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To investigate the relationship between periprocedural myocardial injury (PMI) and plaque characteristics detected by multidetector computed tomography (MDCT) and cardiac magnetic resonance imaging (CMR).This observational retrospective study, between July 2012 and October 2019, included chronic coronary syndrome patients undergoing elective percutaneous coronary intervention (PCI) after MDCT and CMR. High-intensity plaque (HIP) on non-contrast T1-weighted imaging was defined as a coronary plaque-to-myocardium signal intensity ratio of ≥ 1.4. High-risk plaque (HRP) in MDCT displayed ≥ 2 features: positive remodeling, low-attenuation plaque, spotty calcification, and napkin-ring sign. PMI was defined as an increase in cardiac troponin T levels5 times the upper normal limit at 24 h after PCI.Ninety-five target lesions in 76 patients (mean age ± standard deviation, 67 years ± 9; 62 males [82%]) were included. Twenty-one patients (24 lesions) were assigned to the PMI group, while 55 patients (71 lesions) to the non-PMI group. Presence of HRP characteristics on MDCT and HIP on CMR was significantly higher in the PMI group. Multivariate logistic regression analysis showed that HRP in MDCT and HIP in CMR were significant independent predictors of PMI. Target lesions with HRP on MDCT and HIP on CMR were significantly more likely to develop PMI. In 141 plaques with ≥ 50% stenosis (76 patients), patients with PMI had significantly more frequent HRP in MDCT and HIP in CMR in target and non-target lesions.MDCT and CMR can play an important role in the detection of high-risk lesions for PMI following elective PCI.• Multivariate logistic regression analysis showed that high-risk plaque on MDCT and high-intensity plaque on MRI were significant independent predictors of periprocedural myocardial injury (PMI). • Target lesions with high-risk plaque on MDCT and high-intensity plaque on CMR were significantly more likely to develop PMI. • In 141 plaques with ≥ 50% stenosis, patients with PMI were significantly more likely to have high-risk plaques on MDCT and high-intensity plaque on CMR in target and non-target lesions.

Electrocardiogram (ECG) findings showing ST-segment depression in a wide range of leads and ST-segment elevation in aVR are found in patients with acute coronary syndrome with multivessel coronary lesions and left main trunk lesions. A 64-year-old man with a history of eosinophilic granulomatosis presented with chest pain and dyspnea. Although an ECG showed the above findings, he was diagnosed with acute severe aortic regurgitation (AR) complicating aortic root dissection and successfully underwent urgent Bentall operation. These ECG findings indicated that acute severe AR caused subendocardial ischemia.

BACKGROUND The relationship between the characteristics of tissue protrusion detected by using optical coherence tomography (OCT) and the findings of coronary angioscopy (CAS) immediately after stent implantation were evaluated.Methods and Results:A total of 186 patients (192 stents) underwent OCT before and after stenting and were observed by using CAS immediately after stenting and at the chronic phase. Patients were assigned to irregular protrusion, smooth protrusion, and disrupted fibrous tissue protrusion groups according to OCT findings. Serum high-sensitivity C-reactive protein (hs-CRP) levels were measured before and after stent implantation. The grade of yellow color (YC) and neointimal coverage (NC), and incidence of thrombus in the stented segment were evaluated by using CAS. After stent implantation, maximum YC grade (smooth, 0.64±0.80; disrupted fibrous tissue, 0.50±0.77; irregular, 1.50±1.09; P

Atypical aortic coarctation is a rare condition associated with Takayasu arteritis, and is characterized by symptoms caused either by hypotension in the lower half of the body or secondary hypertension in the upper half of the body, and heart failure. We report a rare case of axillofemoral bypass to improve congestive heart failure for atypical aortic coarctation complicating Takayasu arteritis. Augmented vascular bed and retrograde renal blood flow after axillofemoral bypass surgery could achieve effective blood pressure control and improve renal function and cardiac function (LVEF: 30% → 55%, BNP: 2943 pg/mL → 128 pg/mL). There were two contributing factors for improvement of heart failure such as the increased vascular bed and the increase in retrograde renal blood flow. We believe that axillofemoral bypass is effective for Takayasu arteritis patients with refractory heart failure. In daily practice, careful attention should be paid to an impact of cardiorenal‐aorta interaction in atypical aortic coarctation complicating Takayasu arteritis.

