New Insights Into Long- Versus Short-Term Dual Antiplatelet Therapy Duration in Patients After Stenting for Left Main Coronary Artery Disease: Findings From a Prospective Observational Study

State-of-the-art percutaneous coronary intervention for left main coronary artery disease in Japan

Percutaneous coronary intervention for left main coronary artery disease (LM-PCI) represents a high-risk yet life-saving procedure that has evolved significantly over the years. This review outlines the current state-of-the-art practices for LM-PCI in Japan in detail, emphasizing the integration of coronary physiology and intracoronary imaging alongside with evidence-based standardized technique using latest drug-eluting stents. These advancements enable precise lesion assessment, stent sizing, and optimal deployment, thereby enhancing procedural safety and efficacy. Despite discrepancies between current guidelines favoring coronary artery bypass grafting and real-world practice trends towards increased LM-PCI adoption, particularly in elderly populations with multiple comorbidities, careful patient selection and procedural planning are critical. Future perspectives include further refining LM-PCI through conducting randomized controlled trials integrating advanced techniques and addressing the issue of ostial left circumflex lesions and nationwide standardization of medical care for LM disease.

Duration of Dual Antiplatelet Therapy after Percutaneous Coronary Intervention of Unprotected Left Main Coronary Artery Stenosis: 6 versus 12 Months

Background/Objectives: For patients with percutaneous coronary intervention (PCI) of an unprotected left main coronary artery (uLMCA) stenosis, the optimal duration of dual antiplatelet therapy (DAPT) remains a matter of debate. The purpose of this study was to compare clinical outcomes of 6- versus 12-month DAPT duration in patients with PCI of an uLMCA and stable angina. Methods: In this retrospective analysis, we included consecutive patients of our centre who underwent PCI of uLMCA stenosis for stable angina and who received DAPT with acetylsalicylic acid and clopidogrel for either 6 or 12 months. The primary endpoint was the composite of all-cause mortality, myocardial infarction, and target lesion revascularization at one year. Secondary endpoints included individual components of the primary endpoint, definite/probable stent thrombosis, and bleeding. Clinical outcomes were assessed by unadjusted analysis and by inverse probability of treatment weighting (IPTW). Results: Out of 984 included patients, 339 (34.5%) received DAPT for 6 months and 645 (65.5%) for 12 months. The primary endpoint occurred in 51 patients (15.2%) in the 6-month group and in 104 (16.3%) in the 12-month group (p = 0.674). Incidences of stent thrombosis (0.9% versus 0.3%, p = 0.224) and BARC 3,4,5 bleeding (6% versus 5.8%, p = 0.808) were also comparable in both groups. We found no significant differences in the primary endpoint and its components or BARC 3,4,5 bleeding between 6 and 12 months. Conclusions: Our findings do not support the extension of DAPT beyond 6 months after PCI for uLMCA in patients with stable angina.

A New Scoring System Predicting Side-Branch Occlusion in Patients Undergoing Left Main Bifurcation Intervention: The LM V-RESOLVE Score

BACKGROUND

The risk of side-branch (SB) occlusion is pivotal for decision making of stenting strategies during unprotected left main (LM) bifurcation percutaneous coronary intervention (PCI). Accordingly, this study aimed to develop a scoring system for predicting SB occlusion during unprotected LM bifurcation PCI.

METHODS

A total of 855 consecutive patients undergoing unprotected LM bifurcation PCI with provisional strategy at Fuwai Hospital from January 2014 to December 2016 were recruited. A prediction model was selected by means of all-subsets logistic regression, and a multivariable risk score (Left Main Visual Estimation for Risk Prediction of Side Branch Occlusion in Coronary Bifurcation Intervention [LM V-RESOLVE]) was then established with incremental weights attributed to each component variable based on its estimate coefficients. SB occlusion was defined as any decrease in Thrombolysis in Myocardial Infarction (TIMI) flow grade or absence of flow in SB after main vessel (MV) stenting.

RESULTS

SB occlusion occurred in 19 LM bifurcation lesions (2.22%). In multivariable model, 3 variables, including MV/SB diameter ratio, MV plaque ipsilateral to SB, and baseline diameter stenosis of SB, were independent predictors for SB occlusion (model C-statistic 0.829, 95% confidence interval [CI] 0.735-0.923, with good calibration). The risk score had a C-statistics of 0.830 (95% CI 0.738-0.923) with good calibration. Satisfactory discriminative ability of the risk score was also preserved in external validation (C-statistic 0.794, 95% CI 0.691-0.896).

