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The access site for primary percutaneous coronary intervention (PCI) for patients with ST-elevation myocardial infarction (STEMI) recently shifted from femoral to radial. However, few real-world data on Japanese patients exist.To elucidate the clinical selection and impact of the access site in STEMI patients, we analyzed a Japanese observational prospective multicenter registry of acute myocardial infarction (K-ACTIVE: Kanagawa ACuTe cardIoVascular rEgistry) in 2015 to 2021. Data were analyzed in the entire population and a propensity score-matched population adjusted for confounding factors. Major adverse cardiac event (MACE) was defined as cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke. Bleeding Academic Research Consortium (BARC) type 3 or 5 was used to assess bleeding events. MACE plus BARC type 3 or 5 bleeding were considered composite events. Clinical outcomes were followed for 30 days.The 6802 STEMI patients included 4786 patients with radial access (70.3 %) and 2016 with femoral access (29.7 %). Femoral access tended to be selected for more severe conditions than radial access. The median door-to-device time in the radial access group was significantly shorter than the femoral access group in the entire population (75 min versus 79 min, p 0.01). After propensity score matching (each group, n = 1208), the incidence of MACE tended to be lower in the radial access group [risk ratio (RR) 0.83, 95 % confidence interval (CI) 0.63-1.09, p = 0.17]. The incidence of BARC 3 or 5 bleeding was significantly less in the radial access group (RR 0.47, 95%CI 0.23-0.97, p = 0.04). The incidence of composite events was significantly less in the radial access group (RR 0.74, 95%CI 0.57-0.96, p = 0.02).In STEMI patients undergoing primary PCI, in comparison to femoral access, radial access reduced composite events in the entire population and the matched population, through a reduction in MACE and BARC 3 or 5 bleeding.

D-dimer levels can predict ischemic stroke in patients with acute heart failure (AHF). However, the effects of direct oral anticoagulants on D-dimer levels have not been investigated during admission for AHF in patients with atrial fibrillation (AF). This study examined D-dimer levels immediately after admission and following edoxaban initiation as a sub-analysis of a multi-center study that investigated the pharmacokinetics and pharmacodynamics of edoxaban in patients with nonvalvular AF (NVAF) and AHF.Hospitalized patients with NVAF and AHF received edoxaban according to the label. The primary measure was the change in D-dimer levels on 7 consecutive days after admission for AHF. We also investigated differences according to prior edoxaban use (de novo at the time of admission or continuation).In 10/13 (76.9%) de novo patients, D-dimer levels exceeded the reference value (1.0 µg/mL) at admission (mean, 2.12 µg/mL) and subsequently decreased in 9 patients (at final blood sampling: mean, 1.12 µg/mL); 1 patient did not fall below the reference value due to stasis dermatitis. In the continuation group, most patients had D-dimer levels below the reference value from Day 1 (mean, 0.93 µg/mL), and levels remained stable or decreased (at final blood sampling: mean, 0.49 µg/mL). No events of stroke were observed.D-dimer levels may be elevated in patients with NVAF and AHF, particularly in those without prior anticoagulant treatment. Edoxaban may be effective for lowering and keeping D-dimer levels, a biomarker for predicting ischemic stroke, below the reference value in patients with NVAF and AHF.

The clinical incidence and impact of atrial fibrillation (AF) in Japanese acute myocardial infarction (AMI) patients is not fully understood.To elucidate the clinical incidence and impact of AF on in-hospital mortality in AMI patients, we analyzed a Japanese observational prospective multicenter registry of acute myocardial infarction (K-ACTIVE: Kanagawa ACuTe cardIoVascular rEgistry), which spans 2015 to 2019. A major adverse cardiac event (MACE) was defined as cardiovascular death, non-fatal myocardial infarction (MI), and non-fatal stroke. For assessing bleeding events, Bleeding Academic Research Consortium (BARC) type 3 or 5 was used. MACE plus BARC type 3 or 5 bleeding were considered as composite events. The clinical outcomes were followed for 1 year.The total of 5059 patients included 531 patients with AF (10.5%) and 4528 patients with sinus rhythm (SR; 89.5%). AF patients were significantly older and tended to have more comorbidities than SR patients. Oral anticoagulation therapy (OAC) was used in 44% of AF patients while single antiplatelet therapy was selected for 52% of patients with OAC. Crude in-hospital mortality was significantly greater in AF patients than in SR patients (10.4%, 5.0%, respectively, p 0.01). The multivariate analysis was adjusted for age, sex, diabetes, hypertension, hemodialysis, smoking, previous MI, body mass index, Killip classification, out of hospital cardiac arrest, and OAC. In-hospital mortality was still significantly greater in AF patients than in SR patients in the logistic regression analysis [adjusted odds ratio 2.02 (1.31-3.14)]. AF was an independent risk factor for MACE and composite events in the Cox proportional hazards model [adjusted risk ratio (ARR) 1.91 (1.36-2.69), p 0.01; ARR 1.72 (1.25-2.36), p 0.01]. In contrast, AF was not an independent risk factor for bleeding [ARR 1.71 (0.79-3.71), p = 0.18].In Japanese AMI patients, AF was often observed and was associated with worse MACE but not worse bleeding.

