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Aims Acute myocardial infarction complicated by cardiogenic shock (AMICS) is associated with substantial mortality, although there are limited data available on bleeding in this critical condition. This study sought to investigate the incidence and impact of major in-hospital bleeding on all-cause mortality in patients with AMICS who undergo percutaneous coronary intervention (PCI). Methods and results Between 2015 and 2017, a total of 3411 patients hospitalized within 24 h after symptom onset were prospectively enrolled in the Japan Acute Myocardial Infarction Registry (JAMIR) and followed up for a median of 293 (interquartile range, 22–375) days. AMICS developed in 335 (9.8%) patients (mean age, 71.3 ± 13.6 years). Overall, the rate of major in-hospital bleeding (Bleeding Academic Research Consortium types 3 and 5) and in-hospital mortality was 14.6% and 28.7%, respectively. The majority of major in-hospital bleeding (73.5%) occurred within 48 h after PCI. Compared to patients without major in-hospital bleeding, those with it had higher rates of renal failure, left main coronary artery culprit lesion, and intra-aortic balloon pump or extracorporeal membrane oxygenation support, and had longer door-to-device time. The cumulative incidence of 1-year all-cause mortality was significantly higher in the major bleeding group compared to the non-major bleeding group (63.8% vs. 25.5%; log-rank P Conclusions These findings of JAMIR indicate that major in-hospital bleeding is associated with all-cause mortality in patients with AMICS who undergo PCI.

Introduction Chronic inflammation has been receiving considerable attention as an emerging risk factor for cardiovascular disease. In contrast, with the aging of the population, frailty has been also attracting a great deal of attention as the residual risk for cardiovascular disease. Although inflammation and frailty exacerbate each other and have an adverse effect on many diseases, the relationship between chronic inflammation and frailty and the impact of these combination on long-term prognosis in patients with acute coronary syndrome (ACS) are not elucidated. Purpose The aims of this study were to determine the association between chronic inflammation and frailty and its impact on long-term cardiovascular outcomes in patients with ACS. Methods A total of 482 consecutive ACS patients with obstructive coronary artery disease (age 66±12 years, male 81%) were enrolled in this observational study. We evaluated patients' gait speed as a measure of frailty before discharge. C-reactive protein (CRP) levels at 1 month after discharge were also evaluated as inflammation in the chronic phase. According to commonly used criteria of the residual inflammation (CRP>0.2 mg/dL) and the definition of the European Working Group for Sarcopenia (gait speed ≤0.8 m/sec), patients were stratified by 4 subgroups: low/high CRP with slow/normal gait speed. The primary endpoint was composite outcomes of cardiovascular death, myocardial infarction and ischemic stroke. Results While there was no significant association between CRP levels and gait speed in all patients, a significant negative association between two variables was observed in the high CRP group (Spearman's ρ = −0.31, p=0.001). During the median follow-up of 6 years, primary endpoints have occurred in 82 patients. Overall, event-free rates differed significantly among the 4 groups, demonstrating the lowest event-free rate in the patients with high CRP and slow gait speed (p Conclusion In the patients with ACS, CRP levels and gait speed were negatively associated in the high CRP group. Chronic inflammation and frailty were both associated with poor prognosis in ACS and in particular, the combination of these factors was strongly associated with poor prognosis. Funding Acknowledgement Type of funding sources: None. Figure 1

Objectives Doppler echocardiography is a well-recognized technique for noninvasive evaluation; however, little is known about its efficacy in patients with rapid atrial fibrillation (AF) accompanied by acute decompensated heart failure (ADHF). The aim of this study was to explore the usefulness of serial echocardiographical assessment for rapid AF patients with ADHF. Patients A total of 110 ADHF patients with reduced ejection fraction (HFrEF) and rapid AF who were admitted to the CCU unit and received landiolol treatmentto decrease the heart rate (HR) to 20% within 24 hours were enrolled. Interventions Immediately after admission, the patients (n=110) received landiolol, and its dose was increased to the maximum; then, we repeatedly performed echocardiography. Among them, 39 patients were monitored using invasive right heart catheterization (RHC) simultaneously with echocardiography. Measurements and main results There were significant relationships between Doppler and RHC parameters through the landiolol treatment (Figure, baseline–max HR treatment). We observed for the major adverse events (MAE) during initial hospitalization, which included cardiac death, HF prolongation (required intravenous treatment at 30 days), and worsening renal function (WRF). MAE occurred in 44 patients, and logistic regression analyses showed that the mean left atrial pressure (mLAP)-Doppler (odds ratio = 1.132, 95% confidence interval [CI]: 1.05–1.23, p=0.0004) and stroke volume (SV)-Doppler (odds ratio = 0.93, 95% confidence interval [CI]: 0.89–0.97, p=0.001) at 24 hours were the significant predictors for MAE, and multivariate analysis showed that mLAP-Doppler was the strongest predictor (odds ratio = 1.16, 95% CI: 0.107–1.27, p=0.0005) (Table). Conclusions During the control of the rapid AF in HFrEF patients withADHF, echocardiography was useful to assess their hemodynamic condition, even at bedside. Doppler for rapid AF of ADHF Funding Acknowledgement Type of funding source: None

