Volume-outcome relationships for extracorporeal membrane oxygenation in acute myocardial infarction

Acute myocardial infarction (MI) is one of the major scenarios of extracorporeal membrane oxygenation (ECMO) use. The utilization of mechanical circulatory support systems including ECMO varies widely at the hospital level, while whether ECMO volume per hospital is associated with outcomes in acute MI is unclear. Using a Japanese nationwide administrative database, a total of 26,913 patients with acute MI undergoing percutaneous coronary intervention from 154 hospitals were included. The relations among PCI volume for acute MI, observed and predicted in-hospital mortality, and observed and predicted rates of ECMO use were evaluated at the hospital level. Of 26,913 patients, 423 (1.6%) were treated with ECMO, and 1561 (5.8%) died during the hospitalization. Median ECMO use per hospital per year was 0.5. An observed rate of ECMO use was linearly correlated with the predicted probability of ECMO use and was not associated with the observed/predicted in-hospital mortality ratio. The observed/predicted mortality ratio was lowest in hospitals with the observed/predicted ECMO use ratio of around one. In conclusion, ECMO was infrequently used in a setting of acute MI at each hospital annually. An observed rate of ECMO use was not associated with observed/predicted in-hospital mortality ratio, while the observed/predicted in-hospital mortality ratio was lowest when ECMO was used as predicted, suggesting that standardized ECMO use may be an institutional quality indicator in acute MI.

The impact of gender on outcomes of transcatheter aortic valve implantation between self-expanding valve and balloon-expandable valve

BACKGROUND

While females have been found to have a higher rate of procedural complications with transcatheter aortic valve implantation (TAVI) than males, the effect of valve choice has not been fully elucidated. This study aimed to investigate the impact of gender and choice of balloon or self-expanding valve on TAVI complications.

METHODS

Data from patients who received a TAVI in our institution from January 2016 to September 2021 were retrospectively analyzed. A total of 971 patients were included and divided into self-expanding valve (n = 315) and balloon-expandable valve (n = 656) groups. The endpoints were 30-day mortality, need for a new pacemaker, and major adverse cardiovascular events (MACE) which is defined as cardiac arrest, stroke, myocardial infarction, major bleeding, and unplanned vascular surgery/intervention.

RESULTS

There were more females in the self-expanding valve group than in the balloon-expandable valve group (64.1 % vs. 43.6 %: p < 0.0001). There is no significant difference in the prevalence of hypertension, diabetes mellitus, current smoker, hemodialysis, and the STS risk score between the 2 groups. Females had a higher rate of major adverse cardiovascular events (3.7 % in men vs. 6.8 % in women; p = 0.043), which was driven mostly by vascular complications. This difference was particularly observed in the self-expanding valve group (2.7 % in men vs. 9.4 % in women; p = 0.036).

CONCLUSIONS

TAVI complications were more common in females than males, driven mostly by vascular complications. This difference was particularly observed in woman treated with a self-expanding valve. Particular attention should be given to access choices in females undergoing TAVI.

Impact of Cardiac and Cerebrovascular Complications During Hospitalization on Long-Term Prognosis in Patients With COVID-19

The impact of cardiac and cerebrovascular events during COVID-19 hospitalization on long-term prognosis remains uncertain. We aimed to evaluate the effect of myocardial infarction (MI), cerebrovascular accident (CVA), and pulmonary embolism (PE) during hospitalization on the long-term prognosis in patients who survived COVID-19 hospitalization. A retrospective observational analysis was performed on a cohort of 2,389 patients who survived COVID-19 hospitalization in our institution between January and June 2020. The patients were divided into MI (n = 111) and non-MI (n = 2,278) groups according to the presence of MI during hospitalization. As a subanalysis, the patients were assigned to CVA (n = 97) and non-CVA (n = 2,292) and PE (n = 54) and non-PE (n = 2,335) groups. The primary outcome was long-term survival after discharge. During a median follow-up period of 2.4 years after discharge, 30 patients (27.0%) in the MI group and 140 patients (6.2%) in the non-MI group died (p <0.001). The Kaplan-Meier survival curve analysis demonstrated that the MI group was significantly associated with an increased incidence of all-cause death after discharge (log-rank p <0.001), as supported by the multivariate Cox proportional hazards model analysis (hazard ratio [HR] 2.45, 95% confidence interval [CI] 1.61 to 3.74, p <0.001). However, the presence of CVA (HR 1.46, 95% CI 0.91 to 2.34, p = 0.113) or PE (HR 0.94, 95% CI 0.23 to 3.84, p = 0.937) were not associated with an increased incidence of all-cause death after discharge. In conclusion, among the cardiovascular and cerebrovascular complications associated with COVID-19 hospitalization, the presence of MI during hospitalization was proved to be a significant independent predictor of long-term mortality in patients who survived COVID-19 hospitalization.

Antiplatelet drugs may increase the risk for checkpoint inhibitor-related pneumonitis in advanced cancer patients

BACKGROUND

Immune checkpoint inhibitors (ICIs) are indicated for various cancers and are the mainstay of cancer immunotherapy. They are often associated with ICI-related pneumonitis (CIP), however, hindering a favorable clinical course. Recently, non-oncology concomitant drugs have been reported to affect the efficacy and toxicity of ICIs; however, the association between these drugs and the risk for CIP is uncertain. The aim of this study was to assess the impact of baseline concomitant drugs on CIP incidence in ICI-treated advanced cancer patients.

PATIENTS AND METHODS

This was a single-center retrospective study that included a cohort of 511 patients with advanced cancer (melanoma and non-small-cell lung, head and neck, genitourinary, and other types of cancer) treated with ICIs. Univariable analysis was conducted to identify baseline co-medications associated with CIP incidence. A propensity score matching analysis was used to adjust for potential CIP risk factors, and multivariable analysis was carried out to assess the impact of the identified co-medications on CIP risk.

RESULTS

Forty-seven (9.2%) patients developed CIP. In these patients, the organizing pneumonia pattern was the dominant radiological phenotype, and 42.6% had grade ≥3 CIP, including one patient with grade 5. Of the investigated baseline co-medications, the proportion of antiplatelet drugs (n = 50, 9.8%) was higher in patients with CIP (23.4% versus 8.4%). After propensity score matching, the CIP incidence was higher in patients with baseline antiplatelet drugs (22% versus 6%). Finally, baseline antiplatelet drug use was demonstrated to increase the risk for CIP incidence regardless of cancer type (hazard ratio, 3.46; 95% confidence interval 1.21-9.86).

CONCLUSIONS

An association between concomitant antiplatelet drug use at baseline and an increased risk for CIP was seen in our database. This implies the importance of assessing concomitant medications for CIP risk management.