Background Although cardiac resynchronization therapy (CRT) provided functional and clinical improvement in patients with heart failure (HF) and electrical intraventricular conduction disturbances, some patients had re-worsening left ventricular (LV) function after a favorable CRT response. We analyzed the clinical variables and cardiac outcomes associated with this re-worsening LV function after CRT. Methods In this study, 71 patients with CRT response who received CRT between 2006 and 2017 were included. CRT response was defined as a “≥ 10% improvement in LV ejection fraction (LVEF) on follow-up.” Patients were classified into two groups: (i) persistent: (n = 48, 68%), defined as those with a CRT response and (ii) re-worsening: (n = 23, 32%), consisting of those who fell out of the definition of a CRT response after an initial CRT response. Results Half of the patients in the re-worsening group failed to maintain a CRT response from two years upwards. A longer duration from HF diagnosis to CRT implantation, nonspecific intraventricular conduction delay (NIVCD) on electrocardiogram at CRT implantation, and a lower increased LVEF at initial CRT response were independent predictors for the re-worsening group. Patients in the re-worsening group had a higher incidence rate for HF hospitalization and cardiac deaths, compared with those in the persistent group. Conclusion One-third of CRT responders experienced re-worsening LVEF, which was associated with poor outcomes. CRT responders with NIVCD, longer HF duration, and a lower increased LVEF at initial CRT response should be monitored with caution.

Background This analysis aimed to evaluate the clinical impact of high bleeding risk (HBR) on adverse events after percutaneous coronary intervention (PCI). Methods We retrospectively analyzed 1695 patients in the MODEL U-SES study, which was a multicenter, open-label, prospective observational study evaluating safety of 3-month dual antiplatelet therapy (DAPT) after Ultimaster stent (Terumo Corporation, Tokyo, Japan) implantation at 65 sites in Japan. Patients were divided into 2 groups (HBR/Non-HBR) according to modified Academic Research Consortium-HBR criteria. Ischemic/thrombotic event (cardiovascular death, myocardial infarction, ischemic stroke, and stent thrombosis) and bleeding event (Bleeding Academic Research Consortium 3 or 5) at 1 year were evaluated. Results Of 1695 patients, 840 patients were categorized as HBR and 855 patients were Non-HBR. One-year follow-up was completed in 95.3%. During 1-year follow-up, ischemic/thrombotic events were observed in 31 cases (1.8%) and bleeding events occurred in 21 cases (1.2%). Presence of HBR was significantly associated with higher incidence of ischemic/thrombotic events as compared to Non-HBR (adjusted hazard ratio, 0.16; 95% confidence interval, 0.05 to 0.50), whereas the incidence of bleeding events did not reach statistical significance between HBR and Non-HBR. In comparison of monotherapy after DAPT, P2Y12 inhibitor monotherapy after DAPT had comparable ischemic/thrombotic and bleeding events with aspirin monotherapy after DAPT in both HBR and Non-HBR. Conclusion In contemporary PCI practice, nearly half of patients had HBR and presence of HBR significantly increased risk of ischemic/thrombotic events. Both aspirin and P2Y12 inhibitor monotherapy following short DAPT had low and comparable ischemic/bleeding events.

Background The prevalence of acute myocardial infarction (AMI) in elderly people is increasing worldwide. However, their characteristics and prognosis have been rarely investigated. This study aimed to investigate the characteristics and prognosis in elderly patients with cardiac troponin-positive AMI. Methods Consecutive patients with AMI from the J-MINUET study were divided into the following 3 groups: patients aged less than 65 years, those aged between 65 and 79 years, and those aged 80 years or over. Their characteristics and in-hospital outcomes were compared. Results Patients with AMI aged 80 years or over had the highest incidence of female gender, and the highest incidence of hypertension, chronic kidney disease, and cardiovascular disease, such as peripheral artery disease, atrial fibrillation, and stroke, whereas they had the lowest body mass index, and the lowest incidence of current smoker, diabetes mellitus, and dyslipidemia. Patients with AMI aged 80 years or over had significantly longer onset to door time and longer door to device time, and lower peak creatine kinase (CK). The incidence of ST-segment elevation myocardial infarction (STEMI) was the lowest in the AMI patients aged 80 years or over, but the patients had a higher incidence of in-hospital death and cardiac failure than the other two groups. In addition, the presentation with STEMI and non-ST-segment elevation myocardial infarction with CK elevation among patients aged 80 years or over showed the highest incidence of in-hospital death and cardiac failure. Conclusions J-MINUET showed different clinical characteristics between the aged and younger populations. The incidence of in-hospital death and cardiac failure in patients aged 80 years or over with AMI was poorer than their younger counterparts.

