Projections of maternal mortality ratios in Bangladesh

Background

The objective of this study was to predict when Bangladesh would achieve Sustainable Development Goal Target 3.1, which is to reduce the maternal mortality ratio (MMR) to less than 70 per 100 000 live births.

Methods

We used secondary data from the 1993 to 2017 Bangladesh Demographic and Health Surveys and other sources to project the MMR until 2060 under several scenario assumptions using an autoregressive moving average model with exogenous variables (ARMAX). Explanatory variables were selected based on the three delays model, and a reference forecast and four practical scenarios were simulated: Scenario 1 assumed a 4% annual increase in institutional deliveries, Scenario 2 followed the national goals, the reference forecast and Scenario 3 varied in terms of district-wise increase rates (Scenario 3 had a lower rate of increase), and Scenario 4 assumed minimal changes in institutional deliveries.

Results

Scenario 1 was the earliest, with an MMR of <70 per 100 000 live births in 2026. Scenario 2 would meet the target of <70 per 100 000 live births in 2029. The reference forecast had the third lowest MMR, with 69.78 per 100 000 live births (95% prediction intervals (PI) = 32.44 to 107.11) in 2049. Although the MMR for Scenario 3 decreased slowly, it would not reduce below 70 per 100 000 live births by 2060. Scenario 4, which had the highest MMR, also resulted in the MMR not reducing below 70 per 100 000 live births by 2060.

Conclusions

To increase the institutional delivery rate and reduce the MMR, as in Scenarios 1 and 2, it is necessary to improve the institutional delivery rate in regions with low institutional delivery rates. Additionally, health facilities need to provide appropriate quality medical care to increase the institutional delivery rate and contribute to a decrease in the MMR, as shown by the results of this study.

A survey of screening and support systems for socially high-risk pregnancies at obstetric facilities in Japan

AIM

To clarify the state of screening and support systems for socially high-risk pregnant women at obstetric facilities across Japan and identify the characteristics of facilities related to the implementation of screening.

METHODS

This cross-sectional study used a self-administered questionnaire. Participants were managers of hospitals, clinics, and midwifery birth centers handling deliveries in 47 prefectures across Japan. The questionnaire comprised items regarding the characteristics of participants and their facilities, service provision related to socially high-risk women available at the facility, the number of specified pregnant women (tokutei ninpu) per year, methods of screening, and support systems within the obstetric facilities. Descriptive statistics and multivariate logistic regression analysis were performed using IBM-SPSS version 24 for the association between facility characteristics and screening practices for socially high-risk pregnant women.

RESULTS

Valid responses were received from 716 of 2512 obstetric facilities. Rates of specified expectant mothers per annual number of deliveries were identified as follows: perinatal medical centers (2.7%), general hospitals (1.6%), obstetrics and gynecology hospitals (1.0%), and clinics (0.8%). A total of 426 facilities (60.6%) reported screening all expectant mothers to identify socially high-risk pregnant women. Multiple logistic regression analysis revealed that facility characteristics and service/care provision related to screening practices included availability of in-hospital midwife-led care and in-hospital midwifery clinics (adjusted odds ratio 1.61; 95% CI [1.30, 1.47]), one-on-one care by midwife (1.73; 95% CI [1.15, 2.59]), multidisciplinary meetings within the facility (1.70; 95% CI [1.14, 2.56]), follow-up support systems after discharge (1.90; 95% CI [1.17, 3.09]), and participation in the regional council for children in need of protection (2.33; 95% CI [1.13, 4.81]).

CONCLUSIONS

Approximately 60% of surveyed obstetric facilities screen for socially high-risk women. Increasing service provision at facilities may be necessary to implement screening.

Erratum: Search for Cosmic-Ray Boosted Sub-GeV Dark Matter Using Recoil Protons at Super-Kamiokande [Phys. Rev. Lett. 130, 031802 (2023)]

This corrects the article DOI: 10.1103/PhysRevLett.130.031802.

Measurements of neutrino oscillation parameters from the T2K experiment using 3.6×1021 protons on target

The T2K experiment presents new measurements of neutrino oscillation parameters using 19.7 ( 16.3 ) × 10 20 protons on target (POT) in (anti-)neutrino mode at the far detector (FD). Compared to the previous analysis, an additional 4.7 × 10 20 POT neutrino data was collected at the FD. Significant improvements were made to the analysis methodology, with the near-detector analysis introducing new selections and using more than double the data. Additionally, this is the first T2K oscillation analysis to use NA61/SHINE data on a replica of the T2K target to tune the neutrino flux model, and the neutrino interaction model was improved to include new nuclear effects and calculations. Frequentist and Bayesian analyses are presented, including results on sin 2 θ 13 and the impact of priors on the δ CP measurement. Both analyses prefer the normal mass ordering and upper octant of sin 2 θ 23 with a nearly maximally CP-violating phase. Assuming the normal ordering and using the constraint on sin 2 θ 13 from reactors, sin 2 θ 23 = 0 . 561 - 0.032 + 0.021 using Feldman-Cousins corrected intervals, and Δ m 32 2 = 2 . 494 - 0.058 + 0.041 × 10 - 3 eV 2 using constant Δ χ 2 intervals. The CP-violating phase is constrained to δ CP = - 1 . 97 - 0.70 + 0.97 using Feldman-Cousins corrected intervals, and δ CP = 0 , π is excluded at more than 90% confidence level. A Jarlskog invariant of zero is excluded at more than 2 σ credible level using a flat prior in δ CP , and just below 2 σ using a flat prior in sin δ CP . When the external constraint on sin 2 θ 13 is removed, sin 2 θ 13 = 28 . 0 - 6.5 + 2.8 × 10 - 3 , in agreement with measurements from reactor experiments. These results are consistent with previous T2K analyses.

Complementary and alternative medicine use by pregnant women in Japan: a pilot survey

BACKGROUND

Complementary and alternative medicine (CAM) are popular among women, and are used during their pregnancy in Japan. This study aimed to survey the prevalence of CAM use by healthy pregnant women as a health-care prescribed therapy or self-care and to investigate the factors associated with CAM use in Japan.

METHODS

In this cross-sectional study, pregnant women after 34 weeks of gestation were asked to respond to a questionnaire at the clinic or online. The questionnaire comprised questions on the participants' characteristics and their use of CAM for therapy and self-care. Descriptive statistics were calculated in the analyses, and bivariate and multivariate logistic analyses were performed to evaluate the associations between factors and CAM use.

RESULTS

A total of 394 women responded from three hospitals, two clinics, and two midwifery birth centers. CAM was received as treatment by practitioners during pregnancy by 75 women (19.0%). The following therapies were used: traditional Chinese medicine (7.9%), chiropractic (6.9%), moxibustion (6.4%), and acupuncture (5.3%). One or more types of therapy were used as self-care by 348 women (88.3%). Highly used CAM for self-care were: folic acid supplementation (75.4%), other supplements (51.5%), herbs (20.8%), and yoga (19.0%). Multiple logistic regression analyses revealed that the factors associated with CAM use as a therapy were midwifery birth centers for planned childbirth settings (adjusted odds ratio [AOR] 3.64, 95% confidence interval [CI] [1.69-7.83]) and pregnancy complications diagnosed (AOR 2.46, 95%CI [1.38-4.39]). The factors associated with CAM use for self-care were age 30-39 years (AOR 4.48, 95%CI [2.14-9.73]) and over 40 years (AOR 3.92, 95%CI [1.10-13.91]), junior college education or above (AOR 2.30, 95%CI [1.18-4.51]), and primiparas (AOR 3.82, 95%CI [1.86-7.86]). The most common source of information was the "Internet" (43.8%).

CONCLUSIONS

Approximately 20% of Japanese pregnant women received CAM as therapy by practitioners, and the related factors were: tended to have baby at midwifery birth center and pregnancy complications. Almost 90% of respondents used CAM as self-care and the related factors were: older, had a higher educational level and tended to be primiparas. They used the Internet as their main source of information about CAM. Health care providers need to provide evidenced-based information on CAM and to help decision making to ensure safe and effective CAM utilization by pregnant women.

An E-Learning Program for Continuing Midwifery Education on Handling High-Risk Abuse Cases: A Pretest-Posttest Design

It is essential to equip midwives and nurses working in the perinatal period with comprehensive knowledge and awareness regarding child abuse prevention. However, most midwives and nurses in Japan do not have the opportunity to learn about abuse prevention during their basic education. We aimed to develop an e-learning program to assist obstetric midwives and nurses in acquiring the knowledge needed to provide support and handle cases with a high risk of abuse, as well as to assess the program's usefulness. This study employed a single-group pre-post design; e-learning served as the intervention. Seventy-one obstetric midwives and nurses were recruited. The program's usefulness was the difference between the participants' pretest and post-test knowledge and efficacy scores. The score data were analyzed using the t-test. A paired t-test revealed that the post-test scores of knowledge and efficacy were significantly higher than those of the pretest, with a large effect size (d = 1.71). Platforms where basic knowledge on how to respond to high-risk abuse cases are lacking in nursing education; thus, this e-learning program is recommended for nurses working in the perinatal field throughout Japan. This educational opportunity for perinatal midwives and nurses will increase awareness and contribute to abuse prevention.

Prevalence and associated factors of intimate partner violence against pregnant women in urban areas of Japan: a cross-sectional study

BACKGROUND

Intimate partner violence (IPV) against pregnant women is associated with many negative maternal and fetal outcomes and is a common public health problem all over the world. However, the issue has not been fully explored in Japan. This study aimed to explore the prevalence and risk factors of IPV against pregnant women in urban areas of Japan.