Correction: Comparison of short-term clinical outcomes between low-dose prasugrel and clopidogrel as part of triple antithrombotic therapy in patients requiring oral anticoagulant therapy and percutaneous coronary intervention

[This corrects the article DOI: 10.1371/journal.pone.0272140.].

Prehospital predicting factors using a decision tree model for patients with witnessed out-of-hospital cardiac arrest and an initial shockable rhythm

The effect of prehospital factors on favorable neurological outcomes remains unclear in patients with witnessed out-of-hospital cardiac arrest (OHCA) and a shockable rhythm. We developed a decision tree model for these patients by using prehospital factors. Using a nationwide OHCA registry database between 2005 and 2020, we retrospectively analyzed a cohort of 1,930,273 patients, of whom 86,495 with witnessed OHCA and an initial shockable rhythm were included. The primary endpoint was defined as favorable neurological survival (cerebral performance category score of 1 or 2 at 1 month). A decision tree model was developed from randomly selected 77,845 patients (development cohort) and validated in 8650 patients (validation cohort). In the development cohort, the presence of prehospital return of spontaneous circulation was the best predictor of favorable neurological survival, followed by the absence of adrenaline administration and age. The patients were categorized into 9 groups with probabilities of favorable neurological survival ranging from 5.7 to 70.8% (areas under the receiver operating characteristic curve of 0.851 and 0.844 in the development and validation cohorts, respectively). Our model is potentially helpful in stratifying the probability of favorable neurological survival in patients with witnessed OHCA and an initial shockable rhythm.

Complications and Outcomes of Impella Treatment in Cardiogenic Shock Patients With and Without Acute Myocardial Infarction

Background In patients with cardiogenic shock (CS), acute myocardial infarction (AMI) is the most common cause, and a percutaneous microaxial ventricular assist device (Impella, Abiomed, Danvers, MA) is a choice for temporary mechanical circulatory support. However, data are limited on complications and outcomes of Impella treatment in patients with CS with and without AMI. Methods and Results Using nationwide prospective registry data in Japan, we included a total of 2047 patients with CS in whom the Impella devices were successfully placed between February 2020 and December 2021. Patients were divided into 2 groups according to the primary indication for the Impella use: AMI versus non-AMI. The primary end point was a composite of in-hospital all-cause death and major complications. Of the 2047 patients, the Impella was indicated for AMI in 1337 (65.3%). In the group without AMI, myocarditis was the leading cause of CS. Patients with AMI-CS were older and more likely to have cardiovascular risk factors than those with non-AMI-CS. The rates of in-hospital mortality (46.0% versus 43.9%, P=0.38) and major complications (35.2% versus 34.7%, P=0.85) were similar between the 2 groups. Overall, multivariable analysis identified older age, higher body mass index, previous transient ischemic attack or stroke, out-of-hospital cardiac arrest, and the Impella 5.0 as factors significantly associated with the primary end point. Conclusions The use of Impella in patients with and without AMI was related to similar clinical outcomes with high mortality and complication rates. Further studies are needed to identify patients who may benefit from the Impella devices in CS. Registration URL: https://www.umin.ac.jp/english. Identifier: UMIN000033603.

Hepatic encephalopathy due to cardiac cirrhosis

Right-sided heart failure, including tricuspid regurgitation (TR), can cause cardiac cirrhosis. The pathophysiology is reduced arterial perfusion and passive congestion secondary to increased systemic venous pressure. However, hepatic encephalopathy due to cardiac cirrhosis is rare. This is the first case of hepatic encephalopathy with cardiac cirrhosis caused by persistent TR.

Impact of Number of Defibrillation Attempts on Neurologically Favourable Survival Rate in Patients with Out-of-Hospital Cardiac Arrest

AIM

of the study: Defibrillation plays a crucial role in early return of spontaneous circulation (ROSC) and survival of patients with out-of-hospital cardiac arrest (OHCA) and shockable rhythm. Prehospital adrenaline administration increases the probability of prehospital ROSC. However, little is known about the relationship between number of prehospital defibrillation attempts and neurologically favourable survival in patients treated with and without adrenaline.

METHODS

Using a nationwide Japanese OHCA registry database from 2006 to 2020, 1,802,084 patients with OHCA were retrospectively analysed, among whom 81,056 with witnessed OHCA and initial shockable rhythm were included. The relationship between the number of defibrillation attempts before hospital admission and neurologically favourable survival rate (cerebral performance category score of 1 or 2) at 1 month was evaluated with subgroup analysis for patients treated with and without adrenaline.

RESULTS

At 1 month, 18,080 (22.3%) patients had a cerebral performance category score of 1 or 2. In the study population, the probability of prehospital ROSC and favourable neurological survival rate were inversely associated with number of defibrillation attempts. Similar trends were observed in patients treated without adrenaline, whereas a greater number of defibrillation attempts was counterintuitively associated with favourable neurological survival rate in patients treated with prehospital adrenaline.

CONCLUSIONS

Overall, a greater number of prehospital defibrillation attempts was associated with lower neurologically favourable survival at 1 month in patients with OHCA and shockable rhythm. However, an increasing number of shocks (up to the 4th shock) was associated with better neurological outcomes when considering only patients treated with adrenaline.

Delayed Aortic Valve Perforation Caused by Blunt Trauma

Traumatic aortic regurgitation (AR) is a rare complication of blunt chest trauma. We described the case of a 35-year-old male who presented to our hospital with shortness of breath 7 years after sustaining blunt chest trauma associated with a motorcycle accident. Transthoracic and transesophageal echocardiogram detected severe AR with two separate jets. The patient was diagnosed with congestive heart failure due to severe AR, and surgical aortic valve replacement was performed. A large perforation of the right coronary cusp likely sustained during the initial blunt chest trauma injury was confirmed surgically. As AR caused by blunt chest trauma can gradually worsen, it is necessary to confirm if there is a history of trauma in patients with severe AR of unknown origin.

Implantable cardioverter-defibrillator therapy after resuscitation from cardiac arrest in vasospastic angina: A retrospective study

Patients with vasospastic angina (VSA) who are resuscitated from sudden cardiac arrest (SCA) are at a high risk of recurrent lethal arrhythmia and cardiovascular events. However, the benefit of the implantable cardioverter-defibrillator (ICD) therapy in this population has not been fully elucidated. The present study aimed to analyze the prognostic impact of ICD therapy on patients with VSA and SCA. A total of 280 patients who were resuscitated from SCA and received an ICD for secondary prophylaxis were included in the present multicenter registry. The patients were divided into two groups on the basis of the presence of VSA. The primary endpoint was a composite of all-cause death and appropriate ICD therapy (appropriate anti-tachycardia pacing and shock) for recurrent ventricular arrhythmias. Of 280 patients, 51 (18%) had VSA. Among those without VSA, ischemic cardiomyopathy was the main cause of SCA (38%), followed by non-ischemic cardiomyopathies (18%) and Brugada syndrome (7%). Twenty-three (8%) patients were dead and 72 (26%) received appropriate ICD therapy during a median follow-up period of 3.8 years. There was no significant difference in the incidence of the primary endpoint between patients with and without VSA (24% vs. 33%, p = 0.19). In a cohort of patients who received an ICD for secondary prophylaxis, long-term clinical outcomes were not different between those with VSA and those with other cardiac diseases after SCA, suggesting ICD therapy may be considered in patients with VSA and those with other etiologies who were resuscitated from SCA.