Beta-blockers are associated with several clinical benefits in patients with reduced left ventricular ejection fraction (REF) after acute myocardial infarction (AMI), such as lower rates of mortality, recurrence of myocardial infarction, and heart failure. However, the long-term prognosis of beta-blockers has rarely been investigated in patients with non-REF after AMI. This study aimed to investigate the clinical benefits of beta-blockers in these patients.A total of 3281 consecutive patients who were hospitalized within 48 h after AMI were registered in the J-MINUET study. Patients who underwent primary percutaneous coronary intervention (PCI) and had a left ventricular ejection fraction ≥40 % were enrolled, and patients who died during admission were excluded. Included patients were divided into two groups according to the prescription of beta-blockers at discharge. Their characteristics and clinical outcomes were compared.The number of AMI patients treated with beta-blockers was 1353 (70.4 %). Patients who received beta-blockers were younger and had a higher incidence of hypertension, dyslipidemia, and ST-segment elevation myocardial infarction than those who did not receive beta-blockers. The peak creatine kinase level after primary PCI was significantly higher in patients who received beta-blockers. These patients also had a lower incidence of a composite of all-cause death, myocardial infarction, and stroke compared to those that did not receive beta-blockers (7.3 % vs. 11.9 %, p = 0.001). Multivariate analysis showed that beta-blocker use was an independent factor for better clinical outcomes.The J-MINUET study revealed the clinical benefit of beta-blockers in AMI patients with non-REF after primary PCI.

Background The early prediction of frailty at discharge in elderly patients hospitalized with heart failure (HF) is essential for clinical management and therapeutic decision-making. This study was performed to examine whether the rising time from bed measured immediately after admission can be used as a predictor of frailty in these patients. Methods A retrospective cohort study was performed in a population of 387 consecutive elderly patients with HF. Rising time from bed was measured within 2 days after admission when cardiac rehabilitation was started. Frailty was assessed at hospital discharge using a composite of four markers as a frailty score (range, 0–12): gait speed, handgrip strength, serum albumin, and activities of daily living status. The patients were divided into two groups based on frailty score Results The study population had a mean age of 75 years and 63.6 % were men. The median rising time was 6.8 s, and 53.5 % were classified as frail. After adjustment for various factors, rising time was independently associated with frailty (odds ratio = 1.10; 95 % confidence index = 1.04–1.18). The area under the receiver operating characteristics curve of rising time for frailty was 0.71, and the cut-off value for rising time to identify those at high risk of frailty was 7.1 s. Conclusions Rising time from bed measured within 2 days after admission was shown to be an independent predictor of frailty at hospital discharge in elderly patients hospitalized for HF.

Sarcopenic obesity is a health condition involving a combination of excess adipose tissue and loss of muscle mass. Although sarcopenic obesity is known to contribute to the morbidity and mortality of chronic diseases, limited data are available in patients with cardiovascular disease. The present study was performed to examine whether sarcopenic obesity determined by preoperative computed tomography (CT) is a useful predictor of postoperative mortality in patients undergoing cardiovascular surgery.We reviewed the findings in 664 consecutive cardiovascular surgery patients (mean age, 65.8±12.7 years; male, 66.6%) who underwent preoperative CT including the level of the third lumbar vertebra for clinical purposes. Psoas muscle attenuation (MA) and visceral adipose tissue (VAT) were measured as metrics of sarcopenia and obesity, respectively. Sarcopenia was defined as low MA (below median), while obesity was defined as high VAT (≥103cmAfter adjusting for age and sex, sarcopenic obesity showed significant associations with lower grip strength and quadriceps strength, slower gait speed, and shorter 6-min walking distance compared to the normal group (p0.05). On multivariate Cox regression analysis, sarcopenic obesity was associated with increased risk of mortality after adjusting for EuroSCORE (hazard ratio, 3.04; 95% confidence interval, 1.25-7.40).Sarcopenic obesity is associated with poor muscle function and all-cause mortality in patients undergoing cardiovascular surgery.

