Association of cardiac prognosis in chronic limb-threatening ischemia patients after endovascular intervention and wound, ischemia, and foot infection clinical stage

Background

Chronic limb-threatening ischemia (CLTI) represents the end-stage manifestation of peripheral artery disease. Recently, the Society for Vascular Surgery established the Wound, Ischemia, and foot Infection (WIfI) classification system, focusing on disease severity rather than arterial lesion characteristics. While the WIfI clinical stage has been thought to have a prognostic value in CLTI patients, the hemodialysis and left ventricular ejection fraction (LVEF) also appear to represent pivotal factor affecting prognosis among CLTI patients. However, few reports have addressed associations between WIfI clinical stage and cardiac death.

Purpose

The purpose of this study was to investigate the patient's clinical factors including WIfI clinical stage and mortality of CLTI patients undergoing endovascular intervention based on WIfI clinical stage.

Methods

This retrospective study investigated 200 consecutive CLTI patients and we individually assessed WIfI clinical stage. We then compared mortality after endovascular intervention between a WIfI stage 1, 2 group and a stage 3, 4 group, and investigated associations between baseline characteristics and WIfI clinical stage 1, 2 group and a stage 3, 4 group.

Results

Among 200 patients, 123 patients (62%) showed WIfI stage 1 or 2, and the remaining 77 patients (38%) had WIfI stage 3 or 4. Age was significantly higher in the WIfI stage 3, 4 group [median 75, interquartile range (IQR) 68–82] compared with the WIfI stage 1, 2 group (median 70, IQR 63–79, p=0.004). The rate of diabetes mellitus patients was significantly higher in the WIfI stage 3, 4 group (62% vs. 82%, p=0.003), but no differences in the rate of hemodialysis between WIfI stage 3, 4 group and WIfI stage 1, 2 group (53% vs. 37%, p=0.056). Median duration of follow-up was 966 days (IQR, 540–1268 days). Forty patients (20%) died after endovascular intervention. Incidences of all-cause and cardiac deaths were higher in the WIfI stage 3, 4 group than in theWIfI stage 1, 2 group (27% vs. 15%, p=0.047 and 12% vs. 3%, p=0.040, respectively). Kaplan–Meier analysis showed a significantly lower survival rate in the WIfI stage 3, 4 group than in theWIfI stage 1, 2 group (p=0.002 by log-rank test). Cox proportional hazard univariate analysis revealed that WIfI stage 3 or 4 [odds ratio (OR) 4.22, 95% confidence interval (CI) 1.29–13.72, p=0.012), hemodialysis (OR 4.67, 95% CI 1.28–16.96, p=0.010), LVEF (OR 0.96, 95% CI 0.92–0.99, p=0.045) were correlated to cardiac death. Multivariate analysis models using relevant factors from univariate analysis showed only WIfI stage 3 or 4 [odds ratio (OR) 3.74, 95% confidence interval (CI) 1.08–12.87, p=0.028) was significantly associated with cardiac death.

Conclusion

These results indicate that CLTI patients with high WIfI clinical stage may be associated with poor cardiac prognosis after endovascular intervention.

Funding Acknowledgement

Type of funding sources: None.

Secondary rotational atherectomy strategy may reduce the occurrence of prolonged ST-segment elevation following ablation

Background

Rotational atherectomy (RA) has been widely used for severely calcified lesions in performing percutaneous coronary intervention (PCI). The slow flow phenomenon is the most frequently observed complication of RA and leads to prolonged ST-segment elevation. The incidence of the slow flow phenomenon was reported as approximately 5–20%. Several methods have been recommended to treat the slow flow phenomenon; however, the elevation of ST-segment may often persist after disappearance of slow flow phenomenon on angiography.

Purpose

The aim of the present study was to investigate the clinical factors on the incidence of prolonged ST-segment elevation following ablation of RA.