Systemic Endothelial Function, Plasma Xanthine Oxidoreductase Activity, and Blood Pressure Variability in Patients with Stable Coronary Artery Disease

Background and Objectives: Although previous studies showed that an activity of xanthine oxidoreductase (XOR), a rate-limiting enzyme in purine metabolism, beyond the serum uric acid level, was associated with the development of coronary artery disease (CAD), the underlying mechanisms are unclear. Because endothelial dysfunction and a greater blood pressure (BP) variability may play a role, we investigated the relations among the endothelial function, XOR, and BP variability. Materials and Methods: This was a post-hoc study using pooled data of patients with a stable CAD from two prospective investigations, in which the systemic endothelial function was assessed with the reactive hyperemia index (RHI) and the XOR activity was measured. The BP variability was evaluated using BP measurements during the three- and four-day hospitalization. Results: A total of 106 patients with a stable CAD undergoing a percutaneous coronary intervention were included. Of the 106 patients, 46 (43.4%) had a systemic endothelial dysfunction (RHI < 1.67). The multivariable analysis identified a higher body mass index (BMI), female gender, and diabetes as factors associated with an endothelial dysfunction. A higher BMI was also related to an elevated XOR activity, in addition to current smoking. No significant correlation was observed between the RHI and XOR activity. Similarly, the in-hospital BP variability was associated with neither the endothelial function nor XOR. Conclusions: Among patients with a stable CAD, several factors were identified as being associated with a systemic endothelial dysfunction or an elevated XOR activity. However, no direct relations between the endothelial function, XOR, and BP variability were found.

Prehospital diagnostic algorithm for acute coronary syndrome using machine learning: a prospective observational study

Rapid and precise prehospital recognition of acute coronary syndrome (ACS) is key to improving clinical outcomes. The aim of this study was to investigate a predictive power for predicting ACS using the machine learning-based prehospital algorithm. We conducted a multicenter observational prospective study that included 10 participating facilities in an urban area of Japan. The data from consecutive adult patients, identified by emergency medical service personnel with suspected ACS, were analyzed. In this study, we used nested cross-validation to evaluate the predictive performance of the model. The primary outcomes were binary classification models for ACS prediction based on the nine machine learning algorithms. The voting classifier model for ACS using 43 features had the highest area under the receiver operating curve (AUC) (0.861 [95% CI 0.775–0.832]) in the test score. After validating the accuracy of the model using the external cohort, we repeated the analysis with a limited number of selected features. The performance of the algorithms using 17 features remained high AUC (voting classifier, 0.864 [95% CI 0.830–0.898], support vector machine (radial basis function), 0.864 [95% CI 0.829–0.887]) in the test score. We found that the machine learning-based prehospital algorithms showed a high predictive power for predicting ACS.

Comparison of short-term clinical outcomes between low-dose prasugrel and clopidogrel as part of triple antithrombotic therapy in patients requiring oral anticoagulant therapy and percutaneous coronary intervention

BACKGROUND

Triple antithrombotic therapy, including dual antiplatelet therapy and oral anticoagulant (OAC), is recommended for a short-term period after percutaneous coronary intervention (PCI) in patients requiring anticoagulation therapy. The purpose of this study was to compare in-hospital clinical outcomes between low-dose prasugrel (3.75 mg/day) and clopidogrel, as part of triple antithrombotic therapy, using a large database in Japan.

METHODS

Patients with ischemic heart disease who underwent PCI between January 2015 and December 2019, and were prescribed triple therapy with aspirin, a P2Y12 inhibitor (clopidogrel or low-dose prasugrel), and OAC (direct oral anticoagulant: DOAC or vitamin K antagonist: VKA), were selected from the Diagnosis Procedure Combination database. The primary outcome was in-hospital mortality. The secondary outcomes were myocardial infarction, ischemic stroke, bleeding stroke, gastrointestinal bleeding, and blood transfusion.

RESULTS

Overall, 5,777 patients were eligible in this analysis. The patients were divided into 4 subgroups according to the type of P2Y12 inhibitor and OAC: clopidogrel/DOAC (n = 1,628), clopidogrel/VKA (n = 1,334), prasugrel/DOAC (n = 1,607), and prasugrel/VKA (n = 1,208). There was no significant difference in the incidence of death and gastrointestinal bleeding among the 4 subgroups. The prasugrel/DOAC group had significantly lower incidence of MI (OR 0.566, 95% CI 0.348-0.921). The incidence of ischemic stroke was significantly lower in the prasugrel/DOAC group (OR 0.701, 95% CI 0.502-0.979), and significantly higher in the clopidogrel/VKA group (OR 1.680, 95% CI 1.273-2.216). Need for blood transfusion was less frequent in the prasugrel/DOAC group (OR 0.729, 95% CI 0.598-0.890), and more frequent in both the clopidogrel/VKA group (OR 1.424, 95% CI 1.187-1.708) and the prasugrel/VKA group (OR 1.633, 95% CI 1.367-1.950).

CONCLUSIONS

Combination of low-dose prasugrel and DOAC was associated with lower incidence of MI, ischemic stroke, and blood transfusion. Low-dose prasugrel may be feasible as part of triple therapy in patients undergoing PCI.

Relation of glucose variability to vulnerable plaque formation in patients with coronary artery disease

BACKGROUND

Although glucose variability (GV) is reportedly associated with coronary plaque vulnerability, namely lipid-rich plaque, details are not fully understood. The aim of this study was to evaluate relations of GV after discharge to vulnerable plaque formation assessed by near-infrared spectroscopy intravascular ultrasound (NIRS-IVUS) in patients with and without diabetes.

METHODS

A total of 40 patients undergoing percutaneous coronary intervention under NIRS-IVUS guidance were included, among whom 13 (33%) had diabetes and 20 (50%) presented with acute myocardial infarction (MI). GV was evaluated by a flush glucose monitoring system, primarily with mean amplitude of glycemic excursion (MAGE). Lipid-rich plaque was assessed by maximum lipid core burden index in 4 mm (maxLCBI_4mm) in the target lesion using NIRS-IVUS.