Background pre-hospital 12-lead electrocardiogram (ECG) by emergency medical service (EMS) personnel at the site of first medical contact (FMC) and the physician of first contact both play important roles in managing patients with ST-elevation myocardial infarction (STEMI). However, in Japan, pre-hospital 12-lead ECG is not routinely performed by EMS personnel at the site of FMC and the physician of first contact is not always a cardiologist. Methods from October 2015 to October 2019, 2035 consecutive STEMI patients transported from the field by ambulance were analyzed from the K-ACTIVE registry. Based on the presence (+) or absence (-) of pre-hospital 12-lead ECG / first contact by cardiologist, patients were divided into 4 groups (+/+, +/-, -/+, -/-). Patient characteristics, FMC to door time, door to device time and in-hospital mortality were compared. Results the numbers of patients in each group were as follows (+/+, n = 987; +/-, n = 211; -/+, n = 610; -/-, n = 227). For patient characteristics, there were significant differences in the prevalence of dyslipidemia and the presence of chest pain. The FMC to door time was similar (median value, +/+, 24 min; +/-, 25 min; -/+, 24 min; -/-, 24 min; p = 0.23). The door to device time was the shortest in the +/+ group (median value, +/+, 65 min; +/-, 80 min; -/+, 69 min; -/-, 88 min; p 0.0001). Crude in-hospital mortality was the highest in the -/- group (+/+, 3.9%; +/-, 2.4%; -/+, 5.8%; -/-, 11.9%; p 0.0001). After adjustment for age and sex, the adjusted odds ratios for in-hospital mortality were as follows [odds ratio (with 95% confidence interval) +/+, 0.33 [0.19-0.57]; +/-, 0.19 [0.07-0.52]; -/+, 0.49 [0.29-0.86]; -/-, 1 [reference)]. Conclusion pre-hospital 12-lead ECG and the physician of first contact had a significant impact on the door to device time and in-hospital mortality. Continuous efforts should be made to improve acute management of STEMI.

The Global Registry of Acute Coronary Events (GRACE) score is the most accurate risk assessment system for acute myocardial infarction (AMI), which was proposed in Western countries. However, it is unclear whether GRACE score is applicable to the present Japanese patients with a high prevalence of emergent percutaneous coronary intervention (PCI) and vasospasm. This study aimed to clarify the usefulness of GRACE risk score for risk stratification of Japanese AMI patients treated with early PCI and to evaluate a novel risk stratification system, "angiographic GRACE score," which is the GRACE risk score adjusted by the information of the culprit coronary artery and its flow at pre- and post-PCI, to improve its predicting availability.The subjects were 1817 AMI patients who underwent PCI within 24 h of onset between October 2015 and August 2017 and were registered in Kanagawa Acute Cardiovascular (K-ACTIVE) Registry via survey form. The association between the clinical parameters and in-hospital mortality was investigated.A total of 79 (4.3%) in-hospital deaths were identified. The C-statistics for the in-hospital mortality of the GRACE score was 0.86, which was higher than that of the other conventional risk factors, including age (0.65), systolic blood pressure (0.70), heart rate (0.62), Killip classification (0.77), and serum levels of creatinine (0.68) and peak creatine kinase (0.74). The angiographic GRACE score improved the C-statistics from 0.86 of the original GRACE score to 0.89 (p 0.05). In the setting of the cut-off value at 200, in-hospital mortality in the patients with the angiographic GRACE score200 was 0.6%, which was relatively lower than those with ≥200, 9.4%.The GRACE score is a useful predictor of in-hospital mortality among Japanese AMI patients in the PCI era. Moreover, the angiographic GRACE score could improve the predicting availability.

Patients with peripheral artery disease (PAD) are at high risk of cardiovascular events, including myocardial infarction (MI), stroke, and cardiovascular death. However, the impact of PAD on prognosis in Japanese patients with acute MI remains unclear.The Japanese registry of acute Myocardial INfarction diagnosed by Universal dEfiniTion (J-MINUET) is a prospective multicenter registry that registered 3283 patients with acute MI. Among them, 2970 patients with available data of PAD were divided into the following 4 groups: 2513 patients without prior MI or PAD (None group), 320 patients with only prior MI (Prior MI group), 100 patients with only PAD (PAD group), and 37 patients with both previous MI and PAD (Both group). The primary endpoint was a composite of all-cause death, non-fatal MI, non-fatal stroke, cardiac failure, and urgent revascularization for unstable angina.The 3-year cumulative incidence of the primary endpoint was 26.9% in None group, 41.4% in Prior MI group, 48.0% in PAD group, and 60.3% in Both group (p 0.001). In multivariate analysis, hazard ratio using None group as reference was 1.55 (95% confidence intervals 1.25-1.91; p 0.001) for MI group, 2.26 (1.61-3.07; p 0.001) for PAD group, and 2.52 (1.52-3.90; p 0.001) for Both group.Concomitant PAD was associated with poor prognosis in Japanese patients with acute MI.

