Impact of COVID-19 pandemic on emergency medical system and management strategies in patients with acute coronary syndrome

The global coronavirus disease-2019 (COVID-19) pandemic is associated with reduced rate of percutaneous coronary intervention (PCI). However, there were a few data showing how emergency medical system (EMS) and management strategies for acute coronary syndrome (ACS) changed during the pandemic. We sought to clarify changes on characteristics, treatments, and in-hospital mortality of patients with ACS transported via EMS between pre- and post-pandemic. We examined consecutive 656 patients with ACS admitted to Sapporo City ACS Network Hospitals between June 2018 and November 2021. The patients were divided into pre- and post-pandemic groups. The number of ACS hospitalizations declined significantly during the pandemic (proportional reduction 66%, coefficient -0.34, 95% CI -0.50 to -0.18, p < 0.001). The median time from an EMS call to hospital was significantly longer in post-pandemic group than in pre-pandemic group (32 [26-39] vs. 29 [25-36] min, p = 0.008). There were no significant differences in the proportion of patients with ACS receiving PCI, and in-hospital mortality between the groups. The COVID-19 pandemic had a significant impact on EMS and management in patients with ACS. Although a significant decline was observed in ACS hospitalizations, the proportion of patients with ACS receiving emergency PCI remained during the pandemic.

Involvement of growth differentiation factor 15 in paradoxical relationship between body mass index and mortality in patients with suspected or known coronary artery disease; The ANOX Study

Background

Obesity is a well-established risk factor for type 2 diabetes mellitus, hypertension and dyslipidemia, leading to coronary artery disease (CAD). Nevertheless, body mass index (BMI) is inversely associated with cardiovascular (CV) mortality in patients with cardiac disorders, termed “obesity paradox”. However, the underlying mechanism remains unclear.

Purpose

To clarify important factors involved in the pathogenesis of obesity paradox.

Methods

Using data from a multicenter, prospective cohort of 2,418 patients with suspected or known CAD enrolled in the ANOX study, we assessed the relationship between BMI at baseline and the incidence of CV death over 3 years, and investigated the involvement of several endocrine factors which were previously reported to have some roles in obesity and heart diseases, such as adiponectin, N-terminal pro-brain natriuretic peptide (NT-proBNP) and growth differentiation factor 15 (GDF-15), in the relationship between BMI and CV death.

Results

In Kaplan-Meier analyses, the lower quartiles of BMI and the higher quartiles of adiponectin levels were paradoxically associated with the higher cumulative incidence of CV death. To clarify the important factors involved in the paradoxical association between BMI or adiponectin and mortality, we first investigated independent determinants for BMI and adiponectin levels respectively, using multiple stepwise regression analyses among many clinical factors, and then narrow down the prognostic factors commonly associated with BMI and adiponectin, which were age, hemoglobin and NT-proBNP. Interestingly, circulating levels of GDF15 were significantly correlated with NT-proBNP levels, and the presence of anemia raised the gradient of the correlation line in a scatter plot (without anemia, r=0.139, p&lt;0.0001; with anemia, r=0.228, p&lt;0.0001). Moreover, the highest GDF15 quartile showed significantly lower BMI and higher adiponectin levels compared to the lower quartiles (p&lt;0.001 and p&lt;0.001, respectively, by Student t-test). In Cox proportional hazard models, hazard ratios (HRs) of BMI (per 1-unit increase) were 0.90 (95% confidence interval [CI], 0.85–0.96) for CV death. Additional adjustment for hemoglobin, NT-proBNP, adiponectin or GDF15 diminished the statistical significance (HR, 0.92 [95% CI, 0.87–0.99], 0.95 [0.89–1.01], 0.92 [0.87–0.99], or 0.93 [0.87–0.99], respectively).

Conclusions

The lower BMI and the higher adiponectin levels were paradoxically associated with the higher incidence of CV death in patients with CAD. This paradox may be mediated by cardiac endocrine factors induced by cardiac stresses, including GDF-15 in addition to natriuretic peptides.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization.

Vascular endothelial factor C and D in patients with heart failure with preserved, mildly reduced, and reduced ejection fraction: the PREHOSP-CHF study

Background

The lymphatic system has been suggested to play an important role in cardiovascular diseases including heart failure (HF). Vascular endothelial growth factor C (VEGF-C) and D (VEGF-D) are key regulators of lymphangiogenesis, and we recently reported the association of low VEGF-C with the risk of all-cause death and high VEGF-D with the risk of HF hospitalization in patients with HF.

Purpose

To investigate the association of VEGF-C and VEGF-D with prognosis in patients with HF with preserved ejection fraction (EF) (HFpEF: EF≥50%), mildly reduced EF (HFmrEF: EF, 40–49%), and reduced EF (HFrEF: EF&lt;40%).

Methods

The PREHOSP-CHF study is a multicenter prospective cohort study to determine the predictive value of angiogenesis-related biomarkers in HF. A total of 1,024 patients (mean age 75.5±12.6 years; 58.7% male) admitted to acute decompensated HF were included in the analyses. Serum levels of VEGF-C and VEGF-D, as well as N-terminal pro B-type natriuretic peptide (NT-proBNP), high sensitivity cardiac troponin-I (hs-cTnI), high sensitivity C reactive protein, were measured at the time of discharge. Patients were followed-up over two years.

Results

The numbers of HFpEF, HFmrEF, and HFrEF were 429 (41.9%), 186 (18.2%), and 409 (39.9%), respectively. HFpEF patients were older, more likely to be female, and had more hypertension, atrial fibrillation, and anemia, but less coronary artery disease. NT-proBNP and hs-cTnI levels increased with decreasing EF. VEGF-C levels decreased with increasing EF (median [interquartile range]: HFpEF, 4508 [3318–5919] pg/ml; HFmrEF, 4719 [3663–6203] pg/ml; HFrEF, 5023 [3804–6382] pg/ml), whereas VEGF-D levels were comparable among the three EF groups (HFpEF, 404.6 [293.1–560.3] pg/ml; HFmrEF, 386.0 [298.5–556.3] pg/ml; HFrEF, 414.2 [296.1–557.3] pg/ml). In multivariate stepwise logistic regression analyses, anemia and high NT-proBNP were independently associated with low VEGF-C levels, and high NT-proBNP was independently associated with high VEGF-D levels, across all the EF groups. During the follow-up, incidences of all-cause death and HF hospitalizations were similar among the three EF groups (log-rank P=0.6 for all-cause death, and log-rank P=0.3 for HF hospitalization). On multivariate Cox proportional hazard analyses including established risk factors and cardiovascular biomarkers, VEGF-C levels tended to be inversely associated with the incidence of all-cause death in patients with HFpEF and HFrEF (Figure). On the contrary, VEGF-D levels were significantly and positively associated with the incidence of HF hospitalization in patients with HFpEF, and tended to be positively associated with it in patients with HFmrEF and HFrEF (Figure).

Conclusions

Low VEGF-C was associated with the risk of all-cause death in patients with HFpEF and HFrEF, while high VEGF-D was associated with the risk of HF hospitalization especially in HFpEF.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Grant-in-Aid for Clinical Research from the National Hospital Organization

Associations of soluble fms-like tyrosine kinase-1 with cardiovascular events and stroke in patients with atrial fibrillation and suspected or known coronary artery disease: the EXCEED-J study

Background

Atrial fibrillation (AF) increases the risk of stroke. Soluble fms-like tyrosine kinase-1 (sFlt-1), a vascular endothelial growth factor (VEGF) antagonist, has been suggested as a marker of endothelial dysfunction, which are associated with both AF and coronary artery disease (CAD). Recently, we demonstrated that sFlt-1 is independently associated with major adverse cardiovascular (CV) events (MACE) in patients with suspected or known CAD. However, the prognostic utility of sFlt-1 in patients with AF remains unknown.

Methods

Using data from a multicenter, prospective cohort of 3255 patients with suspected or known CAD, we investigated whether AF modifies the prognostic utility of sFlt-1. Heparin-free serum levels of sFlt-1, N-terminal pro-brain natriuretic peptide, high-sensitivity cardiac troponin-I, high-sensitivity C-reactive protein, cystatin C, neutrophil gelatinase-associated lipocalin, VEGF, and placental growth factor were measured in 324 patients with AF and 2931 patients without AF. The primary outcome was MACE defined as a composite of CV death, nonfatal myocardial infarction, and nonfatal stroke. The secondary outcomes were all-cause death, CV death, stroke, heart failure (HF) hospitalization, and coronary/peripheral artery revascularization. The biomarkers were natural log-transformed for use as continuous variables.

