Application of appropriate use criteria for percutaneous coronary intervention in Japan

Implications of transient ischemic dilatation and impaired left ventricular ejection fraction reserve in patients with normal stress myocardial perfusion imaging and elevated coronary artery calcium

PURPOSE

Guidelines recommend stress only (SO) myocardial perfusion imaging (MPI) without follow-up rest imaging if perfusion and left ventricular ejection fraction (LVEF) are normal. However additional rest imaging may show transient ischaemic dilation (TID) and/or impaired LVEF reserve (iLVEFr) suggestive of 'balanced ischemia'. Concurrent coronary artery calcium (CAC) scoring helps to identify subclinical atherosclerosis. The safety of SO MPI when CAC is elevated is unclear. We aim to assess the incidence and outcomes of TID and iLVEFr amongst stress/rest MPIs with normal SO images and elevated CAC.

METHODS

Retrospective analysis of normal stress/rest MPIs performed between 1 March 2016 to 31 January 2017 with concurrently measured CAC >300. Cases were stratified by presence of TID and/or iLVEFr. Major adverse cardiac events (MACE, defined as cardiac death, non-fatal myocardial infarction and revascularization) within 24 months were compared.

RESULTS

There were 230 cases included of which 43 (18.7%) had TID and/or iLVEFr. Presence of TID and/or iLVEFr was associated with higher 24-month MACE (23.3 vs. 8.6%, p = 0.013), driven by more elective revascularizations (18.6 vs. 4.3%, p = 0.001). Cardiac death and non-fatal myocardial infarction rates were similar. TID and/or iLVEFr significantly predicted overall MACE after multivariate analysis (OR 2.933 [1.214 - 7.087], p = 0.017).

CONCLUSIONS

TID and/or iLVEFr is seen in the minority of normal stress MPI with elevated CAC, and is associated with higher 24-month MACE, driven by higher elective revascularizations. Overall cardiac death and non-fatal myocardial infarction rates were low and not significantly different between both groups.

Cardiovascular disease history and β-blocker prescription patterns among Japanese and American patients with CKD: a cross-sectional study of the CRIC and CKD-JAC studies

Cardiovascular disease (CVD) is a major complication in individuals with chronic kidney disease (CKD). In Japan, the incidence of CVD among persons with CKD is lower than that in the United States. Although various classes of antihypertensive agents are prescribed to prevent CVD, the proportion varies between the United States and Japan. Until now, few studies have compared clinical practices and CVD prevalence among patients with CKD in the United States vs. Japan. In this study, we performed a cross-sectional comparison of the prevalence of CVD and the prescription of β-blockers at study entry to the Chronic Kidney Disease Japan Cohort (CKD-JAC) Study and the Chronic Renal Insufficiency Cohort (CRIC) Study. The mean patient age was 58.2 and 60.3 years, the mean estimated glomerular filtration rate (eGFR) was 42.8 and 28.9 (mL/min/1.73 m²), and the median urinary albumin:creatinine ratio was 51.9 and 485.9 (mg/g) among 3939 participants in the CRIC Study and 2966 participants in the CKD-JAC Study, respectively. The prevalence of any CVD according to a self-report (CRIC Study) was 33%, while that according to a medical chart review (CKD-JAC Study) was 24%. These findings were consistent across eGFR levels. Prescriptions for β-blockers differed between the CRIC and CKD-JAC Studies (49% and 20%, respectively). The odds ratios for the association of any history of CVD and β-blocker prescription were 3.0 [2.6-3.5] in the CRIC Study and 2.0 [1.6-2.5] in the CKD-JAC Study (P < 0.001 for the interaction). In conclusion, the prevalence of CVD and treatment with β-blockers were higher in the CRIC Study across eGFR levels.