Background: Serial intravascular ultrasound (IVUS) imaging can be used to evaluate the effect of cholesterol-lowering on coronary atheroma progression and plaque volume, with evidence of potential incremental effects with more aggressive lipid-lowering treatments. Alirocumab is a highly specific, fully human monoclonal antibody to proprotein convertase subtilisin/kexin type 9 (PCSK9). This study will investigate the effect of alirocumab on coronary artery plaque volume in Japanese patients with a recent acute coronary syndrome (ACS) and hypercholesterolemia while on stable statin therapy. Methods: ODYSSEY J-IVUS is a phase IV, open-label, randomized, blinded IVUS analysis, parallel-group, multicenter study in Japanese adults recently hospitalized for an ACS and who have elevated low-density lipoprotein cholesterol (LDL-C) values [≥100 mg/dL (2.6 mmol/L)] at ACS diagnosis and suboptimal LDL-C control on stable statin therapy. Patients will be randomized (1:1) to receive alirocumab or standard-of-care (SOC). The alirocumab arm will receive alirocumab 75 mg every 2 weeks (Q2W) added to statin therapy (atorvastatin ≥10 mg/day or rosuvastatin ≥5 mg/day), with a dose increase to 150 mg Q2W in patients whose LDL-C value remains ≥100 mg/dL at week 12. The SOC arm will receive atorvastatin ≥10 mg/day or rosuvastatin ≥5 mg/day, with dose adjustment to achieve LDL-C

The association between patients with acute myocardial infarction (AMI) who present during off-hours and clinical outcomes has not been fully elucidated.We investigated 3283 consecutive patients with AMI who were selected from a prospective, nationwide, multicenter registry (J-MINUET) database comprising 28 institutions in Japan between July 2012 and March 2014 to determine the current impact of off-hours presentation on in-hospital mortality among Japanese patients with AMI.Among the patients, 52% presented in off-hours. Baseline characteristics were comparable, although those who presented during off-hours were younger and had a higher incidence of ST-elevation myocardial infarction and advanced Killip Class. The time from symptom onset to presentation time was shorter in off-hour patients (120min, interquartile range 60 to 256 vs. 215min, interquartile range 90 to 610, p0.0001). In contrast, 85% of patients underwent primary percutaneous coronary intervention (PCI) and door to balloon time was comparable between the groups (74min, interquartile range 52 to 113 vs. 75min, interquartile range 52 to 126, p=0.34). The rates of in-hospital mortality were comparable (6.2% vs 6.8%, p=0.39). Multivariate logistic regression analysis revealed that off-hours presentation was not significantly associated with in-hospital mortality [odds ratio (OR) 0.94; 95% CI, 0.68-1.30, p=0.70].The clinical impact of presenting during off-hours or regular hours on AMI patients in Japan is comparable in contemporary practice.UMIN Unique trial Number: UMIN000010037.

Background Limited data exist regarding the association between symptom presentation of acute myocardial infarction (AMI) and in-hospital outcomes. Methods We analyzed data of the Japanese registry of acute Myocardial INfarction diagnosed by Universal dEfiniTion (J-MINUET). This was a prospective and multicenter registry consisting of 3085 AMI patients with available data of symptoms, who were hospitalized within 48 h from onset during July 2012 to March 2014. We defined typical symptoms as any of chest pain or pressure due to myocardial ischemia. Results Of this study population, 642 patients (20.8%) had atypical symptoms (atypical group) and the remaining 2443 patients (79.2%) showed typical symptoms (typical group). Compared to the typical group, the atypical group was associated with higher age, more females, hypertension, diabetes, chronic kidney disease, history of cardiovascular disease, non-ST elevation MI, and Killip class ≥2. In the atypical group, urgent percutaneous coronary intervention was less frequently performed than in the typical group, and in STEMI patients door-to-balloon time was longer in the atypical than typical group. Atypical group had larger infarct size than typical group. Furthermore, in-hospital mortality was significantly higher in atypical than in typical group (19.5% vs. 3.3%, p