Methods

The subject comprised 140 consecutive stable angina patients with severe calcified lesions. All patients had undergone successfully elective PCI using RA and intravascular ultrasound, and had been prescribed strong statins more than 2 week before PCI regardless dyslipidemia. We investigated the occurrence of prolonged ST-segment elevation following ablation of RA with resistance to use of nitroprusside as intra-coronary vasodilators, and the clinical factors including of primary or secondary RA strategy for calcification lesions. Secondary RA strategy was defined as RA performed after pre-dilatation with small balloon (balloon/artery ratio = 0.6).

Results

Median of age was 71 years (66–80) and 98 cases (70%) were male. Of 140 target lesions, 82 (59%) were LAD (RCA; 24%, LCX; 16%, and LMT; 1%, respectively). The rates of hemodialysis and diabetes mellitus were 31% and 61%. The incidence of prolonged ST-segment elevation with resistance to use of nitroprusside as intra-coronary vasodilators was 8 cases (6%). Major complications of RA including coronary perforation, coronary rupture, burr entrapment and cardiogenic shock requiring the mechanical support were none. Univariate logistic regression analysis showed that age [Odds ratio (OR); 1.07, 95% confidence interval (CI) 0.99–1.17, p=0.103], hemodialysis (OR; 0.71, 95% CI: 0.10–3.25, p=0.688), diabetes mellitus (OR; 1.08, 95% CI: 0.25–5.46, p=0.915), use of β-blocker (OR; 0.70, 95% CI: 0.14–2.96, p=0.633), left ventricular ejection fraction (OR; 0.99, 95% CI: 0.94–1.05, p=0.781), lesion length ≥20mm (OR; 1.04, 95% CI: 0.23–7.33, p=0.962), and burr size (OR; 2.42, 95% CI: 0.53–16.95, p=0.289) were not associated with the incidence of prolonged ST-segment elevation. Multivariate logistic regression analysis for the incidence of prolonged ST-segment elevation revealed that secondary RA strategy and levels of low-density lipoprotein cholesterol (LDL-C) were independent factors of the incidence of prolonged ST-segment elevation following ablation of RA (OR; 0.05, 95% CI: 0.01–0.39, p=0.017 and LDL-C: OR 0.91, 95% CI 0.83–0.96, p=0.010, respectively).

Conclusion

Secondary RA strategy may be useful to reduce the occurrence of prolonged ST-segment elevation following ablation of RA.

Funding Acknowledgement

Type of funding sources: None.

The impact of malnutrition-inflammation-atherosclerosis (MIA) syndrome on the prognosis of elderly patients with chronic limb-threatening ischemia after endovascular therapy

Background

Chronic limb-threatening ischemia (CLTI) is known to the most advanced form of severe arteriosclerosis in peripheral artery disease and cause poor prognosis. Whereas malnutrition (M), inflammation (I) and atherosclerosis (A) are reported to be involved in the pathophysiology of end-stage renal disease with close relevancy and affect its clinical outcomes, the effect of such MIA syndrome on the mortality in elderly patients with CLTI has not been well evaluated.

Purpose

The aim of the present study was to investigate the influence of patient characteristics including MIA syndrome on the mortality in elderly CLTI patients <3 years after endovascular therapy (EVT).

Methods

The subject was 222 consecutive elderly (≥65 year) CLTI patients who were admitted to undergo endovascular therapy (EVT). We assessed nutritional status using Geriatric Nutritional Risk Index (GNRI) in this study, and defined patients with GNRI <92 at admission as malnutrition. We also assessed inflammatory status using hs-CRP. The patients were divided into four groups based on their nutrition and inflammatory status as follows; Group A; GNRI <92+hs-CRP ≥1 mg/dL, Group B; GNRI <92+hs-CRP <1 mg/dL, Group C; GNRI >92+hs-CRP ≥1 mg/dL, Group D; GNRI >92+hs-CRP <1 mg/dL. Patients in the group A were considered to be under MIA syndrome. We evaluated which Group affected prognosis of elderly CLTI patients after endovascular therapy (EVT).

