Optimal timing of percutaneous coronary intervention for non-ST elevated myocardial infarction with congestive heart failure

OBJECTIVES

This study investigated the optimal timing for percutaneous coronary intervention (PCI) in patients with NSTEMI complicated by heart failure (HF).

METHODS

In total, 762 patients with NSTEMI and HF in a multicenter, prospective registry in South Korea were classified according to the Killip classification (Killip class 2, n = 414 and Killip class 3, n = 348) and underwent early (within 24 h) and delayed (after 24 h) PCI. The primary outcome was all-cause mortality which was further analyzed with landmark analysis with two months as a cut-off. Secondary outcomes were cardiovascular death, in-hospital cardiogenic shock (CS), readmission due to HF, and acute myocardial infarction during follow-up.

RESULTS

Delayed PCI was associated with lower rates of 2-month mortality (6.1 % vs. 15.8 %, p = 0.007) and in-hospital CS (4.3 % vs. 14.1 %, p = 0.003), along with lower risks of 2-month mortality (hazard ratio [HR] = 0.38, 95 % confidence interval [CI] = 0.18-0.83, p = 0.014), in-hospital CS (HR = 0.29, 95 % CI = 0.12-0.71, p = 0.006) in multivariate Cox models of Killip class 3 patients. There was no statistical difference of incidence and risk of all predefined outcomes according to varying timing of PCI in Killip 2 patients.

CONCLUSIONS

Based on these results, the timing of PCI in patients with NSTEMI complicated by HF should be determined based on HF severity. Delayed PCI should be considered in patients with NSTEMI and more severe HF.

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 1 non-IRA lesion with ≥50% stenosis by visual estimation. Patients fulfilling the inclusion criteria were randomized into 2 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 was 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.

Preliminary Investigation on Efficacy and Safety of Substance P-Coated Stent for Promoting Re-Endothelialization: A Porcine Coronary Artery Restenosis Model

BACKGROUND

Current polymer-based drug-eluting stents (DESs) have fundamental issues about inflammation and delayed re-endothelializaton of the vessel wall. Substance-P (SP), which plays an important role in inflammation and endothelial cells, has not yet been applied to coronary stents. Therefore, this study compares poly lactic-co-glycolic acid (PLGA)-based everolimus-eluting stents (PLGA-EESs) versus 2-methacryloyloxyethyl phosphorylcholine (MPC)-based SP-eluting stents (MPC-SPs) in in-vitro and in-vivo models.

METHODS

The morphology of the stent surface and peptide/drug release kinetics from stents were evaluated. The in-vitro proliferative effect of SP released from MPC-SP is evaluated using human umbilical vein endothelial cell. Finally, the safety and efficacy of the stent are evaluated after inserting it into a pig's coronary artery.

RESULTS

Similar to PLGA-EES, MPC-SP had a uniform surface morphology with very thin coating layer thickness (2.074 μm). MPC-SP showed sustained drug release of SP for over 2 weeks. Endothelial cell proliferation was significantly increased in groups treated with SP (n = 3) compared with the control (n = 3) and those with everolimus (n = 3) (SP: 118.9 ± 7.61% vs. everolimus: 64.3 ± 12.37% vs. the control: 100 ± 6.64%, p < 0.05). In the animal study, the percent stenosis was higher in MPC-SP group (n = 7) compared to PLGA-EES group (n = 7) (MPC-SP: 28.6 ± 10.7% vs. PLGA-EES: 16.7 ± 6.3%, p < 0.05). MPC-SP group showed, however, lower inflammation (MPC-SP: 0.3 ± 0.26 vs. PLGA-EES: 1.2 ± 0.48, p < 0.05) and fibrin deposition (MPC-SP: 1.0 ± 0.73 vs. PLGA-EES: 1.5 ± 0.59, p < 0.05) around the stent strut. MPC-SP showed more increased expression of cluster of differentiation 31, suggesting enhanced re-endothelialization.

CONCLUSION

Compared to PLGA-EES, MPC-SP demonstrated more decreased inflammation of the vascular wall and enhanced re-endothelialization and stent coverage. Hence, MPC-SP has the potential therapeutic benefits for the treatment of coronary artery disease by solving limitations of currently available DESs.

Significant Gap Between Guidelines and Practice in the Management of LDL Cholesterol: Insight From the Survey of the Korean Society of Myocardial Infarction

The Guidelines of the 2019 European Society of Cardiology (ESC) and the 5th Society of Lipid and Atherosclerosis (KSoLA) for the Management of Dyslipidemia advocate a more intensive lipid-lowering strategy. However, there is a lack of evidence regarding the current status of lipid management in Korean patients in real-world practice. The Korean Society of Myocardial Infarction conducted a survey among its members of the Korean Society of Cardiology on the new lipid guidelines. Although most participants were aware of the changes in the ESC and the KSoLA guidelines, more than half of them did not agree with lowering the low-density lipoprotein cholesterol levels to < 55 mg/dL, because its safety and efficacy have not yet been proven in Koreans. A substantial disparity exists between lipid management guidelines and current clinical practices, highlighting the necessity for clinical research that specifically targets East Asians and Koreans to bridge this gap.

De-escalation from ticagrelor to clopidogrel in patients with acute myocardial infarction: the TALOS-AMI HBR substudy

BACKGROUND

The benefits of de-escalation of P2Y12 inhibition after percutaneous coronary intervention (PCI) may differ by high bleeding risk (HBR) status.

AIMS

We investigated the efficacy and safety of de-escalation from ticagrelor to clopidogrel after PCI by HBR status.

METHODS

This is a non-prespecified post hoc analysis of the TicAgrelor Versus CLOpidogrel in Stabilized Patients with Acute Myocardial Infarction (TALOS-AMI) trial. Net adverse clinical events (a composite of cardiovascular death, myocardial infarction, stroke, or Bleeding Academic Research Consortium [BARC] bleeding type 2, 3, or 5) at 1 year post-PCI were compared between the de-escalation (clopidogrel plus aspirin) and the active control (ticagrelor plus aspirin) groups by HBR status, as defined by the modification of the Academic Research Consortium (ARC) criteria.

RESULTS

A total of 2,625 patients in the TALOS-AMI trial were analysed. Of these, 589 (22.4%) met the modified ARC-HBR criteria. The de-escalation group had lower primary endpoint rates than the control group in both HBR (hazard ratio [HR] 0.47, 95% confidence interval [CI]: 0.26-0.84) and non-HBR (HR 0.59, 95% CI: 0.41-0.84) patients. There were no differences in treatment effect for the primary endpoint regardless of HBR status (p for interaction=0.904). BARC bleeding type 3 or 5 was less common in the de-escalation than the control group among HBR patients only (HR 0.24, 95% CI: 0.07-0.84).

CONCLUSIONS

In stabilised acute myocardial infarction patients, unguided de-escalation from ticagrelor to clopidogrel was associated with a lower rate of net adverse clinical outcomes irrespective of HBR status. The effect of de-escalation of P2Y12 inhibition on reducing haemorrhagic events was greater in patients with HBR.

Early Left Ventricular Unloading or Conventional Approach After Venoarterial Extracorporeal Membrane Oxygenation: The EARLY-UNLOAD Randomized Clinical Trial

BACKGROUND

Although venoarterial extracorporeal membrane oxygenation (VA-ECMO) is beneficial for the treatment of profound cardiogenic shock, peripheral VA-ECMO cannulation can increase left ventricular afterload, thus compromising myocardial recovery. We investigated whether early routine left ventricular unloading can reduce 30-day mortality compared with the conventional approach in patients with cardiogenic shock undergoing VA-ECMO.

METHODS

This randomized clinical trial involved 116 patients with cardiogenic shock undergoing VA-ECMO from March 2021 to September 2022 at Chonnam National University Hospital, Gwangju, South Korea. The patients were randomly assigned to undergo either early routine left ventricular unloading with transseptal left atrial cannulation within 12 hours after randomization (n=58) or the conventional approach, which permitted rescue transseptal left atrial cannulation in case of an increased left ventricular afterload (n=58). The primary outcome was all-cause mortality within 30 days.

RESULTS

All 116 randomized patients (mean age, 67.6±13.5 years; 34 [29.3%] women) completed the trial. At 30 days, all-cause death had occurred in 27 (46.6%) patients in the early group and 26 (44.8%) patients in the conventional group (hazard ratio, 1.02 [95% CI, 0.59-1.74]; P=0.942). Crossover to rescue transseptal left atrial cannulation occurred in 29 patients (50%) in the conventional group according to a clear indication. Time to rescue transseptal cannulation in the conventional group was a median of 21.8 (interquartile range, 12.4-52.2) hours after randomization. There were no significant differences in other secondary outcomes between the 2 groups except for a shorter time to disappearance of pulmonary congestion in the early group (median, 3 [interquartile range, 2-6] versus 5 [interquartile range, 3-7] days; P=0.027).

CONCLUSIONS

Among patients with cardiogenic shock undergoing VA-ECMO, early routine left ventricular unloading with transseptal left atrial cannulation did not reduce 30-day mortality compared with the conventional strategy, which permitted rescue transseptal left atrial cannulation. These findings should be cautiously interpreted until the results of multicenter trials using other unloading modalities become available.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT04775472.

Culprit lesion plaque characteristics and angiopoietin like 4 in acute coronary syndrome: A virtual histology-intravascular ultrasound analysis

BACKGROUND

Thin-cap fibroatheroma is a rupture-prone vulnerable plaque that leads to acute coronary syndrome (ACS). However, its underlying mechanisms are not fully understood. Several studies have investigated the clinical association between angiopoietin-like protein 4 (ANGPTL4) and coronary artery disease. Therefore, this study aimed to investigate the correlation of plasma ANGPTL4 in culprit lesion of ACS patients using intravascular ultrasound (IVUS) and virtual-histology IVUS (VH-IVUS).