Aims We aimed to determine whether shortening the duration of P2Y12 inhibitor therapy can reduce the risk of bleeding without increasing the risk of major adverse cardiovascular events following coronary stenting in patients with atrial fibrillation (AF). Methods and results The SAFE-A is a randomised controlled trial that compared one-month and six-month P2Y12 inhibitor therapy, in combination with aspirin and apixaban for patients with AF who require coronary stenting. The primary endpoint was the incidence of any bleeding events, defined as Thrombolysis In Myocardial Infarction major/minor bleeding, bleeding with various Bleeding Academic Research Consortium grades, or bleeding requiring blood transfusion within 12 months after stenting. The study aimed to enrol 600 patients but enrolment was slow. Enrolment was terminated prematurely after enrolling 210 patients (72.7±8.2 years; 81% male). The incidence of the primary endpoint did not differ between the one-month and six-month groups (11.8% vs 16.0%; hazard ratio [HR] 0.70, 95% confidence interval [CI]: 0.33-1.47; p=0.35). Conclusions The study evaluated the safety of withdrawing the P2Y12 inhibitor from triple antithrombotic prescription one month after coronary stenting. However, enrolment was prematurely terminated because it was slow. Therefore, statistical power was not sufficient to assess the differences in the primary endpoint.

Background Nilotinib, a second-generation BCR-ABL tyrosine kinase inhibitor (TKI), is highly effective in the treatment of patients with chronic myeloid leukemia (CML), despite being more vasculotoxic than older TKIs such as imatinib. Herein, we present a case of nilotinib-associated vasospastic angina confirmed by an acetylcholine spasm provocation test. Case presentation A 62-year-old CML patient treated with 300 mg nilotinib twice daily complained of several episodes of rest angina and was hospitalized at our institution. Coronary angiography revealed no severe organic stenosis, and the acetylcholine spasm provocation test confirmed the diagnosis of vasospastic angina. Although treatment with a calcium channel blocker and nicorandil reduced the frequency of chest pain, angina symptoms continued to occur. At 10 months post discharge, the patient complained of increased frequency of angina; therefore, the nilotinib dosage was reduced to 150 mg twice daily. Consequently, the patient reported a significant improvement in chest symptoms. Conclusions This case report highlights the potential vasculotoxic effects of nilotinib. Cardiologists and hematologists should be vigilant for coronary artery spasm as a possible vascular adverse event caused by nilotinib.

Isolated right ventricular (RV) infarction is extremely rare and its diagnosis may be challenging, because RV infarction most often occurs simultaneously with infarction of the inferior wall of the left ventricle. A 66-year-old man with a history of diabetes mellitus presented with cold sweat and general malaise. Although his symptoms were atypical for myocardial infarction, he was quickly diagnosed with RV infarction and successfully underwent urgent percutaneous coronary intervention. He was definitely diagnosed with isolated RV infarction by a scintigram and cardiac magnetic resonance imaging. Our review showed the importance of the combined assessment in the diagnosis of isolated RV infarction.

