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Background: Although major guidelines recommend the routine introduction of angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs) and beta-blockers for patients with ST-segment elevation myocardial infarction (STEMI), evidence regarding the target blood pressure (BP) or pulse rate (PR) at hospital discharge is sparse. This retrospective study aimed to compare the clinical outcomes in patients with STEMI between those with good BP and PR control and those with poor BP or PR control., Methods: We included 748 patients with STEMI who received both ACE inhibitors/ARBs and beta-blockers at hospital discharge, and divided them into a good control group (systolic BP ≤140 mmHg and PR ≤80 bpm, n = 564) and a poor control group (systolic BP >140 mmHg or PR >80 bpm, n = 184). The primary endpoint was major cardiovascular events (MACE) defined as the composite of all-cause death, non-fatal myocardial infarction, and re-admission for heart failure., Results: During the median follow-up duration of 568 days, a total of 119 MACE were observed. The Kaplan-Meier curves showed that MACE were more frequently observed in the poor control group (p = 0.009). In the multivariate Cox hazard analysis, the good control group was inversely associated with MACE (HR 0.656, 95 % CI: 0.444-0.968, p = 0.034) after controlling for multiple confounding factors., Conclusions: The good control of systolic BP and PR at discharge was inversely associated with long-term adverse events in STEMI patients treated with both ACE inhibitors/ARBs and beta blockers. This study suggests the importance of titration of ACE inhibitors/ARBs and beta-blockers for better clinical outcomes in patients with STEMI., Competing Interests: Declaration of competing interest Dr. Sakakura has received speaking honoraria from Abbott Vascular, Boston Scientific, Medtronic Cardiovascular, Terumo, OrbusNeich, Japan Lifeline, Kaneka, and NIPRO. Dr. Jinnouchi has received speaking honoraria from Abbott Vascular. Prof. Fujita has served as a consultant for Mehergen Group Holdings, Inc., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Objective Patients with acute myocardial infarction (AMI) often have peripheral artery disease (PAD). It is well known that the long-term clinical outcomes of AMI are worse in patients with a low ankle-brachial index (ABI) than in patients with a preserved ABI. Unlike ABI, the association between the inter-arm blood pressure difference (IABPD) and clinical outcomes in patients with AMI has not yet been established. This retrospective study examined whether or not the IABPD is associated with long-term clinical outcomes in patients with AMI. Methods We included 979 patients with AMI and divided them into a high-IABPD group (IABPD ≥10 mmHg, n=31) and a low-IABPD group (IABPD <10 mmHg, n=948) according to the IABPD measured during hospitalization for AMI. The primary endpoint was the all-cause mortality rate. Results During a median follow-up duration of 694 days (Q1, 296 days; Q3, 1,281 days), 82 all-cause deaths were observed. Kaplan-Meier curves showed that all-cause death was more frequently observed in the high-IABPD group than in the low-IABPD group (p<0.001). A multivariate Cox hazard analysis revealed that a high IABPD was significantly associated with all-cause death (hazard ratio 2.061, 95% confidence interval 1.012-4.197, p=0.046) after controlling for multiple confounding factors. Conclusion A high IABPD was significantly associated with long-term all-cause mortality in patients with AMI. Our results suggest the usefulness of the IABPD as a prognostic marker for patients with AMI.

Rotational atherectomy (RA) is technically more difficult in a diffuse calcified lesion than in a focal calcified lesion. We hypothesized that taking a halftime can be another option for RA to the diffuse calcified lesions. Halftime was defined as at least one long break during RA, in which an operator pulled out the Rotablator system from the guide catheter before crossing the lesion. This study aimed to compare the complications between RA with and without halftime. We included 177 diffuse long severely calcified lesions (lesion lengths ≥ 30 mm) that required RA, and divided those lesions into a halftime group (n = 29) and a no-halftime group (n = 148). The primary outcome was periprocedural myocardial infarction (MI). The reference diameter was smaller in the halftime group than in the no-halftime group [1.82 (1.70-2.06) mm versus 2.17 (1.89-2.59) mm, p = 0.002]. The total run time was longer in the halftime group than in the non-halftime group [133.0 (102.0-223.0) seconds versus 71.5 (42.0-108.0) seconds, p < 0.001]. Although creatinine kinase (CK) and CK-myocardial band (MB) was significantly higher in the halftime group than in the no-halftime group [CK: 156 (97-308) U/L versus 99 (59-216) U/L, p = 0.021; CK-MB: 15 (8-24) U/L versus 5 (3-15) U/L, p < 0.001], periprocedural MI was not observed in the halftime group. In conclusion, periprocedural MI was not observed in RA with halftime. This preliminary study suggests that halftime RA may be a safe option for diffuse severely calcified lesions., (© 2023. The Author(s).)

Serious complications including vessel perforation may occur during rotational atherectomy (RA) to left circumflex (LCX) ostial lesions. In fact, if perforation occurs around LCX ostium, bailout procedures including deployment of covered stents may cause fatal ischemia in the territory of left anterior descending artery, which results in broad anterior acute myocardial infarction and subsequent death. In this review article, we described tips and tricks for RA to LCX ostial lesions. First, we should cautiously decide the indication for RA to LCX ostial lesions, because there are several reasons to avoid RA to LCX ostial lesions. Before procedures, we should estimate the difficulty of RA to LCX ostial lesions, which is mainly determined by the combination of the bifurcation angle and the severity of stenosis. Thus, the combination of the large bifurcation angle and the tight stenosis makes RA to LCX ostial lesions most difficult. Appropriate position of guide catheter and RotaWire is a key to successful RA to LCX ostial lesions. Differential cutting is an essential concept for RA to LCX ostial lesions. However, since there is no guarantee that differential cutting always works, small burr (≤ 1.5 mm) would be a safe choice as initial burr for RA to LCX ostial lesions., (© 2023. The Author(s) under exclusive licence to Japanese Association of Cardiovascular Intervention and Therapeutics.)

Aims: Coronary calcification detected by coronary angiography is a simple risk marker for long-term clinical outcomes in stable coronary artery disease. However, the significance of angiographic coronary calcification in the culprit lesion of acute myocardial infarction (AMI) has not been fully discussed. The purpose of this retrospective study was to assess the usefulness of angiographic coronary calcification as a risk marker for long-term clinical outcomes following percutaneous coronary intervention to the culprit lesions of AMI., Methods: We included 1209 patients with AMI and divided them into the none-mild calcification group (n=923) and the moderate-severe calcification group (n=286) according to angiographic coronary calcification in the culprit lesion of AMI. The primary endpoint was the occurrence of major adverse cardiac events (MACE), which was defined as a composite of all-cause death, nonfatal MI, readmission for heart failure, and ischemia-driven target vessel revascularization., Results: The median follow-up duration was 542 (Q1: 182, Q3: 990) days. A total of 345 MACE were observed during the study period. The occurrence of MACE was significantly greater in the moderate-severe calcification group than in the none-mild calcification group (43.4% vs. 23.9%, p＜0.001). In the multivariate Cox hazard model, moderate-severe calcification was significantly associated with MACE (hazard ratio 1.302, 95% confidence interval 1.011-1.677, p=0.041) after controlling multiple confounding factors., Conclusions: Angiographically moderate to severe calcification in AMI culprit lesion was associated with long-term worse clinical outcomes. Angiographic coronary calcification can be a simple risk marker in patients after AMI.