Background Compared to transpulmonary pressure gradient (TPPG), diastolic pulmonary vascular pressure gradient (DPG) may be a more sensitive and specific indicator for pulmonary hypertension (PH) due to left heart disease (LHD) with significant pulmonary vascular disease (PVD). The aim of this study was to investigate the incidence and clinical features of PH-LHD with PVD classified by DPG and TPPG. Methods We analyzed 410 patients admitted for symptomatic heart failure (HF) (New York Heart Association ≥2) and who underwent right heart catheterization (RHC) at compensated stage between 2007 and 2012. Patients with PH-LHD were divided into 3 groups according to the value of DPG and TPPG (Non-PVD group: DPG 12 mmHg; DPG-PVD group: DPG ≥7 mmHg). Multivariate Cox regression analysis was applied to investigate whether each PH-LHD category predicts death or HF readmission after adjusting for other variables. Results PH-LHD was observed in 164 patients (40%) with symptomatic HF. Thirteen patients (3%) were allocated into DPG-PVD group, while 24 patients were allocated into TPPG-PVD group (6%). DPG-PVD group was significantly associated with death or HF readmission compared to non-PVD group (hazard ratio: 3.57; 95% CI: 1.33 to 9.55, p = 0.01), while the association between TPPG-PVD group and non-PVD group did not reach statistical significance (hazard ratio: 1.89; 95% CI: 0.77 to 4.64, p = 0.17). Conclusions PH-LHD with PVD classified by DPG was significantly associated with poor long-term clinical outcomes, whereas the association between PH-LHD with PVD classified by TPPG and clinical outcomes did not reach statistical significance. However, further studies are needed, because there was no substantial difference in clinical outcomes between PH-LHD with PVD classified by DPG and PH-LHD with PVD classified by TPPG.

BackgroundA low eicosapentaenoic acid (EPA)/arachidonic acid (AA) ratio is known to be associated with cardiovascular events. However, the relationship between the EPA/AA ratio and coronary plaque vulnerability assessed by optical coherence tomography (OCT) has not been examined thoroughly. This study examined the relationship between the EPA/AA ratio and coronary plaque vulnerability assessed by OCT in patients with acute coronary syndrome (ACS).MethodsWe evaluated 59 ACS patients who had undergone percutaneous coronary intervention using OCT. We divided them into 2 groups according to OCT findings—those with and without thin-cap fibroatheroma (TCFA)—and compared the EPA/AA ratio between the groups.ResultsWe identified 32 and 27 patients with and without TCFA, respectively. The EPA/AA ratio was significantly lower in patients with TCFA than in those without TCFA [0.35, interquartile range (0.21–0.44) vs. 0.54, interquartile range (0.42–0.70); p

Background The optimal preoperative therapeutic strategy for patients with coronary artery disease (CAD) is an important concern in the era of drug-eluting stents and antiplatelet therapy. However, there are few studies about the impact of prior percutaneous coronary intervention (PCI) on perioperative major adverse cardiac events (MACEs) and bleeding events associated with oral antiplatelet therapy. The aim of this study was to examine the risks and benefits of performing PCI before non-cardiac surgery (NCS) in patients with CAD. Methods We investigated 130 patients who had angiographically significant and stable CAD and underwent NCS after index coronary angiography. We divided the patients into two groups: patients undergoing PCI with coronary stenting (PCI group), and those not undergoing PCI before NCS (no-PCI group), and compared the MACEs and bleeding events within 30 days from NCS between the groups. Results There were 53 and 77 patients in the PCI and no-PCI groups, respectively. MACEs were observed in 2 patients (3.8%) in the PCI group and 3 patients (3.9%) in the no-PCI group ( p = 0.97), whereas bleeding events were observed in 10 (18.9%) and 8 patients (10.4%) in the PCI and no-PCI groups, respectively ( p = 0.17). There were no significant differences between the two groups in terms of MACEs and bleeding events. Conclusions The rate of MACEs following NCS was not significantly different between the PCI and no-PCI groups, while the rate of bleeding events was higher in the PCI group without reaching statistical significance. This study suggests that patients with stable CAD may be able to safely undergo NCS without revascularization even in the presence of significant coronary artery stenosis.

Background The perioperative risk of non-cardiac surgery (NCS) in the patients on antiplatelet therapy after percutaneous coronary intervention (PCI) remains unclear. Methods This study was a retrospective and single center study. Between January 2008 and December 2011, 198 patients who had already received PCI underwent NCS in our hospital. Among them, 63 patients underwent surgery on dual antiplatelet therapy (DAPT group) and 88 patients on single antiplatelet therapy (SAPT group). We compared bleeding events and cardiovascular events during perioperative period between the two groups. Results There was no stent thrombosis in either group. The bleeding events in the DAPT group were significantly higher than that in the SAPT group (9.5% vs 2.3%, p = 0.049). There was no difference in events between with or without heparin-bridge in the SAPT group. Conclusions The frequency of bleeding events was higher in the DAPT group. Both bleeding and cardiovascular events with aspirin alone were low in our study. It may be safe to undergo NCS with SAPT after PCI.