Results

All-cause death after EVT were 37 cases (17%). In this study, all patients underwent successful EVT for target lesions. As a result of cox proportional hazards analysis, all-cause death was associated with MIA syndrome [hazard ratio (HR): 2.41, 95% confidence interval (CI): 1.13–5.17, p<0.001)], Clinical Fraility Scale (HR: 1.46, 95% CI: 1.127–1.93, p=0.005), and history of stroke (HR: 2.32, 95% CI: 1.11–4.86, p=0.026) in the univariate analysis. Multivariate cox proportional hazards analysis models after adjusted for the demographic characteristics of patients and clinically relevant factors for all-cause death after EVT revealed that MIA syndrome and history of stroke were independent risk factors (HR: 3.94, 95% CI: 1.34–11.63, p=0.013, HR: 3.06, 95% CI: 1.14–8.18, p=0.026,). Kaplan Meier analysis also elucidated that survival rate was significantly lower in Group A compared to those in other Groups (p=0.0131). Furthermore, cox proportional hazards models using each Group A to D revealed that only Group A was associated with all-cause death (Group A: HR 2.41, 95% CI: 1.13–5.17, p=0.024, Group B: HR 1.01, 95% CI: 0.41–2.46, p=0.976, Group C: HR 1.01, 95% CI: 0.35–2.88, p=0.987, Group D: HR 0.57, 95% CI: 0.30–1.13, p=0.109).

Conclusions

MIA syndrome was a strong predictor for incidence of all-cause death in elderly CLTI patients after EVT.

Funding Acknowledgement

Type of funding sources: None.

Priority of non-HDL-C assessment to predict occurrence of new lesions after percutaneous coronary intervention in stable angina patients with diabetes mellitus prescribed strong statins

Background

Diabetes mellitus (DM) patients are known to suffer from a higher risk of adverse outcomes following percutaneous coronary intervention (PCI) despite of low-density lipoprotein cholesterol (LDL-C)-lowering therapy with statins. Thus, identification of factors that may occurrence of new lesions following PCI in DM patients treated with strong statin is clinically important. Although LDL-C is generally calculated using the Friedewald equation method [LDL-C (F)], the effects of LDL-C measured by the Martin method [LDL-C (M)] or non-high-density lipoprotein cholesterol (non-HDL-C) on the occurrence of new lesions on coronary angiography after PCI among stable angina patients with DM receiving treatment with strong statins are unknown.

Purpose

The aim of the present study was to investigate the clinical factor on the occurrence of new lesions in stable angina patients with DM at 9-month follow-up coronary angiography and within 2 years after PCI.

Methods

The subject was 313 consecutive stable angina patients with DM who were admitted to undergo PCI. All patients had undergone successfully elective PCI using second-generation drug-eluting stents and intravascular ultrasound, and had been prescribed strong statins regardless dyslipidemia more than 2 week before PCI. We investigated the clinical factor on the occurrence of new lesions with myocardial ischemia. We estimated LDL-C (F), LDL-C (M), and non-HDL-C in this study. Acute coronary syndrome and hemodialysis patients were excluded from this study.

Results

Median of age and level of glycosylated hemoglobin (HbA1c) were 69 years (62–76) and 6.8% (6.3–7.3). New lesions appeared 9-month follow-up coronary angiography [New lesion(+) 9-month] and within 2 years [New lesion(+) 2-year] after PCI in 19 (6%) and 62 (20%) patients, respectively. The rate of history of smoking, using of β-blocker, and non-HDL-C ≥100 mg/dL and level of HbA1c were significantly higher in the New lesion(+) 9-month group than those in the New lesion(−) 9-month group after PCI. Age, level of high-sensitivity C-reactive protein and triglyceride, frequencies of LDL-C (F) ≥70 mg/dL, LDL-C (M) ≥70 mg/dL and non-HDL-C ≥100 mg/dL were significantly higher in the New lesion(+) 2-year group than those in the New lesion(−) 2-year group after PCI. Multivariate logistic regression analysis demonstrated only non-HDL-C ≥100 mg/dL was associated with the occurrence of new lesions both 9-month and within 2 years [9-month: hazard ratio (HR) 4.25, 95% confidence interval (CI) 1.30–19.23, p=0.014 and 2-year: HR 2.30, 95% CI 1.24–4.45, p=0.010].

