Long-term prognostic factors for cardiovascular events in patients with chest pain without diabetes mellitus nor significant coronary stenosis

Chest pain is the most common symptom of coronary artery disease (CAD) and diabetes mellitus (DM) is a well-known single strongest risk factor for cardiovascular diseases. Thus, the impact of CAD nor DM on long-term clinical effects is reported widely, but the prognostic factors of non-DM patients presenting with chest pain without significant CAD are limited. A total of 1,046 patients with chest pain without DM and significant CAD who underwent coronary angiography (CAG) and acetylcholine (ACH) provocation tests were finally enrolled. Propensity score matching and multivariate Cox-proportional hazard ratio analysis were performed to adjust for baseline potential confounders. Major adverse cardiac and cerebrovascular events (MACCE) were defined as the composite of total death, myocardial infarction (MI), revascularization, stroke, and recurrent angina. This study aimed to evaluate the long-term prognostic factors for MACCE in patients with chest pain without DM and CAD up to 5 years. Coronary artery spasm (CAS) was the most common cause of chest pain. However, long-term MACCE of CAS was not worse than those of patients with chest pain without CAS when patients with CAS had subsequent optimal antianginal medication therapy. However, a recurrent chest pain remains a problem even with continuous antianginal medication therapy. Up to 5 years, the incidence of MACCE was in 7.3%, including recurrent angina 6.9%. Dyslipidemia (HR: 2.010, 95% CI 1.166-3.466, P = 0.012), mild-moderate (30-70%) coronary stenosis (HR: 2.369, 95% CI 1.118-5.018, P = 0.024), the use of aspirin (HR: 2.885, 95% CI 1.588-5.238, P < 0.001), and the use of nitrates (HR: 1.938, 95% CI 1.094-3.433, P = 0.023) were independent risk factors for MACCE. Among the patients with chest pain without DM and significant CAD, the incidence of MACE were rare, but recurrent angina was still a challenging problem who had treated with antianginal medications.

Timing of fractional flow reserve-guided complete revascularization in patients with ST-segment elevation myocardial infarction with multivessel disease: Rationale and design of the OPTION-STEMI trial

BACKGROUND

Current guidelines recommend complete revascularization (CR) in hemodynamically stable patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease (MVD). With regard to the timing of percutaneous coronary intervention (PCI) for non-infarct-related artery (non-IRA), recent randomized clinical trials have revealed that immediate CR was non-inferior to staged CR. However, the optimal timing of CR remains uncertain. The OPTION-STEMI trial compared immediate CR and in-hospital staged CR guided by fractional flow reserve (FFR) for intermediate stenosis of the non-IRA.

METHODS

The OPTION-STEMI is a multicenter, investigator-initiated, prospective, open-label, non-inferiority randomized clinical trial. The study included patients with at least one non-IRA lesion with ≥50% stenosis by visual estimation. Patients fulfilling the inclusion criteria were randomized into two groups at a 1:1 ratio: immediate CR (i.e., PCI for the non-IRA performed during primary angioplasty) or in-hospital staged CR. In the in-hospital staged CR group, PCI for non-IRA lesions was performed on another day during the index hospitalization. Non-IRA lesions with 50-69% stenosis by visual estimation were evaluated by FFR, whereas those with ≥70% stenosis were revascularized without FFR. The primary endpoint was the composite of all-cause death, non-fatal myocardial infarction, and all unplanned revascularization at 1 year after randomization. Enrolment began in December 2019 and was completed in January 2024. The follow-up for the primary endpoint will be completed in January 2025, and primary results will be available in the middle of 2025.

CONCLUSIONS

The OPTION-STEMI is a multicenter, non-inferiority, randomized trial that evaluated the timing of in-hospital CR with the aid of FFR in patients with STEMI and MVD.

TRIAL REGISTRATION

URL: https://www.

CLINICALTRIALS

gov. Unique identifier: NCT04626882; and URL: https://cris.nih.go.kr. Unique identifier: KCT0004457.

Reduced Alcohol Consumption and Major Adverse Cardiovascular Events Among Individuals With Previously High Alcohol Consumption

Importance

Cardiovascular benefits of mild to moderate alcohol consumption need to be validated in the context of behavioral changes. The benefits of reduced alcohol consumption among people who drink heavily across different subtypes of cardiovascular disease (CVD) are unclear.

Objective

To investigate the association between reduced alcohol consumption and risk of major adverse cardiovascular events (MACEs) in individuals who drink heavily across different CVD subtypes.

Design, Setting, and Participants

This cohort study analyzed data from the Korean National Health Insurance Service-Health Screening database and self-reported questionnaires. The nationally representative cohort comprised Korean citizens aged 40 to 79 years who had national health insurance coverage on December 31, 2002, and were included in the 2002 to 2003 National Health Screening Program. People who drank heavily who underwent serial health examinations over 2 consecutive periods (first period: 2005-2008; second period: 2009-2012) were included and analyzed between February and May 2023. Heavy drinking was defined as more than 4 drinks (56 g) per day or more than 14 drinks (196 g) per week for males and more than 3 drinks (42 g) per day or more than 7 drinks (98 g) per week for females.

Exposures

Habitual change in heavy alcohol consumption during the second health examination period. People who drank heavily at baseline were categorized into 2 groups according to changes in alcohol consumption during the second health examination period as sustained heavy drinking or reduced drinking.

Main Outcomes and Measures

The primary outcome was the occurrence of MACEs, a composite of nonfatal myocardial infarction or angina undergoing revascularization, any stroke accompanied by hospitalization, and all-cause death.

Results

Of the 21 011 participants with heavy alcohol consumption at baseline (18 963 males [90.3%]; mean [SD] age, 56.08 [6.16] years) included in the study, 14 220 (67.7%) sustained heavy drinking, whereas 6791 (32.2%) shifted to mild to moderate drinking. During the follow-up of 162 378 person-years, the sustained heavy drinking group experienced a significantly higher incidence of MACEs than the reduced drinking group (817 vs 675 per 100 000 person-years; log-rank P = .003). Reduced alcohol consumption was associated with a 23% lower risk of MACEs compared with sustained heavy drinking (propensity score matching hazard ratio [PSM HR], 0.77; 95% CI, 0.67-0.88). These benefits were mostly accounted for by a significant reduction in the incidence of angina (PSM HR, 0.70; 95% CI, 0.51-0.97) and ischemic stroke (PSM HR, 0.66; 95% CI, 0.51-0.86). The preventive attributes of reduced alcohol intake were consistently observed across various subgroups of participants.

Conclusions and Relevance

Results of this cohort study suggest that reducing alcohol consumption is associated with a decreased risk of future CVD, with the most pronounced benefits expected for angina and ischemic stroke.

Long-term air pollution exposure is associated with higher incidence of ST-elevation myocardial infarction and in-hospital cardiogenic shock

Previous studies have reported the association between myocardial infarction (MI) and air pollution (AP). However, limited information is available regarding the long-term effects of AP on the relative incidence rates of ST-elevation MI (STEMI) and Non-ST-elevation MI (NSTEMI). We investigated the association between long-term exposure to AP and the incidence of STEMI. Between January 2006 and December 2015, a total of 45,619 eligible patients with Acute Myocardial Infarction (AMI) were enrolled in the Korea Acute MI Registry (KAMIR) and KAMIR-National Institutes of Health. Mixed-effect regression models were used to examine the association between the annual average ambient AP before MI onset and the incidence of STEMI, and to evaluate the association of AP with the incidence of in-hospital cardiogenic shock. After mixed-effect regression model analysis, particulate matter (PM) 10 µm or less in diameter (PM10) was associated with increased incidence of STEMI compared with NSTEMI (odds ratio [OR] 1.009, 95% Confidence Interval [CI] 1.002-1.016; p = 0.012). For in-hospital cardiogenic shock complication, PM10 and SO2 were associated with increased risk, PM10 (OR 1.033, 95% CI 1.018-1.050; p < 0.001), SO2 (OR 1.104, 95% CI 1.006-1.212; p = 0.037), respectively. Policy-level strategies and clinical efforts to reduce AP exposure are necessary to prevent the incidence of STEMI and severe cardiovascular complications.

Randomized clinical trial to compare the efficacy of self-expanding bare metal nitinol stent and balloon angioplasty alone for below-the-knee lesions following successful balloon angioplasty: 1-year clinical outcomes

This prospective, multicenter, randomized study aimed to compare the 1-year clinical outcomes after primary stenting with self-expanding bare metal nitinol stent (SENS) and plain old balloon angioplasty (POBA) in patients with critical limb ischemia (CLI) and below-the-knee (BTK) lesions. Overall, 119 patients with CLI and BTK lesions were randomized to POBA alone (POBA group, 61 patients) or primary stenting with SENS (stenting group, 58 patients) after achieving acceptable POBA results in target BTK lesions. Clinical outcomes including amputation and revascularization rates were prospectively compared for 1 year. After 1 year, similar incidence rates of individual clinical endpoints, including cardiac death (6.5% vs. 5.1%, p > 0.999), myocardial infarction (1.6% vs. 0.0%, p > 0.999), repeat revascularization (19.6% vs. 18.9%, p = 0.922), target lesion revascularization (13.1% vs. 17.2%, p = 0.530), and amputation (4.9% vs. 0.0%, p = 0.244), were observed. POBA appeared to have acceptable treatment outcomes compared with primary stenting with SENS after 1 year in CLI patients with BTK lesions undergoing percutaneous transluminal angioplasty (PTA).