BACKGROUND Although elevated levels of oxidized low-density lipoprotein (LDL) could play a critical role in vulnerable plaque, there are no studies that have compared coronary high-intensity plaque (HIP) and circulating malondialdehyde-modified (MDA)-LDL levels for the prediction of cardiac events.Methods and Results:A total of 139 patients with coronary artery stenosis (>70%) were examined with non-contrast T1-weighted magnetic resonance imaging (MRI) (HIP: n=64, non-HIP: n=75). Scheduled percutaneous coronary intervention (PCI) for culprit lesions was performed within 48 h after MRI. HIP was defined as a signal intensity of coronary plaque to cardiac muscle ratio (PMR) ≥1.4. We evaluated the subsequent major adverse cardiac events (MACE) during the follow-up period (5.6±1.3 years). MDA-LDL levels were independently associated with the presence of HIP (P

An 81-year-old woman presented with massive melena. She required urgent hospitalization because of hyperprothrombinemia (international normalized ratio >9.9), induced by warfarin treatment following double valve replacement surgery she underwent 35 years prior, and had cirrhosis caused by chronic liver congestion. The next day, she became comatose (serum ammonia level, 417 μg/dL) and was diagnosed with hepatic encephalopathy with acute hyperammonemia. Despite the decrease in serum levels (53 μg/dL) following 3-day lactulose and rifaximin treatment, her consciousness level remained low (Glasgow Coma Scale, 6). Electroencephalogram on day 8 showed triphasic waves, but no obvious epileptic discharges. Brain magnetic resonance imaging (MRI) on day 1 was unremarkable (Fig. 1A–C) and showed bilateral and symmetrical cortical swelling in the insular, cingulate, frontal, and occipital cortices on day 10 (Fig. 1D–F), and showed reduction in the extent of the lesion at 3 weeks post-hospitalization (Fig. 1G–I). Her consciousness level recovered slightly later than the MRI findings. Ammonia detoxification in the brain occurs through glutamine formation through the glutamine synthesis pathway in astrocytes, leading to glutamine-induced astrocyte swelling and subsequent cerebral edema and even encephalopathy.1 Brain MRIs – which are essential in differential diagnoses – show symmetrical signal abnormalities in the insular and cingulate cortices.2-4 Close attention should be paid to secondary encephalopathy in patients with hyperammonemia.

Background Percutaneous coronary intervention (PCI) is often complicated by periprocedural myocardial injury (PMI) manifested by elevated cardiac biomarkers. The occurrence of PMI has been shown to be associated with worse clinical outcome over short- and long-term. Purpose We performed multidetector computed tomography (MDCT) and cardiac magnetic resonance imaging (CMR) to evaluate the relationship between culprit plaque characteristics and PMI. Methods A total of 90 patients who underwent elective PCI were underwent CMR and multidetector coronary tomography before PCI. The high intensity plaque (HIP) on CMR was defined as a coronary plaque to myocardium signal intensity ratio (PMR) of >1.4. The plaque characteristics and the presence of napkin-ring sign (NRS) were analyzed on MDCT. PMI was defined as an increase in cardiac Troponin T levels to more than 5 times the upper limit of normal at 24 h after PCI. Patients were divided into 2 groups according to the presence (Group I, n=26) or absence (Group II, n=64) of PMI. Results Spotty calcification, positive remodeling, low attenuation plaque and NRS on MDCT were significantly more observed in Group I than in Group II. HIP on CMR was significantly more observed in Group I than in Group II. In the multivariable logistic regression analysis, the presence of NRS and HIP were significantly independent predictors of PMI (odds ratio (OR) 4.82, 95% confidence interval 1.13–20.60, P=0.034 and OR 3.66, 95% CI 1.09–12.30, P=0.036, respectively). Moreover, for prediction of PMI, NRS and HIP showed a high positive predictive value of 81%, and their absence showed a high negative predictive value of 91%. Conclusions MDCT and CMR may play an important role in detecting which lesions are high risks for myocardial necrosis after PCI in elective coronary stenting. Funding Acknowledgement Type of funding source: None