METHODS

This study was a secondary data analysis of a cross-sectional survey that was conducted on women beyond 34 weeks' gestation in five perinatal facilities in urban areas of Japan, from July to October 2015. The sample size was calculated to be 1230. The Violence Against Women Screen was used for IPV screening. Multiple logistic regression analysis was used to calculate the adjusted odds ratio (AOR) with 95% confidence interval (CI) for risks of IPV while adjusting for confounding factors.

RESULTS

Of the 1346 women who participated in this study, 180 (13.4%) were identified as experiencing IPV. Compared to those who did not experience IPV (n = 1166 (86.6%)), women experiencing IPV had higher odds of being single mothers (AOR = 4.8; 95%CI: 2.0, 11.2), having lower household income (< 3 million yen, AOR = 2.6; 95%CI: 1.4, 4.6; ≥ 3 million yen and < 6 million yen, AOR = 1.9; 95%CI: 1.2, 2.9), having junior high school education background (AOR = 2.3; 95%CI: 1.0, 5.3) and being multipara (AOR = 1.6; 95%CI: 1.1, 2.4).

CONCLUSIONS

13.4%, or about one in seven women, experienced IPV while pregnant. This high proportion indicates the need for policy to address the issue of violence against pregnant women. There is an urgent need to build a system for the early detection of victims that offers appropriate support to prevent the recurrence of violence while encouraging victim recovery.

Identifying Core Items of the Japanese Version of the Mother-to-Infant Bonding Scale for Diagnosing Postpartum Bonding Disorder

The Japanese version of the mother-to-infant bonding scale (MIBS-J), a self-report of postpartum bonding disorder, is used in clinical settings for screening postpartum bonding disorder at various time points. However, its psychometric properties, particularly measurement invariance, have rarely been reported, and the validity of comparing scores across time points and sex is unclear. We aimed to select and validate the MIBS-J items suitable for parents at three time points. Postpartum mothers (n = 543) and fathers (n = 350) were surveyed at 5 days, 1 month, and 4 months postpartum. All participants were randomly divided into two subgroups, one for exploratory factor analyses (EFAs) and another for confirmatory factor analyses. Measurement invariance of the best model was tested using the entire sample, between fathers and mothers, and across the three observation periods. A three-item structure (items 1, 6, and 8) extracted through EFAs showed acceptable configural invariance. This model was accepted for scalar invariance between fathers and mothers and for metric invariance across the three time points. Our findings suggest that the three-item MIBS-J is sufficient for diagnosis of postpartum parental bonding disorder through continuous observation for at least 4 postpartum months, in order to detect the priority of parents who need support.

Search for Cosmic-Ray Boosted Sub-GeV Dark Matter Using Recoil Protons at Super-Kamiokande

We report a search for cosmic-ray boosted dark matter with protons using the 0.37  megaton×years data collected at Super-Kamiokande experiment during the 1996-2018 period (SKI-IV phase). We searched for an excess of proton recoils above the atmospheric neutrino background from the vicinity of the Galactic Center. No such excess is observed, and limits are calculated for two reference models of dark matter with either a constant interaction cross section or through a scalar mediator. This is the first experimental search for boosted dark matter with hadrons using directional information. The results present the most stringent limits on cosmic-ray boosted dark matter and exclude the dark matter-nucleon elastic scattering cross section between 10^{-33}cm^{2} and 10^{-27}cm^{2} for dark matter mass from 1  MeV/c^{2} to 300  MeV/c^{2}.

Effectiveness of an educational program for clinical educators to promote novice midwives' clinical judgment: A cluster randomized controlled trial

BACKGROUND

There has been little research on education for clinical educators and particularly on education to promote clinical judgment. Therefore, the purpose of this study was to examine the effectiveness of an educational program for clinical educators to promote the clinical judgment of novice midwives during delivery.

METHODS

A cluster randomized controlled trial was conducted in which a facility was considered a cluster. Eleven facilities (44 participants) were randomly assigned to the intervention group with the educational intervention and 10 facilities (33 participants) to the control group without the educational intervention. Inclusion criteria were midwives who had become clinical educators within five years. The educational program consisted of e-learning and a seminar. The primary outcome was educational skills. The secondary outcomes were attitude, knowledge, and satisfaction. Data on the satisfaction was collected only for the intervention group. Intention-to-treat and multi-model analyses using a random intercept model were used to analyze data. St. Luke's International University ethics review committee approved the study (20-A016).

RESULTS

No differences in baseline characteristics of participants and facilities were noted. There was no significant difference in educational skills scores at post-test between the intervention and control group (MD 1.88, 95 % CI [-0.55-4.31]). There was no significant difference in attitude scores at post-test between the two groups (MD 2.38, 95 % CI [-0.76, 5.51]). The knowledge scores at post-test were significantly higher in the intervention group (intervention group 2.68 ± 0.26, control group 1.57 ± 0.25; MD 1.10, 95 % CI [0.41-1.80], p = .002).

CONCLUSION

The intervention group improved only in knowledge scores, with no effect on educational skills or attitudes compared to the control group. It is necessary to evaluate the effectiveness of the program by conducting long-term follow-up and evaluation.

Evaluation of the effect of a midwife-led online program using cognitive behavioral therapy for pregnant women at risk for anxiety disorder in Japan: A pilot randomized controlled trial

AIM

This study aimed to conduct a pilot randomized controlled trial (RCT) to examine the appropriateness and feasibility of a midwife-led cognitive behavioral therapy (CBT)-based, three-session program delivered remotely to pregnant women at risk for anxiety disorders.

METHODS

The study design was a pilot RCT. Outcome was the difference between the two groups in the change in generalized anxiety disorder-7 (GAD-7), Kessler6 (K6) and Edinberg Postnatal Depression Scale (EPDS) etc. Recruitment was conducted from August 2020 to July 2021 in clinics and web-based survey monitors in Japan, with follow-up through November 2021.

RESULTS

This program involving 63 pregnant women were administered. Although the intervention was remote, a total of three sessions was completed during pregnancy. The change in GAD-7 scores from pre- to 1 month postpartum, was mean -1.77 in the intervention group and mean -0.97 in the control group, with a p-value of .521, indicating no significant difference between the two groups, although GAD-7 scores were lower in the intervention group. The change in K6 score from pre- to 1 month postpartum, was mean -3.55 in the intervention group and mean -1.62 in the control group, with a p-value of .168, indicating no significant difference between the two groups, although the intervention group showed a greater decrease. In particular, in primiparas, the change in GAD-7 scores in the intervention group was large, and some expressed a desire for a postpartum session, suggesting that a follow-up session after delivery may be effective. In multiparas, the control group showed an increase in both GAD-7 and K6 scores from late pregnancy to 1 month postpartum, while the intervention group showed a decrease in scores.

CONCLUSION

The program was implemented using CBT conducted by midwife, anxiety decreased in primiparas. In future RCTs, it was suggested that additional postpartum sessions may be effective.

TRIAL REGISTRATION

UMIN Clinical trial registry ID: UMIN000040304.

Characterization of lipidic plaque materials at calcified atheroma: its association with calcification thickness evaluated by optical coherence tomography and near-infrared spectroscopy imaging

Introduction

The degree of calcification and its thickness have been considered to affect stent expansion, leading to an increases risk of repeat revascularization in patients receiving PCI. Pathophysiologically, accumulation of lipidic materials within vessel wall could trigger the formation of plaque calcification. Elucidating characteristics of lipidic plaque components at calcified atheroma may enable to identify phenotypes with thick calcification which less likely responds to PCI.

Purpose

This study investigated the relationship of calcification thickness with lipidic plaque materials at calcified atheroma by using OCT and near-infrared spectroscopy (NIRS) imaging.

Methods

We analyzed 52 calcified lesions (culprit/non culprit lesions=44/8) in 47 CAD patients (stable CAD/ACS=36/11) from the REASSURE-NIRS registry (NCT04864171). OCT and NIRS imaging evaluated 4-mm segment exhibiting maximum superficial calcification arc. Calcification thickness on OCT imaging, its arc on IVUS imaging, and NIRS-derived lipid arc were analyzed at every 1-mm interval cross-sectional images. In addition, yellow-calcification ratio (YCR = lipid arc/calcification arc) was calculated (Figure 1).

Results

53% of study subjects exhibited chronic kidney disease and 70% of them received a statin (averaged on-treatment LDL-C =89mg/dL). Throughout OCT and NIRS/IVUS imaging analysis of 260 cross-sectional images, the averaged calcification arc, its maximum thickness, lipid arc and YCR were 210° (167–285°), 0.78mm (0.62–0.95mm), 95° (31–169°) and 0.33 (0.09–0.59), respectively. As expected, thicker calcification more likely exhibited a greater calcification arc (r=0.30, p&lt;0.001). Furthermore, a greater thickness of calcification was associated with smaller lipidic plaque burden, reflected by yellow arc (r=−0.36, p&lt;0.001) and YCR (r=−0.36, p&lt;0.001) (Figure 2). After adjusting age, gender and ACS, calcification arc (p&lt;0.001) and YCR (p&lt;0.001) continued to predict thicker calcification.

Conclusion

Thickening of calcification was associated with severer calcification arc, which was accompanied by the shrinkage of lipidic plaques. Our findings suggest the evaluation of lipidic plaque component as a potential tool to identify calcified atheroma harbouring thick calcification, which may cause a greater risk of stent underexpansion.

Funding Acknowledgement

Type of funding sources: None.

The effect of achieving LDL-C &lt;1.8 mmol/L to prevent the first atherosclerotic cardiovascular events in the primary prevention settings of severe heterozygous familial hypercholesterolemia

Introduction

The International Atherosclerosis Society (IAS) has proposed “severe familial hypercholesterolemia” (FH) as a phenotype with the highest cardiovascular risk. LDL-C &lt;2.5 mmol/l is a recommended therapeutic goal for the primary prevention settings of severe FH. However, given that ESC guidelines recommends LDL-C &lt;1.8 mmol/l in FH patients, this stricter goal may be better to prevent the first atherosclerotic cardiovascular disease (ASCVD) in severe FH patients.