Prognostic significance of temporal change in myocardial tissue characterization by cardiovascular magnetic resonance (CMR) has not been elucidated in patients with non-ischemic dilated cardiomyopathy (DCM).Sixty-eight patients with newly-diagnosed DCM who underwent CMR including late gadolinium enhancement (LGE) both at baseline and during follow-up period were enrolled. LGE score was defined by a signal intensity of ≥5 standard deviations above the remote reference myocardium mean. Left ventricular reverse remodeling (LVRR) defined as a LV ejection fraction increase of ≥10% and a decrease in indexed LV end-diastolic diameter of ≥10% compared to those at baseline was detected in 38% of the patients. There was no significant difference in LGE score between baseline and follow-up (5.8% vs. 7.3%; p=0.38). The change in LGE area (delta-LGE) was significantly lower in patients with LVRR than those without (-0.5%±3.4% vs. 3.0±7.4%; p=0.02). On the other hand, T2 ratio during the follow-up significantly reduced (1.95±0.48 vs. 1.67±0.56; p0.01); however, there was no significant difference in the change in T2 ratio between patients with LVRR and those without (-0.29±0.73 vs. -0.27±0.66; p=0.88). Multivariate logistic analysis indicated that baseline LGE score [odds ratio; 0.78; 95% confidence interval (CI) 0.66 to 0.90; p0.01] together with delta-LGE (odds ratio; 0.77; 95% CI 0.61 to 0.92; p=0.01) were independently associated with subsequent LVRR (p0.01).The temporal change of LGE-CMR score during the clinical course was significantly correlated with following LVRR.

Background Dabigatran etexilate (DE), an effective direct oral anticoagulant for patients with atrial fibrillation (AF), should be carefully used in patients with renal insufficiency. Data on the safety of DE in Japanese “real world” patients with mildly impaired renal function are limited. We hypothesized that low-dose DE (110 mg, twice daily) could be safely used in Japanese AF patients with mildly impaired renal function compared to those with preserved renal function. Methods and results One hundred ninety-six consecutive AF patients taking low-dose DE were retrospectively enrolled in this study, and were divided into two groups: preserved creatinine clearance (CCr ≥50 ml/min; n = 127) and reduced CCr (30–49 ml/min; n = 69). Baseline characteristics including CHADS2, CHA2DS2-VASc, and HAS-BLED scores were evaluated. Activated partial thromboplastin time (aPTT) was measured as a surrogate marker of the anticoagulant activity of DE, which was evaluated at 661 time points in total and the data were divided into five time windows after the last DE intake. The incidence of bleeding complications was compared between the two groups of reduced and preserved CCr. Reduced CCr group showed higher age (76.9 ± 6.3 years vs. 67.6 ± 6.7 years), higher CHADS2 (2.6 ± 1.4 vs. 1.8 ± 1.2), higher CHA2DS2-VASc (4.3 ± 1.6 vs. 3.2 ± 1.6), and higher HAS-BLED (2.3 ± 1.0 vs. 2.0 ± 1.0) scores in comparison with preserved CCr group (p Conclusion Low-dose DE was safe in AF patients with mildly reduced CCr.

SummaryIt is considered that percutaneous cardiopulmonary support (PCPS)-associated thrombosis is rare on antithrombotic coated PCPS if anticoagulation therapy is appropriately performed. We experienced two cases in which the association between antithrombotic coated PCPS and venous thrombus formation was highly suspected. These cases suggest that PCPS-associated venous thrombus formation should be checked frequently during and after PCPS even if anticoagulation was appropriately performed.

Summary Background Acute myocardial infarction (AMI) due to left main coronary artery disease is associated with significantly elevated morbidity and mortality. The aim of this study was to identify the predictors of in-hospital death from left main AMI complicated by cardiogenic shock. Methods Clinical record review identified a total of 25 cases of left main AMI with cardiogenic shock. Patients’ background characteristics, laboratory data, and angiographic findings were analyzed according to the in-hospital mortality. Results In this patient subset, in-hospital mortality (60%) was associated with a history of hypertension ( p = 0.02) and a higher heart rate ( p = 0.02). Furthermore, in-hospital mortality was also associated with a complete right bundle branch block (CRBBB) pattern in the admission ECG ( p = 0.01) and low HCO 3 − ( p = 0.0004). In stepwise logistic regression analysis, a CRBBB pattern (OR 48.59, 95% CI 1.34–1768.10, p = 0.03) and low HCO 3 − (OR 0.62, 95% CI 0.40–0.94, p = 0.02) were found to be independent predictors of mortality. Conclusions Left main AMI with cardiogenic shock was associated with high in-hospital mortality. A CRBBB pattern in the ECG on admission and a low HCO 3 − concentration were significant independent predictors of in-hospital death.

