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Multi-slice computed tomography (CT) allows noninvasive evaluation of the severity of coronary calcification. However, there has yet to be a definitive parameter based on the cross-sectional CT image for predicting the need for rotational atherectomy (RA). Therefore, we aimed to investigate the mean density of cross-sectional CT images to predict the need for RA during percutaneous coronary intervention (PCI). A total of 154 lesions with moderate to severe calcification detected in coronary angiography were identified in 126 patients who underwent coronary CT prior to PCI for stable angina. PCI with RA was performed for 48 lesions, and the remaining 106 were treated without RA. Multi-slice CT was retrospectively evaluated for its ability to predict the use of RA. We chose the most severely calcified cross-sectional image for each lesion. The mean density within the outer vessel contour, calcium arc quadrant of the cross-sectional CT image, calcium length, calcification remodeling index, and per-lesion coronary artery calcium score was studied. Receiver-operator characteristic curve analysis revealed 637 Hounsfield units (HU) (area under the curve ​= ​0.98, 95% confidence interval: 0.97–1.00, p ​< ​0.001) as the best mean density cutoff value for predicting RA. Multivariate logistic regression analysis showed that a mean calcium level >637 HU was a strong independent predictor (odds ratio: 32.8, 95% confidence interval: 7.0–153, p ​< ​0.001) for using RA. The mean density of the cross-sectional CT image, a simple quantitative parameter, was the strongest predictor of the need for RA during PCI. TOC Summary : We investigated the mean density of cross-sectional computed tomography (CT) images to predict the need for rotational atherectomy (RA) during the percutaneous coronary intervention (PCI). A total of 154 lesions (48 with RA and 106 without RA) of stable angina were enrolled. Receiver operator characteristic curve analysis revealed that the area under the curve of mean density for predicting RA was 0.98 (95% confidence interval:0.97–1.00). A mean density >637 Hounsfield units was the strongest independent predictor for RA, among other potential predictors: calcium arc quadrant, calcium length, calcification remodeling index, and per-lesion coronary artery calcium score. [ABSTRACT FROM AUTHOR]

This study was performed to investigate whether right ventricular global longitudinal strain (RV-GLS) provides prognostic information in patients with wild-type transthyretin amyloid cardiomyopathy (ATTRwt-CM). Among 129 patients who were diagnosed with ATTRwt-CM at Kumamoto University Hospital from December 2002 to December 2019, 111 patients who had enough information for two-dimensional speckle tracking imaging were retrospectively analyzed. During a median follow-up of 615 days, 26 cardiovascular deaths occurred. Compared with patients in the non-event group, those in the cardiovascular death group were significantly older (81.1 ± 7.4 years vs. 78.2 ± 6.2 years, p = 0.009) and had significantly higher interventricular septal thickness in diastole (16.6 ± 3.1 mm vs. 15.3 ± 2.4 mm, p = 0.048), lower RV-GLS (10.9 ± 2.7% vs. 12.8 ± 3.5%, p = 0.010), and lower right ventricular free wall longitudinal strain (RVFWLS) (13.1 ± 3.3% vs. 15.5 ± 3.8%, p = 0.004). In the univariate Cox proportional hazard analysis, age, left atrial volume index (LAVI), RV-GLS, and RVFWLS were significantly associated with cardiovascular death [age, hazard ratio (HR), 1.10; 95% confidence interval (CI), 1.02–1.19, p = 0.010; LAVI, HR, 1.02; 95% CI, 1.00–1.03, p = 0.009; RV-GLS, HR, 0.86; 95% CI, 0.75–0.97, p = 0.017; RVFWLS, HR 0.89; 95% CI, 0.79–1.00; p = 0.041]. Multivariable Cox proportional hazard analysis showed RV-GLS was significantly and independently associated with cardiovascular death in patients with ATTRwt-CM (HR, 0.86; 95% CI, 0.74–0.99; p = 0.038). Receiver operating characteristic analysis showed that the area under the curve of RV-GLS for cardiovascular death was 0.668 and that the best cut-off value of RV-GLS was 11.59% (sensitivity, 69.2%; specificity, 63.5%). In the Kaplan–Meier analysis, patients with ATTRwt-CM who had low RV-GLS (<11.59%) had a significantly higher probability of total cardiovascular death (p = 0.004) and heart failure-related hospitalization (p = 0.013). RV-GLS has significant prognostic value in patients with ATTRwt-CM and provides greater prognostic power than conventional echocardiographic findings. [Display omitted] • Wild-type transthyretin amyloid cardiomyopathy (ATTRwt-CM) is becoming increasingly recognized. • Echocardiographic prognostic marker of ATTRwt-CM was not fully clarified. • Our study showed that RV-GLS was significant prognostic marker for ATTRwt-CM. • RV function is important for the prognosis in patients with ATTRwt-CM. [ABSTRACT FROM AUTHOR]