Background Although elevated oxidized low-density lipoprotein could play critical roles in vulnerable plaque, there are no studies that compared coronary high-intensity plaque (HIP) on non-contrast T1-weighted magnetic resonance imaging (T1WI_MRI) and circulating malondialdehyde-modified low-density lipoprotein (MDA-LDL) levels for the prediction of cardiac events. Methods and results A total of 139 patients with coronary artery stenosis (>70%) were examined with non-contrast T1WI using a 1.5-T MRI (HIP: n=63, non-HIP: n=76). Scheduled percutaneous coronary intervention (PCI) for culprit lesions was performed within 48 h after MRI. HIP was defined as a signal intensity of coronary plaque to cardiac muscle ratio (PMR) of ≥1.4. At admission, circulating levels of MDA-LDL and other lipid-related markers were measured. We evaluated the subsequent cardiac events, which were defined as major adverse cardiac events (MACE; cardiac death, myocardial infarction, and/or ischemia-driven PCI) during follow-up periods (5.6±1.3 years). Circulating MDA-LDL levels were significantly higher in patients with HIP than in those without HIP (p Conclusions MDA-LDL levels might be associated with the presence of HIP in patients with coronary artery disease. Furthermore, adding PMR to MDA-LDL levels markedly improved MACE prediction. Funding Acknowledgement Type of funding source: None

Antiphospholipid syndrome (APS) is an autoimmune disease characterized by a positive serum antiphospholipid antibody status. Patients with APS usually have an underlying hypercoagulable state, which can increase the risk of perioperative thromboembolism. We describe three patients with APS who underwent transcatheter aortic valve implantation for symptomatic severe aortic stenosis. Of them, two had complicated cerebrovascular events, and the other had no complications. Careful antithrombotic management is essential to minimize the risk of thromboembolism and bleeding in patients with APS.

Hypernatremia due to salt poisoning is clinically rare and standard care procedures have not been established. We report a case of salt poisoning due to massive intake of seasoning soy sauce. Aggressive rapid correction of serum sodium concentration should only be considered in acute phases of hypernatremia within 2–3 h of salt ingestion, before the brain cells adapt to high osmolarity., Background Hypernatremia due to salt poisoning is clinically rare and standard care procedures have not been established. We report a case of salt poisoning due to massive intake of seasoning soy sauce. Case Presentation A 40‐year‐old woman presented to the emergency department with seizures and remarkable hypernatremia with a serum sodium concentration of 183 mEq/L. The initial brain computed tomography scan showed brain shrinkage, which could occur during the acute phase of hypernatremia. We reduced her serum sodium level rapidly, rather than at the recommended slow rate. On day 3, the patient’s brain computed tomography scan showed widespread low‐density areas and edema. The patient died 8 days after admission. Conclusion After reviewing instances of resuscitation following salt intoxication, aggressive rapid correction of serum sodium concentration should only be considered in acute phases of hypernatremia within a few hours from ingestion, and 2–3 h could be one of the criteria.

A 35-year-old woman who had a 15-year history of systemic lupus erythematosus and received multiple drugs, including prednisolone, presented with a 4-year history of hypertrophic obstructive cardiomyopathy (HOCM). Although she was treated with optimal β-blocker and cibenzoline, heart failure

Acute aortic dissection (AAD) is a serious disease with a high mortality rate. The mortality rate for patients with type A AAD who do not get treatment is of 1–2% per hour during the first 24 hours and almost 50% of the patients die within a week (1). The highest mortality associated with AAD occurs in the first 48 hours after onset of symptoms.

A 71-year-old man underwent mitral valve plasty for mitral regurgitation 2 years previously. He had a history of paroxysmal atrial fibrillation but did not undergo left atrial appendage closure simultaneously. He presented with acute ST-segment elevation myocardial infarction complicated by