METHODS

Fifty patients newly diagnosed with ACS between March to September 2021 were selected. Blood samples for baseline laboratory tests, including ANGPTL4, were collected before percutaneous coronary intervention (PCI), and all pre- and post-PCI IVUS examinations were performed of the culprit lesions.

RESULTS

Linear regression analysis between plasma ANGPTL4 and grayscale IVUS/VH-IVUS parameters revealed that plasma ANGPTL4 was strongly correlated with the necrotic core (NC) of the minimal lumen site (r = -0.666, p = 0.003) and largest NC site (r = -0.687, p < 0.001), and patients with lower plasma ANGPTL4 levels showed a significantly higher proportion of TFCA.

CONCLUSION

The present study further demonstrated the protective role of ANGPTL4 in the spectrum of atherosclerotic development in patients with ACS by culprit lesion morphology analysis using IVUS and VH-IVUS.

Assessment of Bladder Filling Type on Radiation Dose to Organs at Risk in MR-Guided Intracavity Brachytherapy for Cervical Cancer

PURPOSE/OBJECTIVE(S)

In this study, we evaluated whether the classification of bladder shape affects the absorbed dose (Gy) of OARs and its geometrical position to normal organs in MR-guided intracavitary brachytherapy (ICBT).

MATERIALS/METHODS

In this study, 269 patients who underwent MR-guided ICBT for cervical cancer from 2016 to 2022 were included. The applicator-inserted bladder filling type (BFT) classification was divided into three types (tilted, curved, and other shapes: group E). The anatomical positional relationship between the uterus and its surroundings was measured on pre-MR images and ICBT simulation MR images. Spearman's rank correlation analysis was used for bladder volume and OAR dose according to BFT. Anatomical differences were analyzed by ANOVA by measuring the distance from the center to both bladder walls.

RESULTS

In the correlation analysis considering the shape of the bladder, the tilted, curved, and group E had Spearman's ρ of 0.211; -0.323, 0.412; -0.307 and -0.035; -0.209 for maximum absorbed dose (D2cc) of bladder and small bowel, respectively. It was statistically significant in the tilted type and curved type. The average left and right bladder lengths differences of the tilted type were the highest at 8.47 cm and 7.11 cm, respectively. It was a statistically significant between bladder shape and the difference in left and right bladder lengths differences (p< 0.01).

CONCLUSION

In this study, it was confirmed that bladder distension increased the maximum bladder dose (D2cc) and decreased the maximum bowel dose (D2cc) to the tilted type and curved type. In addition, if the left and right bladder lengths are measured in pre-MR, the degree of bladder distension can be evaluated in advance by checking the shape of the bladder in the case of the tilting type before ICBT. Based on these findings, a prospective study is needed to evaluate the effect of ICBT on cervical cancer treatment outcomes through bladder type classification.

Renin-Angiotensin-Aldosterone System Inhibitions and Cardiovascular Outcomes in Acute Myocardial Infarction With Renal Impairment

OBJECTIVE

To compare the clinical outcomes of patients with acute myocardial infarction with renal impairment (AMI-RI) treated with either angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) in real-world clinical settings.

PATIENTS AND METHODS

A total of 4790 consecutive patients with AMI-RI between November 1, 2011, and December 31, 2015, were subdivided into ACEI (n=2845) and ARB (n=1945) treatment groups. The primary end points were major adverse cardiac and cerebrovascular events, including all-cause mortality, nonfatal myocardial infarction, any revascularization, cerebrovascular accident, rehospitalization, and stent thrombosis. Propensity score matching (PSM) was used to adjust for group differences.

RESULTS

The ARB group had a significantly higher incidence of major adverse cardiac and cerebrovascular events (at 3-year follow-up) than the ACEI group according to the unadjusted analysis (3-year hazard ratio [HR], 1.60; 95% CI, 1.43 to 1.78) and the PSM-adjusted analysis (3-year HR, 1.34; 95% CI, 1.15 to 1.56). However, any revascularization (3-year HR, 1.21; 95% CI, 0.95 to 1.54) and rehospitalization (3-year HR, 1.21; 95% CI, 0.88 to 1.67) were not significantly different between groups in the PSM-adjusted analysis. Compared with the ARB group, the ACEI group had lower rates of all-cause mortality at estimated glomerular filtration rates of at least 15 or less than 90 mL/min/1.73 m2 in the unadjusted data and at least 60 or less than 90 mL/min/1.73 m2 in the PSM-adjusted analysis.

CONCLUSION

Treatment with ACEIs seemed to be more beneficial than treatment with ARBs for patients with AMI-RI; further prospective studies are required to confirm these results.

Impact of sex difference on clinical outcomes in acute myocardial infarction patients with single-vessel and multi-vessel disease: based on Korea Acute Myocardial Infarction Registry-National Institute of Health

Background

Several studies have compared clinical outcomes according to sex in patients with acute myocardial infarction (AMI). However, studies evaluating sex differences in clinical outcomes of single-vessel disease (SVD) and multi-vessel disease (MVD) in Korean patients with AMI are lacking. Therefore, this study aimed to analyze sex differences in the clinical characteristics of patients with AMI with SVD and MVD and to evaluate the impact of sex differences on the clinical outcomes in patients with AMI with SVD and MVD.

Methods

A total of 11,002 AMI patients from November 2011 to June 2015 in the Korea AMI Registry, National Institute of Health, were enrolled. The current study was retrospective observational study. Patients were divided into SVD (n=5,644) and MVD (n=5,358) groups, and clinical impact of sex difference were analyzed by propensity score matching analysis and Cox proportional hazard regression model.

Results

Women were older and had poor baseline clinical characteristics than men. Propensity score-matched analysis of men and women with SVD and MVD revealed that the adjusted 3-year risk of major adverse cardiac event (MACE) (15.0% vs. 9.4%; hazard ratio, 1.86; 95% confidence interval, 1.10-3.13; P=0.020) was higher in women with SVD aged <65 years. However, the incidence and risk of MACE were similar for men and women with MVD, and those with SVD aged ≥65 years.

Conclusions

In the present study of Korean patients with AMI, women were older and exhibited a higher prevalence of comorbidities than men. Women with SVD aged <65 years had a significantly higher risk of MACE.

Early left ventricular unloading after extracorporeal membrane oxygenation: rationale and design of EARLY-UNLOAD trial

AIMS

The clinical benefits of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for profound cardiogenic shock are well known. However, peripheral VA-ECMO increases the left ventricular afterload, thus compromising myocardial recovery. Recent studies have revealed the benefit of left ventricular unloading using various methods applied at different times. The EARLY-UNLOAD trial compares the clinical outcomes of early left ventricular unloading and conventional approach after VA-ECMO.

METHODS AND RESULTS

The EARLY-UNLOAD trial is a single-centre, open-label, randomized trial that recruited 116 patients with cardiogenic shock undergoing VA-ECMO. Patients meeting the inclusion criteria were randomized in a 1:1 ratio to two groups: routine left ventricular unloading via intracardiac echocardiography-guided transseptal left atrial cannulation within 12 h of VA-ECMO initiation or conventional approach that indicates rescue left ventricular unloading if clinical signs of an increased left ventricular afterload are present. The primary endpoint is the cumulative incidence of all-cause death within 30 days, and patients will be followed-up for 12 months. A key secondary endpoint is a composite measure of all-cause death and rescue transseptal left atrial cannulation in the conventional group (suggestive of VA-ECMO treatment failure) within 30 days. The enrolment of patients was finished in September 2022.

CONCLUSIONS

The EARLY-UNLOAD trial is the first randomized controlled trial to compare early left ventricular unloading and conventional approach after VA-ECMO using the same unloading modality. The results could impact clinical practice to overcome the haemodynamic issues associated with VA-ECMO.

Incidence, Relevant Patient Factors, and Clinical Outcomes of the Misdiagnosis of ST-Segment-Elevation Myocardial Infarction: Results From the Korea Acute Myocardial Infarction Registry

Background Data on the incidence, relevant patient factors, and clinical outcomes of the misdiagnosis of ST-segment-elevation myocardial infarction (STEMI) in the modern era of percutaneous coronary intervention are limited. Methods and Results Data from KAMIR (Korea Acute Myocardial Infarction Registry) between November 2011 and June 2020 were analyzed. Out of 28 470 patients with acute myocardial infarction, 11 796 were eventually diagnosed with STEMI following a coronary angiogram. They were classified into 2 groups: patients with an initial working diagnosis of STEMI before starting the initial treatment and patients with an initial working diagnosis of non-STEMI (misdiagnosed group). Out of 11 796 patients with a final diagnosis of STEMI, 165 (1.4%) were misdiagnosed. The door-to-angiography time in the misdiagnosed group was 5 times longer than that in the timely diagnosed group (median 220 [interquartile range {IQR}, 66-1177] versus 43 [IQR, 31-58] minutes; P<0.001). In a multivariable adjustments model, patients with a history of heart failure, atypical chest pain, anemia, or symptom-to-door time ≥4 hours had significantly higher odds, whereas those with systolic blood pressure <100 mm Hg or anterior ST elevation or left bundle-branch block on ECG had lower odds of STEMI misdiagnosis. For patients with culprit lesions in the left anterior descending artery (n=5838), the adjusted 1-year mortality risk for STEMI misdiagnosis was 1.84 (95% CI, 1.01-3.38). Conclusions Misdiagnosis of STEMI is not rare and is associated with a significant delay in coronary angiography, resulting in increased 1-year mortality for patients with culprit lesions in the left anterior descending artery.