• Reduced staffing affects poor outcomes of patients with acute myocardial infarction (AMI) during off-hours. • On-duty cardiologists' presence is not a prognostic factor for patients with AMI. • Our medical system prevents delaying treatment of AMI without on-duty cardiologists. Owing to reduced staffing, patients hospitalized for acute myocardial infarction (AMI) during off-hours (nights, weekends, and holidays) have poorer outcomes than those admitted during regular hours. Whether the presence of an on-duty cardiologist in a hospital during off-hours is related to better outcomes for patients with AMI remains unclear. The Miyazaki Prefectural Nobeoka Hospital had a unique medical care system in that cardiologists were on call for half of the week and on duty for the other half during off-hours, thus providing an opportunity to assess the relationship between the presence of an on-duty cardiologist and patient outcomes. We examined clinical outcomes of patients admitted for AMI during off-hours according to the presence of an on-duty cardiologist. We recruited 225 consecutive patients with AMI hospitalized during off-hours, who underwent stent implantation at Miyazaki Prefecture Nobeoka Hospital from 2013 to 2017. The endpoints were in-hospital death or long-term major adverse cardiac events (MACE) including cardiovascular death, non-fatal MI, non-fatal stroke, stent thrombosis, ischemia-driven target-lesion revascularization, admission owing to unstable angina, or admission owing to heart failure. Based on the presence of an on-call cardiologist at admission, we divided patients into the cardiologist on-call group (n = 112) or cardiologist on-duty group (n = 113). The presence of an on-duty cardiologist did not affect door-to-reperfusion time (p = 0.776), level of peak creatine kinase (p = 0.971), or in-hospital death (p = 0.776). The Kaplan–Meier curve analysis showed similar prognosis for the cardiologist on-duty and cardiologist on-call groups (p = 0.843), and multivariable Cox regression analysis showed that the presence of an on-duty cardiologist was not associated with MACE. The presence of an on-duty cardiologist is not a prognostic factor for patients hospitalized for AMI during off-hours in our medical system. Further prospective multicenter studies should confirm our results. [ABSTRACT FROM AUTHOR]

Background Coronary spasm is one of the mechanisms of myocardial infarction with nonobstructive coronary arteries (MINOCA). The aim of this study was to investigate the effects of aspirin on future cardiovascular events in patients with coronary vasospastic angina (VSA) with non-significant atherosclerotic stenosis. Methods This was the retrospective analysis of the 640 VSA patients with non-significant atherosclerotic stenosis (≤ 50% stenosis) among 1,877 consecutive patients who underwent acetylcholine (ACh)-provocation testing between January 1991 and December 2010. The patients were divided into 2 groups treated with ( n = 137) or without ( n = 503) low-dose aspirin (81–100 mg/day). We evaluated major adverse cardiac events (MACE), defined as cardiac death, nonfatal myocardial infarction, and unstable angina. Results In the study population, 24 patients (3.8%) experienced MACE; there were 6 cases in VSA patients with aspirin and 6 in those without aspirin. Multivariate Cox hazards analysis for correlated factors of MACE indicated that use of statin (HR: 0.11; 95% CI: 0.02 to 0.84; P = 0.033), ST-segment elevation during attack (HR: 5.28; 95% CI: 2.19–12.7; P < 0.001), but not the use of aspirin as a significant predictor of MACE. After propensity score matching ( n = 112, each), Kaplan–Meier survival analysis indicated almost identical rate of 5-year survival free from MACE in those with aspirin, compared to those without aspirin in the entire and matched cohort ( P = 0.640 and P = 0.541, respectively). Conclusions Low-dose aspirin might not reduce future cardiovascular events in VSA patients with non-significant stenosis. [ABSTRACT FROM AUTHOR]