Long-term clinical outcomes following successful percutaneous coronary intervention in patients with extremely long coronary chronic total occlusion lesions

BACKGROUND

Lesion length is related to worse clinical outcomes following percutaneous coronary intervention (PCI) for the treatment of chronic total occlusion (CTO). However, the data to confirm the association between extremely long lesions and clinical hard endpoints have been limited. Therefore, we investigated the impact of extremely long CTO lesions (≥50 mm, treated lesion length) on the long-term clinical outcomes following successful PCI.

METHODS

A total of 333 consecutive patients with CTO who underwent successful PCI with drug-eluting stents (DESs) were allocated to either the extremely long or the short CTO group according to their CTO lesion length. The 5-year clinical outcomes were compared between the two groups. The incidence of myocardial infarction, cardiac death (CD), revascularization, and major adverse cardiovascular events (MACE) was higher in the extremely long CTO group. The 5-year clinical outcomes were analyzed using the Cox hazard ratio (HR) model.

RESULTS

In the entire study population, the extremely long CTO lesion was an independent predictor for higher rate of revascularization, MACE, CD, or mortality.

CONCLUSIONS

In our study, CTO patients with extremely long lesions (≥50 mm) who underwent successful PCI were associated with a higher risk of worse long-term clinical outcomes, including hard clinical endpoints such as CD and mortality even in the DESs era.

The impact of sex differences on 3-year outcomes of patients with non-ST-segment elevation myocardial infarction after successful stent implantation according to symptom-to-balloon time

BACKGROUND

Because no data are available, we compared the 3-year outcomes of patients with non-ST-elevation myocardial infarction (NSTEMI) based on sex and symptom-to-balloon time (SBT).

METHODS

This study included 4910 patients who were divided into two groups based on SBT: SBT <48 h (n = 3,293, 67.1%) and SBT ≥48 h (n = 1,617, 32.9%). The primary outcome was all-cause death during the 3-year follow-up period. The secondary outcome was major adverse cardiac events (MACE), defined as all-cause death, recurrent myocardial infarction, or repeat coronary revascularization.

RESULTS

After adjustment, the in-hospital mortality rates for males and females in the SBT <48 h and SBT ≥48 h groups were similar. During a 3-year follow-up period, females in the SBT <48 h group had significantly higher rates of all-cause death (adjusted hazard ratio [aHR], 1.482; P = 0.006), cardiac death (CD, aHR, 1.617; P = 0.009), and MACE (aHR, 1.268; P = 0.024) than those males in the same groups. Females and males in the SBT ≥48 h group did not differ significantly in the primary and secondary outcomes. In males, the rates of all-cause death (P = 0.008) and CD (P = 0.024) were significantly higher in the SBT ≥48 h group than in the SBT <48 h group.

CONCLUSIONS

This study has identified a higher 3-year mortality rate in female patients with NSTEMI and SBT <48 h compared to their male counterparts. As such, a more preventive approach may be required to reduce mortality in these female patients.

Effect of delayed hospitalization on patients with non-ST-segment elevation myocardial infarction and complex lesions undergoing successful new-generation drug-eluting stents implantation

In the absence of available data, we evaluated the effects of delayed hospitalization (symptom-to-door time [SDT] ≥ 24 h) on major clinical outcomes after new-generation drug-eluting stent implantation in patients with non-ST-segment elevation myocardial infarction (NSTEMI) and complex lesions. In total, 4373 patients with NSTEMI were divided into complex (n = 2106) and non-complex (n = 2267) groups. The primary outcome was the 3-year rate of major adverse cardiac events (MACE), defined as all-cause death, recurrent MI, and any repeat revascularization. Secondary outcomes included the individual MACE components. In the complex group, all-cause death (adjusted hazard ratio [aHR], 1.752; p = 0.004) and cardiac death (aHR, 1.966; p = 0.010) rates were significantly higher for patients with SDT ≥ 24 h than for those with SDT < 24 h. In the non-complex group, all patients showed similar clinical outcomes. Patients with SDT < 24 h (aHR, 1.323; p = 0.031) and those with SDT ≥ 24 h (aHR, 1.606; p = 0.027) showed significantly higher rates of any repeat revascularization and all-cause death, respectively, in the complex group than in the non-complex group. Thus, in the complex group, delayed hospitalization was associated with higher 3-year mortalities.

Feasibility and safety of non-contrast optical coherence tomography imaging using hydroxyethyl starch in coronary arteries

Intracoronary optical coherence tomography (OCT) requires injection of flushing media for image acquisition. Alternative flushing media needs to be investigated to reduce the risk of contrast-induced renal dysfunction. We investigated the feasibility and safety of pentastarch (hydroxyethyl starch) for clinical OCT imaging. We prospectively enrolled 43 patients with 70 coronary lesions (46-stented; 24-native). Total 81 OCT pullback pairs were obtained by manual injection of iodine contrast, followed by pentastarch. Each pullback was assessed frame-by-frame using an automated customized lumen contour/stent strut segmentation algorithm. Paired images were compared for the clear image segments (CIS), blood-flushing capability, and quantitative morphometric measurements. Overall image quality, as assessed by the proportion of CIS, was comparable between the contrast- and pentastarch-flushed images (97.1% vs. 96.5%; p = 0.160). The pixel-based blood-flushing capability was similar between the groups (0.951 [0.947-0.953] vs. 0.950 [0.948-0.952], p = 0.125). Quantitative two- and three-dimensional morphometric measurements of the paired images correlated well (p < 0.001) with excellent inter-measurement variability. All patients safely underwent OCT imaging using pentastarch without resulting in clinically relevant complications or renal deterioration. Non-contrast OCT imaging using pentastarch is clinically safe and technically feasible with excellent image quality and could be a promising alternative strategy for patients at high risk of renal impairment.

The impact of renal function on the three-year outcomes in patients with myocardial infarction with nonobstructive coronary arteries

BACKGROUND

Due to limited data availability, we compared the 3-year outcomes of patients with acute myocardial infarction (AMI) and nonobstructive coronary arteries (MINOCA) and those with obstructive coronary arteries (MIOCA) according to renal function.

METHODS

From a final cohort of 10,774 patients with AMI were classified into 2 groups: the chronic kidney disease (CKD) group (estimated glomerular filtration rate <60 mL/min/1.73 m2, 2,854 patients; MINOCA, 123; MIOCA, 2,731) and the non-CKD group (7,920 patients; MINOCA, 256; MIOCA, 7,664). The primary outcome was the 3-year all-cause death rate, and the secondary outcomes included cardiac death (CD), non-CD death (NCD), recurrent myocardial infarction (MI), and any revascularization.

RESULTS

In both the CKD and non-CKD groups, the adjusted in-hospital mortality, 3-year all-cause death, CD, and recurrent MI rates were similar between the MINOCA and MIOCA groups, but the adjusted 3-year any revascularization rates were significantly higher in the MIOCA group than in the MINOCA group. Characteristically, in the CKD group, the adjusted 3-year NCD rate (P = 0.032) was higher in the MINOCA group than in the MIOCA group, and sepsis was the main cause of NCD in this group. In both the MINOCA and MIOCA groups, all-cause death and NCD were significantly higher in the CKD group than in the non-CKD group.

CONCLUSIONS

Regardless of renal function, the MINOCA and MIOCA groups had comparable mortality rates. However, patients with MINOCA and CKD had higher NCD rates. Close monitoring of renal function and enhanced strategies are required to reduce mortality in patients with MINOCA.

Development and validation of equation for cardiorespiratory fitness in patients with heart failure with preserved ejection fraction

Background/Aims

Cardiorespiratory fitness (CRF), as measured by maximal oxygen consumption (VO2max), is an important independent predictive factor of cardiovascular outcomes in patients with heart failure (HF). However, it is unclear whether conventional equations for estimating CRF are applicable to patients with HF with preserved ejection fraction (HFpEF).

Methods

This study included 521 patients with HFpEF (EF ≥ 50%) whose CRF was directly measured by cardiopulmonary exercise test using a treadmill. We developed a new equation (Kor-HFpEF) for half of the patients in the HFpEF cohort (group A, n = 253) and validated it for the remaining half (group B, n = 268). The accuracy of the Kor-HFpEF equation was compared to that of the other equations in the validation group.

Results

In the total HFpEF cohort, the directly measured VO2max was significantly overestimated by the FRIEND and ACSM equations (p < 0.001) and underestimated by the FRIEND-HF equation (p <0.001) (direct 21.2 ± 5.9 mL/kg/min; FRIEND 29.1 ± 11.8 mL/kg/min; ACSM 32.5 ± 13.4 mL/kg/min; FRIEND-HF 14.1 ± 4.9 mL/kg/min). However, the VO2max estimated by the Kor-HFpEF equation (21.3 ± 4.6 mL/kg/min) was similar to the directly measured VO2max (21.7 ± 5.9 mL/kg/min, p = 0.124), whereas the VO2max estimated by the other three equations was still significantly different from the directly measured VO2max in group B (all p < 0.001).