Results

After adjustment for potential clinical confounders including anticoagulant drug use, sFlt-1 was significantly associated with MACE (hazard ratio for 1 standard deviation increase [HR], 1.55; 95% confidence interval [CI], 1.14–2.08), CV death (HR, 1.68; 95% CI, 1.10–2.48), and stroke (HR, 1.89; 95% CI, 1.16–3.10), but not with all-cause death (HR, 1.32; 95% CI, 0.99–1.73), HF hospitalization (HR, 0.97; 95% CI, 0.73–1.25), or revascularization (HR, 0.99; 95% CI, 0.74–1.28) in patients with AF, whereas sFlt-1 was significantly associated with MACE (HR, 1.19; 95% CI, 1.02–1.37), all-cause death (HR, 1.19; 95% CI, 1.05–1.34), CV death (HR, 1.26; 95% CI, 1.03–1.48), and HF hospitalization (HR, 1.26; 95% CI, 1.11–1.42), but not with stroke (HR, 1.06; 95% CI, 0.81–1.33) or revascularization (HR, 1.01; 95% CI, 0.95–1.07) in patients without AF. Among other biomarkers, only VEGF was significantly associated with MACE (HR, 1.55; 95% CI, 1.02–2.44), and no biomarkers were significantly associated with CV death or stroke in patients with AF. sFlt-1 added incremental prognostic information for MACE (P=0.005 for net reclassification improvement [NRI], P=0.026 for integrated discrimination improvement [IDI]) and stroke (P=0.034 for NRI, P=0.018 for IDI), but not for CV death (P=0.021 for NRI, P=0.134 for IDI), to the model with potential clinical confounders in patients with AF.

Conclusions

sFlt-1 independently predicted MACE and stroke in patients with AF and suspected or known CAD. sFlt-1 may serve as a novel prognostic biomarker to stratify the risk of MACE and stroke in patients with AF.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Health Labour Sciences Research Grant (2013-2014), AMED (2015-2017, Grant Number JP17ek0210008)

Serum amyloid A-low-density-lipoprotein complex and mortality in patients with suspected or known coronary artery disease: the ANOX study

Background

Serum amyloid A-low-density-lipoprotein (SAA-LDL) is a complex formed from the oxidative interaction between SAA and LDLs. A relatively small-scale study has shown that circulating SAA-LDL levels may serve as a prognostic marker in patients with stable coronary artery disease (CAD). However, the prognostic value of SAA-LDL should be confirmed in a larger-scale cohort study.

Methods

Using data from a multicenter, prospective cohort of 2416 patients with suspected or known CAD enrolled in the ANOX (Development of Novel Biomarkers Related to Angiogenesis or Oxidative Stress to Predict Cardiovascular Events) study, we assessed the prognostic value of serum levels of SAA-LDL. The primary outcome was all-cause death. The secondary outcomes were cardiovascular death and major adverse cardiovascular events (MACE) defined as a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke. Patients were followed up over 3 years.

Results

Stepwise regression analysis including baseline data on potential clinical confounders (i.e., age, sex, body mass index, hypertension, dyslipidemia, diabetes, current smoking, estimated glomerular filtration rate, the Gensini score, previous myocardial infarction, previous stroke, previous heart failure hospitalization, atrial fibrillation, malignancies, anemia, antihypertensive drug use, statin use, and aspirin use) and established cardiovascular biomarkers (i.e., N-terminal pro-brain natriuretic peptide, high-sensitivity cardiac troponin I [hs-cTnI], and high-sensitivity C-reactive protein [hs-CRP]) revealed that independent determinants of SAA-LDL levels were female sex, dyslipidemia, the Gensini score, absence of statin use, hs-cTnI, and hs-CRP. After adjusting for potential clinical confounders and established cardiovascular biomarkers, the highest quartile of SAA-LDL levels (vs. the lowest quartile) was significantly associated with the incidence of all-cause death (hazard ratio [HR], 1.51; 95% confidence interval [CI], 1.02–2.26), but not with that of cardiovascular death (HR, 1.11; 95% CI, 0.59–2.10) or MACE (HR, 1.57; 95% CI, 0.97–2.57). Stratified analyses revealed that this association was pronounced in patients with low hs-cTnI (&lt;75th percentile) (HR, 1.85; 95% CI, 1.06–3.30) and in patients with low hs-CRP levels (≤1.0 mg/L) (HR, 2.30; 95% CI, 1.17–4.79).

Conclusions

Elevated SAA-LDL levels were independently associated with the risk of all-cause death in patients with suspected or known CAD. The SAA-LDL level appears to serve as a prognostic biomarker for risk stratification in relatively low-risk patients with low hs-cTnI (&lt;75th percentile) or low hs-CRP (≤1.0 mg/L).

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization.

Impact of Chronic Kidney Disease on the Associations of Cardiovascular Biomarkers With Adverse Outcomes in Patients With Suspected or Known Coronary Artery Disease: The EXCEED-J Study

Background

The impact of chronic kidney disease (CKD) on the prognostic utility of cardiovascular biomarkers in high‐risk patients remains unclear.

Methods and Results

We performed a multicenter, prospective cohort study of 3255 patients with suspected or known coronary artery disease (CAD) to investigate whether CKD modifies the prognostic utility of cardiovascular biomarkers. Serum levels of cardiovascular and renal biomarkers, including soluble fms‐like tyrosine kinase‐1 (sFlt‐1), N‐terminal pro‐brain natriuretic peptide (NT‐proBNP), high‐sensitivity cardiac troponin‐I (hs‐cTnI), cystatin C, and placental growth factor, were measured in 1301 CKD and 1954 patients without CKD. The urine albumin to creatinine ratio (UACR) was measured in patients with CKD. The primary outcome was 3‐point MACE (3P‐MACE) defined as a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke. The secondary outcomes were all‐cause death, cardiovascular death, and 5P‐MACE defined as a composite of 3P‐MACE, heart failure hospitalization, and coronary/peripheral artery revascularization. After adjustment for clinical confounders, sFlt‐1, NT‐proBNP, and hs‐cTnI, but not other biomarkers, were significantly associated with 3P‐MACE, all‐cause death, and cardiovascular death in the entire cohort and in patients without CKD. These associations were still significant in CKD only for NT‐proBNP and hs‐cTnI. NT‐proBNP and hs‐cTnI were also significantly associated with 5P‐MACE in CKD. The UACR was not significantly associated with any outcomes in CKD. NT‐proBNP and hs‐cTnI added incremental prognostic information for all outcomes to the model with potential clinical confounders in CKD.

Conclusions

NT‐proBNP and hs‐cTnI were the most powerful prognostic biomarkers in patients with suspected or known CAD and concomitant CKD.

Distinct association of VEGF-C and VEGF-D with prognosis in patients with chronic heart failure: the PREHOSP-CHF study

Background

The lymphatic system has been suggested to play an important role in cardiovascular (CV) diseases including heart failure (HF). Vascular endothelial growth factor C (VEGF-C) and VEGF-D are key regulators of lymphoangiogenesis.

Purpose

To investigate the association of VEGF-C and VEGF-D with prognosis in patients with chronic HF (CHF).

Methods

The PREHOSP-CHF study is a multicenter prospective cohort study to determine the predictive value of angiogenesis-related biomarkers in CHF. A total of 1,024 patients (mean age, 75.5±12.6 years; male, 58.7%) admitted to acute decompensated HF were included in the analyses. The primary outcome was MACE defined as a composite of CV death or HF hospitalization. The secondary outcomes were all-cause death, CV death, and HF hospitalizations. Serum levels of VEGF-C and VEGF-D, as well as N-terminal pro B-type natriuretic peptide (NT-proBNP), high sensitivity cardiac troponin-I (hs-cTnI), high sensitive C reactive protein (hs-CRP), VEGF, and soluble VEGF receptor-2 (sVEGFR-2) were measured at the time of discharge. Patients were followed-up over two years.

Results

Median [interquartile range] of VEGF-C and VEGF-D levels were 4821 [3633–6131] pg/ml and 404 [296–559] pg/ml, respectively. In multivariate stepwise regression analysis, independent determinants of VEGF-C levels were younger age, female gender, absence of prior HF hospitalization, chronic kidney disease, and anemia, lower ejection fraction, lower NT-proBNP levels, higher VEGF levels, and higher sVEGFR-2 levels, while those of VEGF-D levels were lower body mass index, presence of diabetes and atrial fibrillation, and higher NT-proBNP levels. During the follow-up, a total of 209 (20.4%) all-cause deaths, 112 (10.9%) CV deaths, and 309 (30.2%) HF hospitalizations occurred. After adjusting for established risk factors and CV biomarkers, VEGF-C levels were significantly and inversely associated with the incidence of MACE and non-CV death (Fig.1, model 4). On the other hand, VEGF-D levels were significantly and positively associated with the incidence of HF hospitalization (Fig. 1, model 4). When we divided the patients into 4 groups based on the median of VEGF-C and VEGF-D levels, patients with low VEGF-C and high VEGF-D showed significantly higher incidence of MACE, all-cause death, CV death, and HF hospitalization compared to those with high VEGF-C and low VEGF-D (Fig. 2).

Conclusions

Among patients with CHF, VEGF-C and VEGF-D had different characteristic and association with the incidence of adverse events. VEGF-C levels were inversely associated with the incidence of MACE and non-CV death, and VEGF-D levels were positively associated with the incidence of HF hospitalization. These results suggests different effects of VEGF-C and VEGF-D in CHF. Combination of VEGF-C and VEGF-D enables us to make good risk stratification in patients with CHF.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Grant-in-Aid for Clinical Research from the National Hospital Organization Figure 1Figure 2

Impact of atrial fibrillation on soluble fms-like tyrosine kinase-1 and cardiovascular events in patients with suspected or known coronary artery disease: the EXCEED-J study

Background

Soluble fms-like tyrosine kinase-1 (sFlt-1), a vascular endothelial growth factor (VEGF) antagonist, has been suggested as a marker of endothelial dysfunction. Circulating sFlt-1 levels are associated with adverse outcomes in patients with preeclampsia, chronic kidney disease, and heart failure. Atrial fibrillation (AF) and coronary artery disease (CAD) are both associated with endothelial dysfunction. However, whether sFlt-1 can predict cardiovascular (CV) events and whether AF modifies the relationship between sFlt-1 and CV events in patients with suspected or known CAD are unknown.