Baseline Lipoprotein(a) Levels and Long-Term Cardiovascular Outcomes After Acute Myocardial Infarction

BACKGROUND

Lipoprotein(a) is a known independent risk factor for atherosclerotic cardiovascular disease. However, the prognostic impact of the baseline lipoprotein(a) levels on long-term clinical outcomes among patients with acute myocardial infarction remain unclear.

METHODS

We analyzed 1,908 patients with acute myocardial infarction from November 2011 to October 2015 from a single center in Korea. They were divided into 3 groups according to their baseline lipoprotein(a) levels: groups I (< 30 mg/dL, n = 1,388), II (30-49 mg/dL, n = 263), and III (≥50 mg/dL, n = 257). Three-point major adverse cardiovascular events (a composite of nonfatal myocardial infarction, nonfatal stroke, and cardiac death) at 3 years were compared among the 3 groups.

RESULTS

The patients were followed for 1094.0 (interquartile range, 1,033.8-1,095.0) days, during which a total of 326 (17.1%) three-point major adverse cardiovascular events occurred. Group III had higher rates of three-point major adverse cardiovascular events compared with Group I (23.0% vs. 15.7%; log-rank P = 0.009). In the subgroup analysis, group III had higher rates of three-point major adverse cardiovascular events compared with group I in patients with non-ST-segment elevation myocardial infarction (27.0% vs. 17.1%; log-rank P = 0.006), but not in patients with ST-segment elevation myocardial infarction (14.4% vs. 13.3%; log-rank P = 0.597). However, in multivariable Cox time-to-event models, baseline lipoprotein(a) levels were not associated with an increased incidence of three-point major adverse cardiovascular events, regardless of the type of acute myocardial infarction. Sensitivity analyses in diverse subgroups showed similar findings to those of the main analysis.

CONCLUSION

Baseline lipoprotein(a) levels in Korean patients with acute myocardial infarction were not independently associated with increased major adverse cardiovascular events at 3 years.

Preclinical Evaluation of an Everolimus-Eluting Bioresorbable Vascular Scaffold Via a Long-Term Rabbit Iliac Artery Model

BACKGROUND

Biodegradable poly (l-lactic acid) (PLLA), a bio safe polymer with a large elastic modulus, is widely used in biodegradable medical devices. However, because of its poor mechanical properties, a PLLA strut must be made twice as thick as a metal strut for adequate blood vessel support. Therefore, the mechanical properties of a drug-eluting metal-based stents (MBS) and a bioresorbable vascular scaffolds (BVS) were evaluated and their safety and efficacy were examined via a long-term rabbit iliac artery model.

METHODS

The surface morphologies of the MBSs and BVSs were investigated via optical and scanning electron microscopy. An everolimus-eluting (EE) BVS or an EE-MBS was implanted into rabbit iliac arteries at a 1.1:1 stent-to-artery ratio. Twelve months afterward, stented iliac arteries from each group were analyzed via X-ray angiography, optical coherence tomography (OCT), and histopathologic evaluation.

RESULTS

Surface morphology analysis of the EE coating on the MBS confirmed that it was uniform and very thin (4.7 μm). Comparison of the mechanical properties of the EE-MBS and EE-BVS showed that the latter outperformed the former in all aspects (radial force (2.75 vs. 0.162 N/mm), foreshortening (0.24% vs. 1.9%), flexibility (0.52 vs. 0.19 N), and recoil (3.2% vs. 6.3%). At all time points, the percent area restenosis was increased in the EE-BVS group compared to the EE-MBS group. The OCT and histopathological analyses indicate no significant changes in strut thickness.

CONCLUSION

BVSs with thinner struts and shorter resorption times should be developed. A comparable long-term safety/efficacy evaluation after complete absorption of BVSs should be conducted.

Evaluation of full-fatted and hydrolysate mealworm (Tenebrio molitor) larvae as a substitute for spray-dried plasma protein diet in weaning pigs

The goal of this experiment was to examine the effect of dietary inclusion of full-fatted mealworm larvae (FFML) or hydrolysate mealworm larvae (HML) (Tenebrio molitor) as a substitute for spray-dried plasma protein (SDPP) as a protein source on the performance and immune status of nursery pigs. A total of 150 crossbred piglets (6.48 ± 0.01 kg) were randomly allocated to 1 of 3 dietary groups in two feeding phases: phase 1 (Days 0-14) and phase 2 (Days 15-35). Each treatment had 10 replicates with 5 pigs per replicate. The nutritious diets were: Phase 1: SDPP-CON (control-basal diet) + 6% SDPP diet; FFML-CON + 3% SDPP and 3% FFML diet; HML-CON + 3% SDPP and 3% HML diet. Phase 2: SDPP-CON (basal diet) + 3% SDPP diet; FFML-CON + 3% FFML diet; HML-CON + 3% HML diet. The inclusion of FFML or HML diet did not show significant difference but had a comparable effect as that of standard control diet containing SDPP on the growth performance, nutrient digestibility and faecal score throughout the trial. In comparison to pigs fed SDPP diet, pigs fed FFML and HML diets had similar and/or higher (p < 0.05) serum immunoglobulin (IgA and IgG) concentration at the end of phase 1 and 2. The result of the present study indictes that SDPP would be partially or fully replaced with FFML or HML to suit weaning pigs diet.

A novel polymer-free everolimus-eluting stent with a nitrogen-doped titanium dioxide film inhibits restenosis and thrombosis in a swine coronary model

BACKGROUND

Short-term outcomes regarding the safety and efficacy of a polymer-free everolimus-eluting stent (EES) with a nitrogen-doped titanium dioxide (N-TiO₂) film in a swine coronary model have been reported. However, the long-term results of the use of this type of stent have not yet been evaluated or compared to those of other polymer-free coronary stents. Therefore, this study aimed to determine the mid- to long-term safety and efficacy of a polymer-free EES with an N-TiO₂ film in a swine coronary model.

METHODS

Polymer-free EES with N-TiO₂ films (n = 30) and polymer-free sirolimus-eluting stents (SES; n = 30) were implanted in 30 pigs. Quantitative coronary analysis and optical coherence tomography were conducted immediately and at 1 (quantitative coronary analysis only), 3, and 6 months after stenting. Histopathologic examinations were performed at 1, 3, and 6 months after stenting.

RESULTS

The polymer-free EES group had a lower percentage of neointimal growth than the polymer-free SES group at 3 months (22.5% ± 11.4% vs. 32.1% ± 12.3%; p < 0.001). The polymer-free EES group had a lower fibrin score than the polymer-free SES group at 1 month (1.9 ± 0.45 vs. 2.5 ± 0.54; p = 0.001). The re-endothelialization rates were similar between groups. The polymer-free EES group had a lower percentage of the area of stenosis than the polymer-free SES group throughout the follow-up period.

CONCLUSIONS

The novel polymer-free EES with an N-TiO₂ film has superior safety and efficacy than the polymer-free SES at the 6-month follow-up in a swine model.

Long-term clinical outcomes in patients with acute myocardial infarction complicated by cardiogenic shock according to the application and initiation time of extracorporeal membrane oxygenation in South Korea

BACKGROUND

Limited data are available regarding the proper application time and long-term outcomes of extracorporeal membrane oxygenation (ECMO) in patients with cardiogenic shock. This cohort study appraised the clinical outcomes according to ECMO application without or before cardiopulmonary resuscitation (CPR) in patients with acute myocardial infarction (AMI) combined with cardiogenic shock.

METHODS

Between 2011 and 2015, a total of 13,104 patients with AMI were enrolled in a nationwide AMI registry. Eligible patients with cardiogenic shock, who underwent percutaneous coronary intervention, with a 3-year clinical follow-up, were analyzed. The 949 included patients were divided into two groups: no ECMO (n = 845) and ECMO application (n = 104). The ECMO group was further divided into ECMO without or before CPR (n = 11) and ECMO after CPR (n = 93).

RESULTS

Significant differences were noted in major adverse cardiac events (MACEs) between the no ECMO and ECMO application groups during the 3-year follow-up (41.5% vs. 80.8%; p < 0.001). However, the ECMO without or before CPR group showed similar outcomes to the no ECMO group in 3-year MACEs (63.6% vs. 41.5%; p = 0.055). MACEs during 3 years of follow-up were significantly lower in the ECMO without or before CPR group than in the ECMO after CPR group (63.6% vs. 82.8%; p = 0.005).

CONCLUSIONS

A significantly lower risk of major cardiac events in ECMO without or before CPR suggests that early application of ECMO can be a reasonable strategy to improve outcomes in patients with AMI complicated by cardiogenic shock.

Impact of P2Y12 inhibitors on cardiovascular outcomes of Korean acute myocardial infarction patients with baseline thrombocytopenia

Background

Antiplatelet therapy is crucial for managing acute myocardial infarction (AMI) and reducing adverse ischemic events after percutaneous coronary intervention (PCI) with drug-eluting stents. However, the ideal P2Y12 inhibitor for patients—particularly East Asians—with AMI and low platelet levels remains unknown. We evaluated the impact of various potencies of P2Y12 receptors on major cardiovascular outcomes of AMI patients with thrombocytopenia in Korea.

Methods

We analyzed the clinical and outcome data of 800 AMI patients with baseline platelet counts &lt;150 × 103/μL who underwent PCI between November 2011 and June 2015. All patient data were obtained from the Korea Acute Myocardial Infarction Registry–National Institutes of Health registry. Subjects were allocated to group A (n = 244; treated with potent P2Y12 inhibitors) or group B (n = 556; treated with clopidogrel). The primary endpoint was major adverse cardiac and cerebrovascular events (MACCEs).