Conclusions

Traditional equations used to estimate VO2max were not applicable to patients with HFpEF. We developed and validated a new Kor-HFpEF equation for these patients, which had a high accuracy.

Korean vs. Western Exercise Capacity Nomograms for Korean Patients With Cardiovascular Disease

BACKGROUND

Exercise capacity is known to be an independent predictor of cardiovascular events and mortality. However, most previous studies were based on Western populations. Further study is warranted for Asian patients according to ethnic or national standards. We aimed to compare prognostic values of Korean and Western nomograms for exercise capacity in Korean patients with cardiovascular disease (CVD).

METHODS

In this retrospective cohort study, we enrolled 1,178 patients (62 ± 11 years; 78% male) between June 2015 and May 2020, who were referred for cardiopulmonary exercise testing in our cardiac rehabilitation program. The median follow-up period was 1.6 years. Exercise capacity was measured in metabolic equivalents by direct gas exchange method during the treadmill test. The nomogram for exercise capacity from healthy Korean individuals and a previous landmark Western study was used to determine the percentage of predicted exercise capacity. The primary endpoint was the composite of major adverse cardiovascular events (MACE; all-cause death, myocardial infarction, repeat revascularization, stroke and hospitalization for heart failure).

RESULTS

A multivariate analysis showed that the risk of primary endpoint was more than double (hazard ratio [HR], 2.20; 95% confidence interval [CI], 1.10-4.40) in the patients with lower exercise capacity (< 85% of predicted) by Korean nomogram. The lower exercise capacity was one of the strong independent predictors along with left ventricular ejection fraction, age, and level of hemoglobin. However, the lower exercise capacity by Western nomogram could not predict the primary endpoint (HR, 1.33; 95% CI, 0.85-2.10).

CONCLUSION

Korean patients with CVD with lower exercise capacity have higher risk of MACE. Considering inter-ethnic differences in cardiorespiratory fitness, the Korean nomogram provides more suitable reference values than the Western nomogram to determine lower exercise capacity and predict cardiovascular events in Korean patients with CVD.

Effect of delayed hospitalization on 3-year clinical outcomes according to renal function in patients with non-ST-segment elevation myocardial infarction

BACKGROUND

We evaluated the effect of delayed hospitalization (symptom-to-door time [STD] ≥ 24 h) on 3-year clinical outcomes according to renal function in patients with non-ST-segment elevation myocardial infarction (NSTEMI) undergoing new-generation drug-eluting stent (DES) implantation.

METHODS

A total of 4513 patients with NSTEMI were classified into chronic kidney disease (CKD) (estimated glomerular filtration rate [eGFR] < 60 mL/min/1.73 m², n = 1118) and non-CKD (eGFR ≥ 60 mL/min/1.73 m², n = 3395) groups. They were further sub-classified into groups with (STD ≥ 24 h) and without (STD < 24 h) delayed hospitalization. The primary outcome was the occurrence of major adverse cardiac and cerebrovascular events (MACCE), defined as all-cause death, recurrent myocardial infarction, any repeat coronary revascularization, and stroke. The secondary outcome was stent thrombosis (ST).

RESULTS

After multivariable-adjusted and propensity score analyses, the primary and secondary clinical outcomes were similar in patients with or without delayed hospitalization in both CKD and non-CKD groups. However, in both the STD < 24 h and STD ≥ 24 h groups, MACCE (p < 0.001 and p < 0.006, respectively) and mortality rates were significantly higher in the CKD group than in the non-CKD group. However, ST rates were similar between the CKD and non-CKD groups and between the STD < 24 h and STD ≥ 24 h groups.

CONCLUSIONS

Chronic kidney disease appears to be a much more important determinant of MACCE and mortality rates than STD in patients with NSTEMI.

Three-Year Clinical Outcomes Based on Pre-Percutaneous Coronary Intervention Coronary Blood Flow Grade and Symptom-to-Balloon Time in Patients with Non-ST-Segment Elevation Myocardial Infarction

We compared the 3-year clinical outcomes according to the degree of pre-percutaneous coronary intervention thrombolysis in myocardial infarction flow grade (pre-PCI TIMI) and symptom-to-balloon time (SBT) individuals who underwent successful stent implantation with a diagnosis of non-ST-segment elevation myocardial infarction (NSTEMI). A total of 4910 patients with NSTEMI were divided into two groups: pre-PCI TIMI 0/1 (SBT < 48 h: n = 1328, SBT ≥ 48 h: n = 558) and pre-PCI TIMI 2/3 (SBT < 48 h: n = 1965, SBT ≥ 48 h: n = 1059). The primary outcome was a 3-year all-cause death rate, and the secondary outcome was the composite endpoint of 3-year all-cause death, recurrent MI, or any repeat revascularization rate. After adjustment, in the pre-PCI TIMI 0/1 group, the 3-year all-cause death (p = 0.003), cardiac death (CD, p < 0.001), and secondary outcome (p = 0.030) values were significantly higher in the SBT ≥ 48 h group than in the SBT < 48 h group. However, patients with pre-PCI TIMI 2/3 had similar primary and secondary outcomes, regardless of the SBT group. Within the SBT < 48 h group, the pre-PCI TIMI 2/3 group exhibited significantly higher rates of 3-year all-cause death, CD, recurrent MI, and secondary outcome values than the pre-PCI TIMI 0/1 group. Patients in the SBT ≥ 48 h group with either pre-PCI TIMI 0/1 or TIMI 2/3 had similar primary and secondary outcomes. Our results suggest that shortening the SBT may confer a survival benefit in patients with NSTEMI and those in the pre-PCI TIMI 0/1 group compared to those in the pre-PCI TIMI 2/3 group.

Effects of delayed hospitalization on the 3-year clinical outcomes of patients with or without diabetes who had non-ST-segment-elevation myocardial infarction and underwent new-generation drug-eluting stent implantation

Clinical outcomes after non-ST-segment-elevation myocardial infarction (NSTEMI) in patients with (symptom-to-door time [SDT] ≥ 24 h) or without (SDT < 24 h) delayed hospitalization among patients with or without diabetes were compared. From the Korea Acute Myocardial Infarction Registry-National Institute of Health, a total of 4517 patients with NSTEMI who underwent new-generation drug-eluting stents implantation were recruited and they were classified into the diabetes mellitus (DM) and non-DM groups. These two groups were subdivided into groups with and without delayed hospitalization. The primary clinical outcome was the occurrence of major adverse cardiac and cerebrovascular events (MACCE), defined as all-cause death, recurrent myocardial infarction, repeat coronary revascularization, and stroke. The secondary clinical outcome was the occurrence of individual components of MACCE and stent thrombosis. Although after multivariable and propensity score-adjusted analyses in the DM group, the primary and secondary clinical outcomes between the SDT < 24 h and SDT ≥ 24 h groups were similar; in the non-DM group, all-cause (p = 0.003 and p = 0.007, respectively) and cardiac (p = 0.001 and p = 0.008, respectively) death rates were significantly higher in the SDT ≥ 24 h group than in the SDT < 24 h group. Our results suggested that there was no significant difference in prognosis between diabetic patients with and without delayed SDT, but delayed SDT was associated with poor prognosis in nondiabetic patients.

Outcomes of early versus delayed invasive strategy in older adults with non-ST-segment elevation myocardial infarction

We evaluated the 3-year clinical outcomes following early invasive (EI) and delayed invasive (DI) strategies in older adults with non-ST-segment elevation myocardial infarction (NSTEMI) undergoing successful new-generation drug-eluting stents (DESs) implantation to reflect current real-world practice. Overall, 2437 older adults (age, ≥ 65 years) with NSTEMI were recruited from the Korea Acute Myocardial Infarction Registry-National Institute of Health. They were divided into two groups: EI (n = 1750) and DI (n = 687). The primary clinical outcome was the occurrence of major adverse cardiac and cerebrovascular events (MACCEs), defined by all-cause death, recurrent MI, any repeat coronary revascularization, and stroke. The secondary clinical outcome was stent thrombosis (ST). After multivariable-adjusted and propensity score-matched analyses, the primary and secondary clinical outcomes were not significantly different between the EI and DI groups. Even after the analysis was confined to those having complex lesions, these major clinical outcomes were similar between these two groups. The EI and DI strategies in older adults with NSTEMI receiving new-generation DES showed comparable results.

Clinical Trial Registration: URL: http://cris.nih.go.kr/cris/en/; Unique identifier: KCT0000863.

Impact of Drug-Eluting Stent-associated Coronary Artery Spasm on 3-Year Clinical Outcomes: A Propensity Score Matching Analysis

Background

It has been reported that significant endothelial dysfunction or clinically evident vasospasm can be associated with drug-eluting stents (DESs). However, the impact of DES associated coronary artery spasm (CAS) on long-term clinical outcomes has not been fully elucidated as compared with those of patients with vasospastic angina.