Methods

We performed a nationwide, multicenter, prospective cohort study to determine the prognostic value of sFlt-1 and other biomarkers in patients with suspected or known CAD undergoing elective angiography. Heparin-free fasting serum was collected from the peripheral vein to determine levels of sFlt-1, VEGF, placental growth factor, cystatin C, neutrophil gelatinase-associated lipocalin, N-terminal pro-brain natriuretic peptide (NT-proBNP), high-sensitivity cardiac troponin-I (hs-cTnI), and high-sensitivity C-reactive protein (hs-CRP). The primary outcome was 3-point major adverse CV events (3P-MACE) defined as a composite of CV death, nonfatal myocardial infarction, and nonfatal stroke. The secondary outcomes were all-cause death, CV death, and 5P-MACE defined as a composite of 3P-MACE, heart failure hospitalization, and coronary/peripheral artery revascularization.

Results

3311 patients were consecutively enrolled between Nov 2013 and May 2017. After excluding 56 ineligible patients, 3255 patients (324 AF and 2931 non-AF) were followed up over 3 years (follow-up rate, 99%). During the follow-up, 156 patients developed 3P-MACE, 215 died from any cause, 82 died from cardiovascular disease, and 1361 developed 5P-MACE. The sFlt-1 level was significantly higher in AF compared to non-AF patients (p&lt;0.001). Stepwise regression analysis revealed that the sFlt-1 level was independently associated with AF. After adjusting for potential clinical confounders, serum levels of sFlt-1, NT-proBNP, hs-cTnI and cystatin C, but not other biomarkers, were significantly associated with 3P-MACE in the entire cohort. These associations were still significant in non-AF patients, whereas only the sFlt-1 level was significantly associated with 3P-MACE in AF patients. Serum levels of sFlt-1, but not other biomarkers, were also significantly associated with CV death in AF patients. Among the biomarkers, only the hs-CRP level was significantly associated with all-cause death, and no biomarker was significantly associated with 5P-MACE in AF patients. Furthermore, sFlt-1 provided an incremental prognostic information for 3P-MACE to the model with potential clinical confounders in AF, but not in non-AF patients.

Conclusions

Serum levels of sFlt-1 were significantly associated with 3P-MACE in patients with suspected or known CAD. This association was pronounced in AF patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The EXCEED-J study is supported by Health Labour Sciences Research Grant (2013-2014), AMED (2015-2017, Grant Number JP17ek0210008) and Grant-in-Aid for Clinical Research from the National Hospital Organization (2018-2020).

Soluble vascular endothelial growth factor receptor 2 and prognosis in patients with chronic heart failure

Aims

Endothelial cell vascular endothelial growth factor receptor 2 (VEGFR‐2) plays a pivotal role in angiogenesis, which induces physiological cardiomyocyte hypertrophy via paracrine signalling between endothelial cells and cardiomyocytes. We investigated whether a decrease in circulating soluble VEGFR‐2 (sVEGFR‐2) levels is associated with poor prognosis in patients with chronic heart failure (HF).

Methods and results

We performed a multicentre prospective cohort study of 1024 consecutive patients with HF, who were admitted to hospitals due to acute decompensated HF and were stabilized after initial management. Serum levels of sVEGFR‐2 were measured at discharge. Patients were followed up over 2 years. The outcomes were cardiovascular death, all‐cause death, major adverse cardiovascular events (MACE) defined as a composite of cardiovascular death and HF hospitalization, and HF hospitalization. The mean age of the patients was 75.5 (standard deviation, 12.6) years, and 57% were male. Patients with lower sVEGFR‐2 levels were older and more likely to be female, and had greater proportions of atrial fibrillation and anaemia, and lower proportions of diabetes, dyslipidaemia, and HF with reduced ejection fraction (<40%). During the follow‐up, 113 cardiovascular deaths, 211 all‐cause deaths, 350 MACE, and 309 HF hospitalizations occurred. After adjustment for potential clinical confounders and established biomarkers [N‐terminal B‐type natriuretic peptide (NT‐proBNP), high‐sensitivity cardiac troponin I, and high‐sensitivity C‐reactive protein], a low sVEGFR‐2 level below the 25th percentile was significantly associated with cardiovascular death [hazard ratio (HR), 1.79; 95% confidence interval (CI), 1.16–2.74] and all‐cause death (HR, 1.43; 95% CI, 1.04–1.94), but not with MACE (HR, 1.11; 95% CI, 0.86–1.43) or HF hospitalization (HR, 1.03; 95% CI, 0.78–1.35). The stratified analyses revealed that a low sVEGFR‐2 level below the 25th percentile was significantly associated with cardiovascular death (HR, 1.76; 95% CI, 1.07–2.85) and all‐cause death (HR, 1.49; 95% CI, 1.03–2.15) in the high‐NT‐proBNP group (above the median), but not in the low‐NT‐proBNP group. Notably, the patients with high‐NT‐proBNP and low‐sVEGFR‐2 (below the 25th percentile) had a 2.96‐fold higher risk (95% CI, 1.56–5.85) for cardiovascular death and a 2.40‐fold higher risk (95% CI, 1.52–3.83) for all‐cause death compared with those with low‐NT‐proBNP and high‐sVEGFR‐2.

Conclusions

A low sVEGFR‐2 value was independently associated with cardiovascular death and all‐cause death in patients with chronic HF. These associations were pronounced in those with high NT‐proBNP levels.

Strongly correlated superconductivity in a copper-based metal-organic framework with a perfect kagome lattice

Metal-organic frameworks (MOFs), which are self-assemblies of metal ions and organic ligands, provide a tunable platform to search a new state of matter. A two-dimensional (2D) perfect kagome lattice, whose geometrical frustration is a key to realizing quantum spin liquids, has been formed in the π - d conjugated 2D MOF [Cu₃(C₆S₆)] _n (Cu-BHT). The recent discovery of its superconductivity with a critical temperature T _c of 0.25 kelvin raises fundamental questions about the nature of electron pairing. Here, we show that Cu-BHT is a strongly correlated unconventional superconductor with extremely low superfluid density. A nonexponential temperature dependence of superfluid density is observed, indicating the possible presence of superconducting gap nodes. The magnitude of superfluid density is much smaller than those in conventional superconductors and follows the Uemura's relation of strongly correlated superconductors. These results imply that the unconventional superconductivity in Cu-BHT originates from electron correlations related to spin fluctuations of kagome lattice.

Impact of Smoking Status on Growth Differentiation Factor 15 and Mortality in Patients With Suspected or Known Coronary Artery Disease: The ANOX Study

Background

Whether circulating growth differentiation factor 15 (GDF‐15) levels differ according to smoking status and whether smoking modifies the relationship between GDF‐15 and mortality in patients with coronary artery disease are unclear.

Methods and Results

Using data from a multicenter, prospective cohort of 2418 patients with suspected or known coronary artery disease, we assessed the association between smoking status and GDF‐15 and the impact of smoking status on the association between GDF‐15 and all‐cause death. GDF‐15 was measured in 955 never smokers, 1035 former smokers, and 428 current smokers enrolled in the ANOX Study (Development of Novel Biomarkers Related to Angiogenesis or Oxidative Stress to Predict Cardiovascular Events). Patients were followed up during 3 years. The age of the patients ranged from 19 to 94 years; 67.2% were men. Never smokers exhibited significantly lower levels of GDF‐15 compared with former smokers and current smokers. Stepwise multiple linear regression analysis revealed that the log‐transformed GDF‐15 level was independently associated with both current smoking and former smoking. In the entire patient cohort, the GDF‐15 level was significantly associated with all‐cause death after adjusting for potential clinical confounders. This association was still significant in never smokers, former smokers, and current smokers. However, GDF‐15 provided incremental prognostic information to the model with potential clinical confounders and the established cardiovascular biomarkers in never smokers, but not in current smokers or in former smokers.

Conclusions

Not only current, but also former smoking was independently associated with higher levels of GDF‐15. The prognostic value of GDF‐15 on mortality was most pronounced in never smokers among patients with suspected or known coronary artery disease.

Impact of glucose tolerance status on the relationship between vascular endothelial growth factor D and mortality in patients with suspected coronary artery disease: a subanalysis of the ANOX study

Background

Vascular endothelial growth factor D (VEGF-D) is a secreted glycoprotein that can act as lymphangiogenic and angiogenic growth factors through binding to its specific receptors, VEGFR-3 and VEGFR-2. VEGF-D signaling via VEGFR-3 plays an important role in lipoprotein metabolisms which may contribute to coronary artery disease (CAD). We recently reported that serum levels of VEGF-D are independently associated with mortality in patients with suspected or known CAD. However, the impact of glucose tolerance status on the relationship between VEGF-D and mortality in patients with suspected CAD is unclear.

Methods

Serum VEGF-D levels were measured in 1,717 patients with suspected CAD undergoing elective coronary angiography, enrolled in the development of novel biomarkers related to angiogenesis or oxidative stress to predict CV events (ANOX) study, and followed up for 3 years. After excluding 67 patients with no HbA1c data, 1,650 patients were divided into 3 groups according to the glucose tolerance status: diabetes (DM, n=693), prediabetes (preDM, n=541) defined as an HbA1c of 5.7 to 6.4%, and normal glucose tolerance (NGT, n=416) defined as an HbA1c of 5.6% or less. The outcomes were total death, CV death, and major adverse CV events (MACE) defined as a composite of CV death, nonfatal myocardial infarction, and nonfatal stroke.