Results

At the 3-year follow-up, clinical outcomes appeared better in group A than in Group B. However, after propensity score weighting-adjusted analysis, these findings were statistically attenuated, showing a similar incidence of MACCEs between the two groups.

Conclusions

Clopidogrel may be reasonable for patients with low platelet counts and is associated with comparable outcomes to potent P2Y12 inhibitors for Korean AMI patients.

Impact of Low Baseline Low-Density Lipoprotein Cholesterol on Long-Term Postdischarge Cardiovascular Outcomes in Patients With Acute Myocardial Infarction

Background

Real‐world data on low baseline low‐density lipoprotein cholesterol (LDL‐C) levels and long‐term postdischarge cardiovascular outcomes in patients with acute coronary syndrome are limited.

Methods and Results

Of the 10 719 patients enrolled in the Korean registry of acute myocardial infarction between January 2004 and August 2014, we identified 5532 patients who were event free from death, recurrent myocardial infarction, or stroke during the in‐hospital period after successful percutaneous coronary intervention. The co–primary outcomes were 3‐point major adverse cardiovascular events (a composite of nonfatal stroke, nonfatal myocardial infarction, and cardiovascular death) and cardiovascular death at 5 years. Of 5532 patients with acute myocardial infarction (mean age, 62.1±12.8 years; 75.0% men), 446 cardiovascular deaths (8.1%) and 695 three‐point major adverse cardiovascular events (12.6%) occurred at 5 years. In the continuous analysis of LDL‐C, the risk of cardiovascular events increased steeply as LDL‐C levels decreased from 100 mg/dL. For categorical analysis of LDL‐C (<70, 70–99, and ≥100 mg/dL), as LDL‐C levels decreased, clinical outcomes worsened (237/3759 [6.3%] in LDL‐C ≥100 mg/dL versus 123/1291 [9.5%] in LDL‐C 70–99 mg/dL versus 86/482 [17.8%] in LDL‐C <70 mg/dL for cardiovascular death; P‐trend<0.001; and 417/3759 [11.1%] in LDL‐C ≥100 mg/dL versus 172/1291 [13.3%] in LDL‐C 70–99 mg/dL versus 106/482 [22.2%] in LDL‐C <70 mg/dL for 3‐point major adverse cardiovascular event; P‐trend<0.001). In a Cox time‐to‐event multivariable model with LDL‐C levels ≥100 mg/dL as the reference, the baseline LDL‐C level <70 mg/dL was independently associated with an increased incidence of cardiovascular death (adjusted hazard ratio, 1.68 [95% CI, 1.30–2.17]) and 3‐point major adverse cardiovascular event (adjusted hazard ratio, 1.37 [95% CI, 1.10–1.71]).

Conclusions

In this Korean acute myocardial infarction registry, the baseline LDL‐C level <70 mg/dL was significantly associated with an increased incidence of long‐term cardiovascular events after discharge. (COREA [Cardiovascular Risk and Identification of Potential High‐Risk Population]‐Acute Myocardial Infarction Registry; NCT02806102).

Registration

URL: https://www.clinicaltrials.gov/; Unique identifier: NCT02806102.

Association between baseline smoking status and clinical outcomes following myocardial infarction

Background

Whether the effect of smoking on clinical outcomes following an acute myocardial infarction (AMI) is beneficial or detrimental remains inconclusive. We invesetigated the effect of smoking on the clinical outcomes in patients following an AMI.

Methods

Among 13,104 patients between November 2011 and June 2015 from a nationwide Korean AMI registry, a total of 10,193 participants were extracted then classified into two groups according to their smoking habit: (1) smoking group (n = 6,261) and (2) non-smoking group (n = 3,932). The participants who smoked were further subclassified according to their smoking intensity quantified by pack years (PYs): (1) <20 PYs (n = 1,695); (2) 20–40 PYs (n = 3,018); and (3) ≥40 PYs (n = 2,048). Each group was compared to each other according to treatment outcomes. The primary outcome was the incidence of major adverse cardiac and cerebrovascular events (MACCEs), which is a composite of all-cause mortality, non-fatal MI (NFMI), any revascularization, cerebrovascular accident, rehospitalization, and stent thrombosis. Secondary outcomes included the individual components of MACCEs. The Cox proportional hazard regression method was used to evaluate associations between baseline smoking and clinical outcomes following an AMI. Two propensity score weighting methods were performed to adjust for confounders, including propensity score matching and inverse probability of treatment weighting.

Results

While the incidence of all clinical outcomes, except for stent thrombosis, was lower in the smoking group than in the non-smoking group in the unadjusted data, the covariates-adjusted data showed statistical attenuation of these differences but a higher all-cause mortality in the smoking group. For smokers, the incidence of MACCEs, all-cause mortality, cardiac and non-cardiac death, and rehospitalization was significantly different between the groups, with the highest rates of MACCE, all-cause mortality, non-cardiac death, and rehospitalization in the group with the highest smoking intensity. These differences were statistically attenuated in the covariates-adjusted data, except for MACCEs, all-cause mortality, and non-cardiac death, which had the highest incidence in the group with ≥40 PYs.

Conclusion

Smoking had no beneficial effect on the clinical outcomes following an AMI. Moreover, for those who smoked, clinical outcomes tended to deteriorate as smoking intensity increased.

Successful implantation of a novel polymer-free everolimus-eluting stent using nitrogen-doped titanium dioxide film with good patency on follow-up angiography: A case report

RATIONALE

Despite technological advances in interventional cardiology during the last decades, many concerns remain regarding the narrowing and occlusion of the in-stent area. Particularly, polymer materials pose several problems, including chronic arterial inflammation, impaired arterial healing, and stent thrombosis. To avoid these complications, we invented the TIGEREVOLUTION stent with a cobalt-chromium alloy-based stent platform deposited with N-TiO2 film, which has demonstrated good biocompatibility. As this stent is not coated with polymer, it is expected to have decreased risk of stent thrombosis.

PATIENT CONCERNS

A 62-year-old Korean man visited our department because of angina. We commenced coronary angiography (CAG).

DIAGNOSIS

CAG revealed critical stenosis in the mid-portion of the right coronary artery, with a minimum lumen area of 1.08mm2 on optical coherence tomography (OCT).

INTERVENTION

Percutaneous coronary intervention was performed with implantation of a novel 3.5 × 26-mm polymer-free everolimus-eluting stent using nitrogen-doped titanium dioxide film (TIGEREVOLUTION® stent). Post-percutaneous coronary intervention OCT showed good stent expansion and apposition, and the patient was discharged successfully and uneventfully.

OUTCOMES

Eight months later, follow-up coronary angiography demonstrated good stent patency with no definitive evidence of in-stent restenosis, with thin stent strut coverage demonstrated on OCT.

LESSONS

We report the first case of TIGEREVOLUTION stent implantation with follow-up OCT at 8 months.

Predictors of recurrent acute myocardial infarction despite successful percutaneous coronary intervention

BACKGROUND/AIMS

Recurrent acute myocardial infarction (AMI) is an adverse cardiac event in patients with a first AMI. The predictors of recurrent AMI after the first AMI in patients who underwent successful percutaneous coronary intervention (PCI) have not been elucidated.

METHODS

We analyzed the data collected from 9,869 patients (63.2 ± 12.4 years, men:women = 7,446:2,423) who were enrolled in the Korea Acute Myocardial Infarction Registry-National Institute of Health between November 2011 and October 2015, had suffered their first AMI and had received successful PCI during the index hospitalization. Multivariable logistic regression analysis was performed to identify the independent predictors of recurrent AMI following the first AMI.

RESULTS

The cumulative incidence of recurrent AMI after successful PCI was 3.6% (359/9,869). According to the multivariable logistic regression analysis, the significant predictive factors for recurrent AMI were diabetes mellitus, renal dysfunction, atypical chest pain, and multivessel disease.

CONCLUSION

In this Korean prospective cohort study, the independent predictors of recurrent AMI after successful PCI for the first AMI were diabetes mellitus, renal dysfunction, atypical chest pain, and multivessel disease.

Comparison of outcomes after transcatheter aortic valve replacement between elderly (65-79 years) and super-elderly (≥80 years) patients

Transcatheter aortic valve replacement (TAVR) is an effective treatment option for patients with severe symptomatic aortic stenosis. Nonetheless, there is a paucity of data regarding the differences in the clinical outcomes of TAVR procedures between elderly and super-elderly patients. This study aimed to compare the clinical characteristics and outcomes of patients aged 65 to 79 years and ≥80 years who underwent TAVR for aortic stenosis. The clinical characteristics and outcomes of 134 patients with aortic stenosis who underwent TAVR were analyzed. Patients were categorized into 2 groups: an elderly group (EG; 65-79 years) and a super-elderly group (SEG) (≥80 years). The in-hospital and follow-up clinical outcomes were compared between the 2 groups. The EG tended to be more overweight, obese, and diabetic than the SEG, whereas the SEG had a higher surgical risk but lower creatinine clearance, hematocrit level, and effective orifice area than the EG. However, no difference was found in in-hospital clinical outcomes between the 2 groups, except for atrial fibrillation. In the propensity score matching and inverse probability of treatment weighting-adjusted analyses, these results were similar. All follow-up clinical outcomes were similar, except for rehospitalization, which was statistically attenuated after propensity score matching and inverse probability of treatment weighting-adjusted analyses. TAVR was associated with similar safety outcomes in the EG (65-79 years) and the SEG (≥80 years). Advanced age is not negatively associated with clinical outcomes after the TAVR procedure.