Methods

A total of 2797 consecutive patients without significant coronary artery lesion (<70%), who underwent the Acetylcholine (Ach) provocation test, were enrolled between Nov 2004 and Oct 2010. DES-associated spasm was defined as significant CAS in proximal or distal to previously implanted DES site at follow-up angiography with Ach test. Patients were divided into two groups (DES-CAS; n = 108, CAS; n = 1878). For adjustment, propensity score matching (PSM) was done (C-statistics = 0.766, DES-CAS; n = 102, CAS; n = 102). SPSS 20 (Inc., Chicago, Illinois) was used to analyze this data.

Results

Baseline characteristics were worse in the DES-CAS group. After PSM, both baseline characteristics and the Ach test results were balanced except higher incidence of diffuse CAS and ECG change in the DES-CAS group. During Ach test, the incidence of diffuse spasm (93.1% vs. 81.3%, p = 0.012) and ST-T change (10.7% vs. 1.9%, p = 0.010) were higher in the DES-CAS group. At 3-year, before and after adjustment, the DES-CAS group showed a higher incidence of coronary revascularization (9.8% vs. 0.0%, p = 0.001), recurrent chest pain requiring follow up coronary angiography (CAG, 24.5% vs. 7.8%, p = 0.001) and major adverse cardiac events (MACEs, 9.8% vs. 0.9%, p < 0.005).

Conclusion

In this study, DES associated CAS was associated with higher incidence of diffuse spasm, ST-T change and adverse 3-year clinical outcomes. Special caution should be exercised in this particular subset of patients.

Comprehensive Assessment of High-Risk Plaques by Dual-Modal Imaging Catheter in Coronary Artery

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Fluorescence lifetime imaging (FLIm) allows label-free biochemical visualization of atheromas; however, it remains unknown whether FLIm can characterize high-risk plaque features in coronary arteries in a beating heart. Also, implementation of a novel analytic methodology is required for multispectral FLIm because it yields massive biochemical readouts.

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This study first demonstrated a simultaneous structural and biochemical assessment of high-risk plaques in the beating swine coronary arteries using a fully integrated optical coherence tomography-FLIm and a 2.9-F low-profile dual-modal catheter.

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Biochemical components of atherosclerotic plaques, including lipids, macrophages, lipids+macrophages, and fibrotic tissues, had unique fluorescence lifetime signatures that were clearly distinguishable using multispectral FLIm.

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Machine learning framework was successfully integrated with multispectral FLIm and enabled an automated, quantitative imaging of multiple key components associated with plaque destabilization.

Coronary plaque destabilization involves alterations in microstructure and biochemical composition; however, no imaging approach allows such comprehensive characterization. Herein, the authors demonstrated a simultaneous microstructural and biochemical assessment of high-risk plaques in the coronary arteries in a beating heart using a fully integrated optical coherence tomography and fluorescence lifetime imaging (FLIm). It was found that plaque components such as lipids, macrophages, lipids+macrophages, and fibrotic tissues had unique fluorescence lifetime signatures that were distinguishable using multispectral FLIm. Because FLIm yielded massive biochemical readouts, the authors incorporated machine learning framework into FLIm, and ultimately, their approach enabled an automated, quantitative imaging of multiple key components relevant for plaque destabilization.

Macrophage targeted theranostic strategy for accurate detection and rapid stabilization of the inflamed high-risk plaque

Rationale: Inflammation plays a pivotal role in the pathogenesis of the acute coronary syndrome. Detecting plaques with high inflammatory activity and specifically treating those lesions can be crucial to prevent life-threatening cardiovascular events. Methods: Here, we developed a macrophage mannose receptor (MMR)-targeted theranostic nanodrug (mannose-polyethylene glycol-glycol chitosan-deoxycholic acid-cyanine 7-lobeglitazone; MMR-Lobe-Cy) designed to identify inflammatory activity as well as to deliver peroxisome proliferator-activated gamma (PPARγ) agonist, lobeglitazone, specifically to high-risk plaques based on the high mannose receptor specificity. The MMR-Lobe-Cy was intravenously injected into balloon-injured atheromatous rabbits and serial in vivo optical coherence tomography (OCT)-near-infrared fluorescence (NIRF) structural-molecular imaging was performed. Results: One week after MMR-Lobe-Cy administration, the inflammatory NIRF signals in the plaques notably decreased compared to the baseline whereas the signals in saline controls even increased over time. In accordance with in vivo imaging findings, ex vivo NIRF signals on fluorescence reflectance imaging (FRI) and plaque inflammation by immunostainings significantly decreased compared to oral lobeglitazone group or saline controls. The anti-inflammatory effect of MMR-Lobe-Cy was mediated by inhibition of TLR4/NF-κB pathway. Furthermore, acute resolution of inflammation altered the inflamed plaque into a stable phenotype with less macrophages and collagen-rich matrix. Conclusion: Macrophage targeted PPARγ activator labeled with NIRF rapidly stabilized the inflamed plaques in coronary sized artery, which could be quantitatively assessed using intravascular OCT-NIRF imaging. This novel theranostic approach provides a promising theranostic strategy for high-risk coronary plaques.

Stress-associated neurobiological activity is linked with acute plaque instability via enhanced macrophage activity: a prospective serial 18F-FDG-PET/CT imaging assessment

AIMS

Emotional stress is associated with future cardiovascular events. However, the mechanistic linkage of brain emotional neural activity with acute plaque instability is not fully elucidated. We aimed to prospectively estimate the relationship between brain amygdalar activity (AmygA), arterial inflammation (AI), and macrophage haematopoiesis (HEMA) in acute myocardial infarction (AMI) as compared with controls.

METHODS AND RESULTS

18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT) imaging was performed within 45 days of the index episode in 62 patients (45 with AMI, mean 60.0 years, 84.4% male; 17 controls, mean 59.6 years, 76.4% male). In 10 patients of the AMI group, serial 18F-FDG-PET/CT imaging was performed after 6 months to estimate the temporal changes. The signals were compared using a customized 3D-rendered PET reconstruction. AmygA [target-to-background ratio (TBR), mean ± standard deviation: 0.65 ± 0.05 vs. 0.60 ± 0.05; P = 0.004], carotid AI (TBR: 2.04 ± 0.39 vs. 1.81 ± 0.25; P = 0.026), and HEMA (TBR: 2.60 ± 0.38 vs. 2.22 ± 0.28; P < 0.001) were significantly higher in AMI patients compared with controls. AmygA correlated significantly with those of the carotid artery (r = 0.350; P = 0.005), aorta (r = 0.471; P < 0.001), and bone marrow (r = 0.356; P = 0.005). Psychological stress scales (PHQ-9 and PSS-10) and AmygA assessed by PET/CT imaging correlated well (P < 0.001). Six-month after AMI, AmygA, carotid AI, and HEMA decreased to a level comparable with the controls.

CONCLUSION

AmygA, AI, and HEMA were concordantly enhanced in patients with AMI, showing concurrent dynamic changes over time. These results raise the possibility that stress-associated neurobiological activity is linked with acute plaque instability via augmented macrophage activity and could be a potential therapeutic target for plaque inflammation in AMI.

Age and sex dependent association of uric acid and incident hypertension

BACKGROUND AND AIMS

A previous meta-analysis suggested that the relationship between hyperuricemia and hypertension may be stronger in younger individuals and women. We aimed to investigate the age and sex dependent association of uric acid (UA) and incident hypertension.

METHODS AND RESULTS

We analyzed data from the Health Examinees Study, a community-based prospective cohort study conducted in Korea from 2004 to 2013. It included 29,088 non-hypertensive subjects aged 40-79 (age, 52.5 ± 7.8 years; men, 31.4%) who had serum UA measurement and participated in the follow-up survey. The risk factors of hypertension were assessed using Cox regression. Over a mean 3.8 years of follow-up, 1388 men (15.2%) and 1942 women (9.7%) were newly diagnosed with hypertension. Upon age- and sex-based stratification, the risk of hypertension was highest in hyperuricemic subjects aged 40-49 years (HR: women, 2.16; men, 1.30). Across the entire cohort, the risk of incident hypertension was higher in groups with higher serum UA levels, and highest in women aged 40-49 years (HR, 1.44; P < 0.001). On multivariable linear regression analysis, the higher the baseline serum UA level, the greater the increase in blood pressure during follow-up, and this effect was strongest in women aged 40-49 years (β = 0.87 and P < 0.01 for systolic blood pressure).

CONCLUSIONS

The relationship between uric acid and incident hypertension tended to be dependent on age and sex. Younger women are at highest risk of UA-related incident hypertension.

New onset diabetes mellitus and cardiovascular events in Korean patients with acute myocardial infarction receiving high-intensity statins

BACKGROUND

High-intensity statin therapy is typically used in patients with acute myocardial infarction (AMI) for secondary prevention. However, there have been consistent concerns regarding its association with diabetes mellitus. We investigated the effect of high-intensity atorvastatin and rosuvastatin on new-onset diabetes mellitus (NODM) and cardiovascular outcomes over a 3-year follow-up period.