Conclusion

Only non-HDL-C ≥100 mg/dL was an independently associated with the occurrence of new lesions both 9-month and within 2 years after PCI in stable angina patients with DM treated with strong statins. Residual risk after PCI in DM patients should be considered by assessing non-HDL-C beyond the scope of LDL-C-lowering therapy with strong statins.

Funding Acknowledgement

Type of funding sources: None.

History of stroke is a major factor to affect prognosis of elderly chronic limb-threatening ischemia patients with frailty after endovascular therapy

Background

Chronic limb-threatening ischemia (CLTI) is the most advanced form of severe arteriosclerosis, and CLTI patients are known to have poor prognosis due to complication of polyvascular diseases, including cerebrovascular disease. Stroke often causes disability of exercise, leading to develop frailty and sarcopenia, and frailty and sarcopenia are known to important factors affecting the prognosis of cardiovascular disease. However, the effect of history of stroke for clinical outcomes in elderly CLTI patients with frailty has not been well evaluated.

Purpose

The aim of the present study was to investigate whether a history of stroke affects prognosis of elderly CLTI patients with frailty after endovascular therapy (EVT).

Methods

The subject was 228 consecutive elderly (≥65 year) CLTI patients underwent EVT. These patients had frailty with clinical frailty scale 5 or 6 or 7 which was defined by Geriatric Medicine Research. Clinical frailty was assessed on admission before procedure of EVT by physicians or other health professionals. The study patients were divided into two groups based on patients with or without history of stroke group (Group A and B). We investigated the association between history of stroke on admission and outcome after EVT.

Results

All-cause death ≤6 month and ≤12 month after EVT were 10 cases (4%) and 19 cases (8%). Group A had higher rate of all-cause death ≤6month and ≤12 month (14 vs. 3%, p=0.012, 19 vs. 6%, p=0.019) than those of Group B. Kaplan Meier analysis elucidated that survival rate was significantly lower in Group A compared to that in Group B (p=0.031). As a result of cox proportional hazards analysis, all-cause death ≤6 month was associated with history of stroke [hazard ratio (HR): 5.07, 95% confidence interval (CI): 1.47–17.52, p=0.010)], hs-CRP (HR: 1.09, 95% CI: 1.01–1.16, p=0.010) in the univariate analysis. Similarly, cox proportional hazards analysis for revealed that history of stroke (HR: 3.02, 95% CI: 1.19–7.68, p=0.020), hs-CRP (HR: 1.09, 95% CI: 1.03–1.14, p<0.001), hemodialysis (HR: 2.53, 95% CI: 1.03–6.24, p=0.043), use of clopidogrel (HR: 0.22, 95% CI: 0.07–0.78, p=0.019) and serum albumin level (HR: 0.40, 95% CI: 0.21–0.80, p=0.008) were significantly associated with all-cause death ≤12 month. Multivariate analysis models after adjusted for the demographic characteristics of patients and clinically relevant factors for all-cause death ≤6 month and ≤12 month after EVT revealed that history of stroke was an independent risk factor (HR: 5.18, 95% CI: 1.44–17.43, p=0.011, HR: 2.98, 95% CI: 1.71–7.61, p=0.022).

Conclusions

These data suggested that history of stroke was a crucial independent predictor for incidence of all-cause death in elderly CLTI patients with frailty.

Funding Acknowledgement

Type of funding source: None

Malnutrition is a major factor to affect prognosis of patients undergo percutaneous coronary intervention for coronary artery disease with calcified lesions

Background

In patients undergo PCI for coronary artery disease, target lesion calcification is associated with major cardiac events. Malnutrition is the important factor to cause frailty and sarcopenia which affect prognosis of cardiovascular diseases. However, the relationship between morphology in target lesions and malnutrition in patients undergo PCI is still uncertain.

Purpose

The aim of the present study was to investigate how malnutrition affects prognosis of stable angina patients underwent PCI and morphology in target lesions.