Purpose

To determine whether achieving LDL-C&lt;1.8 mg/dl is more beneficial to reduce the first ASCVD events.

Methods

A total of 148 severe FH subjects without any history of ASCVD were analyzed. Severe FH was defined as untreated LDL-C &gt;10.3 mmol/l, LDL-C &gt;8.0 mmol/l+ 1 high-risk feature, LDL-C &gt;4.9 mmol/l + 2 high-risk features according to IAS proposed statement. The occurrence of ASCVD (all-cause death, CAD, ischemic stroke and lower extremity artery disease (LEAD)) were compared in those with on-treatment LDL-C &lt; and ≥1.8 mmol/L.

Results

10.1% (=15/148) of study subjects achieved on-treatment LDL-C &lt;1.8 mmol/l. They were more likely to receive PCSK9 inhibitor (15.0 vs. 66.7%, p&lt;0.01), whereas there was no significant difference in FH-related physical characteristics (tendon xanthomas: 72.2 vs. 93.3%, p=0.12) and causative genotypes (LDLR: 68.4 vs. 66.7%, p=1.00, PCSK9: 8.3 vs. 6.7%, p=1.00, LDLR/PCSK9: 3.8 vs. 6.7%, p=0.48), untreated LDL-C (7.3±1.7 vs. 7.9±1.8 mmol/l, p=0.22) and lipoprotein(a) (23 [11–42] vs. 25 [15–70] mg/dl, p=0.41) levels between two groups. During the observational period (median=7.0 years), severe FH achieving on-treatment LDL-C &lt;1.8 mmol/l was associated with a lower likelihood of experiencing ASCVD events (Figure 1). Of note, any cardiovascular events did not occur in severe FH who achieved on-treatment LDL-C &lt;1.8 mmol/l. In those with on-treatment LDL ≥1.8 mmol/L, CAD (76.5%=26/34) was more dominant component of ASCVD, followed by ischemic stroke (17.6%=6/34) and LEAD (5.9%=2/34).

Conclusions

A significantly lower frequency of ASCVD was observed in severe FH who achieved LDL-C &lt;1.8 mmol/L in the primary prevention settings. Given that only 10.1% of severe FH patients achieved LDL-C &lt;1.8 mmol/l, more actions are required to motivate physicians for further intensified management of LDL-C in severe FH patients in the primary prevention settings.

Funding Acknowledgement

Type of funding sources: None.

Deterioration of cardiogenic shock after acute myocardial infarction defined by the society for cardiovascular angiography and intervention cardiogenic shock classification scheme

Background

Cardiogenic shock (CS) in patients with AMI presents worse cardiovascular outcomes, which suggests the need for better risk stratification and management. The Society for Cardiovascular Angiography and Intervention (SCAI) has recently proposed CS classification scheme, which stratifies CS into 5 groups according to hypotension and hypoperfusion. While stage A and B exhibits CS without hypotension and/or hypoperfusion, their clinical condition could rapidly deteriorate into stage C-E. However, clinical characteristics and in-hospital outcomes of CS exhibiting its deterioration remains uncertain.

Purpose

To characterize AMI patients who deteriorated their CS status from stage A and B into stage C-E.

Methods

This single-center observational study included 326 consecutive AMI patients receiving primary PCI who presented CS stage A and B on arrival (2019.09.01–2021.09.30). Deterioration of CS (D-CS) was defined as the progression from stage A and B on arrival to stage C-E after primary PCI. Clinical characteristics and outcomes were compared in those with and without D-CS.

Results

D-CS was identified in 16.0% of entire subjects (=52/326). Of these, 94.2 and 5.8% of them exhibited stage C and E, respectively (Figure). Patients with D-CS more likely presented STEMI (84.6 vs. 67.9%, p=0.01) with a lower systolic BP (sBP) level (130±31 vs. 148±26mmHg, p&lt;0.001) and a reduced LVEF (43±13 vs. 51±9%, p&lt;0.001), whereas there was no significant difference in lactate level (1.5±0.4 vs. 1.2±0.3 mmol/L, p=0.22). Pre-TIMI flow grade 0–1 (69.2 vs. 47.8%, p=0.006), left main trunk stenosis (9.6 vs. 1.5%, p=0.007) and chronic total occlusion (21.2 vs. 8.4%, p=0.01) were more frequently observed in those with D-CS. Despite achieving a shorter onset-to-reperfusion time (199 vs. 276 minutes, p=0.002), D-CS was associated with in-hospital all-cause mortality after adjusting clinical characteristics (HR=33.6, 95% CI: 2.2–502.0, p=0.01). Furthermore, mechanical circulatory support (MCS) (30.8 vs. 0%, p&lt;0.001) was more frequently required in patients with D-CS (IABP: 28.8 vs. 0%, p&lt;0.001, ECMO: 11.5 vs. 0%, p&lt;0.001, Impella: 3.8 vs. 0%, p=0.02). Further analysis identified sBP (HR=0.98, 95% CI: 0.97–1.00, p=0.008), LVEF (HR=0.94, 95% CI: 0.90–0.97, p&lt;0.001) and pre-TIMI flow grade 0–1 (HR=0.41, 95% CI: 0.19–0.86, p=0.01) as independent contributors to D-CS. ROC analysis demonstrated sBP &lt;135 mmHg (AUC=0.65) and LVEF &lt;50% (AUC=0.69) as best cut-off values to predict D-CS. Of note, a risk of D-CS increased in association with the number of these three factors (p&lt;0.001), and 44.0% of those with all of these factors presented D-CS (Figure).

Conclusion

16.0% of AMI without any hypotension/hypoperfusion on arrival exhibited deterioration of CS status on SCAI classification. The combination of sBP, LVEF and pre-TIMI flow grade could help to identify AMI subjects with a risk of D-CS, who may benefit from early adoption of intensified management including MCS prior to PCI.

Funding Acknowledgement

Type of funding sources: None.

Early vascular responses to abluminal biodegradable polymer-coated versus circumferential durable polymer-coated newer-generation drug-eluting stents in humans: a pathologic study

Background

Recent clinical trials are testing strategies for short (1–3 months) dual antiplatelet therapy (DAPT) following newer-generation drug-eluting stent (DES) placement. However, the safety of short DAPT regimens is not supported by biological evidence in humans.

Purpose

We sought to evaluate early pathologic responses to newer-generation DES by comparing abluminal biodegradable polymer-coated DES (BP-DES) with circumferential durable polymer-coated DES (DP-DES) in human autopsy cases.

Methods

The study included a total of 37 coronary lesions with thin strut newer-generation DES (DP-DES=23 [XIENCE=18, Resolute Integrity=5] and BP-DES=14 [SYNERGY=9, Ultimaster=5]) with duration of implantation &lt;90 days in 25 autopsy cases. The process of stent healing was precisely evaluated for every single strut in association with underlying tissue characteristics. The degree of strut coverage was defined as follows: grade 0 (bare struts), grade 1 (struts covered with thrombus, fibrin, or other tissues or cells without endothelium), grade 2 (struts covered with single-layered endothelium without underlying smooth muscle cell layers), and grade 3 (struts covered with endothelium and underlying smooth muscle cell layers) (Figure 1).

Results

Duration of implantation was similar in lesions with DP-DES and those with BP-DES (median=20 vs. 17 days). A total of 1986 struts (DP-DES=1261, BP-DES=725) were pathologically analyzed. Focal grade 2 coverage was observed as early as 5 days after the implantation in both stents. Multilevel mixed-effects ordered logistic regression model demonstrated that BP-DES exhibited greater strut coverage compared with DP-DES (odds ratio; 3.50, 95% CI; 1.31–9.41, P=0.013), which remained significant after adjustment for duration of implantation and underlying tissue characteristics (odds ratio; 2.64, 95% CI; 1.04–6.68, P=0.040). The time course of vessel healing assessed as predictive probability of strut coverage (grade 0–3) stratified by duration of implantation is shown in Figure 2. Predictive probability of grade 2 and 3 coverage was comparably limited at 30 days (DP-DES=17.7% vs. BP-DES=29.0%) and increased at 90 days (DP-DES=76.1% vs. BP-DES=85.9%). Both stents showed few inflammation and similar degree of fibrin deposition.

Conclusions

The current first pathologic study on early biological responses to newer-generation DES in humans demonstrated that single-layered endothelial coverage begins in days following the stent placement, and abluminal BP-DES potentially exhibit faster strut coverage with smooth muscle cell infiltration than circumferential DP-DES. Nevertheless, vessel healing remains suboptimal at 30 days in both DP- and BP-DES, which progresses with time to become substantial at 90 days. Our results suggest that very short duration of DAPT for 1 month should be applied with caution, taking into account the trade-off between bleeding and thrombotic risks.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Grant-in-Aid for Scientific Research (C) from the Japan Society for the Promotion of Science

Intimate partner violence and the situation of women experiencing intimate partner violence during the COVID-19 pandemic: A qualitative study of Japanese clinician views

AIM

Intimate partner violence (IPV) is a major global threat to women's health. Stay-at-home orders during the coronavirus disease 2019 (COVID-19) pandemic were associated with an increase in IPV. The purpose of this study was to clarify IPV and the situation of women experiencing IPV during the COVID-19 pandemic in Japan.

METHODS

A semi-structured interview was conducted with five healthcare providers who gave support to women experiencing IPV during the COVID-19 pandemic. All interviews were audio-recorded, transcribed and analyzed in accordance with thematic analysis methodology.