Background: Epidemiological studies reported that acute myocardial infarction (AMI) occurs more often in winter season or days with low temperatures. However, most of these studies did not distinguish ST-elevation myocardial infarction (STEMI) from AMI. The purpose of this study was to investigate the relationship between temperature and the occurrence of STEMI., Methods: We reviewed all daily temperature in Saitama City between January 2015 and December 2021 (2557 days) and divided them into days in which our institution received STEMI (days with STEMI) and days in which our institution did not receive STEMI (days without STEMI)., Results: The daily maximum temperature was significantly lower in days with STEMI than in days without STEMI [20.0 °C (68.0 °F) versus 21.2 °C (70.2 °F), p = 0.001]. The maximum temperature was significantly lower in days with STEMI than in days without STEMI in the elderly [19.9 °C (67.8 °F) versus 21.1 °C (70.0 °F), p = 0.003], whereas this trend was weaker in the non-elderly [20.2 °C (68.4 °F) versus 20.9 °C (69.6 °F), p = 0.171]. Furthermore, the maximum temperature was significantly lower in days with STEMI than in days without STEMI in male [20.0 °C (68.0 °F) versus 21.1 °C (70.0 °F), p = 0.002], whereas this trend was weaker in females [20.0 °C (68.0 °F) versus 20.9 °C (69.6 °F), p = 0.169]., Conclusions: The daily temperatures were significantly lower in days with STEMI than in days without STEMI, and this relationship was pronounced in elderly or male patients., Competing Interests: Declaration of competing interest Dr. Sakakura has received speaking honoraria from Abbott Vascular, Boston Scientific, Medtronic Cardiovascular, Terumo, OrbusNeich, Japan Lifeline, Kaneka, and NIPRO. Dr. Jinnouchi has received speaking honoraria from Abbott Vascular. Prof. Fujita has served as a consultant for Mehergen Group Holdings, Inc., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Some patients admitted to intensive care units (ICU) would develop delirium, which is associated with poor prognosis. The purpose of this retrospective study was to identify factors associated with ICU delirium in patients with acute myocardial infarction (AMI). We included 753 AMI and divided those into the ICU-delirium group (n = 110) and the non-ICU-delirium group (n = 643) according to the presence of ICU delirium. The ICU delirium was evaluated by confusion assessment method for the intensive care unit. Patient characteristics and clinical outcomes were compared between the 2 groups, and factors associated with ICU delirium were sought by multivariate analysis. The prevalence of female sex was significantly higher in the ICU-delirium group (43.6%) than in the non-ICU-delirium group (20.2%) (p < 0.001). The incidence of in-hospital death was significantly higher in the ICU-delirium group (17.3%) than in the non-ICU-delirium group (0.5%) (p < 0.001). The multivariate logistic regression analysis revealed that age [every 10 years increase: odds ratio (OR) 1.439, 95% confidence interval (CI) 1.127-1.837, p = 0.004], female sex (OR 2.237, 95%CI 1.300-3.849, p = 0.004), triple vessel disease (OR 2.317, 95%CI 1.365-3.932, p = 0.002), body mass index < 18.5 kg/m 2 (OR 2.910, 95%CI 1.410-6.008, p = 0.004), use of mechanical support (OR 2.812, 95%CI 1.500-5.270, p = 0.001), respiratory failure (OR 5.342, 95%CI 3.080-9.265, p < 0.001), and use of continuous renal replacement therapy (OR 5.901, 95%CI 2.520-13.819, p < 0.001) were significantly associated with ICU delirium. In conclusion, ICU delirium was associated with in-hospital death. Older age, female sex, triple vessel disease, leanness, use of mechanical support, respiratory failure, and continuous renal replacement therapy were significantly associated with the occurrence of ICU delirium., (© 2022. Springer Japan KK, part of Springer Nature.)

In-hospital mortality of acute myocardial infarction (AMI) complicated with cardiogenic shock (CS) remains high. Also, in-hospital mortality of AMI complicated with cardiac arrest (CA) has been reported to be highest among any AMI. However, there were few reports that compared in-hospital mortality directly between AMI complicated with CS and complicated with CA. The purpose of this study was to compare in-hospital outcomes between AMI complicated with CS and complicated with CA. We retrospectively included 195 AMI patients complicated by CS or CA, and divided those into the CA group (n = 109) and the CS group (n = 86). We also subdivided the CA group into CA with persistent CS (n = 83) and CA without persistent CS (n = 26). One-third of the study population died during the index admission. In-hospital death was more frequently observed in the CA group (45.0%) than in the CS group (20.9%) (p < 0.001). In-hospital mortality was highest in the CA with persistent CS group (68.7%), followed by the CS group (20.9%), and least in the CA without persistent CS group (11.5%) (p < 0.001). Favorable neurological function was more frequently observed in the CA without persistent CS group (76.9%) and the CS group (74.4%) than in the CA with persistent CS group (27.7%) (p < 0.001). In conclusion, in-hospital mortality was higher in AMI patients with CA than in those with CS. However, when we divided AMI patients with CA into those with and without persistent CS, in-hospital mortality was lowest in CA without persistent CS, followed by CS, and highest in CA with persistent CS., (© 2022. Springer Japan KK, part of Springer Nature.)

The medical expenses for patients with acute myocardial infarction (AMI) has become enormous burden for global healthcare system. In AMI patients, total admission cost for patients with off-hours visit may be higher than those with on-hours visit, because of additional cost for emergent care during off-hours. This study aimed to compare total medical cost in AMI patients between on-hours visit versus off-hours visit. We retrospectively included 368 AMI patients who underwent PCI to the culprit lesion, and divided them into the on-hours group (n = 173) and the off-hours group (n = 195). We compared clinical characteristics, total admission cost, and clinical outcomes between the two groups. The prevalence of Killip class 3/4 was significantly greater in the off-hours group than in the on-hours group. Length of ICU and hospital stay were significantly longer in the off-hours group than in the on-hours group. Total admission cost was significantly higher in the off-hours group [¥1,570,400 (¥1,271,550-¥2,117,090)] than in the on-hours group [¥1,356,270 (¥1,100,990-¥1,957,225)] (P < 0.001). However, multivariate analysis revealed off-hours visit itself was not associated with high total admission cost after adjusting confounding factors. In conclusion, total admission cost was higher in AMI patients with off-hours visit than in those with on-hours visit. However, multivariate logistic regression analysis revealed that the off-hours visit itself was not associated with the highest total admission cost. Off-hours visit itself did not result in higher cost, but severer conditions in AMI patients with off-hours visit resulted in higher cost., (© 2022. The Author(s) under exclusive licence to Japanese Association of Cardiovascular Intervention and Therapeutics.)

Background: Low ankle-brachial index (ABI) is an established risk factor for long-term cardiovascular outcomes in patients with acute myocardial infarction (AMI), and brachial-ankle pulse wave velocity (ba-PWV) may also be a risk factor. However, there is a significant overlap between low ABI and high ba-PWV. The purpose of this retrospective study was to examine whether increased ba-PWV was associated with long-term clinical outcomes in AMI patients with normal ABI., Methods: We included 932 AMI patients with normal ABI and divided them into the high PWV group (≥1,400 cm/s; n=646) and the low PWV group (<1400 cm/s; n=286) according to the ba-PWV values measured during the AMI hospitalisation. The primary endpoint was the major adverse cardiovascular events (MACE) defined as the composite of all-cause death, nonfatal myocardial infarction, and hospitalisation for heart failure., Results: During the median follow-up duration of 541 days (Q1: 215 days-Q3: 1,022 days), a total of 154 MACE were observed. The Kaplan-Meier curves showed that MACE was more frequently observed in the high PWV group than in the low PWV group (p<0.001). The multivariate Cox hazard analysis revealed that high ba-PWV was significantly associated with MACE (hazard ratio [HR] 1.587; 95% CI 1.002-2.513; p=0.049) after controlling multiple confounding factors., Conclusions: High ba-PWV was significantly associated with long-term adverse events in AMI patients with normal ABI. Our results suggest the usefulness of PWV as a prognostic marker in AMI with normal ABI., Competing Interests: Conflicts of Interest Dr Sakakura has received speaking honoraria from Abbott Vascular, Boston Scientific, Medtronic Cardiovascular, Terumo, OrbusNeich, Japan Lifeline, Kaneka, and NIPRO. Dr Jinnouchi has received speaking honoraria from Abbott Vascular. Dr Fujita has served as a consultant for Mehergen Group Holdings, Inc., (Copyright © 2022 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Slow flow during primary percutaneous coronary intervention (PCI) is a common complication. Our group showed that the stent (or post-balloon) diameter-to-vessel diameter ratio was inversely associated with slow flow phenomenon. We advocated the utility of modest stent expansion strategy, which was defined as the stent (or post-balloon) diameter-to-culprit vessel diameter ratio < 0.71, for prevention of slow flow phenomenon. This study aimed to compare the long-term outcomes in patients with acute myocardial infarction (AMI) between the modest stent expansion strategy and the aggressive stent expansion strategy (the stent diameter-to-culprit vessel diameter ratio ≥ 0.71). We included 584 AMI patients, which were divided 177 patients in the modest stent expansion group and 146 patients in the aggressive stent expansion group. The primary endpoint was major adverse cardiac events (MACE), which was defined as a composite of cardiac death, ischemia driven target vessel revascularization, and stent thrombosis. The slow flow after stent deployment was more frequently observed in the aggressive stent expansion group (24.0%) than in the modest stent expansion group (4.0%) (P < 0.001). The Kaplan-Meier curves revealed that MACE was comparable between the two groups (P = 0.64). The multivariate COX hazard model showed the non-significant association between the modest stent expansion strategy and MACE (vs. aggressive stent expansion: hazard ratio 1.005, 95% confidence interval 0.619-3.242, P = 0.41). In conclusion, the modest stent expansion strategy was not associated with long-term MACE. Therefore, the modest stent expansion strategy may be a good choice for the culprit lesion of AMI., (© 2022. The Author(s) under exclusive licence to Japanese Association of Cardiovascular Intervention and Therapeutics.)

Background: As severity of acute myocardial infarction (AMI) varies widely, several risk stratifications for AMI have been reported. We have introduced a novel AMI risk stratification system linked to a rehabilitation program (novel AMI risk stratification; nARS), which stratified AMI patients into low (L)-, intermediate (I)-, and high (H)-risk groups. The purpose of this retrospective study was to compare the long-term clinical outcomes in patients with AMI among L-, I-, H-risk groups., Methods and results: This study included 773 AMI patients, and assigned them into the L-risk group (n=332), the I-risk group (n=164), and the H-risk group (n=277). The primary endpoint was major cardiovascular events (MACE), defined as the composite of all-cause death, readmission for heart failure, non-fatal myocardial infarction, and target vessel revascularization after the discharge of index admission. The median follow-up duration was 686 days. MACE was most frequently observed in the H-risk group (39.4%), followed by the I-risk group (23.2%), and least in the L-risk group (19.9%) (P<0.001). The multivariate Cox hazard analysis revealed that the H-risk was significantly associated with MACE (HR 2.166, 95% CI 1.543-3.041, P<0.001) after controlling for multiple confounding factors., Conclusions: H-risk according to nARS was significantly associated with long-term adverse events after hospital discharge for patients with AMI. These results support the validity of nARS as a risk marker for long-term outcomes.