Results

During the follow-up, 80 DM, 45 preDM, and 30 NGT patients died from any cause, 24 DM, 13 preDM, and 12 NGT died from CV disease, and 54 DM, 30 preDM, and 19 NGT developed MACE. After adjustment for established risk factors, VEGF-D levels were significantly associated with total death (hazard ratio [HR] for 1-SD increase, 1.28; 95% confidence interval [CI], 1.12–1.47), but not with CV death (HR, 1.20; 95% CI, 0.93–1.52) or MACE (HR, 1.23; 95% CI, 0.997–1.48) in DM; VEGF-D levels were not significantly associated with total death (HR, 0.97; 95% CI, 0.70–1.34), CV death (HR, 1.39; 95% CI, 0.92–2.11), or MACE (HR, 1.09; 95% CI, 0.74–1.50) in preDM; VEGF-D levels were not significantly associated with total death (HR, 1.34; 95% CI, 0.98–1.84), CV death (HR, 1.32; 95% CI, 0.78–2.13), or MACE (HR, 1.01; 95% CI, 0.66–1.46) in NGT. Even after incorporation of N-terminal pro-brain natriuretic peptide, contemporary sensitive cardiac troponin I, and high-sensitivity C-reactive protein into a model with established risk factors, the addition of VEGF-D levels further improved the prediction of total death (P=0.040 for continuous net reclassification improvement [NRI], P=0.007 for integrated discrimination improvement [IDI]), but not that of CV death or MACE in DM, while it did not significantly improved the prediction of total death, CV death, or MACE either in preDM or in NGT.

Conclusions

The VEGF-D level was independently associated with total death in DM, but not in preDM or in NGT. The relationship between VEGF-D and total mortality may depend on the presence of DM in patients with suspected CAD.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization.

Impact of anemia on the relationship between vascular endothelial growth factor C and mortality in patients with suspected or known coronary artery disease: a subanalysis of the ANOX study

Background

The lymphatic system has been suggested to play an important role in cholesterol metabolism and cardiovascular (CV) disease. Recently, we demonstrated that serum levels of vascular endothelial growth factor C (VEGF-C), a central player of lymphangiogenesis, are inversely and independently associated with the risk of all-cause mortality in patients with suspected or known coronary artery disease (CAD). However, the impact of anemia on the relationship between VEGF-C and mortality in those patients is unclear.

Methods

Serum VEGF-C levels were measured in 2,418 patients with suspected or known CAD undergoing elective coronary angiography, enrolled in the development of novel biomarkers related to angiogenesis or oxidative stress to predict CV events (ANOX) study, and followed up for 3 years. Anemia was defined as a hemoglobin level of less than 13 g/dL in men and &lt;12 g/dL in women. Patients were divided into 2 groups according to the presence (anemic, n=882) or absence (non-anemic, n=1,536) of anemia. The primary outcome was all-cause death. The secondary outcomes were CV death, and major adverse CV events (MACE) defined as a composite of CV death, nonfatal myocardial infarction, and nonfatal stroke.

Results

During the follow-up, 164 anemic and 90 non-anemic patients died from any cause, 64 anemic and 24 non-anemic patients died from CV disease, and 96 anemic and 69 non-anemic patients developed MACE. After adjustment for established risk factors, VEGF-C levels were significantly and inversely associated with all-cause death (hazard ratio [HR] for 1-SD increase, 0.71; 95% confidence interval [CI], 0.59–0.84), CV death (HR, 0.60; 95% CI, 0.44–0.79), and MACE (HR, 0.76; 95% CI, 0.60–0.95) in anemic, while VEGF-C levels were not significantly associated with all-cause death (HR, 0.87; 95% CI, 0.69–1.11), CV death (HR, 1.32; 95% CI, 0.85–1.93), or MACE (HR, 1.12; 95% CI, 0.87–1.42) in non-anemic patients. Even after incorporation of N-terminal pro-brain natriuretic peptide, contemporary sensitive cardiac troponin I, and high-sensitivity C-reactive protein into a model with established risk factors, the addition of VEGF-C levels further improved the prediction of all-cause death (P&lt;0.001 for continuous net reclassification improvement [NRI], P=0.006 for integrated discrimination improvement [IDI]) and CV death (P&lt;0.001 for NRI, P=0.005 for IDI), but not that of MACE (P=0.021 for NRI, P=0.059 for IDI) in anemic, whereas the addition of VEGF-C levels did not improved the prediction of all-cause death (P=0.234 for NRI, P=0.415 for IDI), CV death (P=0.190 for NRI, P=0.392 for IDI) or MACE (P=0.897 for NRI, P=0.128 for IDI) in non-anemic patients.

Conclusions

The VEGF-C level was inversely and independently associated with all-cause and CV mortality in anemic, but not in non-anemic patients with suspected or known CAD. The inverse relationship between VEGF-C and mortality may depend on the presence of anemia.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization.

Impact of chronic kidney disease on the relationship between vascular endothelial growth factor C and mortality in patients with suspected coronary artery disease: a subanalysis of the ANOX study

Background

The lymphatic system has been suggested to play an important role in cholesterol metabolism and cardiovascular (CV) disease. Recently, we demonstrated that serum levels of vascular endothelial growth factor C (VEGF-C), a central player of lymphangiogenesis, are inversely and independently associated with the risk of all-cause mortality in patients with suspected or known coronary artery disease (CAD). However, the impact of chronic kidney disease (CKD) on the relationship between VEGF-C and mortality in patients with suspected CAD is unclear.

Methods

Serum VEGF-C levels were measured in 1,717 patients with suspected but no history of CAD undergoing elective coronary angiography, enrolled in the development of novel biomarkers related to angiogenesis or oxidative stress to predict CV events (ANOX) study, and followed up for 3 years. Patients were divided into 2 groups according to the presence (CKD, n=674) or absence (non-CKD, n=1,043) of CKD. The primary outcome was all-cause death. The secondary outcomes were CV death, and major adverse CV events (MACE) defined as a composite of CV death, nonfatal myocardial infarction, and nonfatal stroke.

Results

During the follow-up, 95 CKD and 66 non-CKD patients died from any cause, 37 CKD and 13 non-CKD died from CV disease, and 61 CKD and 43 non-CKD developed MACE. After adjustment for established risk factors, VEGF-C levels were significantly and inversely associated with all-cause death (hazard ratio [HR] for 1-SD increase, 0.72; 95% confidence interval [CI], 0.57–0.90) and CV death (HR, 0.69; 95% CI, 0.48–0.97), but not with MACE (HR, 0.78; 95% CI, 0.60–1.03) in CKD, while VEGF-C levels were significantly and inversely associated with all-cause death (HR, 0.69; 95% CI, 0.52–0.91), but not with CV death (HR, 0.91; 95% CI, 0.50–1.66) or MACE (HR, 1.09; 95% CI, 0.81–1.44) in non-CKD. Even after incorporation of N-terminal pro-brain natriuretic peptide, contemporary sensitive cardiac troponin I, and high-sensitivity C-reactive protein into a model with established risk factors, the addition of VEGF-C levels further improved the prediction of all-cause death (P=0.047 for continuous net reclassification improvement [NRI], P=0.048 for integrated discrimination improvement [IDI]), but not that of CV death (P=0.016 for NRI, P=0.245 for IDI) or MACE (P=0.166 for NRI, P=0.311 for IDI) in CKD, whereas the addition of VEGF-C levels did not improve the prediction of all-cause death (P=0.053 for NRI, P=0.012 for IDI), CV death (P=0.864 for NRI, P=0.602 for IDI) or MACE (P=0.999 for NRI, P=0.154 for IDI) in non-CKD.

Conclusions

The VEGF-C level inversely and independently predicted all-cause mortality in CKD, but not in non-CKD patients with suspected CAD. The inverse relationship between VEGF-C and all-cause mortality in patients with suspected CAD seems to be remarkable in the presence of CKD.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization.

Impact of anemia on the relationships of growth differentiation factor 15 with mortality and cardiovascular events in patients with suspected or known coronary artery disease: the ANOX study

Background

Growth differentiation factor 15 (GDF-15) is a stress-responsive cytokine that plays an important role in the regulation of the inflammatory response, growth and cell differentiation. An elevated GDF-15 was found in various conditions including anemia and stable coronary artery disease (CAD), and it was reported to predict mortality and cardiovascular (CV) events in general population and in patients with established CAD. However, the impact of anemia on the relationships of GDF-15 with mortality and CV events in patients with suspected or known CAD is unclear.

Methods

Serum GDF-15 levels were measured in 2,418 patients with suspected or known CAD undergoing elective coronary angiography, enrolled in the development of novel biomarkers related to angiogenesis or oxidative stress to predict CV events (ANOX) study, and followed up for 3 years. Anemia was defined as a hemoglobin level of less than 13 g/dL in men and &lt;12 g/dL in women. Patients were divided into 2 groups according to the presence (anemic, n=882) or absence (non-anemic, n=1,536) of anemia. The primary outcome was all-cause death. The secondary outcomes were CV death, and major adverse CV events (MACE) defined as a composite of CV death, nonfatal myocardial infarction, and nonfatal stroke.