RESULTS

Two categories concerning IPV and the situation of women experiencing IPV during the COVID-19 pandemic emerged from analysis of interviews: (1) the possibility that IPV might change during the pandemic; and (2) barriers that prevent women getting support. "Possibility that IPV might change during the pandemic" consisted of three subcategories: "Male partner takes his stress out on her"; "Male partner forced her out of the home"; and "Conflict occurred more easily at home". "Barriers that prevent women getting support" had four subcategories: "Difficulty in accessing outside support"; "Restricted access to get care due to financial difficulties"; "Lack of support from her family"; and "Women experience a loss of energy".

CONCLUSIONS

During the COVID-19 pandemic, there were barriers to provide support for women despite increased IPV. Healthcare providers should support women using effective methods to protect women's health and safety.

Cognitive behavioral therapy in perinatal mental health: An overview of systematic reviews

AIM

The purpose of this study was to determine whether cognitive behavioral therapy (CBT) started in pregnancy can prevent depression and anxiety.

METHODS

We conducted an overview review by selecting systematic reviews (SRs) that compared CBT with usual care, no CBT, or interventions other than CBT in perinatal women. We restricted the review to studies that included randomized controlled trials. The results of included SRs were descriptively integrated according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Seven SRs met our eligibility criteria. One SR was limited to CBT interventions, whereas others included psychoeducation and interpersonal psychotherapy. There was some variation in the number of sessions and timing of CBT, and whether there was a postpartum intervention. Five SRs showed that CBT reduced depression compared with usual care, an educational intervention, or no intervention. One SR that analyzed the effect on anxiety found that psychotherapy, including CBT, reduced anxiety compared with usual care or no intervention.

DISCUSSION

CBT starting from pregnancy may be effective as a preventive intervention for postpartum depression and anxiety, although the degree of effectiveness varied.

CONCLUSIONS

This overview review aimed to clarify whether CBT is effective in preventing depression and anxiety from pregnancy. CBT may be effective in reducing perinatal depression and anxiety.

Effects of e-learning on the support of midwives and nurses to perinatal women suffering from intimate partner violence: A randomized controlled trial

AIMS

To examine the effects of e-learning on intimate partner violence (IPV) knowledge, preparatory/reinforcing behaviors for supporting IPV victims, and IPV screening of midwives and nurses.

METHODS

Participants were randomly assigned to the intervention group (IG: e-learning) and control group (CG: no e-learning). The primary outcome was the mean change in knowledge score. The secondary outcomes were the mean number of types of practiced preparatory/reinforcing behaviors and the proportions of participants who practice screening. Unpaired t tests were performed in intention-to-treat analysis.

RESULTS

Of the 88 participants, 45 were randomly assigned to the IG and 43 to the CG. For the post-1-test, the IG had a mean change in the knowledge score of 8.5 points with a significant difference from the 1.4 points in the CG (mean difference [MD] 7.1, 95% CI [4.1, 10.1]). The mean change between the pre-test and the post-2-test was significantly larger in the IG (7.9 points) than in the CG (1.3 points) (MD 6.6, 95% CI [3.3, 9.9]). The mean number of types of practiced behaviors at the post-1-test and post-2-test was significantly higher in the IG than in the CG (MD 1.4, 95% CI [0.1, 2.8]). There was no significant difference in the proportions of participants who practice screening between the two groups postintervention.

CONCLUSIONS

The e-learning effectively improved knowledge and promoted preparatory/reinforcing behaviors.

Substantially elevated thromboembolic and bleeding risks in patients with AMI following acute/subacute stroke events

Introduction

AMI infrequently but concomitantly occurs after stroke events. Current guideline recommends primary PCI with DAPT in the setting of AMI. However, this approach is not necessarily applicable in AMI subjects following acute/subacute stroke events due to its bleeding risk. Clinical management and outcomes of these AMI subjects following remains uncertain.

Purpose

To characterize management and clinical outcomes in patients with AMI following acute/subacute stroke events (=post-stroke AMI).

Methods

The current study retrospectively analyzed 2041 AMI patients hospitalized at our institute from 2007 to 2018. Post-stroke AMI was defined as its occurrence within 14 days after ischemic/hemorrhagic stroke. The use of reperfusion and anti-thrombotic therapies, and the occurrence of major adverse cardiovascular events (=CV death, non-fatal MI and non-fatal stroke) and major bleeding events (BARC type 3 or 5) were compared in post-stroke and non-post-stroke AMI patients.

Results

Post-stroke AMI was identified in 1.1% of entire subjects (=23/2041). Of these, 65% of them (=15/23) had AMI within 3 days from the onset of stoke event. Over 60% of them was due to cardioembolic stroke, followed by hemorrhagic (9%), atherothrombotic ones (8%) and other causes (22%). Post-stroke AMI patients were more likely to exhibit Af (p=0.02) and a history of hemodialysis (p=0.009), and have a lower BMI (p=0.04) and hemoglobin level (p=0.02). They were less likely to receive emergent coronary angiography, and primary PCI was conducted in only 65% of post-stroke AMI patients (Table). Furthermore, they more frequently received thrombectomy (p=0.04) alone rather than stent implantation (p=0.002) (Table). With regard to anti-thrombotic therapy, the proportion of DAPT use was significantly lower in post-stroke AMI subjects (52 vs. 89%, p=0.0001), and 17% of them did not receive any anti-thrombotic agents. Of note, only 48% (p=0.04) and 43% (p=0.0001) of post-stroke AMI patients were treated with other established medical therapies including β-blocker and statin, respectively. During the observational period (median = 2.9 years), post-stroke AMI was associated with a greater likelihood experiencing major adverse cardiovascular events (log-rank p&lt;0.001, Figure), CV death (log-rank p&lt;0.0001) and stroke events (log-rank p&lt;0.0001). Furthermore, the frequency of their major bleeding events was substantially elevated (log-rank p&lt;0.001, Figure).

Conclusions

In our real-world data, the adoption of guideline-recommended reperfusion and anti-thrombotic therapies were considerably low in AMI subjects following acute/subacute stroke events. Given their elevated risk of cardiovascular and bleeding events, it is required to establish better therapeutic management for mitigating their thrombotic/bleeding risks.

Funding Acknowledgement

Type of funding sources: None. Table 1Figure 1

The relationship of the underlying lipidic plaque at the implanted newer-generation drug-eluting stents with future stent-related events: insights from the REASSURE-NIRS registry

Background

Lipid-rich plaque is an important substrate causing acute coronary events. Near-infrared spectroscopy (NIRS) imaging has been shown to visualize lipidic coronary plaque at non-culprit site associated with future coronary events. Given that histopathological studies reported that the unstable plaque underlying the implanted drug-eluting stent (DES) could cause neoatherosclerosis formation, we hypothesized that NIRS-based evaluation of lipidic plaque burden behind the implanted DES may clinically predict the occurrence of stent failure in patients with CAD receiving PCI.

Purpose

We aimed to investigate the relationship of stent-related events' risk with lipidic plaque materials behind the implanted DES imaged by NIRS/intravascular ultrasound (NIRS/IVUS) imaging.

Methods

The REASSURE-NIRS registry is an on-going multi-center registry to enroll CAD subjects receiving NIRS/IVUS-guided PCI. In this registry data, 406 lesions in 379 CAD subjects (ACS/non-ACS=150/229) receiving new-generation DES were analyzed. Minimum stent area (MSA) after PCI and maximum lipid-core-burden index in any 4mm-segment within the implanted stents (in-stent maxLCBI4mm) were measured. A 3-year lesion-oriented composite outcome [LOCO: culprit lesion-related MI + ischemia-driven target lesion revascularization (ID-TLR)] was compared in subjects stratified according to the tertile of in-stent maxLCBI4mm.

Results

The mean value of in-stent maxLCBI4mm was 221, and 17% of lesions exhibited in-stent maxLCBI4mm &gt;400. Patients with a greater in-stent maxLCBI4mm were more likely to exhibit a higher LDL-C level (p=0.026) with a longer stent length (p&lt;0.001) and a smaller MSA (p=0.033) (Picture 1). Over 95% of entire study subjects received a statin. During the observational period (median=726 days), the frequency of LOCO up to 3 years was 3.4% in entire study subjects (culprit lesion-related MI=1.0%, ID-TLR=2.8%). Kaplan-Meier curve analysis demonstrated that the occurrence of LOCO did not increase in association with in-stent maxLCBI4mm (log-rank p-value=0.25, Picture 2). In addition, in-stent maxLCBI4mm did not associate with each component of LOCO (culprit lesion-related MI: p=0.502, ID-TLR: p=0.872). Receiver Operating Characteristic analysis revealed that the predictive ability of in-stent maxLCBI4mm for the occurrence of LOCO was unsatisfactorily (c-statistics=0.486).

Conclusion

The amount of underlying lipidic materials at culprit lesions receiving new-generation DES implantation did not necessarily predict future stent-related events. Clinical significance of maxLCBI4mm behind the implanted DES may be different from that at naïve non-culprit plaques.

Funding Acknowledgement

Type of funding sources: None. Background and lesion characteristicsKaplan-Meier analysis for LOCO

Characterization of cholesterol efflux capacity in diabetic and non-diabetic patients with coronary artery disease: comparison between acute coronary syndrome and stable coronary artery disease

Introduction

Type 2 diabetic patients more likely exhibit a lower high-density lipoprotein (HDL) level. Given a greater glycation and oxidative stress in diabetic subjects, these atherogenic characteristics could cause dysfunctional HDL including a reduced cholesterol efflux capacity (CEC), which may account for an increased risk of diabetic macrovascular disease including acute coronary syndrome (ACS). However, it remains to be fully elucidated characteristics of HDL-mediated CEC in type 2 diabetic patients, in association with clinical presentation of coronary artery disease (CAD).