Background Although the prognostic value of non-invasive endothelial function test has been reported in several populations including heart failure patients and angina pectoris patients, it is unknown in patients with acute coronary syndrome (ACS). Furthermore, the role of endothelial dysfunction in increased risk for specific causes of death has not been investigated. Purpose To study the relation between endothelial dysfunction and the risk of death in ACS patients, both overall and with regard to the main causes of death. Method Six hundred and ninety-two patients who were hospitalized for ACS from 2010 to 2014 were enrolled. Reactive hyoeremia index (RHI) was measured to assess endothelial function non-invasively in all patients using the peripheral arterial tonometry. RHI values below 1.67 were interpreted as signs of endothelial dysfunction in accordance with the manufacturer. Patients were followed up for a median of 6.5 years. Result A mean age (standard deviation) was 66 (12) years, and 542 patients (78%) were male. The patients in this study consist of 377 ST-elevation myocardial infarction (54%), and 263 non ST-elevation myocardial infarction (38%), and 52 unstable angina (8%). Endothelial dysfunction was detected in 276 patients (40%). During the follow-up period, 84 patients (12%) died (48 from cardiovascular disease, 36 from other causes). Patients with endothelial dysfunction had an increased risk of death (hazard ratio (HR) 1.83, 95% confidence interval (95% CI): 1.19–2.83, p=0.006) compared with those without endothelial dysfunction. Analyses for specific causes of death showed that patients with endothelial dysfunction had a 2.4-fold higher increased risk of cardiovascular death (HR: 2.44, 95% CI: 1.35 ro 4.59, p=0.003) after multivariate adjustment. However there was no significant relation between endothelial dysfunction and non-cardiovascular mortality (HR: 0.69, 95% CI: 0.34 to 1.36, p=0.29). Conclusion Endothelial dysfunction is strongly associated with an increased risk of cardiovascular mortality in ACS patients. Figure 1 Funding Acknowledgement Type of funding source: None

Background The early transmitral flow velocity (E) divided by the early diastolic velocity of the mitral valve annulus (e') is referred to as the “E/e' ratio,” is useful even for ST elevation acute myocardial infarction (STEMI). However, the role of late diastolic velocity (a') which reveals the atrial function for STEMI is still unclear. Objectives We evaluated the clinical usefulness of tissue Doppler including atrial function for a first-time STEMI by long time follow up. Furthermore, we evaluated the meaning of each parameters by performing immediately after PCI or 2 weeks later. Methods We treated consecutive 571 first-time STEMI patients by immediate PCI within 12 hours after onset, and we examined 270 patients at immediately after PCI (GroupA, 65 years, 250 male) and 301 patients at 2 weeks after onset (GroupB, 64 years, 243 male). We examined trans mitral flow and TDI, then defined E/e' as LV filling pressure and A/a' as left atrial function. We followed them for a long time (>5 years). The primary end point (PE) was cardiac death or re-admission for heart failure (HF). Results We followed the patients in Group A for 10 years, Group B for 5 years. PE occurred in 64 patients in GroupA during 10 years, and 45 patients in GroupB during 5 years. We analyzed the univariate and multivariate Cox hazard analyses and we compared e' and a', E/e' and A/a' (Table). In GroupA, a' and A/a' were the independent predictors, on the other hand neither a' nor A/a' were the predictors in GroupB. E/e' was an independent predictor both in GroupA and B. Conclusion TDI parameters have different meanings by the timing of echocardiography after onset of a first-time STEMI. These results demonstrated that atrial dysfunction immediately after onset of STEMI suggests the poor prognosis after STEMI. Cox Hazard Proportional Analysis Funding Acknowledgement Type of funding source: None