CONCLUSIONS

The LM bifurcation-specific novel scoring system, LM V-RESOLVE, based on 3 simple baseline angiographic findings, could help to rapidly discriminate lesions at risk of SB occlusion during LM bifurcation PCI.

Technological Advances Are Associated With Better Clinical Outcomes of Percutaneous Coronary Intervention in Patients With Unprotected Left Main Disease

BACKGROUND

Few large-scale studies have evaluated the effectiveness of percutaneous coronary intervention (PCI) technological advances in the treatment of patients with unprotected left main coronary artery disease (LM-CAD). We aim to identify independent factors that affect the prognosis of PCI in patients with unprotected LM-CAD and to assess the impact of PCI technological advances on long-term clinical outcomes.

METHODS AND RESULTS

A total of 4512 consecutive patients who underwent unprotected LM-CAD PCI at Fuwai Hospital from 2004 to 2016 were enrolled. Multivariable Cox proportional hazards model was used to identify which techniques can independently affect the incidence of major adverse cardiac events (MACEs; a composite of cardiac death, myocardial infarction, or target vessel revascularization). The incidence of 3-year MACEs was 9.0% (406/4512). Four new PCI techniques were identified as the independent protective factors of MACEs, including second-generation drug-eluting stents (hazard ratio [HR], 0.61 [95% CI, 0.37-0.99]), postdilatation (HR, 0.75 [95% CI, 0.59-0.94]), final kissing balloon inflation (HR, 0.78 [95% CI, 0.62-0.99]), and using intravascular ultrasound (HR, 0.78 [95% CI, 0.63-0.97]). The relative hazard of 3-year MACEs was reduced by ≈50% with use of all 4 techniques compared with no technique use (HR, 0.53 [95% CI, 0.32-0.87]).

CONCLUSIONS

PCI technological advances including postdilatation, second-generation drug-eluting stent, final kissing balloon inflation, and intravascular ultrasound guidance were associated with improved clinical outcomes in patients who underwent unprotected LM-CAD PCI.

Left main bifurcation stenting: impact of residual ischaemia on cardiovascular mortality

AIMS

The present study sought to determine the rate and prognostic implications of post-procedural physiologically significant residual ischemia according to Murray law-based quantitative flow ratio (μQFR) after left main (LM) bifurcation percutaneous coronary intervention (PCI).

METHODS AND RESULTS

Consecutive patients undergoing LM bifurcation stenting at a large tertiary care center between January 2014 and December 2016 with available post-PCI μQFR were included. Physiologically significant residual ischemia was defined by post-PCI μQFR values ≤0.80 in the left anterior descending (LAD) or left circumflex artery (LCX). The primary outcome was 3-year cardiovascular death. The major secondary outcome was 3-year bifurcation-oriented composite endpoint (BOCE). Among 1170 included patients with analyzable post-PCI μQFR, 155 (13.2%) had residual ischemia in either LAD or LCX. Patients with vs. those without residual ischemia had a higher risk of 3-year cardiovascular mortality [5.4% vs. 1.3%; adjusted hazard ratio (HR) 3.20, 95% confidence interval (CI): 1.16-8.80]. The 3-year risk of BOCE was significantly higher in the residual ischemia group (17.8% vs. 5.8%; adjusted HR 2.79, 95% CI: 1.68-4.64), driven by higher incidence of the composite of cardiovascular death and target bifurcation-related myocardial infarction (14.0% vs. 3.3%; adjusted HR 4.06, 95% CI: 2.22-7.42). A significant, inverse association was observed between continuous post-PCI μQFR and the risk of clinical outcomes (per 0.1 μQFR decrease, HR of cardiovascular death 1.27, 95% CI: 1.00-1.62; HR of BOCE 1.29, 95% CI: 1.14-1.47).

CONCLUSION

After angiographically successful LM bifurcation PCI, residual ischemia assessed by μQFR was identified in 13.2% of patients and was associated with higher risk of 3-year cardiovascular death, indicating the superior prognostic value of post-PCI physiological assessment.