METHODS

Data from the Korea Acute Myocardial Infarction Registry were collected from November 2011 to October 2015, and 13,104 patients with AMI were enrolled from major cardiovascular centers. Among them, 2221 patients without diabetes who had been administered with high-intensity atorvastatin (40-80 mg) and rosuvastatin (20 mg) were investigated. The atorvastatin and rosuvastatin groups were evaluated for the incidence of NODM and major adverse cardiac events (MACE) including death, myocardial infarction, and revascularization cases in the following 3 years.

RESULTS

Baseline characteristics were comparable between the two groups. Event-free survival rate of NODM was not significantly different between the atorvastatin and rosuvastatin groups (92.5% vs. 90.8%, respectively; Log-rank P-value = 0.550). The event-free survival rate of MACE was also not significantly different between atorvastatin and rosuvastatin groups (89.0% vs. 89.6%, respectively; Log rank P-value = 0.662). Multivariate Cox analysis revealed that statin type was not a prognostic factor in the development of NODM and MACE.

CONCLUSIONS

Administering high-intensity atorvastatin and rosuvastatin in patients with AMI produced comparable effects on NODM and clinical outcomes, suggesting their clinical equivalence in secondary prevention.

Cardiovascular and Bleeding Risks Associated With Nonsteroidal Anti-Inflammatory Drugs After Myocardial Infarction

BACKGROUND

Limited data are available regarding the risk for adverse clinical events with concomitant nonsteroidal anti-inflammatory drug (NSAID) treatment after myocardial infarction (MI).

OBJECTIVES

The aim of this study was to investigate the risk for cardiovascular and bleeding events according to groups of antithrombotic medications and subtypes of NSAIDs in patients with MI.

METHODS

This was a nationwide cohort study to enroll a study population from the Health Insurance Review and Assessment Service database in Korea between 2009 and 2013. Patients were divided into groups on the basis of the prescribed antithrombotic medications. The primary and secondary outcomes were thromboembolic cardiovascular and clinically relevant bleeding events. The risk for adverse clinical events was assessed by ongoing NSAID treatment and subtypes of NSAIDs.

RESULTS

In total, 108,232 patients (mean age 64.2 ± 12.8 years, 72.1% men, mean follow-up duration 2.3 ± 1.8 years) with first diagnosed MI were enrolled. Concomitant NSAID treatment significantly increased the risk for cardiovascular events (hazard ratio [HR]: 6.96; 95% confidence interval [CI]: 6.24 to 6.77; p < 0.001) and bleeding events (HR: 4.08; 95% CI: 3.51 to 4.73; p < 0.001) compared with no NSAID treatment. Among NSAID subtypes, the risk for cardiovascular and bleeding events was lowest with the use of celecoxib (HR: 4.65; 95% CI: 3.17 to 6.82; p < 0.001, and 3.44; 95% CI: 2.20 to 5.39; p < 0.001, respectively) and meloxicam (HR: 3.03; 95% CI: 1.68 to 5.47; p < 0.001, and 2.80; 95% CI: 1.40 to 5.60; p < 0.001, respectively).

CONCLUSIONS

Concomitant NSAID treatment significantly increased the risk for cardiovascular and bleeding events after MI. Although NSAID treatment should be avoided after MI, celecoxib and meloxicam could be considered as alternative options in cases in which NSAID use is unavoidable.

Impact of Catheter Ablation on Sleep Quality and Relationship Between Sleep Stability and Recurrence of Paroxysmal Atrial Fibrillation After Successful Ablation: 24-Hour Holter-Based Cardiopulmonary Coupling Analysis

Background

Sleep fragmentation and sleep apnea are common in patients with atrial fibrillation (AF). We investigated the impact of radio‐frequency catheter ablation (RFCA) on sleep quality in patients with paroxysmal AF and the effect of a change in sleep quality on recurrence of AF.

Methods and Results

Of 445 patients who underwent RFCA for paroxysmal AF between October 2007 and January 2017, we analyzed 225 patients who had a 24‐hour Holter test within 6 months before RFCA. Sleep quality was assessed by cardiopulmonary coupling analysis using 24‐hour Holter data. We compared cardiopulmonary coupling parameters (high‐frequency coupling, low‐frequency coupling, very‐low‐frequency coupling) before and after RFCA. Six months after RFCA, the high‐frequency coupling (marker of stable sleep) and very‐low‐frequency coupling (rapid eye movement/wake marker) was significantly increased (29.84%–36.15%; P<0.001; and 26.20%–28.76%; P=0.002, respectively) while low‐frequency coupling (unstable sleep marker) was decreased (41.25%–32.13%; P<0.001). We divided patients into 3 tertiles according to sleep quality before RFCA, and the risk of AF recurrence in each group was compared. The second tertile was used as a reference; patients with unstable sleep (Tertile 3) had a significantly lower risk of AF recurrence (hazard ratio [HR], 0.32; 95% CI, 0.12–0.83 for high‐frequency coupling; and HR, 0.22; 95% CI, 0.09–0.58 for low‐frequency coupling).

Conclusions

Sleep quality improved after RFCA in patients with paroxysmal AF. The recurrence rate was significantly lower in patients who had unstable sleep before RFCA. These results suggest that RFCA can influence sleep quality, and sleep quality assessment before RFCA may provide a risk marker for recurrence after RFCA in patients with paroxysmal AF.

Comparison between calcium channel blocker with angiotensin converting enzyme inhibitor or angiotensin II type 1 receptor blocker combination on the development of new-onset diabetes in hypertensive Korean patients

Background and purpose

Rare comparative studies investigated the relationship between combination therapy of antihypertensive drugs and the incidence of new-onset diabetes mellitus (NODM). The aim of this study was to evaluate which combination therapy, calcium channel blocker (CCB) with angiotensin converting enzyme inhibitor (ACEI) or CCB with angiotensin II type 1 receptor blocker (ARB), is best in reducing/preventing the development of NODM during 4-year follow-up periods in non-diabetic hypertensive Korean patients.

Materials and methods

Finally, a total of 1221 consecutive hypertensive patients without a history of diabetes mellitus who had been prescribed CCB were retrospectively enrolled and divided into the two groups, an ACEI group (combination CCB with ACEI, n = 251) and an ARB group (combination CCB with ARB, n = 970). The primary endpoint was NODM, defined as a fasting blood glucose ≥126 mg/dL or hemoglobin A1c ≥ 6.5%. Secondary endpoint was major adverse cardiac events (MACE) defined as total death, non-fatal myocardial infarction (MI) and percutaneous coronary intervention (PCI).

Results

After propensity-score matched (PSM) analysis, two propensity-matched groups (243 pairs, n = 486, C-statistic = 0.696) were generated. During 4-year follow-up periods, there were similar incidence of NODM (Hazard ratio [HR]; 1.198, 95% confidence interval [CI]; 0.591-2.431, P = 0.616), MACE (HR; 1.324, 95% CI; 0.714-2.453, P = 0.373), total death, MI and PCI between the two groups after PSM analysis.

Conclusion

CCB with ACE or CCB with ARB combination strategies are equally acceptable in hypertensive Korean patients regarding the occurrence of NODM.

Validation of FRIEND and ACSM Equations for Cardiorespiratory Fitness: Comparison to Direct Measurement in CAD Patients

The regression equation of the American College of Sports Medicine (ACSM) was a preferred method for estimating maximal oxygen consumption (VO2max). Recently, a more precise equation from the fitness registry and the importance of exercise national database (FRIEND) for healthy people was developed. This study compared VO2max estimated by the ACSM and FRIEND equations to VO2max directly measured in coronary artery disease (CAD) patients. Overall, 293 CAD patients who participated in cardiac rehabilitation between June 2015 and December 2018 were analyzed. Directly measured VO2max values were compared to the ACSM and FRIEND equations. The directly measured VO2max was significantly different from the estimated VO2max by ACSM equation (24.16 vs. 28.7 mL/kg/min, p < 0.001), which was overestimated by 20% in men and 16% in women. However, there was no statistically significant difference between the directly measured VO2max and the estimated VO2max by the FRIEND equation. (24.16 vs. 24.15 mL/kg/min, p = 0.986). In CAD patients, the estimated VO2max from the ACSM equation was significantly higher than the directly measured VO2max. In addition, estimated cardiorespiratory fitness (CRF) by the FRIEND equation showed similar results with directly measured CRF. As a result, the FRIEND equation can predict CRF more accurately than the ACSM.

Impact of Sleep-Disordered Breathing on Functional Outcomes in Ischemic Stroke: A Cardiopulmonary Coupling Analysis

BACKGROUND AND PURPOSE

Cardiopulmonary coupling (CPC) analysis is an easily assessable method to evaluate sleep-disordered breathing (SDB); however, its prognostic impact in patients with acute ischemic stroke needs to be investigated. We performed a CPC analysis using Holter monitoring at the early stage of noncardioembolic ischemic stroke to investigate the prognostic effect of SDB on functional impairment at the 3-month follow-up.

