcomes in patients undergoing coronary revascularization, treatment strategies remain uncertain. Randomized clinical trials of glucose-insulin-potassium infusions have consistently shown no benefit, while those comparing insulin therapy versus standard of care have demonstrated mixed results, likely due to the failure to reach euglycemia with these strategies. Although no glucose-lowering agent has been shown to be superior in peri-procedural glycemic control, the continuation of clinically prescribed long-acting glucose-lowering medications in patients with diabetes mellitus prior to coronary angiography and possible percutaneous coronary intervention may be the simplest and most effective approach to maintain euglycemia and decrease the associated increase in inflammation and platelet activity. However, alternative strategies such as therapies targeted at the underlying mechanism of harm (e.g., more potent anti-platelet therapy, anti-inflammatory therapy) should also be considered and warrant further investigation.