Results

During the follow-up, 164 anemic and 90 non-anemic patients died from any cause, 64 anemic and 24 non-anemic patients died from CV disease, and 96 anemic and 69 non-anemic patients developed MACE. After adjustment for established risk factors, GDF-15 levels were significantly associated with all-cause death (hazard ratio [HR] for 1-SD increase, 1.75; 95% confidence interval [CI], 1.51–2.04), CV death (HR, 1.67; 95% CI, 1.30–2.13), and MACE (HR, 1.46; 95% CI, 1.18–1.81) in anemic, while GDF-15 levels were also significantly associated with all-cause death (HR, 1.47; 95% CI, 1.27–1.69), CV death (HR, 1.56; 95% CI, 1.18–1.99), and MACE (HR, 1.25; 95% CI, 1.004–1.50) in non-anemic patients. Even after incorporation of N-terminal pro-brain natriuretic peptide, contemporary sensitive cardiac troponin I, and high-sensitivity C-reactive protein into a model with established risk factors, the addition of GDF-15 levels further improved the prediction of all-cause death (P&lt;0.001 for continuous net reclassification improvement [NRI], P&lt;0.001 for integrated discrimination improvement [IDI]), CV death (P=0.026 for NRI, P=0.023 for IDI), and MACE (P=0.025 for NRI, P=0.042 for IDI) in anemic, whereas it did not improved the prediction of all-cause death (P=0.072 for NRI, P=0.079 for IDI), CV death (P=0.289 for NRI, P=0.179 for IDI) or MACE (P=0.397 for NRI, P=0.230 for IDI) in non-anemic patients.

Conclusions

The GDF-15 level significantly improved the prediction of all-cause death, CV death, and MACE in anemic, but not in non-anemic patients with suspected or known CAD. The relationships of GDF-15 with mortality and CV events seem to be remarkable in the presence of anemia.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization.

Impact of smoking status on the relationships of growth differentiation factor 15 with mortality and cardiovascular events in patients with suspected or known coronary artery disease: the ANOX study

Background

Growth differentiation factor 15 (GDF-15) is a stress-responsive cytokine that plays an important role in the regulation of the inflammatory response, growth and cell differentiation. An elevated GDF-15 was found in various conditions including cigarette smoking and stable coronary artery disease (CAD), and it was reported to predict mortality and cardiovascular (CV) events in general population and in patients with established CAD. However, the impact of smoking status on the relationships of GDF-15 with mortality and CV events in patients with suspected or known CAD is unclear.

Methods

Serum GDF-15 levels were measured in 2,418 patients with suspected or known CAD undergoing elective coronary angiography, enrolled in the development of novel biomarkers related to angiogenesis or oxidative stress to predict CV events (ANOX) study, and followed up for 3 years. Patients were divided into 3 groups according to the smoking status: current (n=428), past (n=1,035), and never smokers (n=955). The outcomes were total death, CV death, and major adverse CV events (MACE) defined as a composite of CV death, nonfatal myocardial infarction, and nonfatal stroke.

Results

During the follow-up, 48 current, 120 past, and 86 never smokers died from any cause, 17 current, 47 past, and 24 never smokers died from CV disease, and 35 current, 80 past, and 50 never smokers developed MACE. After adjustment for established risk factors, GDF-15 levels were significantly associated with total death (hazard ratio [HR] for 1-SD increase, 1.30; 95% confidence interval [CI], 1.03–1.65), but not with CV death (HR, 1.09; 95% CI, 0.69–1.62) or MACE (HR, 0.95; 95% CI, 0.64–1.34) in current smokers; GDF-15 levels were significantly associated with total death (HR, 1.73; 95% CI, 1.46–2.05) and CV death (HR, 1.41; 95% CI, 1.09–1.85), but not with MACE (HR, 1.20; 95% CI, 0.96–1.48) in past smokers; GDF-15 levels were significantly associated with total death (HR, 1.62; 95% CI, 1.32–1.95), CV death (HR, 1.76; 95% CI, 1.22–2.46), and MACE (HR, 1.64; 95% CI, 1.27–2.07) in never smokers. Even after incorporation of N-terminal pro-brain natriuretic peptide, contemporary sensitive cardiac troponin I, and high-sensitivity C-reactive protein into a model with established risk factors, the addition of GDF-15 levels further improved the prediction of total death (P&lt;0.001 for continuous net reclassification improvement [NRI], P=0.001 for integrated discrimination improvement [IDI]) and MACE (P&lt;0.001 for NRI, P=0.045 for IDI), but not that of CV death, in never smokers, while it did not significantly improved the prediction of total death, CV death, or MACE either in current or in past smokers.

Conclusions

The GDF-15 level was independently associated with total death and MACE in never, but not in current or past smokers with suspected or known CAD. The relationships of GDF-15 with mortality and CV events seem to be attenuated by the presence of current and past smoking.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization.

In-hospital morality associated with acute myocardial infarction was inversely related with the number of coronary risk factors in patients from a Japanese nation-wide real-world database

BACKGROUND

Hypertension, diabetes, dyslipidemia and smoking are established coronary risk factors for coronary heart disease in the general population. However, in Japanese patients with acute myocardial infarction (AMI), the impact of the number of coronary risk factors on in-hospital morality remains unclear.

METHODS

The Japan Acute Myocardial Infarction Registry (JAMIR) is a nationwide real-world database. We examined the association between the number of coronary risk factors and in-hospital mortality.

RESULTS

Data were obtained from total of 20462 AMI patients (mean age, 68.8 ± 13.3 years old; 15281 men, 5181 women). The prevalence of hypertension increased with advancing age, while the prevalence of smoking decreased with advancing age. The prevalence of diabetes and dyslipidemia were highest in middle age. A majority (76.9%) of the patients with AMI had at least 1 of these coronary risk factors. Overall, the number of coronary risk factor was relatively less in older subjects and women under 50 years old. Crude in-hospital mortality rates were 10.7%, 10.5%, 7.2%, 5.0% and 4.5% with 0, 1, 2, 3 and 4 risk factors, respectively. After adjusting for age and sex, there was an inverse association between the number of coronary risk factors and the in-hospital mortality (adjusted odds ratio [1.68; 95% confidence interval, 1.20-2.35] among individuals with 0 vs. 4 risk factors).

CONCLUSION

In the present study of Japanese patients with AMI, who received modern medical treatment, in-hospital mortality was inversely related to the number of coronary risk factors. To investigate the underlying reasons for these findings, further studies are needed.

Difference in the in-hospital prognosis between ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction with high Killip class: Data from the Japan Acute Myocardial Infarction Registry

BACKGROUND

ST-segment elevation myocardial infarction is known to be associated with worse short-term outcome than non-ST-segment elevation myocardial infarction. However, whether or not this trend holds true in patients with a high Killip class has been unclear.

METHODS

We analyzed 3704 acute myocardial infarction patients with Killip II-IV class from the Japan Acute Myocardial Infarction Registry and compared the short-term outcomes between ST-segment elevation myocardial infarction (n = 2943) and non-ST-segment elevation myocardial infarction (n = 761). In addition, we also performed the same analysis in different age subgroups: <80 years and ≥80 years.

RESULTS

In the overall population, there were no significant difference in the in-hospital mortality (20.0% vs 17.1%, p = 0.065) between ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction groups. Patients <80 years of age also showed no difference in the in-hospital mortality (15.7% vs 15.2%, p = 0.807) between ST-segment elevation myocardial infarction (n = 2001) and non-ST-segment elevation myocardial infarction (n = 453) groups, whereas among those ≥80 years of age, ST-segment elevation myocardial infarction (n = 942) was associated with significantly higher in-hospital mortality (29.3% vs 19.8%, p = 0.001) and in-hospital cardiac mortality (23.3% vs 15.0%, p = 0.002) than non-ST-segment elevation myocardial infarction (n = 308). After adjusting for covariates, ST-segment elevation myocardial infarction was a significant predictor for in-hospital mortality (odds ratio 2.117; 95% confidence interval, 1.204-3.722; p = 0.009) in patients ≥80 years of age.

CONCLUSION

Among cases of acute myocardial infarction with a high Killip class, there was no marked difference in the short-term outcomes between ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction in younger patients, while ST-segment elevation myocardial infarction showed worse short-term outcomes in elderly patients than non-ST-segment elevation myocardial infarction. Future study identifying the prognostic factors for the specific anticipation intensive cares is needed in this high-risk group.

Distinct Characteristics of VEGF-D and VEGF-C to Predict Mortality in Patients With Suspected or Known Coronary Artery Disease

Background

VEGF‐D (vascular endothelial growth factor D) and VEGF‐C are secreted glycoproteins that can induce lymphangiogenesis and angiogenesis. They exhibit structural homology but have differential receptor binding and regulatory mechanisms. We recently demonstrated that the serum VEGF‐C level is inversely and independently associated with all‐cause mortality in patients with suspected or known coronary artery disease. We investigated whether VEGF‐D had distinct relationships with mortality and cardiovascular events in those patients.