RESULTS

Mean MAGE and maxLCBI_4mm were 69.7 ± 25.6 mg/dl and 508.0 ± 294.9. Intra-day GV was not significantly associated with maxLCBI_4mm in the entire study population, while MAGE was correlated with maxLCBI_4mm in non-diabetic patients (r = 0.46, p = 0.02). In patients with and without acute MI presentation, no significant relations were found between MAGE and maxLCBI_4mm.

CONCLUSION

GV was associated with lipid core plaque formation, especially in non-diabetic patients.

Volume-Outcome Relationships for Percutaneous Coronary Intervention in Acute Myocardial Infarction

Background Lower primary percutaneous coronary intervention (PCI) volume is known to be associated with worse outcomes in patients with acute myocardial infarction (MI) at hospital level. The present study aimed to evaluate the relations of primary, elective, and total PCI volume and primary/total PCI volume ratio per hospital to in-hospital mortality in patients with acute MI undergoing primary PCI. Methods and Results Using a large nationwide administrative database, we included a total of 83 076 patients from 154 hospitals in Japan undergoing PCI for either acute MI or elective cases. Relations of annual procedural volumes for primary, elective, and total PCI to in-hospital mortality after acute MI at hospital level were evaluated. The ratio of primary to total PCI volume per hospital was also assessed. The primary end point was the ratio of observed to predicted mortality. Of 83 076 patients, 26 913 (32.4%) underwent primary PCI for acute MI, among whom 1561 (5.8%) died during hospitalization. Overall, observed in-hospital mortality after acute MI and observed/predicted mortality ratio were higher in hospitals with lower primary, elective, and total PCI volumes. Observed/predicted in-hospital mortality ratio was higher in hospitals with low primary/total PCI volume ratio, even in those with high total PCI volume. Conclusions Primary, elective, and total PCI volume at hospitals were inversely associated with in-hospital mortality in patients with acute MI undergoing primary PCI. Lower ratio of primary to total PCI volume were related to higher in-hospital mortality, suggesting primary/total PCI volume ratio as an institutional indicator of quality of care for acute MI.

Utility of near-infrared spectroscopy to detect the extent of lipid core plaque leading to periprocedural myocardial infarction

OBJECTIVES

The aim of this study was to investigate whether lipid core plaque (LCP) in the entire stented segment detected by near-infrared spectroscopy-intravascular ultrasound (NIRS-IVUS) could predict procedural myocardial infarction (PMI) in patients undergoing percutaneous coronary artery intervention (PCI).

BACKGROUND

NIRS-IVUS can identify LCP, described as high lipid core burden index (LCBI). Previously, the highest LCBI contained only in the 4-mm segment (maxLCBI_4mm ) was reported to predict PMI.

METHODS

Patients who underwent NIRS-IVUS examination during PCI for coronary artery disease at Chiba University Hospital were included. The extent of LCP in the stented segment derived from NIRS-IVUS analysis was presented as LCBI, maxLCBI_4mm , and LCP area index (LAI), reflecting the total amount of LCP in the entire stented segment calculated as LCBI×lesion length. PMI was defined as an elevation of creatine kinase MB > 3 times upper reference level (URL), and periprocedural myocardial injury (PMInj) was defined as an elevation of troponin I>5 times URL within 12 to 24 h after PCI.

RESULTS

Out of 141 enrolled patients, PMI occurred in 20 (14.2%) and PMInj occurred in 62 (44.0%) patients. Receiver-operating characteristic curve analysis revealed LAI was the strongest predictor for both PMI and PMInj (area under curve 0.771, p < 0.001, and 0.717, p < 0.001, respectively). Multiple logistic regression analysis determined high LAI value as the independent predictor of both PMI and PMInj.

CONCLUSIONS

Greater extent of LCP in the entire stented segment detected by NIRS-IVUS was significantly associated with PMI as well as PMInj in patients undergoing PCI.

Relationship of early intensive- or coronary care unit admission and post-discharge performance of activities of daily living in patients with acute decompensated heart failure

Background

The management of acute decompensated heart failure (ADHF) often requires intensive care. However, the effects of early intensive care unit (ICU)/coronary care unit (CCU) admission on activities of daily living (ADL) in ADHF patients have not been precisely evaluated. Thus, we assessed whether early ICU entry can improve post-discharge ADL performance in these patients.

Methods and results

ADHF patients (New York Heart Association I–III) admitted on emergency between April 1, 2014, and December 31, 2018, were selected from the Diagnosis Procedure Combination database and divided into ICU/CCU (ICU) and general ward (GW) groups according to the hospitalization type on admission day 1. The propensity score was calculated to create matched cohorts where treatment assignment (ICU/CCU admission) is independent of measured baseline confounding factors including ADL at admission. The primary outcome was post-ADL defined according to the Barthel index (BI) at discharge. Secondary outcomes included length of stay (LOS) and total hospitalization cost (expense). Overall, 12,231 patients were eligible, and propensity score matching created 2,985 pairs. After matching, post-ADL was significantly higher in the ICU group (GW 71.5±35.3 vs. ICU 78.2±31.2, P&lt;0.001, difference in mean 6.7 (95% CI 5.1–8.4) points). After matching, LOS was significantly shorter and expenses were significantly higher in the ICU group. Subanalyses showed that patients with low ADL at admission (BI&lt;60) mainly benefited from early ICU/CCU entry.

Conclusions

Early ICU/CCU entry was beneficially associated with post-ADL in patients with emergency ADHF admission. ADL at admission might serve as a useful criterion for ICU admission.

Funding Acknowledgement

Type of funding sources: None.

Implantable cardioverter-defibrillator therapy after resuscitation from cardiac arrest in vasospastic angina

Background

Patients with vasospastic angina (VSA) who are resuscitated from sudden cardiac arrest (SCA) are at high risk of recurrent cardiovascular events. However, there are no recommendations for implantable cardioverter-defibrillator (ICD) therapy in the VSA and SCA patient guidelines.

Purpose

This study investigated the prognostic impact of ICD therapy on patients with VSA and SCA.

Methods

The present multi-center registry included 280 patients who were resuscitated from SCA and received ICD implantation as secondary prophylaxis. The patients were divided into two groups according to the presence of VSA. The primary endpoint was a composite of all-cause death and appropriate ICD therapy, including appropriate anti-tachycardia pacing and shock for recurrent ventricular arrhythmias.

Results

Of 280 patients, 51 (18%) had VSA. Among those without VSA, ischemic cardiomyopathy was the leading cause of SCA (38%), followed by non-ischemic cardiomyopathies and Brugada syndrome (Table 1). During the median follow-up period of 3.8 years, 23 (8%) patients died, and 72 (26%) underwent appropriate ICD therapy. The incidence of the primary endpoint was not significantly different between patients with and without VSA (24% vs 33%, p=0.19). Further, the incidence of the primary endpoint was not significantly different among the etiologies (Figure 1)

Conclusions

In a cohort of patients who underwent ICD implantation as secondary prophylaxis, long-term clinical outcomes were comparable between those with VSA and those with other cardiac diseases after SCA. The results suggest that ICD therapy may be considered in patients with VSA and those with other etiologies after resuscitation from SCA.