Introduction Dyslipidemia, especially an increase in the low-density lipoprotein cholesterol (LDL-C) has been established as one of the most important risk factors for atherosclerotic cardiovascular diseases. In contrast, some recent studies have shown that the low LDL-C level was associated with short-term poor prognosis in patients with cardiovascular disease, and this is so-called “cholesterol paradox”. However, there is few data evaluating the effects on long-term outcome of “cholesterol paradox” in patients with acute coronary syndrome (ACS). Purpose The purpose of this study was to examine whether the low LDL-C level on admission affect long-term prognosis in patients with ACS. Methods A total of 434 ACS patients who survived to hospital discharge were enrolled in this study. All patients were statin-naïve on admission, and were received statin therapy after hospitalization. Patients were divided into the low LDL-C (≤114 mg/dl) and high LDL-C (>114 mg/dl) groups using the first tertile of the LDL-C level on admission. The primary endpoint was composite outcomes of all-cause death, myocardial infarction, ischemic stroke, hospitalization for congestive heart failure and unplanned revascularization. Results During a median follow-up period of 5.5 years, primary endpoint occurred in 117 patients. Overall, event-free rates differed significantly between the low and high LDL-C groups, demonstrating the lower event-free rate in patients with the low LDL-C group (38.9% in low LDL-C group versus 20.7% in high LDL-C group, p=0.0002; Figure). Even after adjustment for age, sex, body mass index, and various classical risk factors, the low LDL-C group was significantly at higher risk for primary composite outcomes compared to the high LDL-C group (adjusted hazard ratio 1.65, 95%-confidence interval 1.10–2.49, p=0.02). Conclusion In patients with ACS, the low LDL-C level on admission was significantly associated with long-term worse prognosis, regardless of statin therapy at discharge. In ACS patients with low LDL-C level, it might be necessary for elucidating the residual risk for secondary adverse event to improve their prognosis. Funding Acknowledgement Type of funding source: None

Background Shortening of onset to admission time (OAT) and door-to-balloon time (DBT) is associated with lower adverse cardiac event after primary percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI). Bleeding event also results in poor outcome in patients with AMI after primary PCI. Little is known about sex differences in DBT and ischemic, bleeding events after AMI. Purpose This study aimed to assess the sex differences of OAT, DTB and adverse cardiac event, incident of bleeding event after primary PCI in patients with AMI. Methods The Japan AMI Registry (JAMIR) is a multicenter, nationwide, prospective registry enrolling patients with AMI from 50 institutes between December 2015 and May 2017. Primary endpoints of this study were ischemic event (composite of cardiovascular death, myocardial infarction and ischemic stroke) and bleeding event (BARC type 3 or 5,).Median follow-up period was 12 months. Results A total of 3,411 patients were enrolled at first. Among them, 329 patients without treated with PCI and 199 patients missing OAT time were excluded from this study. A total 2883 patients of men (n=2240, 77.7%) and women (n=643, 22.3%) were enrolled. OAT and DBT of women were significantly longer than that of men (OAT: 130min, interquartile range 62–300 min vs. 155 min, interquartile range 69–350 min, p=0.040, DBT: 67 min, interquartile range 50–95 min vs. 75 min, interquartile range 53–120 min, p Conclusion The real-world database of the JAMIR showed that the female sex was significant factor for the delay in primary percutaneous coronary intervention and high incident of bleeding, however, ischemic event was lower than that of male sex. Sex difference appears to be associated with ischemic and bleeding event after acute myocardial infarction. Funding Acknowledgement Type of funding source: None

Aims In patients with ST-segment elevation myocardial infarction (STEMI), predicting left ventricular (LV) remodelling (LVR) and prognosis is important. We explored the clinical usefulness of three-dimensional (3D) speckle-tracking echocardiography to predict LVR and prognosis in STEMI. Methods and results The study group comprised 255 first STEMI patients (65 years; 210 men) treated with primary percutaneous coronary intervention between April 2008 and May 2012 at Yokohama City University Medical Center. Baseline global longitudinal strain (GLS) was measured with two-dimensional (2D) and 3D speckle-tracking echocardiography. Within 48 of admission, standard 2D echocardiography and 3D full-volume imaging were performed, and 2D-GLS and 3D-GLS were calculated. Infarct size was estimated by 99mTc-sestamibi single-photon emission computed tomography. Echocardiography was performed at 1 year repeatedly in 239 patients. The primary endpoint was LVR, defined as an increase of 20% of LV end-diastolic volume index and major adverse cardiac and cerebrovascular events (MACE: cardiac death, non-fatal MI, heart failure, and ischaemic stroke) at 1 year, and the secondary endpoint was cardiac death and heart failure. Patients were followed for 1 year; 64, 25, and 16 patients experienced LVR, MACE, and the secondary endpoint, respectively. Multivariate analysis revealed that 3D-GLS was the strongest predictor of LVR (odds ratio = 1.437, 95% CI: 1.047–2.257, P = 0.02), MACE (odds ratio = 1.443, 95% CI: 1.240–1.743, P = 0.0002), and the secondary end point (odds ratio = 1.596, 95% CI: 1.17–1.56, P Conclusion 3D-GLS obtained immediately after STEMI is independently associated with LVR and 1-year prognosis.