Methods and Results

We performed a multicenter, prospective cohort study of 2418 patients with suspected or known coronary artery disease undergoing elective coronary angiography. The serum level of VEGF‐D was measured. The primary outcome was all‐cause death. The secondary outcomes were cardiovascular death and major adverse cardiovascular events defined as a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke. During the 3‐year follow‐up, 254 patients died from any cause, 88 died from cardiovascular disease, and 165 developed major adverse cardiovascular events. After adjustment for possible clinical confounders, cardiovascular biomarkers (N‐terminal pro‐B‐type natriuretic peptide, cardiac troponin‐I, and high‐sensitivity C‐reactive protein), and VEGF‐C, the VEGF‐D level was significantly associated with all‐cause death and cardiovascular death but not with major adverse cardiovascular events.. Moreover, the addition of VEGF‐D, either alone or in combination with VEGF‐C, to the model with possible clinical confounders and cardiovascular biomarkers significantly improved the prediction of all‐cause death but not that of cardiovascular death or major adverse cardiovascular events. Consistent results were observed within patients over 75 years old.

Conclusions

In patients with suspected or known coronary artery disease undergoing elective coronary angiography, an elevated VEGF‐D value seems to independently predict all‐cause mortality.

Positioning an ECG electrode to the dorsal side can record higher amplitude of CMAPs during cryoballoon ablation

PURPOSE

Phrenic nerve injury (PNI) is one of the important complications during cryoballoon (CB) ablation. Recording diaphragmatic compound motor action potentials (CMAPs) during CB ablation can predict PNI. CMAP monitoring may be inaccurate when CMAP amplitudes are low. We examined the effect of positioning an electrocardiography (ECG) electrode at the dorsal side.

METHODS

We retrospectively analyzed the cases of 197 consecutive patients who underwent CB ablation for pulmonary vein isolation (PVI) (April 2016 to December 2018) at our institution. CMAP amplitudes were monitored using two recording methods just before cryoapplication. (a) Conventional method: right-arm ECG electrode positioned 5 cm above the xiphoid on the ventral side; left-arm ECG electrode positioned along the costal margin. (b) Our original method: right-arm electrode positioned 5 cm above the xiphoid on the dorsal side; left-arm electrode positioned along the costal margin.

RESULTS

The CMAP amplitude during right phrenic nerve pacing was significantly higher at the dorsal side than the ventral side (0.80 ± 0.31 mV vs 0.66 ± 0.29 mV, P < .01). Similarly, the CMAP amplitude during left phrenic nerve pacing was significantly higher at the dorsal side than the ventral side (0.92 ± 0.39 mV, 0.73 ± 0.37 mV, P < .01). PNI occurred in six patients (3.0%); three patients experienced transient PNI, another three patients experienced persistent PNI, and none developed permanent PNI.

CONCLUSIONS

CMAP amplitudes were significantly high at the dorsal side compared to the ventral side. Monitoring phrenic nerve function using an ECG electrode at the dorsal side is a simple and easy procedure.

VEGF-C and Mortality in Patients With Suspected or Known Coronary Artery Disease

Background

The lymphatic system has been suggested to play an important role in cholesterol metabolism and cardiovascular disease. However, the relationships of vascular endothelial growth factor‐C (VEGF‐C), a central player in lymphangiogenesis, with mortality and cardiovascular events in patients with suspected or known coronary artery disease are unknown.

Methods and Results

We performed a multicenter, prospective cohort study of 2418 patients with suspected or known coronary artery disease undergoing elective coronary angiography. The primary predictor was serum levels of VEGF‐C. The primary outcome was all‐cause death. The secondary outcomes were cardiovascular death, and major adverse cardiovascular events defined as a composite of cardiovascular death, non‐fatal myocardial infarction, and non‐fatal stroke. During the 3‐year follow‐up, 254 patients died from any cause, 88 died from cardiovascular disease, and 165 developed major adverse cardiovascular events. After adjustment for established risk factors, VEGF‐C levels were significantly and inversely associated with all‐cause death (hazard ratio for 1‐SD increase, 0.69; 95% confidence interval, 0.60–0.80) and cardiovascular death (hazard ratio, 0.67; 95% confidence interval, 0.53–0.87), but not with major adverse cardiovascular events (hazard ratio, 0.85; 95% confidence interval, 0.72–1.01). Even after incorporation of N‐terminal pro‐brain natriuretic peptide, contemporary sensitive cardiac troponin‐I, and high‐sensitivity C‐reactive protein into a model with established risk factors, the addition of VEGF‐C levels further improved the prediction of all‐cause death, but not that of cardiovascular death or major adverse cardiovascular events. Consistent results were observed within 1717 patients with suspected coronary artery disease.

Conclusions

In patients with suspected or known coronary artery disease, a low VEGF‐C value may independently predict all‐cause mortality.

P3615The number of coronary risk factors and mortality in patients with acute myocardial infarction from Japanese nation-wide real-world database

Background

Hypertension, diabetes, dyslipidemia and smoking are so-called coronary risk factors for coronary heart disease, which were established by extensive epidemiological research. However, in Japanese patients with acute myocardial infarction (AMI), the impact of number of coronary risk factors on in-hospital morality has not been elucidated.

Methods

The Japan Acute Myocardial Infarction Registry (JAMIR) is a nationwide real-world database integrated form 10 regional registries. We examined the association between number of coronary risk factors and in-hospital mortality from this JAMIR registry.

Results

The data were obtained from total of 20462 AMI patients (mean age, 68.8±13.3 years old; 15281 men, 5181 women). Figure 1 shows the prevalence of each coronary risk factors stratified by sex and decade. The prevalence of hypertension became higher with the advanced age while the prevalence of smoking became lower with the advanced age. Prevalence of diabetes and dyslipidemia were highest in middle age. Majority (76.9%) of the patients with AMI had at least 1 of these coronary risk factors and, 23.1% had none of them. Overall, except women under 50, number of coronary risk factor was relatively less in older age (Figure 2). In-hospital mortality by sex and decades was shown in figure 3. In-hospital mortality rates were 10.7%, 10.5%, 7.2%, 5.0% and 4.5% with 0, 1, 2, 3 and 4 risk factors, respectively (Figure 4A). After adjusting age and sex, there was an inverse association between the number of coronary risk factors and in-hospital mortality (adjusted odds ratio [1.68; 95% CI, 1.20–2.35] among individuals with 0 vs. 4 risk factors, Figure 4B).

Conclusion

In the present study of Japanese patients with AMI, who received modern medical treatment, in-hospital mortality was inversely related to the number of coronary risk factors.

Acknowledgement/Funding

Grant-in-Aid for Scientific Research

P1645Vascular endothelial growth factor-D and mortality in suspected or known coronary heart disease patients with a history of heart failure: a subanalysis of the ANOX study

Background

Vascular endothelial growth factor-D (VEGF-D) is a secreted glycoprotein that can act as lymphangiogenic and angiogenic growth factors through binding to its specific receptors, VEGFR-3 (Flt-4) and VEGFR-2 (KDR/Flk-1). VEGF-D signaling via VEGFR-3 plays an important role in lipoprotein metabolisms which may contribute to coronary heart disease (CHD). Recent studies suggest that VEGF-D appears to be a biomarker of pulmonary congestion and heart failure in both dyspnea patients and the general population. However, the prognostic value of VEGF-D in suspected or known CHD patients with a history of heart failure is unknown.

Methods

Serum VEGF-D levels were measured in 253 suspected or known CHD patients with a history of heart failure undergoing elective coronary angiography, enrolled in the development of novel biomarkers related to angiogenesis or oxidative stress to predict cardiovascular events (ANOX) study, and followed up for 3 years. The primary outcome was all-cause death. The secondary outcomes were cardiovascular death, and major adverse cardiovascular events (MACE) defined as a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke.

Results

During the follow-up, 54 patients died from any cause, 24 died from cardiovascular disease, and 35 developed MACE. After adjustment for established risk factors, VEGF-D levels were significantly associated with all-cause death (hazard ratio [HR] for 1-SD increase, 1.44; 95% confidence interval [CI], 1.18–1.75), cardiovascular death (HR, 1.73; 95% CI, 1.32–2.25), and MACE (HR, 1.49; 95% CI, 1.14–1.89). Even after incorporation of N-terminal pro-brain natriuretic peptide, contemporary sensitive cardiac troponin-I, and high-sensitivity C-reactive protein into a model with established risk factors, the addition of VEGF-D levels further improved the prediction of all-cause death (continuous net reclassification improvement [NRI], 0.471; 95% CI, 0.176–0.766; P=0.002; integrated discrimination improvement [IDI], 0.036; 95% CI, 0.008–0.064; P=0.011) and cardiovascular death (NRI, 0.722; 95% CI, 0.326–1.118; P<0.001; IDI, 0.063; 95% CI, 0.005–0.122; P=0.033), but not that of MACE (NRI, 0.453; 95% CI, 0.100–0.805; P=0.012; IDI, 0.028; 95% CI, −0.007–0.063; P=0.116).

Conclusions

In suspected or known CHD patients with a history of heart failure undergoing elective coronary angiography, elevated VEGF-D levels may predict all-cause and cardiovascular mortality independent of established risk factors and cardiovascular biomarkers.

Acknowledgement/Funding

The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization.

P3639Vascular endothelial growth factor-C and mortality in patients with suspected but no history of coronary heart disease: a subanalysis of the ANOX study

Background

The lymphatic system has been suggested to play an important role in cholesterol metabolism and cardiovascular disease. Recently, we demonstrated that serum levels of vascular endothelial growth factor-C (VEGF-C), a central player of lymphangiogenesis, are inversely and independently associated with the risk of all-cause mortality in patients with suspected or known coronary heart disease (CHD). However, the prognostic value of VEGF-C in patients with suspected but no history of CHD is still unclear.