Treatment delay and outcomes of ST-segment elevation myocardial infarction treated by primary percutaneous coronary intervention during the COVID-19 era in South Korea

BACKGROUND/AIMS

Little is known about the clinical characteristics and treatment outcomes of ST-segment elevation myocardial infarction (STEMI) in Korea during the coronavirus disease 2019 (COVID-19) era. We aimed to evaluate the clinical characteristics and treatment outcomes of patients with STEMI in the COVID-19 era.

METHODS

A total of 588 consecutive patients with STEMI who underwent primary percutaneous coronary intervention were included in this study. The patients were categorized into the COVID-19 (from January 20, 2020 to December 31, 2020) and control groups (from January 20, 2019 to December 31, 2019).

RESULTS

The COVID-19 group showed pre-hospital and in-hospital delays than the control group. The control group underwent more thrombus aspiration and had a higher proportion of left main coronary artery diseases, while the COVID-19 group had a higher proportion of multivessel diseases with a marked increase in the number and total length of stents than the control group. As for the prescribed medications, the COVID-19 group was administered more beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and statins than the control group. The clinical outcomes were comparable between the groups, except for higher incidences of atrioventricular block and temporary pacemaker implantation in the COVID-19 group.

CONCLUSION

Reperfusion after STEMI treatment during the COVID-19 period was delayed; therefore, efforts should be made to improve on reperfusion.

Off-hour presentation and outcomes for percutaneous coronary intervention in acute myocardial infarction with Killip III-IV

BACKGROUND/AIMS

Acute myocardial infarction (AMI) is conventionally recognized as an urgent medical condition requiring timely and effective reperfusion therapy. However, the results of studies on the clinical outcomes in AMI according to hospital visit timings are inconclusive. To explore the difference in long-term outcomes between off- and on-hour percutaneous coronary interventions (PCI) in patients with AMI of Killip functional classification III-IV (Killip III-IV AMI).

METHODS

Data on the characteristics and clinical outcomes of 1,751 patients with Killip III-IV AMI between November 2011 and June 2015 from the Korea Acute Myocardial Infarction Registry-National Institutes of Health registry were analyzed. All participants were allocated into two groups: off-hour (weekdays from 6:00 PM to 8:00 AM, weekends, and legal holidays) and on-hour (weekdays from 8:00 AM to 6:00 PM) groups. The incidence of major adverse cardiac and cerebrovascular events, defined as a composite of all-cause mortality, nonfatal myocardial infarction, any revascularization, cerebrovascular accident, and stent thrombosis, was the primary endpoint.

RESULTS

Among the 1,751 patients, 572 (39.1%) underwent PCI during on-hours and 892 (60.9%) during off-hours. At the 3-year follow-up, no significant difference was found in the clinical outcomes between the two groups in both the unadjusted and propensity-score weighing-adjusted analyses.

CONCLUSION

The outcomes of patients with Killip III-IV AMI admitted during off- and on-hours were similar.

Long-term outcomes in ST-elevation myocardial infarction patients treated according to hospital visit time

BACKGROUND/AIMS

Rapid percutaneous coronary intervention (PCI) is the cornerstone of treatment for ST-elevation myocardial infarction (STEMI). However, there have been conflicting results regarding the differences in clinical outcomes between on-hours and off-hours presentation in STEMI patients. We aimed to examine the difference in long-term outcomes between off-hours and on-hours PCI in patients with STEMI.

METHODS

The characteristics and clinical outcomes of 5,364 STEMI patients between November 2011 and June 2015 from the Korea Acute Myocardial Infarction Registry-National Institutes of Health (KAMIR-NIH) registry were analyzed. Patients were divided into two groups: the off-hours group (weekdays from 6:01 PM to 7:59 AM, weekends, and legal holidays) and the on-hours group (weekdays from 8:00 AM to 6:00 PM). Major adverse cardiac and cerebrovascular events (MACCEs) were defined as a composite of allcause mortality, non-fatal myocardial infarction, any revascularization, cerebrovascular accident, and stent thrombosis. The primary endpoint was the occurrence of MACCEs, and all other clinical outcomes were analyzed.

RESULTS

A total of 3,119 patients (58.1%) underwent primary PCI due to STEMI during off-hours and 2,245 patients (41.9%) during on-hours. At 36 months, the clinical outcomes of the off-hours group were similar to those of the on-hours group in both the unadjusted and propensity score weighting-adjusted analyses.

CONCLUSION

Our analysis revealed that the long-term outcomes in STEMI patients admitted to hospitals during off-hours were similar to outcomes of those admitted during on-hours.

Prognostic Impact of Chronic Vasodilator Therapy in Patients With Vasospastic Angina

Background

Chronic vasodilator therapy with long‐acting nitrate is frequently used to treat vasospastic angina. However, the clinical benefits of this approach are controversial. We investigated the prognostic impact of vasodilator therapy in patients with vasospastic angina from the multicenter, prospective VA‐KOREA (Vasospastic Angina in KOREA) registry.

Methods and Results

We analyzed data from 1895 patients with positive intracoronary ergonovine provocation test results. The patients were divided into 4 groups: no vasodilator (n=359), nonnitrate vasodilator (n=1187), conventional nitrate (n=209), and a combination of conventional nitrate and other vasodilators (n=140). The primary end point was a composite of cardiac death, acute coronary syndrome, and new‐onset arrhythmia at 2 years. Secondary end points were the individual components of the primary end point, all‐cause death, and rehospitalization due to recurrent angina.

The groups did not differ in terms of the risk of the primary end point. However, the acute coronary syndrome risk was significantly higher in the conventional nitrate (hazard ratio [HR], 2.49; 95% CI, 1.01–6.14; P=0.047) and combination groups (HR, 3.34; 95% CI, 1.15–9.75, P=0.027) compared with the no‐vasodilator group, as assessed using the inverse probability of treatment weights. Subgroup analyses revealed prominent adverse effects of nitrate in patients with an intermediate positive ergonovine provocation test result and in those with low Japanese Coronary Spasm Association scores.

Conclusions

Long‐acting nitrate‐based chronic vasodilator therapy was associated with an increased 2‐year risk of acute coronary syndrome in patients with vasospastic angina, especially in low‐risk patients.

Religious Affiliations and Clinical Outcomes in Korean Patients With Acute Myocardial Infarction

Objective

Although religion is expected to have a direct or indirect effect on various aspects of human life, information on the association between religion and acute myocardial infarction (AMI) is inadequate. Hence, in this study, we aimed to investigate the clinical effect of religion on clinical outcomes in patients with AMI.

Methods

A total of 2,348 patients with AMI who were treated by percutaneous coronary intervention (PCI) were enrolled in the study, and they were categorized into two groups depending on their religious belief: religious and non-religious groups. The characteristics and clinical outcomes of both groups were compared.

Results

Compared with the religious group, the non-religious group was younger, included mostly men, was more likely to smoke, and was more likely to be diagnosed with ST-segment elevation myocardial infarction. However, the non-religious group was less likely to have a history of hypertension and tended to receive PCI more quickly with shorter door-to-balloon time. Regarding 1-year clinical outcomes, no differences were found between the two groups.

Conclusion

Despite a growing body of evidence that religious activities have positive effects on human physical health, our results showed a lack of significant differences in 1-year clinical outcomes in patients with AMI irrespective of their religious beliefs.

Outcomes of Nonagenarians with Acute Myocardial Infarction with or without Coronary Intervention

Percutaneous coronary intervention (PCI) is the mainstay treatment of acute myocardial infarction (AMI); however, many clinicians are reluctant to perform PCI in the elderly population. This study aimed to compare the clinical outcomes of PCI versus medical therapy in nonagenarian Korean patients with AMI. We compared the clinical outcomes of nonagenarian patients with AMI with or without PCI. From the pooled data, based on a series of Korean AMI registries during 2005−2020, 467 consecutive patients were selected and categorized into two groups: the PCI and no-PCI groups. The primary endpoint was 1-year major adverse cardiac event (MACE), a composite of all-cause death, non-fatal myocardial infarction, and any revascularization. Among the 467 participants, 68.5% received PCI. The PCI group had lower proportions of Killip classes III-IV, previous heart failure, and left ventricular ejection fraction <40%, but had higher proportions of all prescribed medications and STEMI diagnosis. The 1-year MACE and all-cause death were higher in the no-PCI group, although partially attenuated post-IPTW. Our study showed that nonagenarian patients with AMI undergoing PCI had better clinical outcomes than those without PCI. Nonetheless, further investigation is needed in the future to elucidate whether PCI is beneficial for this population.

Case Report: Intravascular Ultrasound-guided Intervention for Anastomosis Stenosis of the Left Main Coronary Artery Post-Cabrol Technique

Introduction

Some cases of percutaneous coronary intervention (PCI) for the anastomotic site between the Cabrol-type conduit and the left main coronary artery (LMCA) have been reported. Nevertheless, the combination of PCI with a detailed description of lesion appearance using virtual histology-intravascular ultrasound (VH-IVUS) has never been reported. In this study, we present a case of acute myocardial infarction that was successfully treated with intravascular ultrasound (IVUS)-guided PCI for focal stenosis at the anastomotic site, and the plaque composition was studied in detail.