Coronary collateral flow is an important prognostic marker in percutaneous coronary intervention (PCI) for chronic total occlusion. However, the role of collateral flow to the culprit lesion of acute myocardial infarction (AMI) has not been fully established yet. The purpose of this retrospective study was to examine the association between collateral flow and long-term clinical outcomes in patients with AMI. We included 937 patients with AMI, and divided those into the no-collateral group (n = 704) and the collateral group (n = 233) according to the presence or absence of collateral flow to the culprit lesion of AMI. The primary endpoint was the incidence of major adverse cardiac events (MACE), which was defined as a composite of all-cause death, non-fatal MI, re-admission for heart failure, and ischemia driven target vessel revascularization. The median follow-up duration was 473 days (Q1: 184 days- Q3: 1027 days), and a total of 263 MACE was observed during the study period. The incidence of MACE was significantly greater in the no-collateral group than in the collateral group (29.8% vs. 22.3%, p = 0.027). In the multivariate COX hazard model, the presence of collateral flow was inversely associated with MACE (HR 0.636, 95% CI 0.461-0.878, p = 0.006) after controlling multiple confounding factors. In conclusion, the presence of collateral flow to the culprit lesion of AMI was inversely associated with long-term adverse outcomes. Careful observation of collateral flow may be important in emergent coronary angiography to stratify a high-risk group among various patients with AMI., (© 2022. Springer Japan KK, part of Springer Nature.)

Background There is significant regional or institutional variation in the use of thrombus aspiration (TA) in patients undergoing percutaneous coronary intervention (PCI). We investigated the temporal trend in TA use and its association with clinical outcomes in acute coronary syndrome using the nationwide J-PCI (Japanese PCI) registry. Methods and Results Between 2016 and 2018, patients with acute coronary syndrome undergoing PCI (n=282 606; median age, 71.0 years; interquartile range, 62.0-79.0 years; women, 24.7%) at 1124 hospitals were stratified on the basis of whether TA was performed (TA and non-TA). The patients were subdivided according to clinical presentation (ST-segment-elevation myocardial infarction, non-ST-segment-elevation myocardial infarction, and unstable angina). Successful PCI, defined as the achievement of TIMI (Thrombolysis in Myocardial Infarction) 3 flow, and in-hospital mortality were assessed. During the study period, 83 422 patients (29.5%) underwent TA (52.9%, 23.5%, and 5.2% for ST-segment-elevation myocardial infarction, non-ST-segment-elevation myocardial infarction, and unstable angina, respectively), and the TA implementation rate remained relatively stable throughout. Patients treated with TA had higher rate of successful PCI than non-TA (98.7% versus 97.8%; P <0.001). TA was not associated with in-hospital death among patients with ST-segment-elevation myocardial infarction (adjusted odds ratio [aOR], 1.02 [95% CI, 0.94-1.12]). However, TA use was associated with higher rates of in-hospital death in patients with non-ST-segment-elevation myocardial infarction ( aOR, 1.51 [95% CI, 1.23-1.86]) or unstable angina ( aOR, 1.95 [95% CI, 1.37-2.79]). Conclusions In our retrospective analysis of the nationwide PCI registry, TA use was associated with a higher achievement of successful PCI without impairing in-hospital mortality among patients with ST-segment-elevation myocardial infarction. Nevertheless, its use should be cautioned in less-established indications (eg, non-ST-segment-elevation myocardial infarction and unstable angina).

Aims: Peripheral arterial disease (PAD) is the well-known risk factor for cardiovascular events. Although low ankle-brachial index (ABI) is recognized as a risk factor in general population, low ABI without any symptoms of PAD has not been established as a prognostic marker in patients with acute myocardial infarction (AMI) yet. The purpose of this retrospective study was to examine whether asymptomatic low ABI was associated with long-term clinical outcomes in AMI patients without treatment history of PAD., Methods: We included 850 AMI patients without a history of PAD and divided them into the preserved ABI (ABI ≥ 0.9) group (n=760) and the reduced ABI (ABI ＜0.9) group (n=90) on the basis of the ABI measurement during the hospitalization. The primary endpoint was the major adverse cardiovascular events (MACE) defined as the composite of all-cause death, non-fatal myocardial infarction, and hospitalization for heart failure., Results: During the median follow-up duration of 497 days (Q1: 219 days to Q3: 929 days), a total of 152 MACE were observed. The Kaplan-Meier curves showed that MACE were more frequently observed in the reduced ABI group than in the preserved ABI group (p＜0.001). The multivariate COX hazard analysis revealed that reduced ABI was significantly associated with MACE (hazard ratio 2.046, 95% confidence interval 1.344-3.144, p=0.001) after controlling confounding factors., Conclusions: Reduced ABI was significantly associated with long-term adverse events in AMI patients without a history of PAD. Our results suggest the usefulness of ABI as a prognostic marker in AMI patients irrespective of symptomatic PAD.

Patients with acute myocardial infarction (AMI) with chronic total occlusion (CTO) in nonculprit arteries had worse prognosis than patients with AMI without CTO in nonculprit arteries. However, the reason was not clearly explained. This retrospective study aimed to compare the clinical outcomes between patients with AMI with CTO versus those with severe stenosis (90% to 99% stenosis) in nonculprit arteries, which would help to elucidate the role of CTO in nonculprit arteries. We included 643 patients with AMI and divided those into the CTO group (n = 188) and 90% to 99% stenosis group (n = 455). The primary end point was the major adverse cardiovascular events (MACE) defined as the composite of all-cause death, nonfatal myocardial infarction, and readmission for heart failure. During the median follow-up duration of 431 days (Q1:178 days to Q3:950 days), a total of 189 MACE was observed. The Kaplan-Meier curves showed that MACE was more frequently observed in the CTO group than in the 90% to 99% stenosis group (p <0.001). The multivariate Cox hazard analysis revealed that CTO in nonculprit arteries (vs 90% to 99% stenosis) was significantly associated with MACE (hazard ratio 1.410, 95% confidence interval 1.042 to 1.907; p = 0.026) after controlling known confounding factors. In conclusion, patients with AMI with CTO in nonculprit arteries had worse clinical outcomes than those with 90% to 99% stenosis in nonculprit arteries. Patients with AMI with CTO could be recognized as a high-risk group rather than those with 90% to 99% stenosis and should be carefully managed to prevent cardiovascular events., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Percutaneous coronary intervention (PCI) is a standard strategy for non-ST-segment elevation myocardial infarction (NSTEMI) as well as for ST-segment elevation myocardial infarction (STEMI). The device cost for PCI may be more expensive in NSTEMI, because the culprit lesion morphology may be more complex in NSTEMI. This study aimed to compare the total device cost of PCI between STEMI and NSTEMI. We included 504 patients with acute myocardial infraction (AMI) who underwent PCI, and divided those into a STEMI group (n = 286) and a NSTEMI group (n = 218). We compared the total device cost, the number of used devices, and procedure cost between the 2 groups. The total device cost was significantly higher in the NSTEMI group [¥371,300 (¥320,700-503,350)] than in the STEMI group [¥341,200 (¥314,200-410,475)] (p = 0.001), whereas the procedure cost was significantly higher in the STEMI group [¥343,800 (¥243,800-343,800)] than in the NSTEMI group [¥220,000 (¥216,800-243,800)] (p < 0.001). Drug eluting stent (85.3% vs. 76.1%, p = 0.029) and aspiration catheter (16.8% vs. 2.3%, p < 0.001) were more frequently used in the STEMI group, whereas rotablator (0.7% vs. 8.3%, p < 0.001) were more frequently used in the NSTEMI group. The multivariate logistic regression analysis revealed that NSTEMI was significantly associated with the high device cost (odds ratio 1.899, 95% confidence interval 1.166-3.093, p = 0.01). In conclusion, the total device cost for PCI was significantly higher in the culprit lesions of NSTEMI than in those of STEMI, whereas the procedure cost was significantly higher in the culprit lesions of STEMI than in those of NSTEMI., (© 2021. Japanese Association of Cardiovascular Intervention and Therapeutics.)