Methods

Serum VEGF-C levels were measured in 1,717 patients with suspected but no history of CHD undergoing elective coronary angiography, enrolled in the development of novel biomarkers related to angiogenesis or oxidative stress to predict cardiovascular events (ANOX) study, and followed up for 3 years. The primary outcome was all-cause death. The secondary outcomes were cardiovascular death, and major adverse cardiovascular events (MACE) defined as a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke.

Results

During the follow-up, 161 patients died from any cause, 50 died from cardiovascular disease, and 104 developed MACE. After adjustment for established risk factors, VEGF-C levels were significantly and inversely associated with all-cause death (hazard ratio [HR] for 1-SD increase, 0.69; 95% confidence interval [CI], 0.58–0.83) and cardiovascular death (HR, 0.72; 95% CI, 0.52–0.998), but not with MACE (HR, 0.91; 95% CI, 0.74–1.13). Even after incorporation of N-terminal pro-brain natriuretic peptide, contemporary sensitive cardiac troponin-I, and high-sensitivity C-reactive protein into a model with established risk factors, the addition of VEGF-C levels further improved the prediction of all-cause death (continuous net reclassification improvement [NRI], 0.282; 95% CI, 0.121–0.443; P<0.001; integrated discrimination improvement [IDI], 0.009; 95% CI, 0.003–0.016; P=0.005), but not that of cardiovascular death (NRI, 0.178; 95% CI, r=−0.103–0.458; P=0.214; IDI, 0.004; 95% CI, r=−0.002–0.009; P=0.194) or MACE (NRI, 0.037; 95% CI, r=−0.162–0.235; P=0.717; IDI, 0.000; 95% CI, r=−0.0004–0.0005; P=0.872).

Conclusions

In patients with suspected but no history of CHD undergoing elective coronary angiography, a low VEGF-C value may predict all-cause mortality independent of established risk factors and cardiovascular biomarkers.

Acknowledgement/Funding

The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization

5195Growth differentiation factor-15 and mortality in suspected or known coronary heart disease patients with diabetes: a subanalysis of the ANOX study

Background

Diabetes is a risk factor for coronary heart disease (CHD), but further risk stratification in patients with diabetes is necessary to improve the prediction and prevention of cardiovascular events and deaths. Growth differentiation factor-15 (GDF-15) is a stress-responsive cytokine, which plays an important role in the regulation of the inflammatory response, growth and cell differentiation. Elevated GDF-15 was found in various diseases including diabetes and stable CHD, and was reported to predict mortality and cardiovascular events in general or established CHD population. However, the prognostic value of GDF-15 in suspected or known CHD patients with diabetes is unknown.

Methods

Serum GDF-15 levels were measured in 1,087 suspected or known CHD patients with diabetes undergoing elective coronary angiography, enrolled in the development of novel biomarkers related to angiogenesis or oxidative stress to predict cardiovascular events (ANOX) study, and followed up for 3 years. The primary outcome was all-cause death. The secondary outcomes were cardiovascular death, and major adverse cardiovascular events (MACE) defined as a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke.

Results

During the follow-up, 147 patients died from any cause, 47 died from cardiovascular disease, and 94 developed MACE. After adjustment for established risk factors, GDF-15 levels were significantly associated with all-cause death (hazard ratio [HR] for 1-SD increase, 1.66; 95% confidence interval [CI], 1.48–1.86), cardiovascular death (HR, 1.63; 95% CI, 1.34–1.99), and MACE (HR, 1.41; 95% CI, 1.20–1.65). Even after incorporation of N-terminal pro-brain natriuretic peptide, contemporary sensitive cardiac troponin-I, and high-sensitivity C-reactive protein into a model with established risk factors, the addition of GDF-15 levels further improved the prediction of all-cause death (continuous net reclassification improvement [NRI], 0.344; 95% CI, 0.172–0.517; P<0.001; integrated discrimination improvement [IDI], 0.049; 95% CI, 0.026–0.072; P<0.001), but not that of cardiovascular death (NRI, −0.013; 95% CI, −0.300–0.274; P=0.931; IDI, 0.023; 95% CI, 0.003–0.043; P=0.026) or MACE (NRI, 0.059; 95% CI, −0.151–0.268; P=0.583; IDI, 0.005; 95% CI, −0.004–0.015; P=0.244).

Conclusions

In suspected or known CHD patients with diabetes undergoing elective coronary angiography, elevated GDF-15 levels may predict all-cause mortality independent of established risk factors and cardiovascular biomarkers.

Acknowledgement/Funding

The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization.

P5529Vascular endothelial growth factor-D and mortality in suspected or known coronary heart disease patients with diabetes: a subanalysis of the ANOX study

Background

Diabetes is a risk factor for coronary heart disease (CHD), but further risk stratification in patients with diabetes is necessary to improve the prediction and prevention of cardiovascular events and deaths. Vascular endothelial growth factor-D (VEGF-D) is a secreted glycoprotein that can act as lymphangiogenic and angiogenic growth factors through binding to its specific receptors, VEGFR-3 (Flt-4) and VEGFR-2 (KDR/Flk-1). VEGF-D signaling via VEGFR-3 plays an important role in lipoprotein metabolisms which may contribute to CHD. VEGF-D signaling has been used as a therapeutic target of human diseases such as lymphangioleiomyomatosis and refractory angina. Furthermore, in clinical settings, the VEGF-D level is already established as a diagnostic biomarker for lymphangioleiomyomatosis. However, the prognostic value of VEGF-D in suspected or known CHD patients with diabetes is unknown.

Methods

Serum VEGF-D levels were measured in 1,087 suspected or known CHD patients with diabetes undergoing elective coronary angiography, enrolled in the development of novel biomarkers related to angiogenesis or oxidative stress to predict cardiovascular events (ANOX) study, and followed up for 3 years. The primary outcome was all-cause death. The secondary outcomes were cardiovascular death, and major adverse cardiovascular events (MACE) defined as a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke.

Results

During the follow-up, 147 patients died from any cause, 47 died from cardiovascular disease, and 94 developed MACE. After adjustment for established risk factors, VEGF-D levels were significantly associated with all-cause death (hazard ratio [HR] for 1-SD increase, 1.34; 95% confidence interval [CI], 1.21–1.47), cardiovascular death (HR, 1.40; 95% CI, 1.18–1.62), and MACE (HR, 1.22; 95% CI, 1.07–1.40). Even after incorporation of N-terminal pro-brain natriuretic peptide, contemporary sensitive cardiac troponin-I, and high-sensitivity C-reactive protein into a model with established risk factors, the addition of VEGF-D levels further improved the prediction of all-cause death (continuous net reclassification improvement [NRI], 0.258; 95% CI, 0.088–0.429; P=0.003; integrated discrimination improvement [IDI], 0.013; 95% CI, 0.002–0.024; P=0.022), but not that of cardiovascular death (NRI, 0.046; 95% CI, −0.245–0.336; P=0.759; IDI, 0.013; 95% CI, −0.005–0.031; P=0.146) or MACE (NRI, 0.064; 95% CI, −0.146–0.274; P=0.552; IDI, 0.001; 95% CI, −0.002–0.004; P=0.557).

Conclusions

In suspected or known CHD patients with diabetes undergoing elective coronary angiography, elevated VEGF-D levels may predict all-cause mortality independent of established risk factors and cardiovascular biomarkers.

Acknowledgement/Funding

The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization

P5526Vascular endothelial growth factor-D and mortality in suspected or known coronary heart disease patients with chronic kidney disease: a subanalysis of the ANOX study

Background

Chronic kidney disease (CKD) is an independent risk factor for the development and progression of coronary heart disease (CHD). Vascular endothelial growth factor-D (VEGF-D) is a secreted glycoprotein that can act as lymphangiogenic and angiogenic growth factors through binding to its specific receptors, VEGFR-3 (Flt-4) and VEGFR-2 (KDR/Flk-1). VEGF-D signaling via VEGFR-3 plays an important role in lipoprotein metabolisms which may contribute to CHD. VEGF-D signaling has been used as a therapeutic target of human diseases such as lymphangioleiomyomatosis and refractory angina. Furthermore, in clinical settings, the VEGF-D level is already established as a diagnostic biomarker for lymphangioleiomyomatosis. However, the prognostic value of VEGF-D in suspected or known CHD patients with CKD is unknown.

Methods

Serum VEGF-D levels were measured in 999 suspected or known CHD patients with CKD undergoing elective coronary angiography, enrolled in the development of novel biomarkers related to angiogenesis or oxidative stress to predict cardiovascular events (ANOX) study, and followed up for 3 years. The primary outcome was all-cause death. The secondary outcomes were cardiovascular death, and major adverse cardiovascular events (MACE) defined as a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke.