Purpose

To characterize CEC in CAD subjects with type 2 diabetes mellitus.

Methods

The current study prospectively analyzed 87 statin-naive patients with CAD. CEC was measured by using the collected apolipoprotein B-depleted serum. Liquid scintillation counting (Perkin-Elmer Analytical Sciences, MA, US) was used to quantify the efflux of radioactive cholesterol from J774 cells. Clinical characteristics and CEC were compared in diabetic and non-diabetic subjects.

Results

The averaged HbA1c in diabetic patients was 6.7±1.2, and 66.7% of them achieved HbA1c &lt;7.0%. Diabetic subjects more likely exhibited a history of hypertension and dyslipidemia, and multi-vessel disease (Table). Moreover, a lower CEC level was observed in diabetic patients, accompanied by a lower HDL-C and apolipoprotein A-I levels with a higher level of triglyceride (Table). HDL-C (r=0.62, p-value&lt;0.01) and Apolipoprotein A-I (r=0.70, p-value &lt;0.01) were associated with CEC, whereas there was no significant difference in CEC between subjects with HbA1c &lt;7.0% vs. ≥7.0% (0.74±0.07 vs. 0.78±0.08, p=0.22). On multivariate analysis, type 2 diabetes mellitus was an independent contributor to CEC &lt;0.79 (median) (HR=2.75, 95% CI: 1.11–6.82, p=0.03). Interestingly in particular, CEC was substantially lower in diabetic patients with ACS compared to those with stable CAD (Figure). By contrast, clinical presentation of CAD did not affect CEC in non-diabetic subjects (Figure).

Conclusions

A lower CEC level was observed in subjects with type 2 diabetes mellitus. In particular, this HDL functionality was profoundly diminished in those presenting ACS. Our findings suggest functionality of HDL as a potential therapeutic target in diabetic patients experiencing ACS.

Funding Acknowledgement

Type of funding sources: None. Table 1Figure 1

Characterization of residual lipid-rich plaques despite achieving LDL-C &lt;1.8mmol/l with a statin in patients with coronary artery disease: insights from the REASSURE-NIRS registry

Introduction

Recent studies have demonstrated favourable modification of lipidic plaque materials under achieving LDL-C &lt;1.8mmol/l with a statin, which potentially accounts for its clinical benefit. However, coronary events still occur even under optimal LDL-C management. This may suggest the presence of residual lipid-rich coronary plaque despite on-treatment LDL-C &lt;1.8mmol/l. Given that near-infrared spectroscopy (NIRS) enables quantitative evaluation of lipidic plaque in vivo, we employed this imaging modality to investigate characteristics and drivers of residual lipid-rich plaques in statin-treated patients with coronary artery disease (CAD) who achieved LDL-C &lt;1.8mmol/l.

Purpose

To clarify the frequency, clinical demographics and factors associated with residual lipid-rich plaques under LDL-C &lt;1.8mmol/l.

Methods

The REASSURE-NIRS registry is an on-going multi-center registry to enroll CAD subjects receiving NIRS/intravascular ultrasound-guided PCI. The current analysis included 133 statin-treated stable CAD patients with on-treatment LDL-C &lt;1.8mmol/l from August 2015 to December 2020. The maximum 4-mm lipid core burden index (maxLCBI4mm) at culprit lesions was measured by NIRS imaging prior to PCI. Clinical characteristics were compared in patients with and without maxLCBI4mm ≥400 at culprit lesions.

Results

In the current study, 45% (=58/128) of study subjects exhibited maxLCBI4mm ≥400 at culprit lesions under on-treatment LDL-C &lt;1.8 mmol/l. They were more likely to be female, whereas there were no differences in age and the frequency of risk factors. Most of study subjects received moderate to high-intensity statin (p=0.79), and over one-fourth of them were treated with ezetimibe (p=0.56). Under these lipid-lowering therapies, LDL-C level was significantly higher in patients with maxLCBI4mm ≥400 (Table). Additionally, a lower frequency of LDL-C &lt;1.4mmol/l was observed in those exhibiting maxLCBI4mm ≥400 (31.0 vs. 45.7%), but this comparison failed to meet statistical significance (p=0.09). Despite LDL-C control with a statin, deterioration of coronary flow after PCI with stent implantation more frequently occurred in patients with maxLCBI4mm ≥400 (Table). Multivariate analysis demonstrated that an independent factor associated with maxLCBI4mm ≥400 was LDL-C level (OR=1.05; 95% CI=1.00–1.10, p=0.03), but not other lipid and clinical parameters.

Conclusion

Almost half of CAD subjects who achieved LDL-C level &lt;1.8mmol/l still exhibited the accumulation of lipidic plaque materials within vessel wall. Given that LDL-C level was associated with this residual lipid-rich plaque features, our findings support current ESC-guideline recommended LDL-C goal (&lt;1.4mmol/l) to optimize the secondary prevention in stable CAD patients.

Funding Acknowledgement

Type of funding sources: None.

Breastfeeding support and barriers to women with gestational diabetes mellitus: a nationwide cross-sectional survey of hospitals in Japan

BACKGROUND

Despite the benefits of breastfeeding for women with Gestational Diabetes Mellitus (GDM) and their infants, breastfeeding is less likely to be performed by this group. This study aimed to examine the current levels of implementation of breastfeeding support to women with GDM in Japan and to clarify barriers to promoting breastfeeding among this population.

METHODS

A 25-item questionnaire was developed by the authors to investigate the current levels of implementation of breastfeeding support for women with GDM provided in hospitals, and to explore barriers for promoting breastfeeding among these women. The questionnaire was sent to all 1046 hospitals facilitating childbirth in Japan. Descriptive statistics were used to analyze the quantitative data, and content analysis was used to analyze qualitative data from the open-ended questions.

RESULTS

All 296 respondents were included in this study. Regarding breastfeeding support, 95.2% of the respondents provided general information on breastfeeding to GDM women during antenatal midwife consultations. However, the benefits of breastfeeding for preventing type 2 diabetes were addressed by only 48.0%. Likewise, although follow-up services (e.g., telephone support or breastfeeding consultations) were conducted in 88.9% of hospitals, only 50.7% of hospitals informed women that breastfeeding decreases the risk of developing type 2 diabetes after GDM. Regarding barriers, seven categories and 20 subcategories about promoting breastfeeding for women with GDM were extracted and abstracted into the following three themes: Barriers associated with mother and infant, Barriers associated with health professionals, and Organizational barriers.

CONCLUSIONS

In Japan, most hospitals that responded provided general breastfeeding support from the antenatal to postpartum periods. However, the benefits of breastfeeding in terms of preventing the incidence of type 2 diabetes following GDM were insufficiently communicated to women with GDM. Furthermore, there were numerous barriers to promoting breastfeeding among women with GDM.

Continuous interprofessional collaboration for women with gestational diabetes mellitus: A cross-sectional survey in Japan

AIM

This study aimed to identify the current situation of interprofessional collaboration for gestational diabetes mellitus (GDM) management in Japan including the professionals involved, the collaboration methods employed, and the barriers perceived by nurses and midwives.

METHODS

This nationwide cross-sectional survey of 1,046 total hospitals facilitating childbirth in Japan used an original 60-item questionnaire to investigate GDM management practice through interprofessional collaboration. The questionnaire required one responder to be a midwife or nurse who was familiar with the management practices for GDM women in their respective hospitals. Quantitative data were analyzed using descriptive statistics, and framework analysis was conducted for qualitative data collected by open-ended questions.

RESULTS

All 308 respondents (response rate 29.4%) were included. The professionals included in interprofessional collaboration were limited, and the only strategy used for interprofessional collaboration by a majority (91.5%) of hospitals was medical charts. There were 50.8% of hospitals that provided postpartum GDM follow-ups and 54.5% of hospitals that did not engage in external collaboration for GDM management. The barriers to interprofessional collaboration extracted were seven categories and 23 subcategories, which were aligned within the following units of analysis: individual, team, organization, and community.

CONCLUSIONS

This survey shows that interprofessional collaboration, including support for GDM postpartum follow-up in Japan remains insufficient. Furthermore, nurses and midwives perceive numerous barriers to interprofessional collaboration for continuous GDM management at the individual, team, organizational and community levels.

St. Luke's International University and University of North Carolina at Chapel Hill collaboration project to develop the first DNP program in Japan

We report an international collaborative project to develop the first Doctor of Nursing Practice (DNP) program in Japan. We described the development and implementation of the first DNP program at the St. Luke's International University in Tokyo and the collaboration with the University of North Carolina at Chapel Hill in the United States. Faculty perceptions in both parties gradually evolved from the traditional perspective of international collaboration to the transitional and the beginning of the holistic partnership perspectives. The collaboration resulted in an innovative DNP program that directly addressed the gap between nursing education programs and Japan's clinical needs. The collaborative project cultivated a holistic international partnership. Rather than reporting a manual for international collaboration, we present our reflections and outcomes as narratives that others could use to achieve a holistic global partnership.

Dupilumab treatment in patients with atopic dermatitis: a comparative cohort study between the Netherlands and Japan shows a discrepancy in patient-reported outcome measures

BACKGROUND

Dupilumab was equally effective among all racial subgroups in clinical trials, but a direct comparison in daily practice is lacking.

OBJECTIVES

To investigate the effectiveness of dupilumab in patients with atopic dermatitis (AD) in the Netherlands and Japan over 80 weeks of treatment.

METHODS

A longitudinal comparative cohort study was conducted in patients with AD who were treated with dupilumab in daily practice. We used linear mixed-effects models to determine changes over time.