Case Presentation

A 35-year-old Korean male with Behçet's disease was diagnosed with acute myocardial infarction. He had previously undergone three cardiothoracic surgeries including two aortic replacements, followed by modified Bentall operation with a Cabrol-type aortocoronary anastomosis. Coronary angiogram (CAG) showed focal critical stenosis at the anastomosis site between the conduit and the LMCA, and VH-IVUS showed fibrotic plaque with mainly fibrous tissue but without a confluent necrotic core. PCI was performed using a drug-eluting stent (4.5 × 12 mm, Synergy^TM, Boston Scientific, Marlborough, MA, USA). Since a repeat CAG and IVUS post-surgery showed an under-expanded stent strut, post-dilation ballooning was additionally performed. Subsequently, the repeat IVUS revealed wellapposed and optimized deployment of the drug-eluting stent with full lesion coverage. Final CAG showed optimal angiographic results. After successful PCI, the patient's anginal symptoms improved dramatically, and he was successfully discharged from our hospital.

Conclusion

This study presents an IVUS-guided PCI case for an anastomotic site between the conduit and the LMCA. It is the first to investigate the characteristics of this lesion through VH-IVUS, which demonstrated the presence of fibrous plaques at the anastomotic site. IVUS radiofrequency data allow for a detailed assessment of plaque composition and provide new insights into the histopathological nature of stenotic lesions at the anastomotic site, especially in patients with chronic inflammatory diseases like Behçet's disease.

Long-term clinical outcomes of type 1 vs. type 2 myocardial infarction in patients who underwent angiography: data from the Korea acute myocardial infarction-national institute of health registry

BACKGROUND

In the cause of increase the clinical research observational evidence on type 2 myocardial infraction (T2MI), the study compared the characteristics of T2MI and T1MI with respect to major adverse cardiac events (MACE) and mortality as long-term outcomes from a large, nationwide, prospective Korean cohort registry.

METHODS

From 13,105 consecutively enrolled individuals in the Korea Acute Myocardial Infarction-National Institute of Health (KAMIR-NIH) registry between October 2011 and December 2015, 11,053 acute myocardial infarction (AMI) patients were divided into the T1MI (n=10,545) and T2MI (n=508) groups. All patients completed ≥3 years of follow-up.

RESULTS

The Kaplan-Meier curve analysis and Cox proportional hazard regression models showed that the cumulative rate of MACE was similar between the 2 groups (11.4% vs. 13.4%, log-rank P=0.185) at 3 years. However, the T2MI group showed higher rates of all-cause death [12.6% vs. 9.4%, log-rank P=0.019; hazard ratio (HR), 1.42; 95% CI: 1.08-1.85; P=0.012] and non-cardiac death (3.5% vs. 5.3%, log-rank P=0.043; HR, 1.55; 95% CI: 1.01-2.37; P=0.043) than the T1MI group. Male sex (HR 1.540; 95% CI: 1.218-1.947, P<0.001), old age (≥65 years; HR, 3.546; 95% CI: 2.645-4.753, P<0.001), low hemoglobin level (<12 g/dL; HR, 2.335; 95% CI: 1.841-2.961, P<0.001), high heart rate (>100 beats/min; HR, 1.852; 95% CI: 1.436-2.388, P<0.001), low glomerular filtration rate (GFR) (<60 mL/min/1.73 m2; HR, 2.373; 95% CI: 1.874-3.005, P<0.001), high body mass index (>25 kg/m2; HR, 0.644; 95% CI: 0.514-0.805, P<0.001), and low left ventricular ejection fraction (LVEF) (<40%; HR, 1.487; 95% CI: 1.095-2.020, P=0.011) were the independent predictors for 3-year non-cardiac mortality.

CONCLUSIONS

Although the 2 groups did not differ in MACE, the total mortality rate was higher in T2MI than in T1MI, especially non-cardiac mortality. The independent predictors for non-cardiac mortality were male sex, old age, anemia, low GFR, tachycardia, obesity, and low LVEF.

Comparison of Prognosis According to the Use of Emergency Medical Services in Patients with ST-Segment Elevation Myocardial Infarction

PURPOSE

This study aimed to compare long-term clinical outcomes according to the use of emergency medical services (EMS) in patients with ST-segment elevation myocardial infarction (STEMI) who arrived at the hospital within 12 hr of symptom onset.

MATERIALS AND METHODS

A total of 13104 patients with acute myocardial infarction were enrolled in the Korea Acute Myocardial Infarction Registry-National Institutes of Health from October 2011 to December 2015. Of them, 2416 patients with STEMI who arrived at the hospital within 12 hr were divided into two groups: 987 patients in the EMS group and 1429 in the non-EMS group. Propensity score matching (PSM) was performed to reduce bias from confounding variables. After PSM, 796 patients in the EMS group and 796 patients in the non-EMS group were analyzed. The clinical outcomes during 3 years of clinical follow-up were compared between the two groups according to the use of EMS.

RESULTS

The symptom-to-door time was significantly shorter in the EMS group than in the non-EMS group. The EMS group had more patients with high Killip class compared to the non-EMS group. The rates of all-cause death and major adverse cardiac events (MACE) were not significantly different between the two groups. After PSM, the rate of all-cause death and MACE were still not significantly different between the EMS and non-EMS groups. The predictors of mortality were high Killip class, renal dysfunction, old age, long door-to-balloon time, long symptom-to-door time, and heart failure.

CONCLUSION

EMS utilization was more frequent in high-risk patients. The use of EMS shortened the symptom-to-door time, but did not improve the prognosis in this cohort.

Successful subclavian transcatheter aortic valve replacement in a nonagenarian patient: Case report and review of literature

RATIONALE

In super-aged patients with severe symptomatic aortic stenosis, transcatheter aortic valve replacement (TAVR) is a good treatment option, and the number of TAVR-eligible elderly patients is expected to grow exponentially. We present the case of a nonagenarian woman with severe aortic stenosis who underwent successful subclavian TAVR.

PATIENT CONCERNS

A 90-year-old Korean woman was brought to our department with dyspnea. On physical examination, a grade IV systolic murmur was auscultated in both the upper sternal borders and the left lower sternal border.

DIAGNOSIS

A transthoracic echocardiogram showed heavy calcification of the aortic valve with an increase in both peak velocity (4.36 m/s) and mean pressure (44.8 mm Hg), indicating severe symptomatic aortic stenosis.

INTERVENTIONS

After a heart team conference involving interventional cardiologists, cardiac surgeons, and anesthesiologists, subclavian TAVR was performed. Using the left subclavian artery, we successfully deployed a self-expandable valve prosthesis (CoreValveTM Evolut RTM, Medtronic Inc., Minneapolis, MN).

OUTCOMES

After TAVR, transthoracic echocardiogram showed a decline in both peak velocity (2.06-2.14 m/s) and mean pressure (7.42-7.95 mm Hg) with an increase in the aortic valve area (1.12 cm2). The patient's dyspnea symptoms improved dramatically.

LESSONS

In addition to femoral TAVR, subclavian TAVR may be feasible and safe in super-aged patients.

Clinical impact of pulmonary hypertension on the outcomes of acute myocardial infarction patients with or without chronic obstructive pulmonary disease

Acute myocardial infarction (AMI) and chronic obstructive pulmonary disease (COPD) are leading global causes of morbidity and mortality. In patients with both of these conditions, the presence of pulmonary hypertension (PH) can further worsen their prognosis. We examined the outcomes of AMI patients with COPD (AMI+COPD) and without COPD (AMI-COPD), depending on the presence or absence of PH.A total of 318 AMI patients with COPD (AMI+COPD cohort) (n = 109) or without COPD (AMI-COPD cohort) (n = 209) were included in this study and were subdivided into 2 groups according to right ventricular systolic pressure (RVSP) level (PH group [RVSP ≥35 mm Hg] and no PH group [RVSP <35 mm Hg]).We investigated characteristics and clinical outcomes in both the AMI-COPD and AMI+COPD cohorts. When investigating in-hospital clinical outcomes, the PH group had a higher proportion of new-onset heart failure (HF) in both cohorts. In the AMI+COPD cohort, however, the PH group had a higher incidence of cardiogenic shock than the no PH group, which was consistent with the result of the post-inverse probability of treatment weighting (IPTW) analysis. When investigating 1-year clinical outcomes, the PH group had higher incidences of a major adverse cardiac event and all-cause mortality in both cohorts. This finding was mainly driven by cardiac death in the AMI-COPD cohort, whereas it was mainly driven by non-cardiac death in the AMI+COPD cohort. After IPTW adjustment, these differences were statistically attenuated such that all variables were similar between both groups.PH may be associated with the development of new-onset HF (in all patients) and cardiogenic shock (in the AMI+COPD cohort). In addition, PH may be also associated with all-cause mortality, although it was statistically attenuated after IPTW adjustment.

Prognostic Value of Baseline Neutrophil-to-Lymphocyte Ratio Combined With Anemia in Patients With ST-Segment Elevation Myocardial Infarction: A Nationwide Prospective Cohort Study

Objective

Data pertaining to the prognostic value of the combination of high neutrophil-to-lymphocyte ratio (NLR) and anemia on admission in patients with ST-segment elevation myocardial infarction (STEMI) are limited. The objective of this study was to investigate the clinical value of baseline NLR in combination with anemia in predicting clinical outcomes after STEMI.

Methods

A total of 5,194 consecutive patients with STEMI within 12 hours of symptom onset from the Korea Acute Myocardial Infarction Registry-National Institute of Health database between 2011 and 2015 were categorized into 4 groups according to their NLR and hemoglobin levels: low NLR (<4) without anemia (n=2,722; reference group); high NLR (≥4) without anemia (n=1,527); low NLR with anemia (n=508); and high NLR with anemia (n=437). The co-primary outcomes were 180-day and 3-year all-cause mortality.