Background: Among various mechanical support devices, veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is the last resort for acute myocardial infarction (AMI) patients complicated with refractory cardiogenic shock or cardiac arrest. The purpose of this study was to investigate the V-A ECMO-related complications in AMI patients who underwent percutaneous coronary intervention (PCI), and to find the association between complications and in-hospital death in that population., Methods: We retrospectively included 101 AMI patients who received V-A ECMO and underwent PCI to the culprit lesion, and divided them into the survivor group (n=43) and the in-hospital death group (n=58). We compared the clinical characteristics and outcomes including complications between the 2 groups, and performed multivariate logistic regression analysis to find factors associated with in-hospital death and major bleeding., Results: The incidence of major bleeding including V-A ECMO site bleeding and intracranial hemorrhage was higher in the in-hospital death group (34.5%) than in the survivor group (7%) (p=0.001). Multivariate logistic regression analysis revealed that final thrombolysis in myocardial infarction (TIMI) flow grade ≤2 (OR 4.453, 95% CI1.427-13.894, p=0.010) and major bleeding (OR 4.986, 95% CI1.277-19.466, p=0.021) were significantly associated with in-hospital death. Out-of-hospital cardiac arrest (OHCA) was significantly associated with major bleeding (OR 3.881, 95% CI 1.358-11.089, p=0.011)., Conclusions: In AMI patients who received V-A ECMO and underwent PCI, final TIMI flow grade ≤2 and major bleeding were associated with in-hospital death. OHCA was closely associated with major bleeding., Competing Interests: Declaration of Competing Interest Dr Sakakura has received speaking honoraria from Abbott Vascular, Boston Scientific, Medtronic Cardiovascular, Terumo, OrbusNeich, Japan Lifeline, Kaneka, and NIPRO; he has served as a proctor for Rotablator for Boston Scientific, and he has served as a consultant for Abbott Vascular and Boston Scientific. Prof. Fujita has served as a consultant for Mehergen Group Holdings, Inc. Other authors have no conflicts of interest to declare., (Copyright © 2021. Published by Elsevier Ltd.)

Periprocedural myocardial infarction (PMI) following percutaneous coronary intervention (PCI) is more frequently observed in true bifurcation lesions such as Medina (1,1,1) and (0,1,1). The aim of this study is to compare the incidence of PMI in elective PCI between Medina (1,1,1) and (0,1,1) bifurcation lesions. This was a retrospective, single-center study. We included 162 true bifurcation lesions, which were divided into the (1,1,1) group (n = 85) and the (0,1,1) group (n = 77). We compared the incidence of PMI between the two groups and performed multivariate logistic regression analysis using PMI as a dependent variable. The incidence of PMI was similar in the (1,1,1) group and the (0,1,1) group (12.9% versus 15.6%, P = 0.658). The final TIMI flow grade of the side branches and that of the main branches were also similar in the two groups. In multivariate logistic regression analysis, Medina classification (1,1,1) was not associated with PMI (odds ratio (OR), 0.996; 95% confidence interval (CI), 0.379-2.621; P = 0.994), but the angle of the side branch < 45° (OR, 3.569; 95% CI, 1.320-9.654; P = 0.012), lesion length in a main vessel (per 10-mm increase) (OR, 1.508; 95% CI, 1.104-2.060; P = 0.010), and absence of side branch protection (OR, 3.034; 95% CI, 1.095-8.409; P = 0.033) were significantly associated with PMI. In conclusion, the Medina (1,1,1) bifurcation lesions did not increase the incidence of PMI as compared to Medina (0,1,1). However, the narrow side branch angle, diffuse long lesion, and absence of side branch protection were significantly associated with PMI. We should pay attention to these high-risk features in the treatment of true bifurcation lesions.

In percutaneous coronary intervention (PCI) to the culprit lesion of acute myocardial infarction (AMI), unsuccessful guidewire crossing causes immediate poor outcomes. It is important to determine the factors associated with unsuccessful guidewire crossing in AMI lesions. The purpose of this study was to find factors associated with difficulty in crossing the culprit lesion of AMI. We defined the difficult group when the guidewire used to cross the culprit lesion was a polymer jacket type guidewire or a stiff guidewire. We included 937 patients, and divided those into the non-difficult group (n = 876) and the difficult group (n = 61). Proximal reference diameter was significantly smaller in the difficult group than in the non-difficult group (p < 0.001), and degree of calcification was severer in the difficult group than in the non-difficult group (p < 0.001). In the multivariate stepwise logistic regression analysis, proximal reference diameter [odds ratio (OR) 0.313, 95% confidence interval (CI) 0.185-0.529, p < 0.001)], previous PCI (OR 3.065, 95% CI 1.612-5.830, p = 0.001), moderate-severe calcification (OR 4.322, 95% CI 2.354-7.935, p < 0.001), blunt type obstruction (OR 12.646, 95% CI 6.805-23.503, p < 0.001), and the presence of collateral to the culprit lesion (OR 2.110, 95% CI 1.145-3.888, p = 0.017) were significantly associated with difficulty in crossing the culprit lesion. In conclusion, previous PCI, calcification, blunt type obstruction, and the presence of collateral were associated with difficulty in crossing the culprit lesion, whereas proximal reference diameter was inversely associated with difficulty. Our study provides a reference to recognize the difficulty in crossing the culprit lesions of AMI for PCI operators, especially junior operators., (© 2021. The Author(s).)

Left ventricular remodeling (LVR) after ST-elevation myocardial infarction (STEMI) is generally thought to be an adaptive but compromising phenomenon particularly in patients with diabetes mellitus (DM). However, whether the extent of LVR is associated with poor prognostic outcome with or without DM after STEMI in the modern era of reperfusion therapy has not been elucidated. This was a single-center retrospective observational study. Altogether, 243 patients who were diagnosed as having STEMI between January 2016 and March 2019, and examined with echocardiography at baseline (at the time of index admission) and mid-term (from 6 to 11 months after index admission) follow-up were included and divided into the DM (n = 98) and non-DM groups (n = 145). The primary outcome was major adverse cardiovascular events (MACEs) defined as the composite of all-cause death, heart failure (HF) hospitalization, and non-fatal myocardial infarction. The median follow-up duration was 621 days (interquartile range: 304-963 days). The DM group was significantly increased the rate of MACEs (P = 0.020) and HF hospitalization (P = 0.037) compared with the non-DM group, despite of less LVR. Multivariate Cox regression analyses revealed that the patients with DM after STEMI were significantly associated with MACEs (Hazard ratio [HR] 2.79, 95% confidence interval [CI] 1.20-6.47, P = 0.017) and HF hospitalization (HR 3.62, 95% CI 1.19-11.02, P = 0.023) after controlling known clinical risk factors. LVR were also significantly associated with MACEs (HR 2.44, 95% CI 1.03-5.78, P = 0.044) and HF hospitalization (HR 3.76, 95% CI 1.15-12.32, P = 0.029). The patients with both DM and LVR had worse clinical outcomes including MACEs and HF hospitalization, suggesting that it is particularly critical to minimize LVR after STEMI in patients with DM., (© 2021. The Author(s).)

The clinical outcomes in acute myocardial infarction (AMI) patients with Killip class 3 are often inconsistent with those in the literature, and the factors associated with poor outcomes have not been sufficiently investigated. The purpose of this study was to identify factors associated with in-hospital death in AMI patients with Killip class 3. We included 205 AMI patients with Killip class 3, and divided them into a survived group (n = 189) and in-hospital death group (n = 16). The primary objective was to identify factors associated with in-hospital death using multivariate analysis. Age was significantly younger in the survived group than in the in-hospital death group (73.1 ± 11.2 versus 83.2 ± 6.2 years, P < 0.001). Systolic blood pressure (SBP) was significantly higher in the survived group than in the in-hospital death group (150.0 ± 31.2 versus 124.8 ± 25.3 mmHg, P = 0.002). The prevalence of TIMI thrombus grade ≥ 2 was significantly greater in the in-hospital death group than in the survived group (56.3 versus 22.2%, P = 0.005). In multivariate logistic regression analysis, in-hospital death was significantly associated with age [odds ratio (OR) 1.168, 95% confidence interval (CI) 1.061-1.287, P = 0.002] and TIMI thrombus grade ≥ 2 (versus ≤ 1: OR 5.743, 95% CI 1.717-19.214, P = 0.005), and inversely associated with SBP on admission (per 10 mmHg increase: OR 0.764, 95% CI 0.613-0.953, P = 0.017). In conclusion, in-hospital death was associated with age and coronary thrombus burden, and was inversely associated with SBP on admission in patients with Killip class 3. It may be important to recognize these high risk features to improve the clinical outcomes of patients with Killip class 3.

The rapid introduction of dual antiplatelet therapy (DAPT) is important for patients with acute myocardial infarction (AMI). The risks and benefits of reduced-dose prasugrel (20 mg loading and 3.75 mg maintenance) over clopidogrel have not been fully discussed. The purpose of this study was to compare the 90-days clinical outcomes of AMI between prasugrel-based DAPT and clopidogrel-based DAPT. We included 534 AMI patients and divided them into the clopidogrel group (n = 330) and the prasugrel group (n = 204). The primary endpoint was the total ischemic events and total bleeding events. In all, 52 ischemic events and 35 bleeding events were observed during the study period. The total ischemic events were similar between the clopidogrel and the prasugrel groups (P = 0.385). The total bleeding events were similar between the clopidogrel and the prasugrel groups (P = 0.125). The multivariate Cox hazard analysis showed that prasugrel was not associated with the total ischemic events (hazard ratio (HR) 0.955, 95% confidence interval (CI) 0.499-1.829, P = 0.890) and was not associated with the total bleeding events after controlling confounding factors (HR 0.972, 95% CI 0.528-1.790, P = 0.927). In conclusion, as compared to clopidogrel, the reduced dose of prasugrel was not associated with the excess risk of bleeding or the excess risk of ischemic events. Our real-world data support the current regimen of prasugrel for AMI patients who underwent primary percutaneous coronary intervention.