Funding Acknowledgement

Type of funding sources: None. Table 1. Patient characteristics and outcomesFigure 1. Incidence of the primary endpoint

Impact of glycemic variability on coronary and peripheral endothelial dysfunction in patients with coronary artery disease

BACKGROUND

Previous studies have reported that glucose variability leads to endothelial dysfunction and progression of coronary atherosclerosis. However, few studies have directly evaluated the relation between glucose variability and coronary endothelial function in patients with coronary artery disease (CAD).

METHODS

A total of 38 patients with chronic CAD and a history of coronary drug-eluting stent implantation were enroled. Coronary endothelial function was evaluated by measuring the coronary vasoreactivity using quantitative coronary angiography in the segment distal to implanted stent in response to intracoronary acetylcholine (ACh) infusion (10-7 mol/l). Peripheral endothelial function was also assessed with reactive hyperemia index (RHI). The mean amplitude of glycemic excursion (MAGE) was calculated as a primary metric of glucose variability using a flash glucose monitoring system.

RESULTS

Of 38 patients, 17 (45%) had diabetes mellitus. The mean levels of glycated hemoglobin, MAGE, and RHI were 6.3 ± 0.8%, 71.4 ± 29.8 mg/dl, and 1.85 ± 0.63. In the distal segment to coronary stent, lumen diameter was constricted by 0.6 ± 7.3% in response to intracoronary ACh infusion compared to that at baseline. While peripheral endothelial function assessed with RHI was not significantly associated with MAGE (r = -0.16, p = 0.35), coronary endothelial function was correlated with MAGE (r = -0.38, p = 0.02).

CONCLUSION

Greater glucose variability was significantly associated with coronary rather than peripheral endothelial dysfunction in patients with CAD, suggesting an impact of glucose variability on coronary atherosclerosis.

Relation Between Cancer and Vasospastic Angina

INTRODUCTION

Patients with cancer have an increased risk of cardiovascular disease including ischemic heart disease and vice versa. Anticancer drugs and radiotherapy are known to contribute to endothelial injury and vasospasm. However, the relations between vasospastic angina (VSA) and cancer or its treatment are poorly investigated.

METHODS

A total of 786 patients underwent intracoronary acetylcholine (ACh) provocation tests to diagnose VSA. The positive ACh provocation test was defined as angiographic coronary artery spasm accompanied by chest pain and/or ischemic electrocardiographic changes. Patients were divided into active cancer, a history of cancer, and no cancer according to the status of malignancy. The impact of types of cancer, anticancer drugs, and radiotherapy on VSA was evaluated.

RESULTS

Of 786 patients, 38 (4.8%) and 84 (10.7%) had active cancer and a history of cancer, respectively, and 401 (51.0%) were diagnosed as VSA. There was no significant difference in rates of positive ACh test among patients with active cancer, a history of cancer, and no cancer (39.5% vs. 57.1% vs. 50.9%, p = 0.20). Types of cancer and cancer treatment also had no impact on positive ACh provocation test.

CONCLUSIONS

In this cross-sectional observational study, we did not find an association of active and a history of cancer with the diagnosis of VSA. Anticancer treatment including chemotherapy and radiotherapy was not significantly associated with positive ACh provocation test.

Association between early intensive care or coronary care unit admission and post-discharge performance of activities of daily living in patients with acute decompensated heart failure

The management of acute decompensated heart failure often requires intensive care. However, the effects of early intensive care unit/coronary care unit admission on activities of daily living (ADL) in acute decompensated heart failure patients have not been precisely evaluated. Thus, we retrospectively assessed the association between early intensive care unit admission and post-discharge ADL performance in these patients. Acute decompensated heart failure patients (New York Heart Association I–III) admitted on emergency between April 1, 2014, and December 31, 2018, were selected from the Diagnosis Procedure Combination database and divided into intensive care unit/coronary care unit (ICU) and general ward (GW) groups according to the hospitalization type on admission day 1. The propensity score was calculated to create matched cohorts where admission style (intensive care unit/coronary care unit admission) was independent of measured baseline confounding factors, including ADL at admission. The primary outcome was ADL performance level at discharge (post-ADL) defined according to the Barthel index. Secondary outcomes included length of stay and total hospitalization cost (expense). Overall, 12231 patients were eligible, and propensity score matching created 2985 pairs. After matching, post-ADL was significantly higher in the ICU group than in the GW group [mean (standard deviation), GW vs. ICU: 71.5 (35.3) vs. 78.2 (31.2) points, P<0.001; mean difference: 6.7 (95% confidence interval, 5.1–8.4) points]. After matching, length of stay was significantly shorter and expenses were significantly higher in the ICU group than in the GW group. Stratified analysis showed that the patients with low ADL at admission (Barthel index score <60) were the most benefited from early intensive care unit/coronary care unit admission. Thus, early intensive care unit/coronary care unit admission was associated with improved post-ADL in patients with emergency acute decompensated heart failure admission.

Deep learning-based intravascular ultrasound segmentation for the assessment of coronary artery disease

BACKGROUND

Accurate segmentation of the coronary arteries with intravascular ultrasound (IVUS) is important to optimize coronary stent implantation. Recently, deep learning (DL) methods have been proposed to develop automatic IVUS segmentation. However, most of those have been limited to segmenting the lumen and vessel (i.e. lumen-intima and media-adventitia borders), not applied to segmenting stent dimension. Hence, this study aimed to develop a DL method for automatic IVUS segmentation of stent area in addition to lumen and vessel area.

METHODS

This study included a total of 45,449 images from 1576 IVUS pullback runs. The datasets were randomly split into training, validation, and test datasets (0.7:0.15:0.15). After developing the DL-based system to segment IVUS images using the training and validation datasets, we evaluated the performance through the independent test dataset.

RESULTS

The DL-based segmentation correlated well with the expert-analyzed segmentation with a mean intersection over union (± standard deviation) of 0.80 ± 0.20, correlation coefficient of 0.98 (95% confidence intervals: 0.98 to 0.98), 0.96 (0.95 to 0.96), and 0.96 (0.96 to 0.96) for lumen, vessel, and stent area, and the mean difference (± standard deviation) of 0.02 ± 0.57, -0.44 ± 1.56 and - 0.17 ± 0.74 mm² for lumen, vessel and stent area, respectively.

CONCLUSION

This automated DL-based IVUS segmentation of lumen, vessel and stent area showed an excellent agreement with manual segmentation by experts, supporting the feasibility of artificial intelligence-assisted IVUS assessment in patients undergoing coronary stent implantation.