Background Coronary artery spasm contributes to the pathogenesis of variant angina and ischemic heart disease and may play a role in the progression of atherosclerosis. It is unclear whether the location of spasm is related to outcome. Objectives This study compared the clinical features and prognosis of patients with coronary spasm at the site of significant atherosclerotic stenosis with patients with spasm at sites without stenosis or nonsignificant stenosis. Methods This was a retrospective, observational study of 1,877 consecutive patients with typical or atypical angina-like chest pain undergoing acetylcholine (ACh)-provocation testing. A total of 1,760 patients were eligible for analysis. ACh-provoked coronary spasm and significant organic stenosis were observed in 873 and 358 patients, respectively. Results In patients with significant atherosclerotic stenosis, ACh-positive patients (n = 233) were younger and without diabetes mellitus compared with nonspasm patients (n = 125). In patients without organic stenosis, ACh-positive patients (n = 640) were older, had dyslipidemia, and were more likely to have a family history of ischemic heart disease than nonspasm patients (n = 762). Multiple logistic regression analysis identified ST-segment elevation during anginal attacks, organic stenosis of the left anterior descending artery, and multivessel spasm as correlates of spasm at sites of significant organic stenosis (n = 192). Multivariate analysis identified ACh-provoked spasm at the site of significant stenosis and use of nitrates as the 2 prognostic factors for major adverse cardiac events. Conclusions The clinical features and prognosis of patients with ACh-provoked coronary spasm were different when it occurred at the site of significant atherosclerotic stenosis compared with patients with spasm elsewhere. Both spasm at the site of significant organic stenosis and nitrate use were significant predictors of major adverse cardiac events. [ABSTRACT FROM AUTHOR]

Clinically driven target lesion revascularization (CD-TLR) frequently occurs after endovascular therapy (EVT) in patients with chronic limb-threatening ischemia (CLTI). The total thrombus-formation analysis system (T-TAS) can quantitatively evaluate thrombogenicity. Therefore, we aimed to elucidate the association of the T-TAS parameters with CD-TLR. We analyzed 34 patients with CLTI and 62 patients without CLTI who had undergone EVT. Blood samples collected on the day of EVT were used in the T-TAS to compute the thrombus formation area under the curve for the first 10 minutes for the platelet chip tested at a flow rate of 24 μL/min (PL 24 -AUC 10) and area under the curve for the first 30 minutes for the atheroma chip tested at a flow rate of 10 μL/min (AR 10 -AUC 30). After EVT, clinical follow-up was performed, and the presence of CD-TLR was assessed. During the follow-up period (median, 574 days), 10 patients (29%) in the CLTI group and 11 (18%) in the non-CLTI group had required CD-TLR. In the CLTI group, the patients with CD-TLR had had a higher AR 10 -AUC 30 vs those without (median, 1694 [interquartile range, 1657-1799] vs median, 1561 [interquartile range, 1412-1697]; P =.01). In contrast, the PL 24 -AUC 10 showed no significant differences when stratified by CD-TLR in either group. For the CLTI patients, multivariable Cox regression analysis using propensity score matching revealed that the AR 10 -AUC 30 was an independent predictor of CD-TLR even after adjusting for baseline demographics, lesion characteristics, and anticoagulant use (hazard ratio, 2.04; 95% confidence interval, 1.18-3.88; P =.01; per 100-unit increase). In contrast, for those without CLTI, neither the AR 10 -AUC 30 nor the PL 24 -AUC 10 was significantly associated with CD-TLR. Receiver operating characteristics curve analysis identified an AR 10 -AUC 30 level of 1646 as an optimal cutoff value to predict for CD-TLR (AUC, 0.85; sensitivity, 0.93; specificity, 0.56). For patients with CLTI, but not for those without CLTI, the AR 10 -AUC 30 showed potential to predict for CD-TLR. This finding suggests that hypercoagulability might play a predominant role in the progression of CLTI and that anticoagulant therapy might be useful in preventing revascularization. [ABSTRACT FROM AUTHOR]