Complications such as slow flow are frequently observed in percutaneous coronary intervention (PCI) with rotational atherectomy (RA). However, it remains unclear whether the high incidence of slow flow results in the high incidence of periprocedural myocardial infarction (PMI), reflecting real myocardial damage. The aim of this study was to compare the incidence of PMI between PCI with versus without RA using propensity score-matching. We included 1350 elective PCI cases, which were divided into the RA group (n = 203) and the non-RA group (n = 1147). After propensity score matching, the matched RA group (n = 190) and the matched non-RA group (n = 190) were generated. The primary interest was to compare the incidence of PMI between the matched RA and non-RA groups. Before propensity score matching, the incidence of slow flow and PMI was greater in the RA group than in the non-RA group. After matching, the incidence of slow flow was still greater in the matched RA group than in the matched non-RA group (16.8% vs. 9.5%, p = 0.048). However, the incidence of PMI was similar between the matched RA and matched non-RA group (7.4% vs. 5.3%, p = 0.528, standardized difference: 0.086). In conclusion, although use of RA was associated with greater risk of slow flow, use of RA was not associated with PMI after a propensity score-matched analysis. The fact that RA did not increase the risk of myocardial damage in complex lesions would have an impact on revascularization strategy for severely calcified coronary lesions.

Background: High-degree atrioventricular block (HAVB) is a prognostic factor for survival in patients with inferior ST-segment elevation myocardial infarction (STEMI). However, there is little information about factors associated with temporary pacing (TP). The aim of this study was to find factors associated with TP in patients with inferior STEMI., Methods: We included 232 inferior STEMI patients, and divided those into the TP group (n = 46) and the non-TP group (n = 186). Factors associated with TP were retrospectively investigated using multivariate logistic regression model., Results: The incidence of right ventricular (RV) infarction was significantly higher in the TP group (19.6%) than in the non-TP group (7.5%) (p = 0.024), but the incidence of in-hospital death was similar between the 2 groups (4.3% vs. 4.8%, p = 1.000). Long-term major adverse cardiovascular events (MACE), which were defined as a composite of all-cause death, non-fatal myocardial infarction (MI), target vessel revascularization (TVR) and readmission for heart failure, were not different between the 2 groups (p = 0.100). In the multivariate logistic regression analysis, statin at admission [odds ratio (OR) 0.230, 95% confidence interval (CI) 0.062-0.860, p = 0.029], HAVB at admission (OR 9.950, 95% CI 4.099-24.152, p<0.001), and TIMI-thrombus grade ≥3 (OR 10.762, 95% CI 1.385-83.635, p = 0.023) were significantly associated with TP., Conclusion: Statin at admission, HAVB at admission, and TIMI-thrombus grade ≥3 were associated with TP in patients with inferior STEMI. Although the patients with TP had the higher incidence of RV infarction, the incidence of in-hospital death and long-term MACE was not different between patients with TP and those without., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: Dr. Sakakura has received speaking honoraria from Abbott Vascular, Boston Scientific, Medtronic Cardiovascular, Terumo, OrbusNeich, Japan Lifeline, Kaneka, and NIPRO; he has served as a proctor for Rotablator for Boston Scientific, and he has served as a consultant for Abbott Vascular and Boston Scientific. Prof. Fujita has served as a consultant for Mehergen Group Holdings, Inc. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Although the incidence of acute myocardial infarction (AMI) has been decreasing in the elderly, it has been increasing in the young, especially in Japan. A social impact of AMI would be greater in the young, because loss of the young directly influences social activities such as business, child-raising, and tax payment. The aim of this study was to identify the specific characteristics of young AMI patients. We retrospectively included 408 consecutive AMI patients < 70 years of age, divided into a young group (< 55 years: n = 136) and an older group (55 to < 70 years: n = 272). The prevalence of overweight was greater in the young group (58.5%) than in the older group (40.7%) (P = 0.001). The frequency of current smokers was higher in the young group (67.6%) than in the older group (44.9%) (P < 0.001). Although the prevalence of hypertension was lower in the young group (66.7%) than in the older group (77.2%) (P = 0.017), that of untreated hypertension was greater in the young group (40.4%) than in the older group (27.2%) (P = 0.007). Furthermore, the prevalence of untreated dyslipidemia was greater in the young group (45.0%) than in the older group (26.6%) (P < 0.001). In conclusion, the young AMI patients had more modifiable risk factors such as obesity, smoking, untreated hypertension, and untreated dyslipidemia than the older patients. There is an unmet medical need for the prevention of AMI in the young generation.

Periprocedural myocardial infarction (PMI) is closely associated with long-term cardiovascular events. The factors associated with PMI are not fully understood. The purpose of this study was to investigate the determinants of PMI in contemporary elective percutaneous coronary intervention (PCI). Overall, 731 elective PCI was divided into the PMI (n = 27) and non-PMI (n = 704) groups. Univariate and multivariate logistic regression analysis was used to find factors associated with PMI. In the univariate analysis, PMI was associated with complex lesion characteristics, such as the lesion length, lesion angle, calcification, and Medina classification. In the multivariate logistic regression analysis, the lesion length (per 10-mm increase: odds ratio (OR), 1.477; 95% confidence interval (CI), 1.161‒1.879; P = 0.002), lesion angle ≥ 45° (versus lesion angle < 45°: OR, 4.244; 95% CI, 1.187‒15.171; P = 0.026), and Medina classification (0,1,1) / (1,1,1) (versus other lesions: OR, 14.843; 95% CI, 6.235‒35.334; P < 0.001) were significantly associated with PMI. Of the 24 lesions with lesion angle ≥ 45° in the PMI group, 14 had final TIMI flow grade ≤ 2 in side branches and 9 had transient slow flow in main branches/transient ST elevation during PCI. Of the 87 lesions with Medina classification (1,1,1) / (0,1,1), 19 had final TIMI grade ≤ 2 in side branches. In conclusion, the lesion length, lesion angle ≥ 45°, and Medina classification (0,1,1) / (1,1,1) were significantly associated with PMI in contemporary elective PCI. Preventing flow limitation in both side branches and main vessels in elective PCI for the diffuse long, angulated, or true bifurcation lesions is important.

Acute myocardial infarction (AMI) would sometimes raise severe in-hospital complications such as cardiopulmonary arrest, shock, stroke, atrioventricular block, and respiratory failure. The purpose of this retrospective study was to compare the clinical outcomes of AMI patients who recovered from severe in-hospital complications with those who did not have in-hospital complications. We included 494 AMI patients, and divided those into the in-hospital complications group (n = 166) and noncomplications group (n = 328). The primary end point was the major adverse cardiovascular events (MACE) defined as the composite of all cause death, nonfatal myocardial infarction (MI), and readmission for heart failure within 1 year after the hospital discharge. A total of 50 postdischarge MACE were observed during the study period. MACE was more frequently observed in the in-hospital complications group (14.5%) than in the noncomplications group (7.9%) (p = 0.023). The presence of in-hospital complications was significantly associated with the MACE (Odds Ratio 1.889, 95% Confidence Interval 1.077 to 3.313, p = 0.026) after controlling age, gender, ST-elevation MI, and culprit of AMI. In conclusion, the MACE was significantly frequent in AMI patients who recovered from severe in-hospital complications and discharged to home, as compared with those who did not have in-hospital complications. AMI patients who recovered from complications could be recognized as a high risk group, and should be carefully managed after discharge to prevent cardiovascular events., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Since the number of elderly patients suffering from acute myocardial infarction (AMI) has been increasing in developed countries, primary percutaneous coronary intervention (PCI) for the very elderly aged ≥80 years old is already common. The study aimed to examine the determinants of in-hospital death among the very elderly with AMI in current PCI era. We included 412 consecutive AMI patients aged ≥ 80 years old who received PCI to the culprit lesion; however, 42 patients (10.2%) died during the index hospitalization. Thus, univariate and multivariate logistic regression analyses were performed to identify the determinants of in-hospital death. Of note, the modified KATZ index, which is a seven-point scale ranging from 0 to 6 (0 point indicating no dependence and six points indicating full dependence), was calculated to evaluate pre-admission activity of daily living (ADL). In multivariate analysis, cardiac arrest (OR 4.642, 95% CI 1.177-18.305, P = 0.028), Killip class IV (versus Killip class I: OR 5.732, 95% CI 1.076-16.630, P = 0.001), modified KATZ index (OR 1.212, 95% CI 1.001-1.469, P = 0.049), hemoglobin levels (OR 0.803, 95% CI 0.656-0.983, P = 0.033), use of temporary pacemaker (OR 2.603, 95% CI 1.010-6.709, P = 0.048), final Thrombolysis In Myocardial Infarction (TIMI) flow grade 3 (versus TIMI ≤ 2: OR 0.240, 95% CI 0.093-0.618, P = 0.003), and mechanical circulatory support (OR 4.264, 95% CI 1.818-10.005, P = 0.001) were found to be significantly associated with in-hospital death. In conclusion, in-hospital outcomes of the very elderly with AMI were still poor in the current PCI era. Poor pre-admission ADL as well as cardiogenic shock and anemia were determined to be strongly associated with in-hospital death.