RESULTS

We found statistically significant differences in sex, disease onset, body mass index and therapeutic history between Dutch (n = 208) and Japanese (n = 153) patients. The baseline Eczema Area and Severity Index (EASI) score was higher in Japanese patients (23·8 vs. 14·8), while baseline Patient-Reported Outcome Measures (PROMs) were higher in Dutch patients. EASI scores decreased quickly to a level indicating 'mild disease' (EASI < 7), and remained low in both countries. However, PROMs showed different trajectories with better scores in Japan.

CONCLUSIONS

Dupilumab showed significant, comparable and sustained improvement of EASI scores in Japanese and Dutch patients. However, we found striking differences in the effect on PROMs between the countries, with a better outcome in Japanese patients.

Effects of timing of umbilical cord clamping on preventing early infancy anemia in low-risk Japanese term infants with planned breastfeeding: a randomized controlled trial

BACKGROUND

Japanese infants have relatively higher risk of anemia and neonatal jaundice. This study aimed to assess the effects of delayed cord clamping (DCC) on the incidence of anemia during early infancy in low-risk Japanese term infants with planned exclusive breastfeeding for 4 months. This study also aimed to explore the effects of DCC on neonatal jaundice.

METHODS

We conducted an open-label, parallel-arm, multicenter randomized controlled trial of DCC (clamping the cord after more than a minute or pulsation stops) vs. early cord clamping (ECC; clamping the cord within 15 s) at one birth center and two clinics in Japan. Low-risk pregnant women planning to have a vaginal birth and to exclusively breastfeed and term singleton infants delivered in cephalic presentation were included in this study. The primary outcome was spectrophotometric estimation of hemoglobin at 4 months. Secondary outcomes were anemia incidence at 4 months, four outcomes related to neonatal jaundice, hematocrit levels, and related outcomes.

RESULTS

Overall, 150 pregnant women were recruited. Participants (N = 138) were randomly allocated to two groups (DCC n = 68, ECC n = 70). There were no significant differences between the two groups in spectrophotometric estimation of hemoglobin at 4 months: mean difference = 0.1 g/dL, 95% confidence interval - 0.14, 0.35, DCC 12.4 g/dL, ECC 12.3 g/dL. Only the hematocrit levels on days 3 to 5 were significantly higher in the DCC group than in the ECC group: DCC 57.0%, ECC 52.6%, mean difference = 4.4, 95% confidence interval 2.61, 6.20. There were no significant differences in other secondary outcomes, including outcomes related to neonatal jaundice.

CONCLUSION

Among low-risk Japanese term infants with planned exclusive breastfeeding, DCC showed no significant effects on spectrophotometric hemoglobin levels at 4 months compared with ECC. We observed significantly higher hematocrit levels on days 3 to 5 in infants who underwent DCC, while these levels were within the normal range. Jaundice outcomes remained similar to those of infants who underwent ECC. Although a larger sample size is required to assess the effects of cord clamping on neonatal jaundice, DCC may prevent anemia in newborn infants.

TRIAL REGISTRATION

UMIN-CTR; UMIN000022573, 06/01/2016 - retrospectively registered, https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000023056.

Lp (a) &gt;50 mg/dl predicts atherosclerotic cardiovascular events in patients with heterozygous familial hypercholesterolemia who achieved LDL-C &lt;2.6 mmol/l

Introduction

Lipoprotein (a) [Lp (a)] is a plasma lipoprotein which exhibits atherogenic properties. Lp(a) ≥50 mg/dl has been recently shown to associate with a risk of atherosclerotic cardiovascular diseases (ASCVD) in patients with heterozygous familial hypercholesterolemia (HeFH). While current guideline recommends lowering LDL-C as a first-line therapeutic approach in HeFH subjects, it remains to be fully determined whether an elevated level of Lp(a) confers additional ASCVD risks in HeFH patients who achieved a lower LDL-C level.

Purpose

To investigate cardiovascular outcomes in HeFH subjects with a lower LDL-C but an elevated Lp(a) levels.

Methods

182 HeFH patients with on-treatment LDL-C &lt;2.6 mmol/l under lipid-lowering therapies were analyzed. Clinical characteristics and MACE (= a composite of all-cause death, ACS, stroke, PAD and coronary revascularization) were compared in HeFH subjects with Lp(a) ≥ vs. &lt;50 mg/dl.

Results

The averaged LDL-C and Lp (a) levels were 1.9 mmol/l and 26.8 mg/dl, respectively. 19.2% of study subjects exhibited Lp(a)≥50 mg/dl. HeFH patients with Lp(a) ≥50 mg/dl were more likely to be older and have a history of hypertension, but these comparisons did not meet statistical significance. There was no significant difference in on-treatment LDL-C, HDL-C and Triglyceride level (Table). However, during the observational period (median=4.7 years), there was a 2.7-fold (95% CI, 1.41–5.02; p=0.004) greater likelihood of experiencing MACE in subjects with Lp(a) ≥50 mg/dl (picture). Even after adjusting clinical demographics, Lp(a) ≥50 mg/dl remained an independent predictor for the occurrence of MACE (hazard ratio=2.53, 95% CI: 1.29–4.82, p&lt;0.001).

Conclusions

Despite achieving on-treatment LDL-C &lt;2.6 mmol/l, an elevated risk of MACE was observed in HeFH patients with Lp(a) ≥50 mg/dl. Our findings suggest an increased level of Lp(a) as a risk stratification marker and a potential therapeutic target in patients with HeFH.

Clinical outcome

Funding Acknowledgement

Type of funding source: None

Characterization of thromboembolic and bleeding risks in cancer patients with acute myocardial infarction under the use of guideline-recommended dual-antiplatelet therapy

Background

Atherosclerotic cardiovascular disease including acute myocardial infarction (AMI) has become one of major co-existing diseases in cancer patients due to their improved survival rate. Current guideline recommends dual-antiplatelet therapy (DAPT) in patients with AMI. Given that the presence of cancer elevates not only coagulability but bleeding risks, these substrate may further worsen cardiovascular outcomes and bleeding risks in cancer subjects with AMI receiving DAPT.

Methods

We retrospectively analyzed 712 AMI patients treated by primary PCI with drug-eluting stent and DAPT between 2007 and 2017. The diagnosis of cancer was determined through medical record review. Clinical characteristics, thromboembolic (=all-cause death+non-fatal MI+stroke) and bleeding events were compared in AMI subjects with vs. without cancer.

Results

Cancer was identified in 11.1% (=79/712) of study subjects. Of these, around 40% of them had gastrointestinal cancer (=35/79), followed by lung cancer (=5/79) and breast cancer (=8/79). Cancer patients were more likely to be older (77±7 v. 69±13 years, p&lt;0.001) with a history of Af (25 v. 10%, p&lt;0.001), CKD (eGFR&lt;60: 60 v. 42%, p=0.002), anemia (hemoglobin: 12.8±1.8 v. 13.9±1.8 g/dl, p&lt;0.001). Under anti-thrombotic (DAPT=86%, triple-antiplatelet therapy=14%) and optimal medical therapies (ACE-I=90%, beta-blocker=76%, statin=96%), more frequent occurrence of thromboembolic events was observed in patients with cancer (34.2 v. 12.6%, p=0.004, Picture). Furthermore, the presence of cancer was associated with more than four times greater risk of bleeding events compared to non-cancer subjects (18.9 v. 4.3%, p&lt;0.001, Picture). In particular, the frequency of both major (10.1 vs. 3.3%, p=0.003) and minor (8.9 vs. 0.9%, p&lt;0.001) bleeding events was significantly higher in patients with cancer. In multivariate analysis, cancer independently predicted bleeding events (Table).

Conclusions

Under the use of guideline recommended DAPT, the concomitance of cancer in AMI subjects was a predictor for thromboembolic as well as bleeding events. In particular, the relationship between cancer and bleeding was significant. These observations underscore the appropriate selection and duration of anti-thrombotic agents in AMI subjects with cancer.

Cardiac/Bleeding Events in AMI Subjects

Funding Acknowledgement

Type of funding source: None

Coronary artery echo-attenuated plaques in acute coronary syndromes: a serial intravascular ultrasound imaging study

Background

Echo attenuation of atherosclerotic plaque (EAP) identified with intravascular ultrasound (IVUS) has been shown to correlate with vulnerable plaque morphologies and their presence is predictive of future cardiovascular events. EAP have predominantly been assessed at a single time point and their natural history in the immediate post acute coronary syndrome (ACS) period remains unknown. We aimed to assess this and whether their presence correlated with a more modifiable plaque composition in the immediate post-ACS setting.

Methods

Serial IVUS imaging was performed in non-culprit vessels of 270 patients undergoing angiogram for ACS and at 3 month follow up. IVUS analysis of plaque burden and EAP was performed.

Results

Baseline characteristics are described in Table 1. EAP were present at baseline in 62 patients (23%) with these patients more likely to be male (89.1% vs. 76.7%, p=0.03) but no differences in other atherosclerotic risk factors. There was no difference in baseline plaque burden between patients with EAP and those without (Percent atheroma volume [PAV] 38.9% vs. 37.8%, p=0.32). At follow up IVUS change in PAV was not statistically significantly different between patients with baseline EAP and those without (ΔPAV 0.09% vs. −0.36%, p=0.43), and neither was there a difference in the frequency of plaque regressors (42.7% vs 50%, p=0.31). EAP had resolved in 25 patients (40%) within 3 months at the follow up IVUS. Despite contemporary post-ACS therapy 18 patients who had not had EAP present at baseline (9%) developed new EAP at the follow up IVUS.