Results

During the follow-up, 154 patients died from any cause, 61 died from cardiovascular disease, and 96 developed MACE. After adjustment for established risk factors, VEGF-D levels were significantly associated with all-cause death (hazard ratio [HR] for 1-SD increase, 1.41; 95% confidence interval [CI], 1.27–1.56), cardiovascular death (HR, 1.48; 95% CI, 1.28–1.71), and MACE (HR, 1.34; 95% CI, 1.18–1.53). Even after incorporation of N-terminal pro-brain natriuretic peptide, contemporary sensitive cardiac troponin-I, and high-sensitivity C-reactive protein into a model with established risk factors, the addition of VEGF-D levels further improved the prediction of all-cause death (continuous net reclassification improvement [NRI], 0.272; 95% CI, 0.100–0.445; P=0.002; integrated discrimination improvement [IDI], 0.015; 95% CI, 0.003–0.027; P=0.013), but not that of cardiovascular death (NRI, 0.230; 95% CI, −0.029 to 0.488; P=0.082; IDI, 0.012; 95% CI, −0.007 to 0.031; P=0.207) or MACE (NRI, 0.102; 95% CI, −0.106 to 0.310; P=0.337; IDI, 0.005; 95% CI, −0.005 to 0.015; P=0.337).

Conclusions

In suspected or known CHD patients with CKD undergoing elective coronary angiography, elevated VEGF-D levels may predict all-cause mortality independent of established risk factors and cardiovascular biomarkers.

Acknowledgement/Funding

The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization

P3765Low vascular endothelial growth factor-C was a predictor for cardiovascular events in patients with atrial fibrillation and suspected or known coronary artery disease: a subanalysis of the ANOX study

Background

Lymphatic system has been considered to play an important role in cardiovascular disease. We recently reported that vascular endothelial growth factor-C (VEGF-C), a central player in lymphangiogenesis, predicted all-cause mortality in patients with suspected or known coronary artery disease (CAD). However, relationship between VEGF-C and atrial fibrillation (AF) remains unclear.

Methods

The ANOX study is a multicenter, prospective cohort study of 2,418 patients with suspected CAD, to determine the predictive value of possible novel biomarkers related to angiogenesis or oxidative stress for major adverse cardiovascular events (MACE) among patients undergoing elective angiography. Blood samples were collected from the arterial catheter sheath at the beginning of coronary angiography. Serum levels of VEGF-C, as well as N-terminal pro-brain natriuretic peptide (NT-proBNP), high-sensitivity troponin-I (cTnI), and high-sensitivity C-reactive protein (hsCRP), were measured. The outcome was a MACE defined as a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke.

Results

Of a total of 2,418 patients, 261 patients had AF at baseline. AF group were older, and had more chronic kidney disease, history of heart failure, and history of stroke, but less diabetes, dyslipidemia, and CAD. The median level of NT-proBNP, cTnI, and hsCRP were higher in AF group [AF vs non-AF: NT-proBNP, 1048 pg/ml vs 162 pg/ml (p<0.0001); cTnI, 0.0003 ng/ml, vs 0.0 ng/ml (p<0.0001); hsCRP, 1.43 ug/ml vs 0.88 ug/ml (p=0.0005)], whereas median level of VEGF-C was lower in AF group [3107 pg/ml vs 3590 pg/ml (p<0.0001)]. AF was associated with lower VEGF-C and higher hsCRP after adjustment for potential confounders. During the 3-year follow-up, 29 (11.1%) patients in AF group and 136 (6.3%) patients in non-AF group developed MACE (p=0.007). Incidence of stroke was higher in AF group (17 (6.5%) vs 52 (2.4%); p<0.0009), despite that the incidence of cardiovascular death and myocardial infarction were similar between the groups. We divided the entire cohort into two groups based on the lowest quartile of VEGF-C or highest quartile of other biomarkers, lowest quartile of VEGF-C (log rank p=0.0004), as well as highest quartile of cTnI (log rank p=0.0009), were significantly associated with MACE in AF group. After adjustment for established risk factors and these biomarkers, both lowest quartile of VEGF-C (HR, 2.73; 95% CI, 1.27–6.06) and highest quartile of cTnI (HR, 2.54; 95% CI, 1.08–6.09) were significantly associated with MACE in AF group.

Conclusions

AF was associated with lower level of VEGF-C, and low VEGF-C as well as high cTnI might serve as an independent predictor of MACE in patients with AF and suspected or known CAD.

P3635Vascular endothelial growth factor-D and mortality in patients with suspected but no history of coronary heart disease: a subanalysis of the ANOX study

Background

Vascular endothelial growth factor-D (VEGF-D) is a secreted glycoprotein that can act as lymphangiogenic and angiogenic growth factors through binding to its specific receptors, VEGFR-3 (Flt-4) and VEGFR-2 (KDR/Flk-1). VEGF-D signaling via VEGFR-3 plays an important role in lipoprotein metabolisms which may contribute to coronary heart disease (CHD). VEGF-D signaling has been used as a therapeutic target of human diseases such as lymphangioleiomyomatosis and refractory angina. In clinical settings, the VEGF-D level is already established as a diagnostic biomarker for lymphangioleiomyomatosis. However, the prognostic value of VEGF-D in patients with suspected but no history of CHD is unknown.

Methods

Serum VEGF-D levels were measured in 1,717 patients with suspected but no history of CHD undergoing elective coronary angiography, enrolled in the development of novel biomarkers related to angiogenesis or oxidative stress to predict cardiovascular events (ANOX) study, and followed up for 3 years. The primary outcome was all-cause death. The secondary outcomes were cardiovascular death, and major adverse cardiovascular events (MACE) defined as a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke.

Results

During the follow-up, 161 patients died from any cause, 50 died from cardiovascular disease, and 104 developed MACE. After adjustment for established risk factors, VEGF-D levels were significantly associated with all-cause death (hazard ratio [HR] for 1-SD increase, 1.29; 95% confidence interval [CI], 1.17–1.42), cardiovascular death (HR, 1.37; 95% CI, 1.20–1.56), and MACE (HR, 1.22; 95% CI, 1.08–1.37). Even after incorporation of N-terminal pro-brain natriuretic peptide, contemporary sensitive cardiac troponin-I, and high-sensitivity C-reactive protein into a model with established risk factors, the addition of VEGF-D levels further improved the prediction of all-cause death (continuous net reclassification improvement [NRI], 0.165; 95% CI, 0.004–0.325; P=0.044; integrated discrimination improvement [IDI], 0.012; 95% CI, 0.002–0.023; P=0.013), but not that of cardiovascular death (NRI, 0.078; 95% CI, r=−0.203–0.359; P=0.586; IDI, 0.014; 95% CI, r=−0.009–0.037; P=0.235) or MACE (NRI, r=−0.011; 95% CI, r=−0.207–0.184; P=0.337; IDI, 0.003; 95% CI, r=−0.003–0.009; P=0.354).

Conclusions

In patients with suspected but no history of CHD undergoing elective coronary angiography, elevated VEGF-D levels may predict all-cause mortality independent of established risk factors and cardiovascular biomarkers.

Acknowledgement/Funding

The ANOX study is supported by a Grant-in-Aid for Clinical Research from the National Hospital Organization.

Full-Gap Superconductivity Robust against Disorder in Heavy-Fermion CeCu_{2}Si_{2}

A key aspect of unconventional pairing by the antiferromagnetic spin-fluctuation mechanism is that the superconducting energy gap must have the opposite sign on different parts of the Fermi surface. Recent observations of non-nodal gap structure in the heavy-fermion superconductor CeCu_{2}Si_{2} were then very surprising, given that this material has long been considered a prototypical example of a superconductor where the Cooper pairing is magnetically mediated. Here we present a study of the effect of controlled point defects, introduced by electron irradiation, on the temperature-dependent magnetic penetration depth λ(T) in CeCu_{2}Si_{2}. We find that the fully gapped state is robust against disorder, demonstrating that low-energy bound states, expected for sign-changing gap structures, are not induced by nonmagnetic impurities. This provides bulk evidence for s_{++}-wave superconductivity without sign reversal.

Hindfoot alignment at one year after total knee arthroplasty

PURPOSE

It has previously been found that valgus hindfoot alignment (HFA) improves 3 weeks following total knee arthroplasty (TKA) for varus knee osteoarthritis (OA). In the present study, HFA was evaluated prior to TKA, as well as 3 weeks and 1 year following TKA. Using these multiple evaluations, the chronological effects of TKA on HFA were investigated.

METHODS

The study included 71 patients (73 legs) who underwent TKA for varus knee OA. Radiograph examinations of the entire limb and hindfoot were performed in the standing position prior to TKA, as well as 3 weeks and 1 year following TKA. The varus-valgus angle was used as an indicator of HFA in the coronal plane. Patients were divided into two groups according to the preoperative varus-valgus angle: a hindfoot varus group (varus-valgus angle <76°) and a hindfoot valgus group (varus-valgus angle ≥76°). The changes in the varus-valgus angle were evaluated and compared in both groups.

RESULTS

In the hindfoot valgus group, the mean ± standard deviation varus-valgus angle significantly declined from 80.5 ± 3.1° prior to TKA to 78.6 ± 3.7° 3 weeks following TKA and 77.1 ± 2.7° 1 year following TKA. However, in the hindfoot varus group, the mean varus-valgus angle prior to TKA (72.7 ± 2.6°) did not differ significantly from the mean varus-valgus angles 3 weeks (72.3 ± 3.3°) or 1 year (73.5 ± 3.0°) following TKA.

CONCLUSIONS

HFA improved chronologically in legs with hindfoot valgus as a result of the alignment compensation ability of the hindfoot following TKA. However, no improvement was noted in legs with hindfoot varus because the alignment compensation ability of the hindfoot had been lost. The patients with hindfoot varus should be attended for ankle pain in the outpatient clinic after TKA.

LEVEL OF EVIDENCE

III.