Objective Although the importance of evidence-based optimal medical therapy (OMT) after acute myocardial infarction (AMI) has been recognized, the prescription rate of OMT is not sufficiently high in real-word clinical settings. The purpose of this study was to identify the clinical characteristics of AMI patients who did not receive OMT. Methods The present study was a retrospective study. OMT was defined as the combination of antiplatelet therapy, angiotensin-converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARBs), beta-blockers, and statins at the time of hospital discharge. Non-OMT was defined as the lack of either antiplatelet therapy, ACE inhibitors/ARBs, beta-blockers, or statins. Results A total of 457 AMI patients were included as the final study population, and 98 patients (22.4%) lacked at least 1 OMT medication. The prescription rates of antiplatelet therapy, ACE inhibitors/ARBs, beta-blockers, and statins were 98.7%, 87.5%, 90.4%, and 96.7%, respectively. In the multivariate logistic regression analysis, age [per 1-year increase: odds ratio (OR) 1.033, 95% confidence interval (CI) 1.007-1.059, p=0.014], hemodialysis (vs. no hemodialysis: OR 2.707, 95% CI 1.082-6.774, p=0.033), estimated glomerular filtration rate <30 mL/min/1.73 m 2 without hemodialysis (OR 4.585, 95% CI 1.975-10.644, p<0.001), AMI caused by vasospastic angina (VSA) (vs. no VSA: OR 13.198, 95% CI 1.809-96.260, p=0.011), and asthma (vs. no asthma: OR 7.241, 95% CI 1.716-30.559, p=0.007) were significantly associated with non-OMT, whereas heart rate on admission (per 1-bpm increase: 0.987, 95% CI 0.975-0.999, p=0.033), any PCI (vs. no PCI: OR 0.156, 95% CI 0.066-0.373, p<0.001), and ST-elevation myocardial infarction (STEMI) (vs. NSTEMI: OR 0.384, 95% CI 0.218-0.675, p=0.001) were inversely associated with non-OMT. Conclusion An advanced age, VSA, bradycardia, asthma, impaired renal function, non-PCI revascularization, and non-ST-elevation myocardial infarction were significantly associated with non-OMT.

Recently, we developed a novel acute myocardial infarction (AMI) risk stratification system (nARS), which stratifies AMI patients into low- (L), intermediate- (I), and high- (H) risk groups. We have shown that the nARS shortened the length of intensive care unit (ICU) stay as well as that of hospitalization. However, the incidence of AMI-related adverse outcomes has not been fully investigated. The purpose of this study was to investigate the incidence of severe complications requiring ICU care among the 3 risk groups stratified by nARS. We retrospectively reviewed AMI patients between October 2016 and December 2018. A total of 592 patients were divided into the L- (n = 285), I- (n = 124), and H- (n = 183) risk groups. The primary endpoint was in-hospital complications requiring ICU care defined as death/cardiopulmonary arrest, shock, stroke, atrioventricular block, and respiratory failure. Among 592 patients, 239 (40.4%) developed at least 1 complication requiring ICU care, but only 28 (11.7%) developed complications in general wards. Complications requiring ICU care were most frequently observed in the H-risk group (68.9%), followed by the I-risk group (50.8%), and least in the L-risk group (17.5%) (P < 0.001). Complications requiring ICU care that occurred in the general wards were more frequently observed in the H-risk group (8.7%) compared to the I-risk (3.2%) and L-risk (2.8%) groups (P = 0.009). In conclusion, complications requiring ICU care rarely happened in the general wards, and were less in the I- and L-risk groups than in the H-risk group. These results validated the nARS, and might support the widespread use of nARS.

Recent guidelines do not recommend the routine use of intra-aortic balloon pumping (IABP) for patients with cardiogenic shock. However, IABP support is still selected for acute myocardial infarction (AMI) in clinical practice because an Impella device did not show superiority over IABP and the mortality of AMI with cardiogenic shock is still high. This study aimed to find factors associated with in-hospital mortality in patients with AMI who required IABP support. Overall, 104 patients with AMI who required IABP support were included as the study population. Of 104 patients, in-hospital death was observed in 19 (18.3%). Multivariate stepwise logistic regression analysis was performed to investigate the determinants of in-hospital death. Shock, resuscitation, estimated glomerular filtration rate (eGFR), pre-systolic blood pressure of IABP insertion, multi-vessel disease, fluoroscopy time, initial lactic acid dehydrogenase levels, and timing of IABP support were included as independent variables. Shock (OR 25.27, 95% CI 3.26-196.11, P = 0.002) was significantly associated with in-hospital death after controlling other covariates, whereas eGFR (every 10 mL/minute/1.73 m 2 increase: OR 0.65, 95% CI 0.51-0.82, P < 0.001) and pre-percutaneous coronary intervention (pre-PCI) insertion of IABP (versus on-PCI insertion of IABP: OR 0.06, 95% CI 0.008-0.485, P = 0.008) were inversely associated with in-hospital death. In conclusion, shock was significantly associated with in-hospital death, whereas eGFR and pre-PCI insertion of IABP were inversely associated with in-hospital death in patients with AMI who received IABP support. Pre-PCI insertion of an IABP catheter might be associated with better survival in AMI patients who potentially require IABP support.

Acute myocardial infarction (AMI) in the very elderly is associated with high morbidity and mortality. Although there are earlier studies regarding AMI in octogenarians, clinical evidences of AMI in nonagenarians are sparse. The aim of the present study was to compare in-hospital outcomes of AMI between octogenarians and nonagenarians. We included consecutive 415 very elderly (≥ 80 years) with AMI and divided them into the nonagenarian group (n = 38) and the octogenarian group (n = 377). Clinical characteristics and in-hospital outcomes were compared between the two groups. Furthermore, we used propensity score matching to find the matched octogenarian group (n = 38). Percutaneous coronary interventions (PCI) to the culprit of AMI were similarly performed between the nonagenarian (86.8%) and octogenarian (87.0%) groups. The incidence of in-hospital death in the nonagenarian group (10.5%) was similar to that in the octogenarian group (12.5%) (P = 0.487). After using the propensity score matching, the incidence of in-hospital death was less in the nonagenarian group (10.5%) than in the matched octogenarian group (18.4%) without reaching statistical significance (P = 0.328). The length of hospitalization was significantly shorter in the nonagenarian group [7.0 (4.0-9.0)] than in the matched octogenarian group [10.0 (6.5-15.0)] (P = 0.01). In conclusion, the in-hospital mortality of nonagenarians with AMI was comparable to that of octogenarians with AMI. In-hospital outcomes in nonagenarians with AMI may be acceptable as long as acute medical management including PCI to the culprit of AMI is performed.

Background: Slow flow can be fatal in primary percutaneous coronary interventions for left main trunk (LMT)-acute myocardial infarction (AMI), however, risk factors for slow flow in LMT-AMI have not been well investigated. Intravascular ultrasound (IVUS) may help to stratify the high-risk lesion for slow flow in LMT-AMI., Methods: A total of 51 LMT-AMI were included as the study population, and were divided into the slow-flow group (n=22) and the non-slow-flow group (n=29). Slow flow was defined as either transient or persistent Thrombolysis in Myocardial Infarction (TIMI) flow grade ≤2., Results: The incidence of in-hospital death was higher in the slow-flow group (27.3%) than the non-slow-flow group (10.3%) without reaching statistical significance (p=0.116). Although the reference diameter measured by angiography was not different between the two groups, the vessel diameter measured by IVUS was significantly longer in the slow-flow group (5.22±0.69mm) than in the non-slow-flow group (4.50±0.47mm) (p<0.001). Multivariate logistic regression analyses revealed that the vessel diameter by IVUS (OR 27.487, 95%CI 3.975-190.062, p=0.001) and the vessel area by IVUS (OR 1.458, 95%CI 1.160-1.832, p=0.001) were significantly associated with slow flow., Conclusions: In LMT-AMI, the vessel diameter measured by IVUS was closely associated with slow flow, while the reference diameter measured by angiography was not associated with slow flow. IVUS would be important to find high-risk features for slow flow in LMT-AMI., (Copyright © 2019 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Persistent severe left ventricular (LV) systolic dysfunction after acute myocardial infarction (AMI) is associated with increased morbidity and mortality, whereas mid-term recovery of LV systolic function after AMI is associated with better long-term outcomes. The purpose of this study was to investigate the determinants of mid-term improvement of LV ejection fraction (EF) in AMI patients. We included 210 AMI patients who had modified Simpson EF both at the index admission and mid-term follow up. The difference of EF between the index admission and mid-term follow-up was calculated in all study patients. The EF improvement group was defined as mid-term ≥ 10% EF increase compared with the index admission EF. Of 210 AMI patients, 46 (21.9%) were allocated to the EF improvement group and 164 (78.1%) to the non-EF improvement group. Brain natriuretic peptide (BNP) at the timing of admission was significantly greater in the EF improvement group (735.8 ± 1077.6 pg/mL) than in the non-EF improvement group (239.0 ± 419.8 pg/mL) (P < 0.001). Multivariate logistic regression analysis revealed that log 10 BNP at the timing of admission (OR 3.36, 95% CI 1.69-6.66, P < 0.001) and left main trunk-left anterior descending artery (LM-LAD) as the infarct-related artery (OR 3.34, 95% CI 1.59-7.02, P = 0.001) were significantly associated with EF improvement. In conclusion, elevated BNP at the timing of admission and LM-LAD as the infarct-related artery were significantly associated with mid-term LVEF recovery. Our results support aggressive acute treatment for those severe AMI, because the possibility of mid-term LVEF recovery is greater compared with other AMI.