Greater coronary lipid core plaque assessed by near-infrared spectroscopy intravascular ultrasound in patients with elevated xanthine oxidoreductase: a mechanistic insight

Elevated serum uric acid level was reportedly associated with greater coronary lipid plaque. Xanthine oxidoreductase (XOR) is a rate-limiting enzyme in purine metabolism and believed to play an important role in coronary atherosclerosis. However, the relation of XOR to coronary lipid plaque and its mechanism are unclear. Patients with stable coronary artery disease undergoing elective percutaneous coronary intervention under near-infrared spectroscopy intravascular ultrasound (NIRS-IVUS) guidance were prospectively enrolled. They were divided into three groups according to serum XOR activities: low, normal, and high. Coronary lipid core plaques in non-target vessels were evaluated by NIRS-IVUS with lipid core burden index (LCBI) and a maximum LCBI in 4 mm (maxLCBI_4mm). Systemic endothelial function and inflammation were assessed with reactive hyperemia index (RHI) and high-sensitivity C-reactive protein, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio. Of 68 patients, 26, 31, and 11 were classified as low, normal, and high XOR activity groups. LCBI (474.4 ± 171.6 vs. 347.4 ± 181.6 vs. 294.0 ± 155.9, p = 0.04) and maxLCBI_4mm (102.1 ± 56.5 vs. 65.6 ± 48.5 vs. 55.6 ± 37.8, p = 0.04) were significantly higher in high XOR group than in normal and low XOR groups. Although RHI was significantly correlated with body mass index, diabetes, current smoking, and high-density lipoprotein cholesterol, no relation was found between XOR activity and RHI. There were also no relations between XOR activity and C-reactive protein, neutrophil-to-lymphocyte ratio, or platelet-to-lymphocyte ratio. In conclusion, elevated XOR activity was associated with greater coronary lipid core plaque in patients with stable coronary artery disease, without significant relations to systemic endothelial function and inflammation.

Greater coronary lipid core plaque assessed by near-infrared spectroscopy intravascular ultrasound in patients with elevated xanthine oxidoreductase: a mechanistic insight

Background

Elevated serum uric acid level was reportedly associated with greater coronary lipid plaque. Xanthine oxidoreductase (XOR) is a rate-limiting enzyme in purine metabolism and believed to play important roles in coronary atherosclerosis. However, the relation of XOR to coronary lipid plaque and its mechanism are unclear.

Purpose

The aim of this study was to assess the impact of XOR on coronary lipid plaque and the associated factors with XOR in coronary artery disease (CAD).

Methods

Patients with stable CAD undergoing elective percutaneous coronary intervention under near-infrared spectroscopy intravascular ultrasound (NIRS-IVUS) guidance were prospectively enrolled. They were divided into three groups according to serum XOR activities; low, normal, and high. Coronary lipid core plaques in non-target vessels were evaluated by NIRS-IVUS with lipid core burden index (LCBI) and a maximum LCBI in 4 mm (maxLCBI4mm). Systemic endothelial function and inflammation were assessed with reactive hyperemia index (RHI) and high-sensitivity C-reactive protein, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio.

Results

Of 68 patients, 26, 31, and 11 were classified as low, normal, and high XOR activity groups. LCBI (474.4±171.6 vs. 347.4±181.6 vs. 294.0±155.9, p=0.04) and maxLCBI4mm (102.1±56.5 vs. 65.6±48.5 vs. 55.6±37.8, p=0.04) were significantly higher in high XOR group than in normal and low XOR groups. Although RHI was significantly correlated with body mass index, diabetes, current smoking, and high-density lipoprotein cholesterol, no relation was found between XOR activity and RHI (Figure). There were also no relations between XOR activity and high-sensitivity C-reactive protein, neutrophil-to-lymphocyte ratio, or platelet-to-lymphocyte ratio (Figure).

Conclusion

Elevated XOR activity was associated with greater coronary lipid plaque in patients with stable CAD, without significant relations to systemic endothelial function and inflammation.

Funding Acknowledgement

Type of funding source: None

Comparison of clinical characteristics between patients with microvascular and epicardial coronary artery spasm

Background

Coronary functional abnormalities including both epicardial and microvascular coronary artery spasm represent an important role responsible for myocardial ischemia in patients with angina and nonobstructive coronary artery disease. However, clinical characteristics associated with microvascular spasm (MVS) have not been fully evaluated.

Purpose

The aim of this study was to assess differences in clinical features between patients with MVS and epicardial coronary spasm.

Methods

A total of 732 consecutive patients with suspected angina who presented nonobstructive coronary arteries and underwent intracoronary acetylcholine provocation test were retrospectively enrolled in this study. Epicardial coronary spasm was defined as total or subtotal occlusion of epicardial coronary arteries accompanied by chest pain and/or ischemic electrocardiographic changes in response to acetylcholine provocation test. MVS was diagnosed when chest pain and/or ischemic electrocardiographic changes developed after administration of acetylcholine in the absence of epicardial coronary spasm. Clinical characteristics were compared between patients with MVS and epicardial coronary spasm.

Results

Of all patients, 83 patients (11%) had MVS, 367 (50%) had epicardial coronary spasm, and the other patients (39%) showed neither MVS nor epicardial coronary spasm. Patients with MVS tended to be older (65.6±12.7 vs. 63.0±12.3 years, P=0.088) and were more frequently female (60.2% vs. 41.1%, P=0.0016) in comparison with patients with epicardial coronary spasm. Patients with MVS were less likely to be smokers (8.6% vs. 22.9%, P=0.0018), while there were no significant differences in the other coronary risk factors such as hypertension, dyslipidemia, and diabetes mellitus. Serum uric acid were significantly lower in patients with MVS (4.9±1.1 vs. 5.4±1.3 mg/dl, P=0.0018).

Conclusion

Our study demonstrated that patients with MVS had distinctive clinical background from those with epicardial coronary spasm, suggesting different mechanisms may involve the development of MVS.

Funding Acknowledgement

Type of funding source: None

Age-related differences and vascular function test findings in patients with vasospastic angina

Background

Vasospastic angina (VSA) accounts for the majority of angina cases with no epicardial stenosis and develops amongawide range of age, which is reportedly induced by coronary functional abnormalities including endothelial dysfunction and smooth muscle hypercontraction. However, the relation of noninvasive vascular function tests to VSA remains to be fully elucidated.

Purpose

The aim of this study was to assess differences in clinical characteristics and findings from noninvasive vascular function tests among groups by age in patients with VSA.

Methods

We enrolled a total of 732 patients with angina who underwent intracoronary acetylcholine provocation test. VSA was defined as total or subtotal occlusion of epicardial coronary arteries accompanied by chest pain and/or ischemic electrocardiographic changes in response to acetylcholine administration. Patients with VSA were divided into 3 groups by age (young [&lt;50 years], intermediate [50–64 years], and elderly group [≥65 years]). Noninvasive vascular function test findings such as ankle-brachial index (ABI), brachial-ankle pulse wave velocity (baPWV), andpercentage of mean arterial pressure (%MAP) were compared among groups by age in patients with VSA.