Background Temporary vena cava filters have been used for protection from potentially fatal pulmonary embolism. However, recent reports suggested that they may be associated with serious adverse complications including filter-related thrombosis. The purpose of this study was to examine the clinical complications of temporary vena cava filter placement. Methods We enrolled 40 consecutive patients from January 2006 to December 2010 who underwent percutaneous temporary vena cava filter insertion in Saitama Medical Center, Jichi Medical University. Results Major filter complications related to temporary vena cava filters were filter thrombosis in 4 patients (10.2%), filter dislocation in 4 (10.2%), and catheter-related infection in 3 (7.7%). Massive pulmonary embolism and cardiogenic shock was observed in one case (2.5%) at the time of retraction. Conclusion Temporary filter placement was associated with a high incidence of device-related complications. The benefit of temporary filter placement should be judiciously weighed against the risk of complications.

Summary Background Little has been known about clinical features and prognosis of very old patients with heart failure with preserved ejection fraction (HFPEF). The aim of this study was to compare clinical features and clinical outcomes between HFPEF and heart failure with reduced ejection fraction (HFREF) in patients older than 80 years. Methods We enrolled a total of 113 patients over 80 years old, who were admitted for heart failure between 2006 and 2009. We retrospectively analyzed the clinical features including laboratory data and echocardiography parameters. Results In 53 patients (49%) left ventricular ejection fraction was preserved. The clinical characteristics and treatment between HFPEF and HFREF showed that anemia was one of the risk factors for HFPEF, and the long-term outcomes of HFPEF in this population were not different from that of HFREF. Conclusion These results suggest that anemia is one of the important risk factors for HFPEF in the very elderly.

SummaryBackgroundThe aim of this study was to characterize coronary plaque composition of non-target lesions in diabetic patients using virtual histology intravascular ultrasound (VH-IVUS).Methods and resultsIn 134 stable angina pectoris patients, plaque components of non-culprit (

Summary Background Acute hyperglycemia is associated with increased mortality rates in patients with acute coronary syndrome. Objective This study aimed to evaluate the relationship between the glucose level and clinical variables during primary intervention in patients with ST-elevation acute myocardial infarction (STEMI). Methods and results Of consecutive 94 patients with STEMI treated by primary stent implantation, acute hyperglycemia (plasma glucose level on admission > 198 mg/dl) was recognized in 29 patients. There were no significant differences in baseline characteristics, except for the presence of diabetes and HbA 1c level, between patients with and without acute hyperglycemia. In patients with acute hyperglycemia, corrected TIMI frame counts were significantly higher compared with those in patients without acute hyperglycemia (46.3 ± 30.3 vs. 34.0 ± 17.9, p = 0.02). And corrected TIMI frame count was independently associated with plasma glucose level ( p = 0.006). Maximum level of creatine kinase (CK) and CK-MB were significantly higher in patients with acute hyperglycemia (CK, 4840.0 ± 4690.3 vs. 2410.7 ± 2302.9 IU, p = 0.001; CK-MB, 315.3 ± 257.7 vs. 195.9 ± 191.1, p = 0.01). Conclusion The presence of acute hyperglycemia was associated with the impairment of epicardial coronary flow after primary stent implantation. This mechanism might be responsible for the increased infarct size.

Background The circumstances surrounding infective endocarditis (IE) are under constant change due to an increase in drug-resistant organisms, a decrease in rheumatic valve disease, progress in surgical treatment, and aging society. The purpose of this study was to compare clinical features of IE between the 1990s and 2000s and to elucidate the determinants of death or clinical event. Methods All hospital admission records between January 1990 and December 2009 were retrospectively analyzed. The definition of IE was based on modified Duke criteria. Clinical presentation, blood culture, laboratory results, and echocardiography findings were compared between the 1990s and 2000s. Results There were 112 patients with definite or probable IE according to modified Duke criteria. The most frequent organism causing IE was Streptococcus viridians both in the 1990s and 2000s. The determinants of in-hospital death were hemodialysis and congestive heart failure. The in-hospital mortality of IE was 5.4% in the 1990s and 13.3% in the 2000s. Composite events of in-hospital death and central nervous system disorders were significantly higher in the 2000s compared with the 1990s. Conclusion The most frequent causative organism of IE was S. viridians , both in the 1990s and 2000s. Independent predictors of in-hospital mortality in IE were hemodialysis and congestive heart failure.