METHODS

A total 615 patients with acute noncardioembolic ischemic stroke who underwent Holter monitoring within 30 days of stroke onset were enrolled from a multicenter, prospective, all-comer cohort. CPC analysis was conducted, and SDB was defined by the presence of narrow-band coupling during sleep time. We investigated the association between SDB and functional impairment at 3 months as measured by the modified Rankin Scale.

RESULT

Narrow-band coupling was present in 191 (31.1%) of 615 patients (mean age 64.5±12.6 years). The narrow-band group showed a significantly higher rate of severe functional impairment (modified Rankin Scale score >2; 45.5% versus 12.9%, P<0.001) and persistent disability (Δmodified Rankin Scale score ≤0; 53.9% versus 39.8%, P<0.001) at the 3-month follow-up. In multivariate analysis, narrow-band coupling was an independent predictor of higher risk of severe and persistent functional impairment at 3 months (odds ratio, 3.98 [95% CI, 2.34-6.78]; P<0.001; and odds ratio, 1.81 [95% CI, 1.23-2.66]; P<0.001, respectively). The results remained consistent after propensity-score matched analysis with 157 patient pairs (C-statistic=0.770).

CONCLUSIONS

SDB assessed by CPC analysis at the early stage of ischemic stroke could predict severe and prolonged functional impairment at 3 months. CPC analysis using Holter monitoring can help predicting functional impairment in acute ischemic stroke.

Cilostazol-based triple versus potent P2Y12 inhibitor-based dual antiplatelet therapy in patients with acute myocardial infarction undergoing percutaneous coronary intervention

Although potent P2Y12 inhibitor-based dual antiplatelet therapy (DAPT) has replaced clopidogrel-based therapy as the standard treatment in patients with acute myocardial infarction (AMI), there is a concern about the risk of bleeding in East Asian patients. We compared the efficacy and safety of cilostazol-based triple antiplatelet therapy (TAT) with potent P2Y12 inhibitor-based DAPT in Korean patients. A total of 4152 AMI patients who underwent percutaneous coronary intervention (PCI) in the Korea Acute Myocardial Infarction Registry were analyzed retrospectively. Patients were divided into two groups: the TAT group (aspirin + clopidogrel + cilostazol, n = 3161) and the potent DAPT group (aspirin + potent P2Y12 inhibitors [ticagrelor or prasugrel], n = 991). Major clinical outcomes at 30 days and 2 years were compared between the two groups using propensity score matching (PSM) analysis. After PSM (869 pairs), there were no significant differences between the two groups in the incidence of total death, cardiac death, myocardial infarction (MI), target vessel revascularization, stent thrombosis, and stroke at 30 days and 2 years. However, the Thrombolysis in Myocardial Infarction (TIMI) major or minor bleeding rates were significantly lower in the TAT group compared with the potent DAPT group at 2 years (6.4% vs. 3.6%, p = 0.006). In Korean AMI patients undergoing PCI, TAT with cilostazol was associated with lower bleeding than the potent P2Y12 inhibitor-based DAPT without increased ischemic risk. These results could provide a rationale for the use of TAT in East Asian AMI patients.

P3715Impact of sleep-disordered breathing on short-term functional outcomes in ischemic stroke patients: a cardiopulmonary coupling analysis using holter-monitoring

Background

Sleep-disordered breathing (SDB) assessed by conventional polysomnography is reported to have close association with worsened clinical outcomes in patients with ischemic stroke. The cardiopulmonary coupling (CPC) analysis using Holter-monitoring is an easily assessable method to evaluate SDB. However, its prognostic impact needs to be investigated.

Purpose

The present study investigated the prognostic impact of SDB defined by CPC analysis using Holter-monitoring at early stage of ischemic stroke on the functional disability at 3-month follow-up.

Methods

Total 692 patients with acute ischemic stroke who underwent Holter-monitoring were enrolled. The CPC analysis was conducted and SDB was defined as the presence of narrow-band (NB) coupling during sleep time. We investigated the association between SDB and functional disability at 3-month measured by modified Rankin scale (mRS).

Result

The NB coupling was present in 216 (31.2%) of 692 patients with mean age of 64.2±12.8 years. The NB group showed significantly higher proportion of severe functional disability (mRS ≥3; 45.3% vs. 12.3%, p<0.001) and persistent disability (ΔmRS≤0; 42.6% vs. 56.4%, p<0.001) after 3-month. In multivariate analysis, the presence of NB coupling was an independent predictor of higher risk of both severe and persistent functional disability (HR: 3.97; 95% CI: 2.37–6.64; p<0.001; and HR 1.92; 95% CI: 1.34–2.77; p<0.001, respectively). The results were consistent after propensity-score matched analysis with 175 patient pairs (C-statistics=0.759).

Parameters of functional disability Overall population (n=692) PSM population (n=350) no NB (n=476) NB (n=216) OR (95% CI) p-value no NB (n=175) NB (n=175) OR (95% CI) p-value Initial NIHSS ≥5 89 (18.6) 81 (37.5) <0.001 52 (29.7) 52 (29.7) >0.999 Discharge mRS ≥3 146 (30.6) 126 (58.3) <0.001 90 (51.4) 89 (50.8) 0.915 3-month mRS ≥3 59 (12.3) 98 (45.3) 5.86 (4.00–8.60) <0.001 38 (21.7) 72 (41.1) 2.52 (1.57–4.02) <0.001 3-month ΔmRS ≤0 (persisent disability) 203 (42.6) 122 (56.4) 1.74 (1.26–2.41) 0.001 77 (44.0) 100 (57.1) 1.69 (1.11–2.58) 0.014 Data are expressed as n (%). mRS = modified Rankin's scale; NB = narrow-band; NIHSS = National Institutes of Health Stroke Scale; OR = odds ratio; PSM = propensity-score matched.

Functional disabilities after 3-month

Conclusion

SDB assessed by CPC analysis at early phase of ischemic stroke was able to predict both greater and persistent functional disability at 3-month. The CPC analysis using Holter-monitoring is a useful modality for predicting functional disabilities in acute ischemic stroke.

P1249Prognostic impact of sarcopenia on major adverse cardiovascular outcomes in coronary artery disease patients undergoing successful percutaneous coronary intervention

Background

Sarcopenia is an emerging marker of frailty. Its prognostic impact on atherosclerotic cardiovascular disease (ASCVD) requires further investigation.

Purpose

We investigated the long-term prognostic impact of computed tomography (CT)-determined sarcopenia in patients with coronary artery disease (CAD).

Methods

Total 475 CAD patients those who underwent successful percutaneous coronary intervention (PCI) and performed CT scan within 30 days of PCI were enrolled. The cross-sectional area of skeletal muscle at the first lumbar vertebra (L1) level was measured. Sarcopenia was defined as L1 skeletal muscle index of less than 34.60 cm2/m2 for men and of less than 25.90 cm2/m2 for women. Primary outcome was 3-year all-cause mortality and secondary outcome was 3-year major adverse cardiovascular event (MACE), a composite of all-cause mortality, any myocardial infarction, and repeat revascularization.

Results

Sarcopenia was present in 214 (45.1%) of 475 patients. The incidence of 3-year all-cause mortality and MACE was significantly higher in patients with sarcopenia than in those without sarcopenia (17.7% vs. 5.7%, p<0.001; and 35.0% vs. 11.2%, p<0.001, respectively). In the fully adjusted multivariable analysis, sarcopenia was an independent predictor of higher risk of 3-year all-cause mortality (odds ratio [OR]: 2.98; 95% confidence interval [CI]: 1.35 to 6.58, p=0.007) and MACE (OR: 4.39; 95% CI: 2.49 to 7.73, p<0.001). The results were consistent after propensity-score matched analysis with 100 pairs of study population (C-statistics = 0.868).

Kaplan–Meier analysis of 3-year outcomes Overall population PSM population Sarcopenia (n=214) No sarcopenia (n=261) Log-rank p-value Sarcopenia (n=100) No sarcopenia (n=100) Log-rank p-value All-cause mortality 36 (17.7) 14 (5.7) <0.001 19 (20.0) 7 (7.7) 0.013 Non-fatal MI 12 (6.6) 5 (2.0) 0.021 6 (7.0) 2 (2.3) 0.134 Repeat revascularization 32 (20.3) 14 (6.2) <0.001 17 (23.3) 8 (8.0) 0.027 Total MACEs 68 (35.0) 27 (11.2) <0.001 36 (39.3) 14 (15.4) 0.001 Data are expressed as n (%). MACE = major adverse cardiovascular event; MI = myocardial infarction; PSM = propensity-score matched.

Clinical impact of sarcopenia on CAD

Conclusion

Sarcopenia is a useful predictor of adverse clinical outcomes in patients with CAD undergoing PCI. CT-determined sarcopenia may further aid in risk stratification and decision-making for patients with established ASCVD.