Methods

The subject was 206 consecutive stable angina patients undergone successful PCI using second-generation drug eluting stents and intravascular ultrasound (IVUS). The study patients were divided into two groups based on malnutrition or non-malnutrition. Nutritional status was assessed by Geriatric Nutritional Risk Index (GNRI), and patients with GNRI<92 at admission were defined as malnutrition group (MG). We investigated the association between malnutrition on admission and outcome, and morphology in target lesions assessed by IVUS. Target lesion morphology were divided into moderate/severe calcified group and none/mild calcified group.

Results

All-cause death and MACCE (major cardiovascular and cerebrovascular events) ≤3 years after PCI were 15 cases (7%) and 33 cases (16%). MG had higher rate of all-cause death (20 vs. 6%, p=0.001) and MACCE (37 vs. 10%, p<0.001) than those of non-MG. Kaplan Meier analysis elucidated that survival rate was significantly lower in MG compared to that in non-MG (p<0.001). As a result of cox proportional hazards analysis, all-cause death was associated with age [hazard ratio (HR): 1.05, 95% confidence interval (CI): 1.01–1.10, p=0.006)], hs-CRP (HR: 1.03, 95% CI: 1.03–1.12, p<0.001), hemodialysis (HR: 2.25, 95% CI: 1.08–4.68, p=0.029), left ventricular ejection fraction (LVEF) (HR: 0.97, 95% CI: 0.95–0.99, p=0.017) and malnutrition (HR: 4.38, 95% CI: 2.11–9.09, p<0.001) in the univariate analysis. Similarly, cox proportional hazards analysis revealed that age (HR: 1.04, 95% CI: 1.01–1.07, p=0.018), hs-CRP (HR: 1.08, 95% CI: 1.03–1.11, p<0.001), hemodialysis (HR: 2.68, 95% CI: 1.45–4.94, p=0.002), LVEF (HR: 0.97, 95% CI: 0.95–0.99, p=0.002) and malnutrition (HR: 4.14, 95% CI: 2.23–7.67, p<0.001) were significantly associated with MACCE. Multivariate analysis for all-cause death and MACCE revealed that malnutrition was an independent risk factor (HR: 3.47, 95% CI: 1.52–7.94, p=0.003, HR: 3.76, 95% CI: 1.87–7.58, p<0.001). Furthermore, MG was significantly associated with moderate/severe target calcified lesions assessed by IVUS compared to those of patients in non-MG (67 vs. 27%, p<0.001) regardless with or without hemodialysis.

Conclusions

Malnutrition was a crucial independent risk factor for stable angina patients who underwent PCI and was significantly associated with moderate/severe target calcified lesions.

Funding Acknowledgement

Type of funding source: None

P3626Malnutrition is a major factor to affect prognosis of coronary artery disease patients with myocardial damage

Background

Malnutrition is the important factor to cause frailty and sarcopenia which affect the prognosis of cardiovascular diseases. However, the effect of malnutrition on prognosis of coronary artery disease (CAD) patients with myocardial damage is still uncertain.

Purpose

The aim of the present study was to investigate the effect of malnutrition on prognosis of CAD patients with myocardial damage who received percutaneous coronary intervention (PCI).

Methods

The subjects were 241 CAD patients with myocardial damage due to myocardial ischemia by coronary artery stenosis or occlusion. These patients underwent successful revascularization for CAD by PCI using second-generation drug eluting stents and discharged. Geriatric Nutritional Risk Index (GNRI) was used to assess nutritional status in this study, and patients with GNRI<92 at baseline were defined as malnutrition group. The association between MACCE (major cardiovascular and cerebrovascular events) after discharged and patient's characteristics including nutritional status at baseline were assessed.