Results

Of all patients, 367 (50.1%) were diagnosed as VSA with intracoronary acetylcholine test, including 66 (18.0%), 113 (30.8%), and 188 (51.2%) patients in the young, intermediate, and elderly groups. Among groups by age, there was no significant difference in gender (female, 31.8% vs. 40.7% vs. 44.7%, P=0.19). Patients in the young group were more often smokers and alcohol drinkers than those in the intermediate and elderly groups, while the prevalence of hypertension, dyslipidemia, and diabetes were lower in younger patients. A history of percutaneous coronary intervention was less frequently found in the young group compared tothe intermediate and elderly groups (7.6% vs. 16.8% vs. 20.7%, P=0.033). The baPWV was higher in the elderly group (1424±232 vs. 1537±247 vs. 1774±358 cm/s, P&lt;0.0001), while there was no difference in ABI between the 3 groups. %MAP at arms was significantly and progressively decreased with an increase in age (54.0±4.5% vs. 53.0±2.6% vs. 51.2±2.8%, P&lt;0.0001).

Conclusion

Our study demonstrated that there were distinct age-related differences in clinical characteristics of patients with VSA. The higher %MAP in younger patients suggests that more impaired endothelial dysfunction may play a role in the development of VSA in this age group.

Funding Acknowledgement

Type of funding source: None

Feasibility of management of hemodynamically stable patients with acute myocardial infarction following primary percutaneous coronary intervention in the general ward settings

BACKGROUND

Although current guidelines recommend admission to the intensive/coronary care unit (ICU/CCU) for patients with ST-segment elevation myocardial infarction (MI), routine use of the CCU in uncomplicated patients with acute MI remains controversial. We aimed to evaluate the safety of management in the general ward (GW) of hemodynamically stable patients with acute MI after primary percutaneous coronary intervention (PCI).

METHODS

Using a large nationwide administrative database, a cohort of 19426 patients diagnosed with acute MI in 52 hospitals where a CCU was available were retrospectively analyzed. Patients with mechanical cardiac support and Killip classification 4, and those without primary PCI on admission were excluded. A total of 5736 patients were included and divided into the CCU (n = 3488) and GW (n = 2248) groups according to the type of hospitalization room after primary PCI. Propensity score matching was performed, and 1644 pairs were matched. The primary endpoint was in-hospital mortality at 30 days.

RESULTS

The CCU group had a higher rate of Killip classification 3 and ambulance use than the GW group. There was no significant difference in the incidence of in-hospital mortality within 30 days among the matched subjects. Multivariable Cox proportional hazard model analysis among unmatched patients supported the findings (hazard ratio 1.12, 95% confidence interval 0.66-1.91, p = 0.67).

CONCLUSIONS

The use of the GW was not associated with higher in-hospital mortality in hemodynamically stable patients with acute MI after primary PCI. It may be feasible for the selected patients to be directly admitted to the GW after primary PCI.

Mental Health Status in Patients Undergoing Intracoronary Acetylcholine Provocation Test

BACKGROUND

Previous studies showed the relation of mental distress such as anxiety and depression to coronary vasoconstriction and myocardial ischemia. However, the mental health status of patients suspected to have vasospastic angina is unclear.

METHODS

A total of 99 patients underwent intracoronary acetylcholine (ACh) provocation tests for the diagnosis of vasospastic angina and mental health assessment using the 12-item General Health Questionnaire (GHQ-12) and State-Trait Anxiety Inventory Form Y (STAI Y-2). Patients with binary GHQ-12 ≥ 4 were defined as having poor mental health.

RESULTS

Median GHQ-12 and STAI Y-2 were 3 [1, 6] and 44 [36, 50]. Forty-one (41%) patients had binary GHQ-12 ≥ 4, and 48 (48%) had positive ACh provocation tests. The number of provoked vasospasms and rate of electrocardiographic change and chest pain during ACh tests were not significantly different between patients with and without GHQ-12 ≥ 4. The incidence of positive ACh provocation test was similar between the two groups (49% vs. 48%, p = 1.00). The multivariable analysis indicated that younger age, no history of percutaneous coronary intervention and no diabetes mellitus were factors associated with higher GHQ-12 and/or STAI Y-2 scores.

CONCLUSIONS

More than 40% of patients who underwent ACh provocation tests had poor mental condition. No impact of mental distress on positive ACh tests was found in this study.

Relation of Plasma Xanthine Oxidoreductase Activity to Coronary Lipid Core Plaques Assessed by Near-Infrared Spectroscopy Intravascular Ultrasound in Patients With Stable Coronary Artery Disease

Previous studies reported that elevated serum uric acid level was associated with greater coronary lipid plaque. Xanthine oxidoreductase (XOR) is a rate-limiting enzyme in purine metabolism and is believed to play important roles in coronary atherosclerosis. However, the relation between XOR and coronary lipid plaque is unclear. Patients with stable coronary artery disease who underwent elective percutaneous coronary intervention under near-infrared spectroscopy intravascular ultrasound (NIRS-IVUS) guidance were prospectively included. They were divided into 3 groups according to plasma XOR activities based on a previous report: low, normal, and high. Quantitative coronary angiography and gray-scale IVUS were analyzed. The primary end point was coronary lipid plaques in a nontarget vessel assessed by NIRS-IVUS with lipid core burden index (LCBI) and maximum LCBI in 4 mm (maxLCBI_4mm). Out of 68 patients, 26, 31, and 11 patients were classified as low, normal, and high XOR activity groups. Quantitative coronary angiography demonstrated that the high XOR activity group had longer lesion length, smaller minimum lumen diameter, and higher percentage of diameter stenosis in a nontarget vessel among the 3 groups. Gray-scale IVUS analysis also showed smaller lumen area in the high XOR activity group than the others. LCBI (102.1 ± 56.5 vs 65.6 ± 48.5 vs 55.6 ± 37.8, p = 0.04) and maxLCBI_4mm (474.4 ± 171.6 vs 347.4 ± 181.6, 294.0 ± 155.9, p = 0.04) in a nontarget vessel were significantly higher in the high XOR group than in the normal and low groups. In conclusion, elevated XOR activity was associated with coronary lipid-rich plaque in a nontarget vessel in patients with stable coronary artery disease.

P5538Safety and efficacy of acetylcholine provocation test for diagnosis of vasospastic angina in young patients

Background

Vasospastic angina (VSA) is considered as a cause of myocardial infarction with nonobstructive coronary arteries. Given the previous reports of higher incidence of cardiovascular events in young VSA patients, early diagnosis and optimal treatment are important for these patients. While acetylcholine provocation test (ACh test) for VSA diagnosis is well reported, ACh test among young patients is not as commonly performed, therefore its safety and usefulness for this patient subset have not been fully evaluated.