Acknowledgement/Funding

National Research Foundation of Korea (NRF-2016R1A2B3013825), Ministry of Future Creation and Science of Korea (2018K000255)

P4339Reference values for cardiorespiratory fitness in healthy Koreans: compared to western nations and nomogram

Introduction

Cardiorespiratory Fitness (CRF), defined as the integrated ability to properly oxygenate skeletal muscles during physical activity, is associated with a high risk of cardiovascular disease and all-cause mortality. The reference range for CRF may differ among nations, with Asians under-represented in previous data.

Purpose

In this study, we sought to establish reference values of CRF for Asians using a recent Korean cohort.

Methods

We analyzed 2646 healthy Korean adults recently enrolled in the Korea Institute of Sports Science Fitness Standards (KISS FitS) project with estimated maximal oxygen uptake (VO2max) values during treadmill test. Patients with cardiovascular or renal disease, systemic infection, pregnant women and those with orthopedic injuries unable to measure physical fitness were excluded. Age-specific mean VO2max values were compared with those from recent American, Norwegian, Danish cohorts and old Korean data.

Results

Age-specific reference values for healthy Korean adults in this cohort were as shown (Table). We were able to draw a nomogram to predict exercise capacity for a given age and MET value (Figure). When compared to other countries, less CRF reduction by aging was seen in Asians than in other Westerners. When compared to old Korean data from the 1980s, values were similar after adjustment for difference in methods, except for those under 30 years old which were decreased.

Exercise capacity of healthy Korean Men Women Age VO2max (ml/kg/min) N P-value for trend Age VO2max (ml/kg/min) N P-value for trend 19–29 42.3±6.3± 209 <0.01 19–29 34.3±4.3± 110 <0.01 30–39 42.0±5.0± 170 39–39 32.2±4.5± 211 40–49 41.4±5.6± 238 40–49 30.8±4.6± 284 50–59 38.0±5.7± 274 50–59 28.3±4.6± 367 60–69 32.4±6.2± 134 60–69 26.0±5.7± 336 70–79 27.2±5.6± 83 70–79 23.9±4.4± 195 >80 24.1±4.0± 11 >80 21.0±3.7± 24 Total 38.6±7.4± 1119 Total 28.5±5.8 1527 Data are presented as mean ± standard deviation. VO2max, maximal oxygen uptake; N, number.

Nomogram of exercise capacity in Koreans

Conclusions

While there was no significant change in CRF over time in the same ethnic group, there was a clear inter-ethnic difference. CRF should be assessed according to ethnic or national standards, and it is necessary to establish a reference for each nation or ethnicity with periodic updates.

Acknowledgement/Funding

National Sports Promotion Fund of the Korea Sports Promotion Foundation in 2015

P5744Sleep-disordered breathing assessed by holter-monitoring is associated to worsened one-year clinical outcomes in ischemic stroke patients: a cardiopulmonary coupling analysis

Background

Sleep-disorder breathing (SDB) using polysomnography is closely associated to poor functional and clinical outcomes in ischemic stroke patients. The cardiopulmonary coupling analysis using Holter-monitoring (CPC-Holter analysis) is an emerging feasible modality to investigate SDB.

Purpose

We investigated the association between SDB defined by CPC-Holter analysis and one-year clinical outcome in patients with acute ischemic stroke.

Methods

Total 666 patients with acute ischemic stroke who underwent Holter-monitoring were enrolled. The CPC-Holter analysis was conducted and SDB was defined as the presence of narrow-band (NB) coupling during sleep time. Primary outcome was recurrent ischemic stroke, and secondary outcome was major adverse cerebrovascular event (MACE), a composite of recurrent ischemic stroke, transient ischemic attack, and all-cause mortality within one year since discharge.

Result

The NB coupling was present in 205 (30.8%) of 666 patients with mean age of 64.1±12.8 years. The NB group showed significantly higher incidence of both recurrent ischemic stroke (8.3% vs. 1.4%, p<0.001) and MACE (14.9% vs. 3.0%, p<0.001) within one-year. In multivariate analysis, presence of NB coupling remained as an independent predictor of both recurrent ischemic stroke and MACE (HR: 4.81; 95% CI: 1.73–13.4; p=0.003; and HR 4.17; 95% CI: 1.74–10.0; p<0.001, respectively). The results were consistent after propensity-score matched analysis with 164 patient pairs (C-statistics=0.757).

One-year clinical outcomes Overall population (n=666) PSM population (n=328) no NB (=461) NB (n=205) Log-rank p-value OR (95% CI) no NB (n=164) NB (n=164) Log-rank p-value OR (95% CI) Recurrent ischemic stroke 6 (1.4) 14 (8.3) <0.001 5.73 (2.20–14.9) 3 (2.0) 11 (8.1) 0.026 3.85 (1.07–13.8) Transient ischemic attack 3 (0.7) 3 (1.7) 0.275 2 (1.3) 3 (2.1) 0.633 Hemorrhagic stroke 0 (0.0) 2 (1.2) 0.027 0 (0.0) 2 (1.5) 0.148 Total death 3 (0.7) 9 (4.8) 0.001 2 (1.3) 3 (1.9) 0.641 MACEs 12 (3.0) 25 (14.9) <0.001 4.63 (2.06–10.4) 7 (5.2) 17 (13.1) 0.030 2.95 (1.06–8.21) Data are expressed as n (%). CI = confidence interval; MACE = major adverse cardiovascular event; NB = narrow-band; OR = odds ratio.

One-year clinical outcomes

Conclusion

SDB assessed by CPC-Holter analysis at early phase of ischemic stroke is a powerful prognostic marker for predicting one-year adverse clinical outcomes. The CPC analysis using Holter-monitoring is a useful modality and could be easily applied to predict clinical outcomes in acute ischemic stroke patients.

P2501Validation of FRIEND and ACSM equations for cardiorespiratory fitness: comparison to direct measurement in male CAD patients

Introduction

Cardiorespiratory fitness (CRF) is associated with a high risk of cardiovascular disease and all-cause mortality. The regression equation of American College of Sports Medicine (ACSM) was a preferred method for estimating maximal oxygen consumption (VO2max). It is well-known that CRF is overestimated in ACSM equation. Recently, Kokkinos reported more precise equation from the Fitness Registry and the Importance of Exercise National Database (FRIEND). Both equations were made from western healthy people.

Purpose

In this study, we compared VO2max estimated by ACSM and FRIEND equations to VO2max directly measured in male coronary artery disease (CAD) patients.

Methods

We analyzed 103 male CAD patients who underwent percutaneous coronary intervention and who participated in cardiac rehabilitation between June 2015 and December 2018. VO2max was directly measured by the gas exchange analysis during treadmill test with modified Bruce protocol. Exclusive criteria were pulmonary disease, chronic kidney disease on hemodialysis, malignancy, peripheral artery disease, insufficient cardiopulmonary exercise test and orthopedic injuries. Directly measured VO2max were compared to ACSM and FRIEND equations.

Results

Age-specific VO2max values, which were directly measured from male CAD patients, were shown in Table. Smaller CRF difference was shown in FRIEND equation than ACSM equation. Compared to the measured value, CRF estimated by ACSM equation was overestimated by 22%, but the one estimated by FRIEND equation had only 2% gap. Figure presents Bland-Altman plots. ACSM equation had the higher bias (5.52ml/kg/min) compared with FRIEND equation (0.200ml/kg/min).

Comparison table of VO2max estimated by ACSM and FRIEND equations with directly measured VO2max in male CAD patients Age Number VO2max (ml/kg/min) Measured ACSM % predicted FRIEND % predicted 30–39 4 29.5 ± (6.6) 35.7 ± (6.1) 122.3 ± (8.5) 29.1 ± (4.3) 100.1 ± (8.7) 40–49 20 29.1 ± (5.1) 35.7 ± (5.4) 123.6 ± (11.1) 29.1 ± (3.8) 101.2 ± (9.5) 50–59 32 25.6 ± (4.3) 31.5 ± (5.1) 123.8 ± (10.1) 26.2 ± (3.6) 103.2 ± (8.5) 60–69 27 26.0 ± (5.1) 31.1 ± (2.6) 120.5 ± (12.6) 25.9 ± (4.0) 100.8 ± (10.5) 70–79 18 21.2 ± (6.0) 26.8 ± (5.4) 123.2 ± (14.8) 22.8 ± (3.9) 105.2 ± (12.0) >80 2 25.0 ± (10.1) 22.8 ± (2.6) 97 ± (28.9) 19.9 ± (1.9) 85.1 ± (27.0) Total 103 25.7 ± (5.6) 31.4 ± (6.0) 122.2 ± (12.4) 26.1 ± (4.3) 102.1 ± (10.4) Data are presented as mean ± (standard deviation).

Bland-Altman plots

Conclusions

FRIEND equation can estimate CRF more accurately than ACSM equation, even in Asian patients with CAD.

4098Reduced skeletal muscle mass is associated to worsened long-term clinical outcomes in patients with coronary artery disease: a quantitative analysis by computed tomography

Background

Sarcopenia is closely associated to poor clinical outcomes in patients with atherosclerotic cardiovascular disease (ASCVD). However, it is unclear whether the skeletal muscle mass at baseline has quantitative effect on future cardiovascular outcomes.