Results

The mean follow-up period was 546±310 days, with a maximum follow-up duration of 1092 days. MACCE within 3 years after PCI were 42 cases (17%) and malnutrition group had high rate of MACCE (38 vs. 11%, P<0.01) compared with non- malnutrition group. In malnutrition group, age (77±9 vs. 67±11 years, P<0.01) and high-sensitivity C-reactive protein (hs-CRP) level (5.52±6.63 vs. 0.72±1.86 mg/dl, P<0.01) were higher than those of non-malnutrition group. The serum albumin (Alb) level (3.0±0.5 vs. 4.0±0.4 mg/dL, P<0.01), hemoglobin (Hb) (10.4±1.9 vs. 12.8±2.4 g/dL, P<0.01), total cholesterol (151.8±32 vs. 174.1±41.6 mg/dL, P<0.01), triglycerides (96.9±49.1 vs. 140.6±128.3 mg/dL, P<0.01), and left ventricular ejection fraction (LVEF) (50.2±15.9 vs. 55.9±15.3%, P=0.03) were lower in malnutrition group than those in non-malnutrition group. Moreover, malnutrition group had lower rate of hemodialysis (HD) (35 vs. 65%, P<0.01), dyslipidemia (16 vs. 84%, P<0.01) and using of statins (16 vs. 83%, P=0.02) than those in non-malnutrition group. As a result of Cox proportional hazards analysis, MACCE was associated with age [hazard ratio (HR): 1.04, 95% confidence interval (CI): 1.01–1.07, p p<0.01)], hs-CRP (HR: 1.08, 95% CI: 1.03–1.11, p<0.01), HD (HR: 2.63, 95% CI: 1.51–4.58, p<0.01) and malnutrition (HR: 3.69, 95% CI: 2.11–6.42, p<0.01) in the univariate analysis. The multivariate Cox proportional hazards analysis revealed that HD (HR: 2.24, 95% CI: 1.24–4.08, p<0.01) and malnutrition (HR: 2.10, 95% CI: 1.04–4.23, p=0.03) were significantly associated with MACCE. Furthermore, malnutrition additively facilitated incidence of MACCE among patients underwent HD (GNRI <92+HD: HR 4.19, 95% CI: 2.22–7.88, p<0.001, GNRI >92+HD: HR 1.26, 95% CI: 0.65–2.47, p=0.493).

Conclusions

In CAD patients with myocardial damage, malnutrition (GNRI<92) is a major risk factor for MACCE after PCI.

Werner syndrome as a possible cause of non-alcoholic steatohepatitis

Non-alcoholic steatohepatitis (NASH) is characterised by steatosis, liver cell injuries, the presence of a mixed inflammatory lobular infiltrate, and variable degrees of fibrosis. Werner syndrome (WS) is a rare autosomal recessive disease characterised by the premature onset of multiple age-related disorders. Central obesity and insulin resistance are common symptoms of both NASH and WS. Three cases were studied to evaluate the association between WS and NASH. NASH was diagnosed by liver biopsies and imaging studies following the exclusion of alcohol consumption, viral disease or autoimmune liver disease. Liver histology was compatible with NASH in all cases. Liver dysfunction, hyperlipidaemia, insulin resistance and regional increase of intra-abdominal fat even though the body mass indices were all normal or low, were observed. Metabolic disorders due to WS may complicate and cause NASH. Hence, the observed clinical association between WS and NASH suggests that patients with WS should also be screened for NASH.

Prevalence of hepatitis G virus in liver disease

The prevalence of hepatitis G virus (HGV) in liver disease of non-A, -B, -C viral hepatitis, hepatitis B and hepatitis C was determined. Two of 44 patients (4.5%) with liver injury without any hepatitis A, B or C marker were positive for HGV. One of five cases of hepatocellular carcinoma was positive for HGV. One of three cases with fulminant hepatitis was positive for HGV. This case was negative at the onset of fulminant hepatitis and became positive after plasmapheresis. No patient with acute (n=8) or chronic (n=5) hepatitis or liver cirrhosis (n=8) was positive for HGV in non-A, -B, -C liver disease. One of 30 patients with various HBV-positive liver diseases and nine (17.3) of 52 patients with type C liver disease were positive for HGV. In patients with hepatitis C, four (28.6%) of 14 HGV-co-infected patients were complicated with diabetes mellitus compared with four (10.5%) of 38 single hepatitis C virus (HCV)-infected patients (not significant). In 12 HGV-positive patients, eight of 10 (80%) had a history of blood transfusion. In HCV-positive patients, co-infection with HGV was not a risk factor in patients with diabetes mellitus as a complication. HGV appeared to cause non-A, -B, -C hepatitis rarely, and its main route of infection was blood transfusion.