Conclusion

EAP were present in a quarter of ACS patients and were not associated with baseline plaque burden or a more modifiable plaque phenotype. In the setting of contemporary ACS treatments the natural history of high risk IVUS plaque characteristics such as EAP is dynamic with significant change even over a 3 month period in the post ACS setting.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Royal Adelaide Hospital Research Fund AR Clarkson Scholarship

Prevalence, clinical characteristics and prognosis of intracranial artery atherosclerosis in heterozygous familial hypercholesterolemia: insights from magnetic resonance angiography imaging analysis

Introduction

Heterozygous familial hypercholesterolemia (HeFH) exhibits substantially atherogenic substrate which involves coronary and peripheral arteries. Whether atherosclerosis in HeFH propagates to intracranial arteries causing stroke remains to be determined.

Purpose

To characterize intracranial artery stenosis (IAS) in subjects with HeFH.

Methods

148 HeFH subjects who underwent MRI/MRA imaging to evaluate intracranial arteries were analyzed. IAS was defined as the presence of stenosis with its % diameter stenosis ≥25%. Clinical demographics and cardiovascular events (all-cause death, ACS, stroke and PAD) were compared in those with and without IAS.

Results

IAS was observed in 24.3% (=36/148) of study subjects. It was more frequently located at middle cerebral artery (30.6%=11/36), followed by internal carotid artery (25.0%=9/36). 47.2% of IAS exhibited % diameter stenosis ≥75%. Furthermore, 58.3% of HeFH patients with IAS exhibited concomitance of CAD, PAD or carotid stenosis. They were more likely to be older (Table). While there was no significant difference in LDL-C level, an elevated triglyceride level was observed in those with IAS (Table). Of note, during the observational period (median=14.1 years), IAS was associated with a greater likelihood of experiencing not only stroke but other cardiovascular events (all-cause death + ACS + PAD) (picture). Multivariate analysis demonstrated triglyceride level ≥1.7mmol/l as an independent predictor of IAS in HeFH patients (HR=5.53, 95% CI: 1.85–16.5, p=0.002).

Conclusions

Around one-fourth of HeFH patients harboured IAS, which was associated with concomitance of atherosclerosis in other vascular beds and the occurrence of stroke and other cardiovascular events. Given the relationship of IAS with hypertriglyceridemia, this lipid feature may be an important contributor to atherosclerotic formation which involves intracranial artery in HeFH patients.

Clinical outcome

Funding Acknowledgement

Type of funding source: None

Characterization of plaque features exhibiting physiological mismatch between fractional flow reserve and resting index: near-infrared spectroscopy imaging analysis

Background

In addition to fractional flow reserve (FFR), resting indexes (RI) have been shown as another physiological measure to evaluate myocardial ischemia. Despite the clinical usefulness of RI without the use of intravenous vasodilatory agent, discrepancy between FFR and RI infrequently occurs. Whether this physiological mismatch is derived by specific plaque feature remains unknown.

Purpose

To characterize coronary plaques associated with coronary physiological mismatch.

Methods

We analyzed 59 coronary arteries (LAD/RCA/LCX=49/4/6) with FFR≤0.80 in 57 stable CAD subjects receiving PCI. Following measurement of FFR and RI, culprit lesion was evaluated by near-infrared spectroscopy and intravascular ultrasound (NIRS/IVUS). The analyzed vessels were stratified according to FFR and RI values: FFR≤0.75+RI&gt;0.89 (n=6: physiological mismatch), FFR&gt;0.75+RI&gt;0.89 (n=6), FFR≤0.75+RI≤0.89 (n=33) and FFR&gt;0.75+RI≤0.89 (n=14).

Results

The median values of percent diameter stenosis, FFR and RI were 51%, 0.75 and 0.87, respectively. Physiological mismatch was observed in 10.1% (=6/59) of analyzed vessels. On IVUS imaging, maximum percent plaque area was greater than 70% in all groups (p=0.29). Furthermore, there were no significant differences in angiographic and IVUS-derived minimum lumen area across 4 groups (Table). However, culprit lesions exhibiting physiological mismatch contained a substantially larger amount of lipid plaque, reflected by a higher maximum 4-mm lipid-core burned index (maxLCBI4mm: p=0.04) on NIRS imaging (Table). Multivariate analysis demonstrated maxLCBI4mm as the only plaque feature associated with physiological mismatch (odds ratio=1.010, 95% CI: 1.001–1.019, p=0.02).

Conclusion

Plaque feature associated with coronary physiological mismatch was the extent of lipidic materials but not the quantity of coronary atheroma. Since the accumulation of lipidic plaque component is caused by endothelial dysfunction, this vascular substrate could impair baseline vasomotion, thereby causing a lower FFR despite preserved RI value. Evaluation of lipidic burden may be a potential option to avoid unnecessary deferral of revascularization in subjects with normal RI value.

maxLCBI4mm in each group

Funding Acknowledgement

Type of funding source: None

Prevalence and risk factors for hyperbilirubinemia among newborns from a low-risk birth setting using delayed cord clamping in Japan

AIM

Neonatal jaundice is a common problem among infants. Among the several risk factors are East Asian race and delayed cord clamping. Birth centers manage low-risk term deliveries using physiological management, which may include delayed cord clamping. This study aimed to investigate the occurrence of hyperbilirubinemia, a pathological process of jaundice, and its risk factors among neonates born at a Japanese birth center.

METHODS

This was a retrospective cohort study. Data were collected from March 2006 to October 2014 from healthy mothers and neonates at a birth center in a metropolitan area of Japan. Demographic data and background factors of hyperbilirubinemia, including blood and transcutaneous values of jaundice, were collected and statistically analyzed.

RESULTS

Of the 1,211 neonates analyzed, 4.7% exceeded the standard transcutaneous bilirubin value, and 1.8% needed phototherapy. Multiple logistic regression with adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs) was used to identify the risk factors of hyperbilirubinemia, which were found to be cephalohematoma (OR = 30.18, 95% CI 5.63-161.69), delay of meconium elimination (OR = 2.66, 95% CI 1.28-5.51), previous history of phototherapy of siblings (OR = 10.28, 95% CI 3.53-29.92), and primiparity (OR = 4.55, 95% CI 2.59-8.02).

CONCLUSIONS

In low-risk Japanese neonates delivered at a birth center expected to practice delayed cord clamping, the rate of neonates requiring phototherapy was not high compared to previous studies, and the identified risk factors of hyperbilirubinemia were related to bilirubin metabolism.

Search for Electron Antineutrino Appearance in a Long-Baseline Muon Antineutrino Beam

Electron antineutrino appearance is measured by the T2K experiment in an accelerator-produced antineutrino beam, using additional neutrino beam operation to constrain parameters of the Pontecorvo-Maki-Nakagawa-Sakata (PMNS) mixing matrix. T2K observes 15 candidate electron antineutrino events with a background expectation of 9.3 events. Including information from the kinematic distribution of observed events, the hypothesis of no electron antineutrino appearance is disfavored with a significance of 2.40σ and no discrepancy between data and PMNS predictions is found. A complementary analysis that introduces an additional free parameter which allows non-PMNS values of electron neutrino and antineutrino appearance also finds no discrepancy between data and PMNS predictions.

Search for Magnetic Monopoles and Stable High-Electric-Charge Objects in 13 Tev Proton-Proton Collisions with the ATLAS Detector

A search for magnetic monopoles and high-electric-charge objects is presented using 34.4  fb^{-1} of 13 TeV pp collision data collected by the ATLAS detector at the LHC during 2015 and 2016. The considered signature is based upon high ionization in the transition radiation tracker of the inner detector associated with a pencil-shape energy deposit in the electromagnetic calorimeter. The data were collected by a dedicated trigger based on the tracker high-threshold hit capability. The results are interpreted in models of Drell-Yan pair production of stable particles with two spin hypotheses (0 and 1/2) and masses ranging from 200 to 4000 GeV. The search improves by approximately a factor of 5 the constraints on the direct production of magnetic monopoles carrying one or two Dirac magnetic charges and stable objects with electric charge in the range 20≤|z|≤60 and extends the charge range to 60<|z|≤100.

Efficacy and safety of dupilumab in Japanese adults with moderate-to-severe atopic dermatitis: a subanalysis of three clinical trials

Background

Dupilumab, a human monoclonal antibody, blocks the shared receptor unit for interleukin‐4 and interleukin‐13. International phase II and III studies have evaluated the efficacy and safety of dupilumab in adults with moderate‐to‐severe atopic dermatitis (AD), but the effects of dupilumab in Japanese patients have not been reported.

Objectives

To evaluate the efficacy and safety of dupilumab in Japanese patients with moderate‐to‐severe AD.

Methods

We analysed the efficacy and safety of dupilumab in the Japanese cohorts of a 16‐week, phase IIb dose‐finding trial (AD‐1021; NCT01859988); a 16‐week, phase III, placebo‐controlled monotherapy trial (LIBERTY AD SOLO 1; NCT02277743) and a 52‐week, phase III, placebo‐controlled study of dupilumab with topical corticosteroids (LIBERTY AD CHRONOS; NCT02260986).

Results

Twenty‐seven, 106 and 117 Japanese patients were enrolled in AD‐1021, SOLO 1 and CHRONOS, respectively. Baseline disease severity was numerically higher in the Japanese cohort than in the overall study population. Generally, dupilumab significantly improved signs and symptoms of AD, including pruritus and patient quality of life, compared with placebo in the Japanese cohort, consistent with the overall study population. The combined safety profile of dupilumab in the Japanese cohort was similar to that in the total study populations; dupilumab was associated with an increased incidence of injection‐site reactions and conjunctivitis compared with placebo. Dupilumab was associated with rapid reduction in thymus and activation‐regulated chemokine and gradual IgE reductions.

Conclusions

Dupilumab alone or with topical corticosteroids improved signs and symptoms of AD, had an acceptable safety profile, and suppressed biomarkers of type 2 inflammation compared with placebo in Japanese adult patients with moderate‐to‐severe AD.