Implications of bleeding on subsequent cardiovascular events in patients with atrial fibrillation after acute coronary syndrome or PCI

INTRODUCTION

The association between bleeding and subsequent major adverse cardiac and cerebrovascular events (MACCE) remains poorly characterized. We aimed to evaluate the impact of hemorrhagic events in patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI).

MATERIALS AND METHODS

A total of 1877 consecutive patients with AF and ACS or undergoing PCI were prospectively recruited. The primary endpoint was MACCE, including all-cause death, myocardial infarction, ischemic stroke, systemic embolism or ischemia-driven revascularization during follow-up. Post-discharge bleeding was graded according to TIMI criteria. Associations between bleeding and subsequent MACCE were examined using time-dependent multivariate Cox regression after adjusting for baseline covariates and the time from bleeding.

RESULTS

During a median follow-up of 34.2 months, 341 (18.2 %) had TIMI major or minor bleeding events, of whom 86 (25.2 %) also experienced MACCE. The risk of MACCE was significantly higher in patients with bleeding than those without (8.85 % versus 6.99 % per patient-year; HR, 1.568, 95 % CI, 1.232-1.994). In patients who had both bleeding and MACCE, 65.1 % (56 of 86) bleeding events occurred first. Temporal gradients in MACCE risk after major bleeding was highest within 30 days (HRadj, 23.877; 95 % CI, 12.810-44.506) and remained significant beyond 1 year (HRadj, 3.640; 95 % CI, 1.278-10.366). Minor bleeding was associated with increased risk of MACCE within 1 year.

CONCLUSIONS

In patients with AF and ACS or PCI, major and minor bleeding were associated with subsequent MACCE with time-dependency. Our findings may aid in better defining net clinical benefit of optimal antithrombotic therapy.

Effect of Periprocedural Myocardial Infarction After Initial Revascularization With Left Main PCI in Patients With Recent Myocardial Infarction

Background

Periprocedural myocardial infarction (PMI) after percutaneous coronary intervention (PCI) for left main coronary artery disease (LMCAD) may be particularly deleterious in patients with recent myocardial infarction (MI). We sought to determine the rates and prognostic relevance of PMI using different definitions and biomarker thresholds after PCI for LMCAD in patients with recent MI.

Methods

Between January 2004 and December 2016, 442 patients underwent PCI for LMCAD at a median of 3 days after presentation with MI. A total of 350 patients presented with elevated cardiac biomarker levels (349 with serial creatine kinase-myocardial band [CK-MB] and 219 with serial cardiac troponin I (cTnI) values) that were stable or falling before the PCI. In this cohort, PMI within 48 hours of PCI was adjudicated using Society for Cardiovascular Angiography & Interventions (SCAI), Academic Research Consortium 2 (ARC-2), and fourth Universal Definition of Myocardial Infarction (UDMI) criteria. The primary and secondary end points were 3-year rates of cardiovascular (CV) and all-cause death.

Results

An incremental post-PCI rise in CK-MB starting at ≥10× the upper reference limit from baseline was significantly associated with 3-year CV death (adjusted hazard ratio [aHR], 7.96; 95% confidence interval [CI], 2.89-21.90), whereas CV death was not associated with any threshold elevation of cTnI. The frequencies of PMI according to the fourth UDMI, ARC-2, and SCAI definitions were 19.4%, 12.3%, and 8.6%, respectively. PMI by all 3 definitions was significantly associated with 3-year CV death, with the SCAI definition having the strongest relationship (aHR, 6.34; 95% CI, 2.47-16.27) compared with those of ARC-2 (aHR, 2.82; 95% CI, 1.15-6.96) and fourth UDMI (aHR, 2.65; 95% CI, 1.14-6.14).

Conclusions

In patients with recent MI undergoing PCI for LMCAD, an incremental elevation in postprocedural CK-MB of ≥10× the upper reference limit as a stand-alone measure was strongly predictive of 3-year CV and all-cause death, whereas no cTnI elevations of any level were prognostic. All 3 contemporary PMI definitions in widespread use were associated with 3-year mortality after PCI in this high-risk cohort, with the SCAI definition having the strongest relationship with subsequent death.