Purpose

The purpose of this study was to evaluate the safety and the proportion of positive results of ACh test for young patients.

Methods

Data from patients who underwent ACh test in our institution from May 2012 to September 2018 were retrospectively analyzed. A total of 669 patients were enrolled and divided into 2 groups according to age: Young group (Age≤50, n=106); and Senior group (Age>50, n=563).

Results

The senior group had a higher incidence of hypertension, dyslipidemia, diabetes mellitus, and coronary artery disease. On the other hand, the young group had a significantly higher incidence of current smoker and tendency of daily alcohol. The rate of positive ACh test was similar, and there were no significant differences in major or minor complications between the 2 groups.

Patient characteristics and outcome Young group Senior group p (n=106) (n=563) Age (years) 42.8±7.3 68.0±9.0 <0.001 Male (%) 56.6 52.2 0.407 Current smoker (%) 34.9 15.4 <0.001 Daily alcohol (%) 31.1 22.9 0.070 Hypertension (%) 33.0 66.6 <0.001 Dyslipidemia (%) 50.0 68.4 <0.001 Diabetes (%) 12.3 20.8 0.047 ACh positive (%) 52.8 49.9 0.581 Minor adverse event (%) 4.7 5.9 0.820 Major adverse event (%) 0.9 1.4 1.000 Major adverse event: composite of death, ventricular fibrillation, sustained ventricular tachycardia (VT), myocardial infarction and stroke. Minor adverse event: non-sustained VT and paroxysmal atrial fibrillation.

Conclusion

ACh provocation test for young patients can be safely performed, and the rate of positive results was similar to that of senior patients. In young patients suspected of having VSA, ACh test should be actively performed to identify optimal medical therapy for prevention of cardiovascular events.

Acknowledgement/Funding

None

Association Between Multivessel Coronary Artery Disease and Return of Spontaneous Circulation Interval in Acute Coronary Syndrome Patients with Out-of-Hospital Cardiac Arrest

Acute coronary syndrome (ACS) is the major cause of out-of-hospital cardiac arrest (OHCA). The relationship between the findings from the study of coronary images and return of spontaneous circulation (ROSC) interval is still unknown. Hence, we investigated this relationship in ACS patients with OHCA.A cohort of 2779 patients was admitted to our emergency center due to cardiopulmonary arrest (CPA) between April 2011 and March 2015. We included ACS patients who had CPA with ventricular fibrillation (VF) as an initial rhythm, were successfully resuscitated, underwent coronary angiography (CAG), had a culprit lesion, and were diagnosed with ACS (n = 58; age, 63.7 ± 12.0 years; 93.1% male).We divided the 58 patients into two groups, an early ROSC group (ROSC ≤ 20 minutes: E-ROSC) and a late ROSC group (ROSC > 20 minutes: L-ROSC), and then analyzed their characteristics.The finding of a collateral artery for the culprit lesion location, Rentrop II-III, and TIMI III flow on CAG on arrival presented no significant differences between the two groups (Rentrop II-III: 25.0% versus 23.5%, P = 0.90; TIMI III: 33.3% versus 35.3%, P = 0.88). The incidence of multivessel coronary artery disease (MVD) was lower in the E-ROSC group than in the L-ROSC group (16.7% versus 58.8%, P = 0.001).Collateral and TIMI flow were not associated with ease of resuscitation, but MVD may have a negative impact on resuscitation, especially in VF patients.

Safety and usefulness of acetylcholine provocation test in patients with no culprit lesions on emergency coronary angiography

BACKGROUND

Vasospastic angina (VSA), which often causes acute coronary syndrome (ACS), can be diagnosed by intracoronary acetylcholine (ACh) provocation test. However, the safety and usefulness of ACh provocation test in ACS patients on emergency coronary angiography (CAG) compared to non-emergency settings are unclear.

METHODS

A total of 529 patients undergoing ACh provocation test during emergency or non-emergency CAG were included. Patients with resuscitated cardiac arrest were excluded. The primary endpoint was adverse events defined as a composite of death, ventricular fibrillation or sustained ventricular tachycardia, myocardial infarction, cardiogenic shock, cardiac tamponade, and stroke within 24 h after ACh provocation test.

RESULTS

There were no significant differences of the clinical characteristics between the groups of emergency (n = 84) and non-emergency (n = 445) ACh provocation test. The rate of positive ACh provocation test was similar between the 2 groups (50% vs. 49%, p = 0.81). Similarly, the incidence of adverse events in patients with emergency and non-emergency ACh provocation test did not significantly differ (1.2% vs. 1.3%, p = 1.00).

CONCLUSION

ACh provocation test can be safely performed in ACS patients with no obstructive culprit lesions on emergency CAG, and may be useful to diagnose VSA in those patients.

Clinical value of ST-segment change after return of spontaneous cardiac arrest and emergent coronary angiography in patients with out-of-hospital cardiac arrest: Diagnostic and therapeutic importance of vasospastic angina

Background:

We investigated the association between initial ST-segment change after return of spontaneous circulation (ROSC) and the incidence of acute coronary lesions in patients with out-of-hospital cardiac arrest (OHCA), and clinical outcomes of patients with OHCA caused by vasospastic angina pectoris (VSA).

Methods:

Among 2779 OHCA patients in our institution, all patients with ROSC underwent emergent coronary angiography (CAG) except for those with an obvious extra-cardiac cause of OHCA. Initial ST-segment changes after ROSC were reviewed, and 30-day survival and neurological outcome (Cerebral Performance Category) were evaluated.

Results:

Of the 155 patients, 52 (34%) had ST-segment elevation (STE) and 103 (66%) had non-STE. Significant coronary culprit lesions were present in 81% of patients with STE and in 33% of patients with non-STE ( P<.001). Percutaneous coronary intervention (PCI) was successful in 60 patients (93.8%) and failed in 4 patients (6.2%). Among 155 patients, 74 patients (47.7%) had favorable neurological prognosis, and 104 patients (67.1%) were alive at 30 days. ST-segment analysis showed good positive predictive value (81%) but low negative predictive value (68%) in diagnosing the presence of acute coronary lesions. VSA was found in 5 patients (9.6%) in the STE group and in 12 patients (11.7%) in the non-STE group. Of these 17 patients, 9 (52.9%) had favorable neurological outcome and 14 (82.4%) were alive at 30 days.

Conclusion:

An acute culprit lesion may be the cause of OHCA even in the absence of STE. In survivors of OHCA with normal coronary arteries, spasm provocation testing should be performed to detect VSA as a cause of the arrest.