What's already known about this topic?

Differences in atopic dermatitis (AD) pathology have been reported between Asian and Western populations, in which distinct helper T‐cell activation profiles have been observed.

International clinical studies in adults with moderate‐to‐severe AD have evaluated the efficacy and safety of dupilumab, which blocks interleukin‐4 and interleukin‐13, key molecules in type 2 inflammation.

The effects of dupilumab in Japanese patients specifically have not yet been reported.

What does this study add?

Dupilumab alone or with topical corticosteroids improved signs and symptoms of AD and had an acceptable safety profile compared with placebo in Japanese patients with moderate‐to‐severe AD.

The effects were comparable with those observed in the overall study population.

Reported immunological differences in AD pathology in Asian patients may be secondary to type 2 immune activation.

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Observation of Electroweak Production of a Same-Sign W Boson Pair in Association with Two Jets in pp Collisions at sqrt[s]=13 TeV with the ATLAS Detector

This Letter presents the observation and measurement of electroweak production of a same-sign W boson pair in association with two jets using 36.1  fb^{-1} of proton-proton collision data recorded at a center-of-mass energy of sqrt[s]=13  TeV by the ATLAS detector at the Large Hadron Collider. The analysis is performed in the detector fiducial phase-space region, defined by the presence of two same-sign leptons, electron or muon, and at least two jets with a large invariant mass and rapidity difference. A total of 122 candidate events are observed for a background expectation of 69±7 events, corresponding to an observed signal significance of 6.5 standard deviations. The measured fiducial signal cross section is σ^{fid}=2.89_{-0.48}^{+0.51}(stat)_{-0.28}^{+0.29}(syst)  fb.

P5635Predictive ability of lipdic burden for FFR-derived physiological measures: insights from near-infrared spectroscopy imaging analysis

Background

Fractional flow reserve (FFR) has enabled to physiologically assess the myocardial ischemia of coronary artery with intermediate stenosis. Mechanistically, not only the severity of coronary stenosis but also the extent of maximal vasodilatation within the entire coronary artery potentially affects this physiological measure. Since the accumulation of lipidic materials within vessel wall increases vascular stiffness via inducing endothelial dysfunction, the presence of lipidic atheroma burden may affect physiological measures.

Purpose

To investigate the association of FFR with lipidic coronary atheroma by near-infrared spectroscopy/intravascular ultrasound (NIRS/IVUS) imaging, which quantitatively visualize lipidic burden in vivo.

Methods

We analyzed 61 coronary arteries (LAD/RCA/LCX=52/5/4) with FFR≤0.80 in 59 stable coronary artery disease subjects receiving PCI. Following FFR measurement, NIRS/IVUS imaging was conducted to evaluate the extent of atheroma burden (maximum percent plaque area=max%PA) and lipidic materials (lipid core burden index within the entire vessel=LCBIvessel). The analyzed vessels were stratified according to FFR: definite FFR group (FFR≤0.74, n=34) and gray-zone FFR group (0.75≤FFR≤0.80, n=27).

Results

NIRS/IVUS imaging analysis (analyzed longitudinal length=77±7mm) was more likely to exhibit a significantly higher LCBIvessel and a larger max%PA in the definite FFR group (Table). Of note, FFR was significantly correlated to LCBIvessel (ρ=-0.299, p=0.02), but not max%PA (ρ=-0.255, p=0.07). Multivariate analysis demonstrated that an independent determinant of FFR≤0.74 was LCBIvessel [odds ratio (OR)=1.016, 95% confidential interval (CI)=1.002–1.031, p=0.02], but not max%PA [OR=1.084, 95% CI=0.994–1.182, p=0.07]. Area under the receiver-operating characteristic curve analysis elucidated that the addition of LCBIvessel to angiography- and IVUS-derived measures resulted in a significant improvement for detecting FFR≤0.74 (picture).

Definite FFR Group (FFR≤0.74, n=34) Gray-zone FFR Group (0.75≤FFR≤0.80, n=27) p value Fractional flow reserve (FFR) 0.68±0.05 0.78±0.02 <0.01 Percent diameter stenosis (%) 56.2±13.1 51.9±7.8 0.16 Maximum percent plaque area (max%PA, %) 84.3±6.9 79.9±7.2 0.01 Lipid core burden index within the entire vessel (LCBIvessel) 102.0±60.2 65.6±51.6 0.01

ROC analysis for detecting FFR≦0.74

Conclusion

The propagation of lipidic burden associates with the physiological measures. The present findings indicate the possibility that vessel characteristics or instability may have influence for causing ischemia on the coronary artery.

P938Extensive formation of atherosclerotic cardiovascular disease in subjects with severe familial hypercholesterolemia defined by the international atherosclerosis society criteria

Introduction

The International Atherosclerosis Society (IAS) has proposed “severe familial hypercholesterolemia (FH)” as a FH phenotype with the highest cardiovascular risk. Coronary artery disease (CAD) represents a major atherosclerotic change in FH patients. Given their higher LDL-C level and atherogenic clinical features, more extensive formation of atherosclerosis cardiovascular disease including not only CAD but stroke/peripheral artery disease (PAD) may more frequently occur in severe FH.

Methods

481 clinically-diagnosed heterozygous FH subjects were analyzed. Severe FH was defined as untreated LDL-C>10.3 mmol/l, LDL-C>8.0 mmol/l+ 1 high-risk feature, LDL-C>4.9 mmol/l + 2 high-risk features or presence of clinical ASCVD according to IAS proposed statement. Cardiac (cardiac death and ACS) and non-cardiac (stroke and peripheral artery disease) events were compared in severe and non-severe FH subjects.

Results

Severe FH was identified in 50.1% of study subjects. They exhibit increased levels of LDL-C and Lipoprotein (a) with a higher frequency of LDLR mutation. Furthermore, a proportion of %LDL-C reduction>50% was greater in severe FH under more lipid-lowering therapy (Table). However, during the observational period (median=6.3 years), severe FH was associated with a 5.9-fold (95% CI, 2.05–25.2; p=0.004) and 5.8-fold (95% CI, 2.02–24.7; p=0.004) greater likelihood of experiencing cardiac-death/ACS and stroke/PAD, respectively (picture). Multivariate analysis demonstrated severe FH as an independent predictor of both cardiac-death/ACS (hazard ratio=3.39, 95% CI=1.12–14.7, p=0.02) and stroke/PAD (hazard ratio=3.38, 95% CI=1.16–14.3, p=0.02) events.

Clinical characteristics of severe FH Non-severe FH Severe FH P-value Baseline LDL-C (mmol/l) 5.3±1.5 6.6±2.0 <0.0001 Lp(a) (mg/dl) 15 [8–28] 21 [10–49] <0.0001 LDLR mutation (%) 49.6% 58.9% 0.00398 On-treatment LDL-C (mmol) 133 [106–165] 135 [103–169] 0.9856 %LDL-C reduction>50% 21.3% 49.8% <0.0001 High-intensity statin (%) 13.3% 42.3% <0.0001 PCSK9 inhibitor (%) 6.3% 21.2% <0.0001

Clinical outcome

Conclusions

Severe FH subjects exhibit substantial atherosclerotic risks for coronary, carotid and peripheral arteries despite lipid lowering therapy. Our finding underscore the screening of systemic arteries and the adoption of further stringent lipid management in severe FH patients.

P1561An elevated risk of heart failure and stroke events in octogenarian Japanese patients with acute myocardial infarction who received percutaneous coronary intervention

Background

The proportion of the octogenarian population is expanding especially in Eastern society. Due to the clustering of risk factors, acute myocardial infarction (AMI) represents a major cardiovascular complication in octogenarian subjects. This suggests the need to further optimize their therapeutic management to prevent future cardiac events after AMI. However, analysis of clinical characteristics and cardiovascular outcomes in octogenarian subjects with AMI who received the current established medical therapies is limited.

Purpose

To investigate clinical features and prognosis in octogenarian AMI subjects treated with percutaneous coronary intervention (PCI).

Methods

We analyzed 1547 AMI subjects underwent PCI between 2007 and 2017. Baseline characteristics and the occurrence of composite major adverse cardiovascular events (cardiac death, non-fatal MI, revascularization, heart failure and stroke) were compared in octogenarian and non-octogenarian subjects.

Results

22.0% (340/1547) of study subjects was octogenarian. They were more likely to have chronic kidney disease (CKD) and a lower level of LDL-C on admission (Table). Moreover, a higher prevalence of severer Killip class and LVEF <30% were observed in octogenarians (Table). However, they were not optimally treated with the established medical therapies at discharge (Table). During the observational period (median=3.1 years), the composite of cardiovascular events more frequently occurred in octogenarian subjects. Of note, they exhibited a 2.15-fold and 3.01-fold increased risk for heart failure and stroke events, respectively (Figure).

Table 1 Non-Octogenarian (n=1207) Octogenarian (n=340) P-value CKD* (%) 33.8 63.2 <0.0001 LVEF <30% (%) 5.7 10.3 0.02 Killip class 1.33±0.03 1.55±0.05 <0.0001 LDL-C (mmol/L) 3.20±0.03 2.80±0.05 <0.0001 Statin (%) 86.3 78.2 0.0006 Beta-blocker (%) 74.0 65.8 0.005 ACE-I/ARB (%) 87.3 76.6 <0.0001 DAPT (%) 86.0 88.6 0.42 *CKD is defined as estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2.

Figure 1

Conclusions

Octogenarian subjects with AMI were high-risk group associated with heart failure and stroke events. Their distinct clinical backgrounds may affect the adoption of optimal medical therapies, potentially resulting in worse cardiovascular outcomes. Further intensified management should be applied to octogenarian subjects with AMI.