Comparison of Estimated LDL Cholesterol Equations with Direct Measurement in Patients with Angiographically Confirmed Coronary Artery Disease

Background and aims: Our goals in the study were to (1) quantify the discordance in LDL-C levels between equations (the Friedewald, Sampson, and Martin/Hopkins equations) and compare them with direct LDL-C (dLDL-C); and (2) explore the proportion of misclassified patients by calculated LDL-C using these three different equations. Methods: A total of 30,349 consecutive patients with angiographically confirmed coronary artery disease (CAD) were prospectively enrolled. Concordance was defined as if the LDL-C was <1.8 mmol/L with each pairwise comparison of LDL-C equations. Estimated LDL-C that fell into the same category as dLDL-C at the following levels: <1.4, 1.4 to 1.7, 1.8 to 2.5, 2.6 to 2.9, and ≥3.0 mmol/L was considered to have been correctly categorized. Results: The concordance was 96.3% (Sampson vs. Martin/Hopkins), 95.0% (Friedewald vs. Sampson), and 91.4% (Friedewald vs. Martin/Hopkins), respectively. This proportion fell to 82.4% in those with hypertriglyceridemia (TG ≥ 1.7 mmol/L). With an accurate classification rate of 73.6%, the Martin/Hopkins equation outperformed the Sampson equation (69.5%) and the Friedewald equation (59.3%) by a wide margin. Conclusions: Comparing it to the validated Martin/Hopkins equation, the Friedewald equation produced the lowest levels of LDL-C, followed by the Sampson equation. In the classification of LDL-C, the Martin/Hopkins equation has also been shown to be more accurate. There is a significant difference between the equations and the direct measurement method, which may lead to overtreatment or undertreatment.

High neutrophil to lymphocyte ratio with type 2 diabetes mellitus predicts poor prognosis in patients undergoing percutaneous coronary intervention: a large-scale cohort study

BACKGROUND

Inflammation plays a crucial role in the pathogenesis and progression of coronary artery disease (CAD). The neutrophil to lymphocyte ratio (NLR) is a novel inflammatory biomarker and its association with clinical outcomes in CAD patients with different glycemic metabolism after percutaneous coronary intervention (PCI) remains undetermined. Therefore, this study aimed to investigate the effect of NLR on the prognosis of patients undergoing PCI with or without type 2 diabetes mellitus (T2DM).

METHODS

We consecutively enrolled 8,835 patients with CAD hospitalized for PCI at Fuwai hospital. NLR was calculated using the following formula: neutrophil (*10⁹/L)/lymphocyte (*10⁹/L). According to optimal cut-off value, study patients were categorized as higher level of NLR (NLR-H) and lower level of NLR (NLR-L) and were further stratified as NLR-H with T2DM and non-T2DM, and NLR-L with T2DM and non-T2DM. The primary endpoint was major adverse cardiovascular and cerebrovascular events (MACCEs), defined as all-cause mortality, myocardial infarction (MI), stroke and target vessel revascularization.

RESULTS

A total of 674 (7.6%) MACCEs were recorded during a median follow-up of 2.4 years. The optimal cut-off value of NLR was 2.85 determined by the surv_cutpoint function. Compared to those in the NLR-H/T2DM groups, patients in the NLR-L/non-T2DM, NLR-H/non-T2DM and NLR-L/T2DM groups were at significantly lower risk of 2-year MACCEs [adjusted hazard ratio (HR): 0.67, 95% confidence interval (CI): 0.52 to 0.87, P = 0.003; adjusted HR: 0.62, 95%CI: 0.45 to 0.85, P = 0.003; adjusted HR: 0.77, 95%CI: 0.61 to 0.97, P = 0.025; respectively]. Remarkably, patients in the NLR-L/non-T2DM group also had significantly lower risk of a composite of all-cause mortality and MI than those in the NLR-H/T2DM group (adjusted HR: 0.57, 95%CI: 0.35 to 0.93, P = 0.024). Multivariable Cox proportional hazards model also indicated the highest risk of MACCEs in diabetic patients with higher level of NLR than others (P for trend = 0.009). Additionally, subgroup analysis indicated consistent impact of NLR on MACCEs across different subgroups.

CONCLUSIONS

Presence of T2DM with elevated NLR is associated with worse clinical outcomes in CAD patients undergoing PCI. Categorization of patients with elevated NLR and T2DM could provide valuable information for risk stratification of CAD patients.