Results

Mortality rates significantly increased at the 3-year follow-up across the groups (3.3% vs. 5.4% vs. 16.5% vs. 21.7% for 180-day mortality and 5.3% vs. 9.0% vs. 23.8% vs. 33.4% for 3-year mortality; all p-trends <0.001). After adjusting for baseline covariates, the combination of high NLR and anemia was a significant predictor of 180-day mortality after STEMI with low NLR and no anemia as the reference (adjusted hazard ratio, 2.16; 95% confidence interval, 1.58–2.95; p<0.001). Similar findings were observed for the 3-year mortality.

Conclusions

This nationwide prospective cohort study showed that the combination of high NLR (≥4) and anemia is a strong predictor of all-cause mortality after STEMI.

Different outcomes between iso-osmolar and low-osmolar contrast media in acute myocardial infarction with renal impairment

BACKGROUND

The selection of appropriate contrast media (CM) remains an important issue in terms of renal preservation in patients with acute myocardial infarction (AMI) and renal impairment scheduled for percutaneous coronary intervention (PCI). We compared the clinical outcomes of patients with AMI and renal impairment, depending on the CM type (iso-osmolar CM [IOCM] vs. low-osmolar CM [LOCM]) that was used during PCI.

METHODS

From the Convergent Registry of Catholic and Chonnam University for Acute Myocardial Infarction, 3174 post-PCI patients with AMI and renal impairment were subdivided into two groups (IOCM [n = 2101] and LOCM [n = 1073]).

RESULTS

Regarding in-hospital clinical outcomes, the IOCM group had a higher peak creatinine (Cr) level and lower "Cr differential" than the LOCM group. A higher proportion of dialysis was noted in the IOCM group. In 30-day clinical outcomes, the IOCM group showed higher incidence of new-onset heart failure (HF) but lower incidence of revascularization than the LOCM group. The differences in in-hospital and 30-day clinical outcomes were attenuated after inverse probability of treatment weighting, except for new-onset HF. All other variables in 30-day clinical outcomes, including all-cause death, non-fatal myocardial infarction, cerebrovascular accidents, stent thrombosis, and any dialysis events, were similar between the two groups.

CONCLUSIONS

IOCM use did not prevent future incidence of dialysis compared to LOCM use in AMI patients with renal impairment.

Optimal low-density lipoprotein cholesterol target level in Korean acute myocardial infarction patients (<70 mg/dL vs. <55 mg/dL): Based on Korea acute myocardial infarction registry-National Institute of Health

BACKGROUND

Current treatment guidelines for acute myocardial infarction (AMI) recommend lowering low density lipoprotein cholesterol (LDL-C). However, previous clinical studies among East Asian AMI patients failed to prove its clinical efficacy of lipid lowering therapy based on Western target LDL-C level. Thus, the purpose of this study is directly to compare the clinical outcomes of target LDL-C < 70 mg/dL and < 55 mg/dL and identify optimal target LDL-C level and in Korean AMI patients.

METHODS AND RESULTS

A total of 2198 AMI patients in Korea AMI Registry - National Institute of Health were enrolled. Patients were initially divided into LDL-C non-target group (n = 1115) and target group (n = 1083). Successful achievement of follow up target LDL-C was defined as <70 mg/dL and ≥ 50% reduction from baseline. Target group patients were additionally divided to <70 mg/dL group (n = 698) and <55 mg/dL group (n = 385). Propensity score matching analysis was done in non-target vs. target group and <70 mg/dL vs. <55 mg/dL group. In the matched population, the risk of 3 years major adverse cardiac event (MACE) (13.0% vs 9.8%, HR: 0.73; 95% CI: 0.56-0.96; p = 0.025) was higher in non-target group patients. However, the risk of MACE was similar in <70 mg/dL and < 55 mg/dL group patients (10.0% vs 8.1%, HR: 0.75, 95% CI: 0.46-1.22; p = 0.247).

CONCLUSION

In the present study, target LDL-C level of <70 mg/dL and ≥ 50% reduction from baseline level was associated with better clinical outcomes in Korean AMI patients. However, further lowering target LDL-C level of <55 mg/dL showed no additional benefits.

Preclinical Evaluation of a Novel Polymer-free Everolimus-eluting Stent in a Mid-term Porcine Coronary Restenosis Model

BACKGROUND

Titanium dioxide films exhibit good biocompatibility and may be effective as drug-binding matrices for drug-eluting stents. We conducted a mid-term evaluation of a novel polymer-free everolimus-eluting stent using nitrogen-doped titanium dioxide film deposition (TIGEREVOLUTION^®) in comparison with a commercial durable polymer everolimus-eluting stent (XIENCE Alpine^®) in a porcine coronary restenosis model.

METHODS

Twenty-eight coronary arteries from 14 mini-pigs were randomly allocated to TIGEREVOLUTION^® stent and XIENCE Alpine^® stent groups. The stents were implanted in the coronary artery at a 1.1-1.2:1 stent-to-artery ratio. Eleven stented coronary arteries in each group were finally analyzed using coronary angiography, optical coherence tomography, and histopathologic evaluation 6 months after stenting.

RESULTS

Quantitative coronary analysis showed no significant differences in the pre-procedural, post-procedural, and 6-month lumen diameters between the groups. In the volumetric analysis of optical coherence tomography at 6 months, no significant differences were observed in stent volume, lumen volume, and percent area stenosis between the groups. There were no significant differences in injury score, inflammation score, or fibrin score between the groups, although the fibrin score was zero in the TIGEREVOLUTION^® stent group (0 vs. 0.07 ± 0.11, P = 0.180).

CONCLUSION

Preclinical evaluation, including optical coherence tomographic findings 6 months after stenting, demonstrated that the TIGEREVOLUTION^® stent exhibited efficacy and safety comparable with the XIENCE Alpine^® stent, supporting the need for further clinical studies on the TIGEREVOLUTION^® stent.

Transcatheter aortic valve replacement via a transsubclavian approach in a patient with severe aortic stenosis who had previously undergone kidney transplantation: A case report

RATIONALE

Although the transfemoral approach is the gold standard for transcatheter aortic valve replacement (TAVR), it is not feasible in a considerable number of patients. We report a case of successful transsubclavian TAVR (TS-TAVR) in a patient with severe aortic stenosis (AS) who was ineligible for transfemoral TAVR because she was a kidney transplant recipient.

PATIENT CONCERNS

A 72-year-old Korean woman, who had previously undergone kidney transplantation in the right iliac fossa for end-stage kidney disease, was admitted to our center with dyspnea. Upon auscultation, grade IV systolic murmurs were detected in both upper sternal borders and the left lower sternal border, suggestive of valvular heart disease.

DIAGNOSIS

Two-dimensional transthoracic echocardiography revealed heavy calcification of the aortic valve with a high peak velocity (4.54 m/s) and mean pressure gradient (48.49 mm Hg), indicative of severe AS.

INTERVENTIONS

TS-TAVR was performed by a heart team comprised of interventional cardiologists, cardiac surgeons, and anesthesiologists. A self-expandable valve prosthesis (CoreValveTM Evolut RTM, Medtronic Inc., Minneapolis, MN) was successfully deployed via the left subclavian artery.

OUTCOMES

Post-TAVR 2-dimensional transthoracic echocardiography demonstrated a well-functioning valve with mild paravalvular leakage. The peak velocity had declined from 4.54 m/s to 2.22 to 2.24 m/s, and the mean pressure gradient had declined from 48.49 to 8.57-9.61 mmHg. The patient was discharged successfully and uneventfully.

LESSONS

Because kidney transplant recipients with severe AS are considered poor candidates for transfemoral TAVR, TS-TAVR is a suitable alternative to consider.

Comparison of long-term clinical outcomes among zotarolimus-, everolimus-, and biolimus-eluting stents in acute myocardial infarction patients with renal impairment

BACKGROUND

It is important to determine the best drug-eluting stent (DES) for acute myocardial infarction (AMI) in patients with renal impairment. In this studythe outcomes of everolimus-eluting stents (EESs), zotarolimus-eluting stents (ZESs) and biolimus-eluting stents (BESs) were evaluated.

METHODS

From the Korea Acute Myocardial Infarction-National Institutes of Health registry, a total of 1,470 AMI patients with renal impairment undergoing percutaneous coronary intervention (PCI) were enrolled (816 with EES, 345 with ZES, and 309 with BES). Renal impairment was defined as creatinine clearance < 60 mL/min/1.73 m² estimated by the Cockcroft-Gault method. Major adverse cardiac and cerebrovascular events were determined as the composite of all-cause death, non-fatal myocardial infarction (MI), cerebrovascular accident, any revascularization, rehospitalization and stent thrombosis. All clinical outcomes were analyzed.

RESULTS

The baseline characteristics of the patients revealed no significant difference between the three groups, except for Killip classification > 2, beta-blockers, lesion type, vascular approach, staged PCI, left main coronary artery (LMCA) complex lesions, LMCA PCI, and the number and length of implanted stents. In the Kaplan-Meier analysis, similar clinical outcomes were derived from the unadjusted data between the three DES groups. However, after the inverse probability of treatment weighting, a statistically significant difference was found in non-fatal MI, which implied a higher incidence of non-fatal MI in the ZES group than in the other two DES groups.

CONCLUSIONS

In AMI patients with renal impairment, there was no significant difference between the three stent groups in terms of long-term clinical outcomes, except for non-fatal MI.