Purpose

We investigated the quantitative effect of skeletal muscle mass on future cardiovascular outcomes in patients with coronary artery disease (CAD).

Methods

Total 475 patients those who underwent successful percutaneous coronary intervention (PCI) for CAD and performed computed tomography (CT) scan within 30 days of PCI were enrolled. The cross-sectional area of skeletal muscle at the first lumbar vertebra (L1) level was measured. Whole study population was divided into 4 groups according to the sex-specific quartiles of skeletal muscle index (SMI). Primary outcome was all-cause mortality and secondary outcome was major adverse cardiovascular event (MACE) within 3 years of follow-up.

Results

Mean follow-up duration was 4.11±3.02 years and average time period from the date of PCI to CT scan was −3.33±11.72 days. The incidence of 3-year all-cause mortality (23.2% vs. 9.9% vs. 6.6% vs. 4.4%, p<0.001) and MACE (42.9% vs. 24.0% vs. 14.3% vs. 6.2%, p<0.001) was significantly higher in the group of lower quartiles of L1-SMI. In the fully adjusted multivariable analysis, lower quartiles of L1-SMI was an independent predictor of higher risk of all-cause mortality and MACE (lowest vs. highest quartile; OR: 4.90, 95% CI: 1.54 to 15.5, p=0.007; and OR: 12.3, 95% CI: 4.99 to 30.4, p<0.001, respectively).

Results of 3-year clinical outcomes SMI Q1 (n=124) SMI Q2 (n=116) SMI Q3 (n=112) SMI Q4 (n=123) Log-rank p-value All-cause mortality 27 (23.2) 11 (9.9) 7 (6.6) 5 (4.4) <0.001 Non-fatal MI 9 (8.7) 3 (3.0) 2 (2.0) 3 (2.6) 0.038 Repeat revascularization 20 (24.9) 15 (15.2) 7 (7.1) 4 (3.8) <0.001 Total MACEs 47 (42.9) 26 (24.0) 15 (14.3) 7 (6.2) <0.001 Data are expressed as n (%). MACE = major adverse cardiovascular event; MI = myocardial infarction; SMI = skeletal muscle index; Q = quartile.

Impact of reduced skeletal muscle on CAD

Conclusion

Skeletal muscle mass at baseline is a powerful predictor of future adverse clinical outcomes in patients with CAD undergoing successful PCI. Quantitative assessment of skeletal muscle mass at L1 level by CT scan provides prognostic implication for future cardiovascular risk stratification.

Acknowledgement/Funding

National Research Foundation of Korea (NRF-2016R1A2B3013825), Ministry of Future Creation and Science of Korea (2018K000255)

P2523Hand grip strength as a predictor of exercise capacity in coronary heart disease

A recent study has shown that quadriceps strength can be used to predict the level of exercise capacity in patients with coronary heart disease (CHD). We investigated whether the relationship between muscular strength and exercise capacity is also observed with hand grip strength (HGS). We studied 443 participants (age, 61.8±11.2 y; 77.7% male) who underwent coronary intervention and participated in cardiac rehabilitation between 2015 and 2018. Participants were assessed for grip strength, measured using a Jamar dynamometer. Logistic regression was used to assess the relationship between various clinical measures (HGS, age, sex, etc) with the distance walked on a 6-minute walk test (6MWT) and maximal oxygen uptake (VO2max). HGS was significantly related to distance walked on the 6MWT (r=0.435, p<0.001). It was the only predictor of all exercise capacity categories, and one of the strongest predictors of each exercise capacity category. A HGS of 25.5% of body weight predicted an achievement of a 200 m walk on the 6MWT (positive predictive value = 0.95). However, HGS less than 35.5% of body weight predicted that 500m could not be done in 6 minutes (negative predictive value = 0.97). This trend was also observed in the subgroups in which VO2max was measured. This study demonstrates that HGS is associated with exercise capacity in CHD and can be used to predict the level of exercise capacity. These findings may contribute to setting the recommended level of daily activity as well as the level of cardiac rehabilitation in CHD.

Logistic regression models for different levels of exercise capacity Level of exercise capacity B±S.E p-value Odd ratio 95% CI Distance of 6MWT   200 m Grip strength 0.054±0.014 <0.001 1.056 1.027–1.086   300 m Grip strength 0.042±0.009 <0.001 1.042 1.024–1.062   400 m Grip strength 0.047±0.011 <0.001 1.048 1.026–1.070   500 m Grip strength 0.051±0.016 0.001 1.053 1.021–1.086 VO2max level   4 METs Grip strength 0.054±0.010 <0.001 1.056 1.036–1.076   6 METs Grip strength 0.059±0.011 <0.001 1.061 1.039–1.083   8 METs Grip strength 0.081±0.015 <0.001 1.085 1.053–1.117   10 METs Grip strength 0.113±0.049 0.019 1.12 1.019–3.232 Data are presented as mean ± standard deviation (SD). 6MWT, 6-minute walk test; STEMI, ST-Elevation Myocardial Infarction; SE, standard error; CI, confidence interval; VO2max, Maximal Oxygen uptake; METs, Metabolic equivalents.

Three-year major clinical outcomes of phosphorylcholine polymer- vs biolinx polymer-zotarolimus-eluting stents: A propensity score matching study

There are limited long-term outcome data comparing BioLinx polymer (B)-zotarolimus-eluting stents (ZES) with phosphorylcholine polymer (P)-ZES. The aim of this study was to compare the efficacy and safety of B-ZES with P-ZES in patients who underwent percutaneous coronary intervention (PCI) during a 3-year follow-up period.One thousand two hundred fifty four patients who underwent PCI with P-ZES (Endeavor [ZES-E] or Endeavor sprint [ZES-S], n = 356) or B-ZES (Endeavor resolute [ZES-R] or Resolute Integrity [ZES-I], n = 889) were enrolled. The primary endpoint was major adverse cardiac events (MACE); the composite of total death, non-fatal myocardial infarction (MI), target lesion revascularization (TLR), target vessel revascularization (TVR), non-target vessel revascularization (Non-TVR), and the secondary endpoint was stent thrombosis (ST).After PSM, 2 propensity-matched (PSM) groups (275 pairs, n = 550, C-statistic = 0.730) were generated. During the 3-year follow-up period, the cumulative incidence of MACE (hazard ratio [HR], 1.525; 95% confidence interval [CI], 0.920-2.526; P = .101) and ST (HR, 1.248; 95% CI, 0.335-4.4649; P = .741) were similar between P-ZES and B-ZES after PSM. However, TLR rate was significantly higher in ZES-S than ZES-I (11.3% vs 3.8%, log rank P = .029) and TVR rate was higher in ZES-S than ZES-R (14.1% vs 4.8%, log rank P = .025).In this single-center, all-comer registry, despite different polymers, P-ZES, and B-ZES showed comparable safety and efficacy during a 3-year follow-up period after PCI.

Time-dependent prognostic effect of high sensitivity C-reactive protein with statin therapy in acute myocardial infarction

BACKGROUND

Elevated high sensitivity C-reactive protein (hs-CRP) in acute myocardial infarction (AMI) patients undergoing percutaneous coronary intervention (PCI) has prognostic value for future cardiovascular events. This study aimed to ascertain a valid prognostic time-period for predicting cardiovascular outcome based on baseline hs-CRP in AMI patients undergoing successful PCI on statin therapy.

METHODS

Overall, 4410 AMI patients were enrolled from the Korea Acute Myocardial Infarction-National Institutes of Health (KAMIR-NIH) registry. Participants were divided into groups according to cut-off values of baseline hs-CRP (1.0, 3.0, and 10.0mg/L) and statin therapy intensity. The primary outcome was 36-month major adverse cardiovascular events (MACE), a composite of all-cause mortality, any myocardial infarction, and repeat revascularization. The secondary outcome was MACE developed 0-6, 6-12, and 12-36 months after AMI.

RESULTS

The overall incidence of 36-month MACE was significantly higher as baseline hs-CRP increased (by groups: 8.8% vs. 8.6% vs. 10.7% vs. 15.4%, log-rank p<0.001). The prognostic effect of baseline hs-CRP was mostly confined to the first 6 months after AMI (0-6 months MACE by groups: 1.6% vs. 2.3% vs. 4.3% vs. 6.1%, log-rank p<0.001) and attenuated in high-intensity statin users. Six months after AMI, this prognostic effect of baseline hs-CRP was remarkably reduced (6-12 month MACE by groups: 2.4% vs. 2.1% vs. 2.8% vs. 4.0%, log-rank p=0.111, 12-36 month MACE by groups: 4.7% vs. 4.1% vs. 4.0% vs. 6.2%, log-rank p=0.218); however, high-intensity statin treatment showed a consistent improvement in outcome. The observed time-dependent prognostic effects remained consistent following multivariate analysis.

CONCLUSIONS

The prognostic impact of elevated hs-CRP at baseline was most evident during the first 6 months after AMI; however, the use of high-intensity statin persistently improved the clinical outcome even after the resolution of inflammatory reactions.