Because living alone is associated with an increased risk of type 2 diabetes mellitus in men but not women, living alone may be a risk factor of cardiovascular events after acute myocardial infarction (AMI) in diabetic men. The aim of the present study was to investigate the association between living alone and mid-term clinical outcomes after AMI in diabetic men. We conducted a single center, retrospecitve study. The primary endpoint was the major adverse cardiovascular events (MACE) defined as the composite of all cause death, AMI, and target vessel revascularization. A total of 253 AMI men with diabetes mellitus were included from our hospital records, and divided into the living together group (n = 203) and the living alone group (n = 50). Median follow-up duration was 239 days (Q1: 94 days, Q3: 451 days). A total of 66 MACE was observed during the study period, and Kaplan-Meier curves were constructed to compare the MACE. The MACE was more frequently observed in the living alone group than the living together group (P = 0.041). Multivariate Cox regression analysis revealed that the living alone group was significantly associated with the MACE (Odds ratio: 1.770, 95% confidence interval 1.018-3.077, P = 0.043) after known clinical risk factors. In conclusion, living alone was significantly associated with the mid-term MACE after AMI in diabetic men. It may be important to provide multiple interventions including lifestyle guidance as well as sufficient acute medical care for such high-risk patients.

Right ventricular infarction (RVI) is a complication following inferior ST-elevation myocardial infarction (STEMI). The aim of the present study was to investigate the clinical outcomes of RVI in the contemporary primary percutaneous coronary intervention (PCI) era. The primary endpoint was in-hospital death, and the secondary endpoint was major adverse cardiac events (MACE), defined as the composite of cardiovascular death, re-hospitalization for heart failure, and non-fatal acute myocardial infarction (AMI). Event-free survival curves for MACE were constructed using the Kaplan-Meier method, and statistical differences between curves were assessed using the log-lank test. A total of 1354 patients with AMI were screened from January 2010 to December 2016. The final study population involved 315 patients with STEMI whose infarct related artery (IRA) was the right coronary artery (RCA). We categorized these 315 patients into the RVI group (n = 85) and the non-RVI group (n = 230). Median follow-up duration was 358 (IQR: 208-987) days. In-hospital deaths were more frequently observed in the RVI group (9.4%) than in the non-RVI group (3.0%) (P = 0.018). However, the incidence of MACE was not different between the groups (P = 0.537). In conclusion, in-hospital clinical outcomes were poorer in the RVI group than in the non-RVI group. However, mid-term MACE was not different between the two groups, suggesting the importance of aggressive acute treatment for STEMI patients with RVI.

Background: The novel Acute Myocardial Infarction (AMI) Risk Stratification (nARS) system was recently developed based on original criteria. The use of nARS may reduce the length of hospitalization. Methods and Results: We allocated 560 AMI patients into the pre-nARS group (before adopting nARS) or the nARS group. Patients in the nARS group were subdivided into the low (L), intermediate (I), and high (H) risk groups, whereas patients in the pre-nARS group were subdivided into the equivalent L (eL), equivalent I (eI), or equivalent H (eH) risk groups based on the nARS criteria. Length of coronary care unit (CCU) stay was significantly shorter in the nARS group (2.8±3.5 days) compared with the pre-nARS group (4.4±5.4 days; P<0.001). Length of hospital stay was also shorter in the nARS group (9.4±8.9 days) compared with the pre-nARS group (13.4±12.8 days; P<0.001). Length of CCU stay was significantly shorter in the L (1.1±1.0 days), I (2.8±3.5 days), and H (5.0±4.8 days) risk groups compared with corresponding eL (2.2±1.1 days), eI (4.4±5.4 days), and eH (7.1±7.8 days) risk groups., Conclusions: Length of CCU and hospital stay were significantly shorter in the nARS group compared with the pre-nARS group. The use of nARS may save medical resources in the treatment of AMI in the regional health-care system.

Percutaneous coronary interventions to the proximal left anterior descending artery (pLAD)-acute myocardial infarction (AMI) are still challenging, especially in the ostial pLAD. Clinical outcomes of the ostial pLAD-AMI were not well investigated. The aim of the present study was to compare clinical outcomes of the ostial pLAD-AMI with those of the non-ostial pLAD-AMI. The primary endpoint was the major cardiovascular events (MACE), defined as the composite of cardiac death, AMI, stent thrombosis (ST), target lesion revascularization (TLR), and target vessel revascularization (TVR). Between January 2009 and March 2016, a total of 401 pLAD-AMI were included as the study population and were divided into 78 ostial pLAD-AMI (the ostial pLAD group), and 323 non-ostial pLAD-AMI (the non-ostial pLAD group). The median follow-up duration was 414 days. The MACE tended to be higher in the ostial pLAD group (8.0% at 30 days, 19.9% at 400 days) than in the non-ostial pLAD group (4.4% at 30 days, 12.9% at 400 days) without reaching statistical significance (P = 0.087). The prevalence of cardiac death was significantly higher in the ostial pLAD group (6.6% at 30 days, 9.5% at 400 days) as compared with the non-ostial pLAD group (3.1% at 30 days, 4.5% at 400 days) (P = 0.034). There were no significant differences in ST, AMI, TLR, or TVR. We concluded that, as compared with the non-ostial pLAD-AMI, the clinical outcomes of the ostial pLAD-AMI, especially cardiac death, tended to be worse, requiring special attention to the ostial pLAD-AMI.

In-hospital outcomes of acute myocardial infarction (AMI) with cardiogenic shock (CS) were still not satisfactory even in the primary percutaneous coronary intervention (PCI) era. The aim of this study was to compare in-hospital outcomes of AMI with CS caused by right coronary artery (RCA) occlusion vs. left coronary artery (LCA) occlusion. Consecutive 894 AMI patients from January 2010 to March 2015 were screened for inclusion. A total of 114 AMI patients with CS were included as the final study population, and were divided into the RCA group (n = 56) and LCA group (n = 58). The patient characteristics were compared between the two groups. Multivariate logistic regression analysis was performed to show whether the RCA group was associated with better outcomes even after controlling confounding factors. In-hospital mortality was significantly lower in the RCA group (8.9%) than in the LCA group (46.6%) (P < 0.001). The RCA group (vs. the LCA group) was inversely associated with in-hospital death (OR 0.08, 95% CI 0.02-0.21, P < 0.001) after controlling covariates. Aspartate transaminase value (per 50 U/L incremental: OR 1.22, 95% CI 1.03-1.45, P = 0.02), aging (per 10-year-old incremental: OR 2.14, 95% CI 1.26-3.63, P = 0.01) and using VA-ECMO (OR 22.13, 95% CI 5.22-93.90, P < 0.001) were also significantly associated with in-hospital death. In conclusion, among AMI patients with CS, IRA of RCA was significantly associated with the better in-hospital outcome.

Background: A risk classification of acute myocardial infarction (AMI) linked to a rehabilitation program has not been established., Methods: We allocated 292 patients with AMI into the low- (L) (n=108), intermediate- (I) (n=72), and high- (H) (n=112) risk groups according to our original risk classification. The primary endpoint was major adverse cardiac events (MACE), defined as the composite of cardiac death, non-fatal AMI, stent thrombosis, and ischemia-driven target vessel revascularization. The mean follow-up period was 252 days., Results: The length of coronary care unit (CCU) stay and hospital stay was shortest in the L-risk group (CCU stay, 1.0±1.0 days; hospital stay, 5.6±3.2 days), followed by the I-risk group (CCU stay, 2.3±1.8 days; hospital stay, 8.1±2.7 days), and longest in the H-risk group (CCU stay, 5.1±5.0 days; hospital stay, 14.6±12.6 days) (p<0.001). MACE were most frequently observed in the H-risk group (26.8%), followed by the I-risk group (5.6%), and least in the L-risk group (1.9%) (p<0.001)., Conclusions: The lengths of hospital stay and CCU stay were significantly shortest in the L-risk group, followed by the I-risk group, and longest in the H-risk group. MACE were most frequently observed in the H-risk group, followed by the I-risk group, and least in the L-risk group. These results support the validity of our new classification system., (Copyright © 2018 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Acute myocardial infarction (AMI) is more frequently observed in patients with chronic kidney disease (CKD) than in patients without CKD. Initial treatment strategy for AMI includes primary percutaneous coronary intervention (PCI), which requires substantial amount of contrast media. We hypothesized that the clinical outcomes are comparable or worse in patients with AMI and advanced CKD off chronic hemodialysis as compared to patients with AMI and advanced CKD on chronic hemodialysis. The purpose of this study was to compare the clinical outcomes of patients with AMI and advanced CKD on hemodialysis versus off hemodialysis. A total of 148 patients with estimated glomerular filtration rate < 30 ml/min/1.73 m 2 on admission were included and were divided into the HD group (n = 68) and non-HD group (n = 80). The length of hospitalization was significantly less in the HD group (15.7 ± 14.8 days) than in the non-HD group (22.4 ± 21.3 days) (P = 0.01). In-hospital death was significantly less in the HD group (10.3%) than in the non-HD group (25.0%) (P = 0.02). While the non-HD group was not significantly associated with in-hospital death after controlling clinical covariates, the non-HD group (odd ratio 2.89, 95% confidence interval 1.03-8.12, P = 0.04) was significantly associated with long hospitalization even after controlling clinical covariates. In conclusion, as compared to advanced CKD on chronic hemodialysis, advanced CKD off hemodialysis had higher morbidity and mortality in patients with AMI. Advanced CKD off hemodialysis was closely associated with long hospitalization even after controlling clinical factors.