A model of atherosclerosis using nicotine with balloon overdilation in a porcine

Pigs are important experimental animals for cardiovascular research. Few porcine coronary atherosclerosis models have been developed; however, their induction requires more than six months. We developed a porcine coronary artery atherosclerosis model using nicotine injection with a balloon overdilation. A coronary balloon was placed in the porcine coronary artery and overdilated to induce a mechanical injury. Nicotine was administrated via intramuscular injection every day, and changes in the coronary artery were observed after four weeks. Coronary angiography revealed nicotine injection with a balloon overdilation group showed narrowing of the coronary artery at the injury site. The combination of balloon and nicotine significantly increased the intimal hyperplasia in optical coherence tomography analysis. Proliferated tunica media were noted in the nicotine injection with balloon overdilation groups and lack of collagen was observed in the tunica media at eight weeks. Quantitative analysis showed increased smooth muscle actin alpha (SMA), cluster of differentiation 68 (CD68), and Krüppel-like factor 4 (KLF4) in the nicotine injection with balloon overdilation groups. Immunohistochemistry results showed CD68-positive cells displayed SMA- and KLF4-positive reactivity in the border zone of the intimal hyperplasia. Our results show that nicotine injection with balloon overdilation can induce atherosclerotic lesions within one month, which can serve as an alternative pig animal model for the development of coronary stents.

The change in high-sensitivity troponin-T as a risk factor for significant coronary stenosis in patients with acute coronary syndrome

BACKGROUND/AIMS

High-sensitivity cardiac troponin (hs-TnT) assays detect very low levels of cardiac troponin. This study examined the interval change between initial and subsequent hs-TnT levels and evaluated its ability to predict significant coronary stenosis.

METHODS

The study analyzed 163 patients who presented with acute coronary syndrome (ACS) and underwent coronary angiography (CAG) between April 2014 and May 2018. The 0 and 3-hour hs-TnT were checked. The patients were subdivided into positive (n = 32) and negative (n = 131) interval change groups. The presence of significant coronary artery stenosis on CAG in the two groups was compared.

RESULTS

The positive interval change group was older and had higher 0 and 3-hour hs-TnT and blood glucose levels than the negative interval change group. Significant coronary stenosis was more common in the positive interval change group than in the negative interval change group (68.8% vs. 23.7%, p = 0.001). However, vasospasm was more common in the negative interval change group (6.3% vs. 31.3%, p = 0.003). The positive interval change group had higher rates of bifurcation lesions and received more percutaneous coronary intervention. In multivariate analysis, age, interval change of serial hs-TnT and diabetes mellitus were independent predictors of significant coronary artery stenosis.

CONCLUSION

This study identified a relationship between the serial change in cardiac biomarkers and the presence of significant coronary stenosis in patients with ACS. Serial hs-TnT change was associated with real angiographic stenosis in patients with ACS.

Higher Long-Term Mortality in Patients with Non-ST-Elevation Myocardial Infarction than ST-Elevation Myocardial Infarction after Discharge

PURPOSE

This study aimed to compare mortality rates after discharge between the patients with non-ST-elevation myocardial infarction (NSTEMI) and those with ST-elevation myocardial infarction (STEMI), and identify each mortality risk factors in these two types of myocardial infarction.

MATERIALS AND METHODS

Between 2011 and 2015, 13105 consecutive patients were enrolled in the Korea Acute Myocardial Infarction-National Institute of Health registry (KAMIR-NIH); 12271 patients with acute myocardial infarction met the inclusion criteria and were further stratified into the STEMI (n=5828) and NSTEMI (n=6443) groups. The occurrence of mortality and cardiac mortality at 3 years were compared between groups, and the factors associated with mortality for NSTEMI and STEMI were evaluated.

RESULTS

The comparison between these two groups and long-term follow-up outcomes showed that the cumulative rates of all-cause and cardiac mortality were higher in the NSTEMI group than in the STEMI group [all-cause mortality: 10.9% vs. 5.8%; hazards ratio (HR), 0.464; 95% confidence interval (CI), 0.359-0.600, p<0.001; cardiac mortality: 6.6% vs. 3.5%, HR, 0.474; 95% CI, 0.344-0.654, p<0.001, respectively). In the NSTEMI group, low left ventricular ejection fraction (LVEF; <40%), no percutaneous coronary intervention (PCI), old age (≥65 years), and low hemoglobin level (<12 g/dL) were identified as risk factors for 3-year mortality. In the STEMI group, old age, low glomerular filtration rate (<60 mL/min/1.73 m²), low LVEF, high heart rate (>100 beats/min), no PCI, and low hemoglobin level were identified as the risk factors for 3-year mortality.

CONCLUSION

The NSTEMI group had higher mortality compared to the STEMI group during the 3-year clinical follow-up after discharge. Low LVEF and no PCI were the main risk factors for mortality in the NSTEMI group. In contrast, old age and renal dysfunction were the risk factors for long-term mortality in the STEMI group.

Long-Term Outcomes of Patients With Late Presentation of ST-Segment Elevation Myocardial Infarction

BACKGROUND

Real-world data on baseline characteristics, clinical practice, and outcomes of late presentation (12 to 48 h of symptom onset) in patients with ST-segment elevation myocardial infarction (STEMI) are limited.

OBJECTIVES

This study aimed to investigate real-world features of STEMI late presenters in the contemporary percutaneous coronary intervention (PCI) era.

METHODS

Of 13,707 patients from the Korea Acute Myocardial Infarction Registry-National Institutes of Health database, 5,826 consecutive patients diagnosed with STEMI within 48 h of symptom onset during 2011 to 2015 were categorized as late (12 to 48 h; n = 624) or early (<12 h; n = 5,202) presenters. Coprimary outcomes were 180-day and 3-year all-cause mortality.

RESULTS

Late presenters had remarkably worse clinical outcomes than early presenters (180-day mortality: 10.7% vs. 6.8%; 3-year mortality: 16.2% vs. 10.6%; both log-rank p < 0.001), whereas presentation at ≥12 h of symptom onset was not independently associated with increased mortality after STEMI. The use of invasive interventional procedures abruptly decreased from the first (<12 h) to the second (12 to 24 h) 12-h interval of symptom-to-door time ("no primary PCI strategy" increased from 4.9% to 12.4%, and "no PCI" from 2.3% to 6.6%; both p < 0.001). Mortality rates abruptly increased from the first to the second 12-h interval of symptom-to-door time (from 6.8% to 11.2% for 180-day mortality; from 10.6% to 17.3% for 3-year mortality; all p < 0.05).

CONCLUSIONS

Data from a nationwide prospective Korean registry reveal that inverse steep differences in the use of invasive interventional procedures and mortality rates were found between early and late presenters after STEMI. A multidisciplinary approach is required in identifying late presenters of STEMI who can benefit from invasive interventional procedures until further studied.

Sex differences in long-term clinical outcomes of acute myocardial infarction according to the presence of diabetes mellitus

BACKGROUND/AIMS

This study compared long-term clinical outcomes between male and female acute myocardial infarction (AMI) patients with and without diabetes mellitus (DM).

METHODS

From November 2011 to December 2015, 13,104 patients with AMI were enrolled in the Korea Acute Myocardial Infarction Registry National Institutes of Health (KAMIR-NIH) (4,458 diabetic patients and 8,646 non-diabetic patients). Propensity score matching (PSM) was used to reduce bias due to confounding variables. Following PSM, 2,046 diabetic patients, 1,023 males (69.8 ± 9.4 years) and 1,023 females (69.9 ± 9.4 years); and 3,412 non-diabetic patients, 1,706 males (70.0 ± 10.4 years) and 1,706 females (70.4 ± 10.8 years) were analyzed. Clinical outcomes were compared between male and female patients with and without diabetes over a 3-year clinical follow-up.

RESULTS

In diabetic patients, mortality (21.1% vs. 21.5%, p = 0.813) and major adverse cardiac events (MACE) (30.6% vs. 31.4%, p = 0.698) were not significantly different between males and females. However, mortality (15.8% vs. 12.0%, p = 0.002) and MACE (20.8% vs. 15.6%, p < 0.001) were significantly higher in male non-diabetic patients than in female non-diabetic patients. The predictors of mortality for both males and females in the diabetic and non-diabetic groups were old age, heart failure, renal dysfunction, anemia, and no percutaneous coronary intervention.

CONCLUSION

The long-term clinical outcomes in AMI patients with DM did not significantly differ by sex. However, the mortality and MACE in non-diabetic male patients were higher than those in females.

Clinical Benefit of Statins in Korean Patients with Acute Myocardial Infarction: Experience of the Korea Acute Myocardial Infarction Registry

Statins (3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitor) are among the most important medications for treating patients with acute myocardial infarction (AMI). Herein, we review the clinical benefit and future scope of statin therapy in Korean patients with AMI from the experience of the Korea AMI Registry. Statins are effective and safe in AMI patients, even in those with very low low-density lipoprotein cholesterol (LDL-C). Peri-procedural statin treatment could reduce the incidence of early stent thrombosis in patients with AMI after percutaneous coronary intervention. Reduction of high sensitivity C-reactive protein levels in patients with AMI plays an important role in the beneficial effect of statins on regression and compositional change of coronary plaques. Obtaining ≥50% reduction in LDL-C is associated with better clinical outcomes after AMI, whereas achieving <70 mg/dL LDL-C is not. Statin therapy has positive effects on clinical outcomes in patients with cardiogenic shock, ischemic heart failure, chronic kidney disease, and vasospasm. The combination of high-dose statin plus N-acetyl cysteine is associated with lower incidence of contrast-induced nephropathy in patients who underwent primary percutaneous coronary intervention. Moderate-intensity pitavastatin therapy is associated with a lower incidence of new-onset diabetes mellitus in patients with AMI and has similar clinical outcomes to moderate-intensity atorvastatin and rosuvastatin therapy. Future studies are required to assess the optimal intensity and LDL-C target concerning statin therapy, and the implementation of guidelines based cholesterol lowering practice in Korean patients with AMI.