Abstract: We report a case of acute myocardial infarction caused by left anterior descending artery occlusion presenting as ST elevation in the inferior leads and ST depression in the precordial leads, suggesting an involvement of the right coronary artery (RCA). However, coronary angiography (CAG) showed a complete occlusion of the proximal left anterior descending (LAD) coronary artery and collaterals from the left circumflex coronary artery and the RCA. Although he underwent primary percutaneous coronary intervention (PCI), he had chest pain at four days after primary PCI. His electrocardiogram (ECG) showed precordial ST elevation, suggesting an involvement of the LAD. Emergent CAG showed a complete occlusion of the proximal LAD without collaterals, but his ECG showed precordial ST elevation that was different from ST changes seen on admission. These unusual ST-segment changes might be associated with a weaker anterior ischemia due to collaterals and a strong inferior ischemia due to wrapped LAD artery. [Copyright &y& Elsevier]

Established antithrombotic therapies can increase bleeding risk, especially in hemodialysis (HD) patients. The Total Thrombus-formation Analysis System (T-TAS) is useful for evaluating thrombogenicity. The aim of this study was to examine the relationship between HD and thrombogenicity, or bleeding events in patients undergoing percutaneous coronary intervention (PCI). In this retrospective cohort study, 300 patients undergoing elective PCI were enrolled between April 2017 and March 2019. Blood samples obtained on the day of PCI were analyzed with T-TAS to compute the thrombus formation area under the curve (AUC; PL 18 -AUC 10 for platelet chip; AR 10 -AUC 30 for atheroma chip). The patients were divided into three groups according to estimated glomerular filtration rate (eGFR): 33 HD patients, 124 non-HD patients with eGFR <60 mL/min/1.73m2, and 143 non-HD patients with eGFR ≥60. We examined the thrombogenicity and spontaneous bleeding events within 1-year post-PCI. HD was significantly associated with both low PL 18 -AUC 10 and AR 10 -AUC 30 levels determined by T-TAS. Bleeding events defined by the Bleeding Academic Research Consortium criteria types 2, 3, or 5 occurred during follow-up in 27 patients (9.0%): 7 in HD, 10 in non-HD with eGFR <60, and 10 in non-HD with eGFR ≥60. Both T-TAS parameters in the patients with bleeding were lower compared with those in the patients without bleeding, and HD was significantly associated with 1-year bleeding events. The results suggested that HD patients undergoing PCI might be a predictor for low thrombogenicity measured by T-TAS and 1-year bleeding risk. • Total Thrombus-formation Analysis System (T-TAS) can evaluate the thrombogenicity. • We examined the thrombogenicity in patients undergoing PCI. • Hemodialysis (HD) was associated with low thrombogenicity measured by T-TAS. • It is meaningful to evaluate bleeding risk by T-TAS in HD patients undergoing PCI. [ABSTRACT FROM AUTHOR]

Background Although acute coronary syndrome (ACS) mainly arises from plaque ruptures (PR), precise mechanisms underlying ACS without PR are unknown. We sought to examine clinical, angiographic and intravascular ultrasound (IVUS) characteristics of ACS without PR. Methods and results Culprit lesions of 161 ACS patients were categorized by the presence or absence of PR (PR group: n = 57, Non-PR group: n = 104). Lower abdominal circumference (86 ± 10 cm vs 90 ± 9 cm, p = 0.02), lower prevalence of myocardial infarction (53% vs 82%, p = 0.0002), and higher prevalence of definite vasospasm (15% vs 2%, p = 0.006) were found in Non-PR group. Morphologically, Non-PR group was associated with simpler Ambrose classification (36% vs 14%, p = 0.004), less hypoechoic plaque (45% vs 65%, p = 0.04) and lower incidence of IVUS-detected thrombus (21% vs 54%, p < 0.0001), compared with PR group. On quantitative IVUS, although minimum lumen area (MLA) was similar between the groups, vessel (14.2 ± 5.4 mm 2 vs 17.5 ± 5.1 mm 2 , p = 0.0002) and plaque (11.6 ± 5.0 mm 2 vs 14.9 ± 4.9 mm 2 , p < 0.0001) areas were significantly smaller at MLA site in Non-PR group than in PR group. On multivariate analysis, average plaque area was only an independent IVUS-predictor of non-rupture ACS (odds ratio: 0.85, p = 0.01). Conclusion Compared to ACS with PR, non-rupture ACS arise from more hyperechoic (allegedly “stable”) plaque with smaller vessel and plaque area, leading to lower incidence of thrombotic occlusion. Coronary vasospasm might be a possible pathogenic mechanism underlying non-rupture ACS. [ABSTRACT FROM AUTHOR]