Takotsubo syndrome (TTS) is a poorly recognized heart disease that was initially regarded as a benign condition. Recently, it has been shown that TTS may be associated with severe clinical complications including death and that its prevalence is probably underestimated. Since current guidelines on TTS are lacking, it appears timely and important to provide an expert consensus statement on TTS. The clinical expert consensus document part I summarizes the current state of knowledge on clinical presentation and characteristics of TTS and agrees on controversies surrounding TTS such as nomenclature, different TTS types, role of coronary artery disease, and etiology. This consensus also proposes new diagnostic criteria based on current knowledge to improve diagnostic accuracy. ispartof: EUROPEAN HEART JOURNAL vol:39 issue:22 pages:2032-2046 ispartof: location:England status: published

Introduction Sarcopenia, characterized by the loss of skeletal muscle mass and muscle strength, has been demonstrated the importance in cardiovascular diseases including ST-segment elevation myocardial infarction (STEMI). However, there is few data comparing the effects on the prognosis of skeletal muscle mass of upper and lower extremities in STEMI patients. Purpose Our purpose was to examine whether skeletal muscle mass of upper and lower extremities affect the prognosis after STEMI. Methods A total of 432 patients with STEMI were enrolled in this study. Dual-energy X-ray absorptiometry scan was performed before discharge. Each of upper and lower extremity skeletal muscle masses was indexed by height squared (kg/m2), and divided into two groups using the first quartile value for each sex. All patients were followed up for the primary composite outcome of all-cause death, nonfatal myocardial infarction, nonfatal ischemic stroke, hospitalization for congestive heart failure, and unplanned revascularization. Results During a median follow-up of 32 months, 68 patients experienced primary composite outcome. The event rate was significantly higher in patients with low-lower extremity skeletal muscle mass index (LESMI) than in those with high-LESMI (24.3% vs 12.9%, log-rank p Conclusions Decreased muscle mass of lower extremity, rather than upper extremity, might have prognostic impact in patients with STEMI.

Background Low muscle mass with or without fat mass is a main component of cachexia in heart failure (HF) and associated with poor prognosis. There is a paucity of data, however, regarding prognostic impact of each component of body composition (i.e., muscle, fat, and bone mass). Purpose We hypothesized that muscle, fat, and bone mass have different impact on prognosis in HF. Methods We retrospectively analyzed 418 patients admitted with a diagnosis of HF (71±13 years, 59% male, 46 and 54% with preserved/mid-range (left ventricular ejection fraction (LVEF) ≥40%) and reduced ( Results Mean appendicular skeletal mass index (ASMI) was 6.9±1.2 kg/m2 in men and 5.6±0.9 in women, so that 55% of patients had low muscle mass categorized by the Asian Working Group of Sarcopenia. During median follow-up of 502 days, 163 (39.0%) patients experienced primary outcome defined as death or heart failure hospitalization. Using optimal cut-off of each body component chosen on the basis of a receiver operating characteristic curve and the Youden method, we demonstrated that lower ASMI defined by the cut-off of 6.5 kg/m2 in male and 5.2 in female (adjusted hazard ratio (HR): 1.768, 95% CI: 1.210–2.581, p=0.003) and bone mass (adjusted HR: 1.498, 95% CI: 1.051–2.152, p=0.025), but not lower fat mass (p=0.34), were associated with elevated risk of primary outcome after multivariate adjustment. Kaplan-Meier curves with p value by Log-rank test were shown in figure. In subgroup analysis, negative impact of lower ASMI was significant regardless of sex and LVEF category, whereas negative impact of low bone mass was significant only in 78 female patients with reduced LVEF. Figure 1 Conclusions Indices about muscle and bone mass rather than fat mass had prognostic impact in HF. The impact of each body component may different according to sex and LVEF.