Blunt chest trauma can cause a wide variety of injuries including acute myocardial infarction (AMI). Although AMI due to coronary artery dissection caused by blunt chest trauma is very rare, it is associated with high morbidity and mortality. In the vast majority of patients with AMI, primary percutaneous coronary interventions (PCI) are performed to recanalize obstructed arteries, but PCI carries a substantial risk of hemorrhagic complications in the acute phase of trauma. We report a case of AMI due to right coronary artery (RCA) dissection caused by blunt chest trauma. The totally obstructed RCA was spontaneously recanalized with medical therapy. We could avoid primary PCI in the acute phase of blunt chest trauma because electrocardiogram showed early reperfusion signs. We performed an elective PCI in the subacute phase when the risk of bleeding subsided. Since the risk of severe hemorrhagic complications is greater in the acute phase of blunt chest trauma as compared with the late phase, deferring emergency PCI is reasonable if signs of recanalization are observed.

Percutaneous coronary interventions to ostial left anterior descending artery (LAD)-acute myocardial infarction (AMI) were challenging, especially in crossover stenting from left main trunk (LMT) to LAD. The clinical outcomes of ostial LAD-AMI that needed crossover stenting were not well investigated. The objective of this study was to compare the clinical outcomes of LMT crossover stenting with those of ostial LAD just proximal (jp) stenting. Between January 2009 and March 2016, 1499 patients were diagnosed as AMI in our institution. Among them, 76 ostial LAD-AMIs were included in this study, and divided into 30 LMT crossover stenting (the crossover group) and 46 jp stenting (the jp stenting group). The primary endpoint was major cardiovascular events (MACE) defined as the composite of cardiac death, acute myocardial infarction (AMI), stent thrombosis (ST), target lesion revascularization (TLR) and target vessel revascularization (TVR). The frequency of MACE was comparable between the 2 groups (16.7% in the crossover group and 21.7% in the jp stenting group, P = 0.587). Similarly, the frequency of cardiac death was comparable between the 2 groups (6.7% in the crossover group and 13.0% in the jp stenting group, P = 0.376). The frequencies of TLR (6.7% in the crossover group and 6.5% in the jp stenting group, P = 0.980) and TVR (10.0% in the crossover group and 8.7% in the jp stenting group, P = 0.848) were not significantly different between the 2 groups. In conclusion, the clinical outcomes of the crossover stenting were comparable to the jp stenting in the stenting strategy for ostial LAD-AMI. LMT-LAD crossover stenting would be the acceptable strategy for ostial LAD-AMI.

Compared to acute myocardial infarction (AMI) with single vessel disease (SVD) or double vessel disease (DVD), AMI with triple vessel disease (TVD) is associated with higher mortality. The aim of this study was to identify the determinants of in-hospital death in AMI with TVD. We identified AMI patients with TVD in our tertiary medical center between January 2009 and December 2014. Baseline patient characteristics including laboratory data, echocardiograms, and coronary angiograms were collected from our hospital records. We divided our study population into a survivor group and non-survivor group. Multivariate stepwise logistic regression analysis was performed to identify the determinants of in-hospital death. A total of 138 AMI patients with TVD were identified and included as the final study population. Fifteen patients died during the hospitalization (mortality rate, 10.9%). Mean systolic blood pressure (134 ± 27 mmHg) was significantly greater in the survivor group compared with the non-survivor group (114 ± 31 mmHg) (P = 0.02). The prevalence of shock on admission was significantly less in the survivor group (15.4%) than in the non-survivor group (66.7%) (P < 0.001). Multivariate stepwise logistic regression analysis revealed that shock status on admission (OR 11.50, 95% CI 3.21-41.14, P < 0.001), the left anterior descending artery (LAD) as the infarct related artery (IRA) (OR 3.83, 95% CI 1.04-14.09, P = 0.04), and serum albumin on admission (OR 0.26, 95% CI 0.08-0.84, P = 0.02) were significantly associated with in-hospital death. In conclusion, shock status on admission, the LAD as the IRA, and a low serum albumin level were the determinants of in-hospital death in AMI patients with TVD.

Diabetes mellitus and impaired glucose tolerance are well-known risk factors for coronary artery disease (CAD) and adverse clinical events after percutaneous coronary intervention (PCI). Postprandial hyperglycemia is an important risk factor for CAD and serum 1,5-anhydroglucitol (1,5-AG) reflects postprandial hyperglycemia more robustly than hemoglobin (Hb)A1c. We aimed to clarify the relationship between serum 1,5-AG level and adverse clinical events after PCI. We enrolled 141 patients after PCI with follow-up coronary angiography. We evaluated associations between glycemic biomarkers including HbA1c and 1,5-AG and cardiovascular events during follow-up. Median serum 1,5-AG level was significantly lower in patients with any coronary revascularization and target lesion revascularization (TLR) [13.4 µg/ml (first quartile, third quartile 9.80, 18.3) vs. 18.7 (12.8, 24.2), p = 0.005; 13.4 µg/ml (10.2, 16.4) vs. 18.7 (12.9, 24.2), p = 0.001, respectively]. Multivariate logistic analysis showed lower 1,5-AG was independently associated with any coronary revascularization and TLR (odds ratio 0.93, 95 % confidence interval 0.86-0.99, p = 0.04; 0.90, 0.81-0.99, p = 0.044, respectively), whereas higher HbA1c was not. Postprandial hyperglycemia and lower 1,5-AG are important risk factors for adverse clinical events after PCI.

Dipeptidyl peptidase-4 (DPP4) is an integral membrane glycoprotein that modulates the pathological state of diabetes mellitus (DM), and DPP4 inhibitors are a new class of anti-type-2 DM drugs. Recent preclinical studies have associated DPP4 inhibition with improved myocardial systolic and diastolic function. Based on preclinical findings, we investigated associations between the administration of DPP4 inhibitors and cardiac function after acute myocardial infarction (AMI) in a clinical setting. We enrolled 34 patients with diabetes who were treated for acute myocardial infarction at our hospital between January 2010 and December 2012. We retrospectively compared changes in cardiac parameters determined by trans-thoracic echocardiography between patients treated with (DPP4-I group; n = 13) or without (non-DPP4-I group; n = 21) a DPP4 inhibitor during follow-up. The values of E/e' and of e'/a' significantly decreased and increased, respectively, in the DPP4-I, compared with the non-DPP4-I group (-2.53 ± 5.53 vs. 2.58 ± 5.68, p = 0.038 and 0.08 ± 0.23 vs. -0.12 ± 0.21, p = 0.036, respectively). We concluded that DPP4 inhibitors could improve E/e' and e'/a' in patients with DM and AMI and thus might be effective for treating left ventricular diastolic failure.

Background: Clinical outcomes of implantation of the newer-generation drug-eluting stent (DES) following rotational atherectomy for heavily calcified lesions remain unclear in the real-world setting., Methods and results: We enrolled 252 consecutive patients (273 lesions) treated with newer-generation DES following rotational atherectomy. The primary endpoint was the cumulative 2-year incidence of major adverse cardiovascular events (MACE), defined as cardiac death, myocardial infarction, clinically-driven target lesion revascularization, and definite stent thrombosis. Complete clinical follow-up information at 2-year was obtained for all patients. The mean age was 73.2±9.0 years and 155 patients (61.5%) were male. Cumulative 2-year incidence of MACE (cardiac death, myocardial infarction, clinically-driven target lesion revascularization and definite stent thrombosis) was 20.3% (7.0%, 2.1%, 18.1% and 2.1%, respectively). Predictors of MACE were presenting with acute coronary syndrome (hazard ratio [HR]: 3.80, 95% confidence interval [CI]: 1.29-11.2, P=0.02), hemodialysis (HR: 1.93, 95% CI: 1.04-3.56, P=0.04) and previous coronary artery bypass graft (HR: 2.26, 95% CI: 1.02-5.00, P=0.045)., Conclusions: PCI for calcified lesions requiring rotational atherectomy is still challenging even in the era of newer-generation DES.