Introduction Muscle, fat and bone mass may play some roles to keep physical activity and favorable outcome in patients with cardiovascular diseases. However, there is a paucity of data regarding the effects on the prognosis of skeletal muscle, fat, and bone mass in patients with ST-segment elevation myocardial infarction (STEMI). Purpose Our purpose was to examine whether skeletal muscle, fat, and bone mass each affect the prognosis after STEMI. Methods A total of 354 male patients with STEMI were enrolled in this study. Dual-energy X-ray absorptiometry scan was performed before discharge. All patients were followed up for the primary composite outcome of all-cause death, nonfatal myocardial infarction, nonfatal ischemic stroke, hospitalization for congestive heart failure, and unplanned revascularization. Results During a median follow-up of 32 months, 57 patients experienced primary composite outcome. Each of skeletal muscle, fat, and bone mass were indexed by height squared (kg/m2) and divided into two groups using the cut-off value obtained from the maximum Youden index to predict the primary composite outcome. The event rate was significantly higher in patients with low appendicular skeletal muscle mass index (ASMI) (29.2% vs 11.7%, p Conclusions Index about muscle mass rather than fat and bone mass have prognostic impact in male patients with STEMI.

Negative T waves in precordial leads often occur in patients with acute coronary syndrome (ACS), but are also found in acute pulmonary embolism (APE) and Takotsubo cardiomyopathy (TC). Because the clinical features of these two diseases mimic those of ACS, differential diagnosis is essential to select an appropriate treatment strategy improve outcomes. This study aimed to clarify the differences in negative T waves among ACS, APE and TC.We studied admission ECGs in 300 patients (198 patients with ACS caused by the left anterior descending coronary artery disease, 81 with APE and 21 with TC). All patients were admitted within 48 h from symptom onset and had negative T waves ≥1.0 mm without ST-segment elevation in leads V1 to V4. The number and maximal amplitude of negative T waves were greatest in patients with TC, followed by in those with ACS, and were lowest in patients with APE (p0.001, respectively). The prevalence of negative T waves significantly differed in all 12 leads among the three groups (p0.01, respectively). Negative T waves in both leads III and V1 identified APE with 90% sensitivity and 97% specificity. Negative T waves in lead -aVR (i.e., positive T waves in lead aVR) and no negative T waves in lead V1 identified TC with 95% sensitivity and 97% specificity. These values represented the highest diagnostic accuracies.The distributions of negative T waves differed among ACS, APE and TC, and these differences were useful for differentiating among these three diseases.

QT interval may change when cardiac function is improved by optimizing the atrioventricular the (AV) delay. The relationship between AV delay, QT interval and cardiac function in patients with implanted DDD pacemakers was studied in 12 patients (aged 71&12 SD years) with complete or high degree AV block. Cardiac output (CO) was measured using a Swan‐Ganz catheter or by continuous Doppler echocardiography. The pacing rate was fixed at 70‐80/min to eliminate the influence of heart rate. The AV delay was prolonged stepwise by 30 ms starting from 90 ms. All measurements were performed after 5 min of pacing. When the AV delay was prolonged, the CO and QT interval gradually increased and reached a peak, and then decreased. When the CO was increased from the minimum to the maximum value by optimizing the AV delay, the QT interval was significantly prolonged from 440&40 to 456&39 ms (P

Background: Calcified lesions sometimes cause stent underexpansion which increase the risk of stent thrombosis and target lesion revascularization after percutaneous coronary intervention (PCI). Rotational atherectomy (RA) plays an important role to facilitate the dilation or stenting of these lesions. Optical coherence tomography (OCT) is a new imaging modality that visualize calcium component without signal attenuation. The aim of this study was to examine the effects of RA and subsequent balloon angioplasty on calcified coronary plaques using OCT. Methods: From October 2011 to December 2012, a total of 17 calcified lesions requiring RA in patients with CAD were interrogated by FD-OCT. In all patients, OCT images just after atherectomy and after balloon angioplasty (before stent implantation) were analyzed to assess calcium component. The thickness of the calcium component was measured at its thinnest part. The arc, thickness of the calcium component, and the lumen area in each segment as determined by OCT were measured at 1-mm intervals. The incidence of calcium cracks after balloon angioplasty following RA was also assessed by OCT. Results: A total of 328 segments in 17 lesions were analyzed. Calcium cracks were observed in 138 segments (42%) in 14 patients (82%). The segment with calcium cracks after angioplasty had smaller lumen area (3.39±1.43 vs 3.92±1.78 mm2, P