Objectives This study aimed to evaluate the association with coronary high-intensity plaque (HIP) on non-contrast T1-weighted magnetic resonance imaging (T1WI) and circulating levels of malondialdehyde-modified low-density lipoprotein (MDA-LDL). Methods A total of 139 patients with coronary artery stenosis (>70%) were imaged with non-contrast T1WI by using a 1.5-T magnetic resonance system (HIP: n=60, non-HIP: n=79). HIP was defined as a signal intensity of coronary plaque to cardiac muscle ratio (PMR) of ≥1.4. At admission, circulating levels of MDA-LDL and other lipid-related markers (triglyceride, HDL, LDL, Lp(a), RLP-C, and EPA/AA) were measured. Results Circulating levels of MDA-LDL (p=0.001) and LDL (p=0.041) were significantly higher in patients with HIP than those without, whereas the other lipid-related markers were not significantly different between both groups. In multivariable logistic regression analysis, MDA-LDL levels were independently associated with the presence of HIP (OR 1.03; 95% CI, 1.00–1.06, p=0.015) after adjusting for cofounding factors (age, sex, triglyceride, LDL, Lp(a), RLP-C, and EPA/AA). The optimal MDA-LDL threshold for predicting coronary HIP was 90.4 U/L, identified by the receiver operating characteristic curve. Conclusion MDA-LDL levels might be associated with the presence of HIP in patients with coronary artery disease.

INTRODUCTION There are few studies analyzing the association between the presence of coronary artery disease (CAD) and recurrence of atrial fibrillation (AF). This study evaluated the clinical impact of concomitant CAD and coronary revascularization on the recurrence of AF after catheter ablation. METHODS AND RESULTS From April 2008 to December 2015, 700 consecutive patients were treated with pulmonary vein isolation for AF as the initial procedure. Of those, 681 patients who simultaneously underwent coronary angiography were investigated. Patients with at least one coronary stenosis (≥70%) were classified as having obstructive CAD. Of 681 patients, 90 patients had CAD and 42 patients underwent percutaneous coronary intervention (PCI) for lesions with perfusion abnormalities on single-photon emission tomography. The recurrence of AF was significantly more frequent in patients with CAD (56%) than in those without CAD (39%) (P = .0011). On multivariable analysis, the predictors of AF recurrence were persistent or long-standing persistent AF [hazard ratio (HR): 1.36; 95% confidence interval (CI): 1.04-1.77; P = .023], left atrial diameter (HR: 1.04; 95% CI: 1.02-1.06; P

Background There have been no reviews regarding intravascular ultrasound (IVUS) catheter entrapment during percutaneous coronary intervention (PCI). This study investigated the incidence, retrieval methods, and outcomes of IVUS catheter stuck within implanted stents. Methods Between January 2015 and July 2018, a total of 794 consecutive patients underwent PCI for coronary artery disease. Among them, 705 patients underwent stent implantation using IVUS. The patients with IVUS catheter entrapment in an implanted stent were investigated. Results Ten patients (1.4%) suffered from an IVUS catheter stuck in an implanted stent. Among them, 7 patients had very tortuous lesions while 5 patients had severely calcified lesions. Seven patients (70%) underwent placement of the 3rd generation drug-eluting stent (DES), and the stent diameters were ≤2.5 mm among 8 patients (80%). Retrieval methods were the buddy wire technique, the double guide catheter technique, covering the exit port of IVUS catheter with a balloon catheter, and covering with GuideLiner® catheter (Vascular Solutions Inc., Minneapolis, MN, USA). On multivariable analysis, the predictors of IVUS catheter entrapment were tortuous lesion [odds ratio (OR), 8.21; 95% confidence interval (CI), 2.19–30.7; p = 0.002], 3rd generation DES (OR, 5.31; 95% CI, 1.08–26.1; p = 0.021), and stent diameter ≤2.5 mm (OR, 6.31; 95% CI, 1.29–30.8; p = 0.010). Furthermore, we identified 6 cases of IVUS catheter entrapment through a systematic literature review. Conclusions The IVUS catheter was almost stuck in tortuous lesions and the 3rd generation DES with a small diameter. We could successfully retrieve it in all cases using various retrieval techniques.

BackgroundIncreased levels of uric acid (UA) have been associated with cardiovascular disease. This association is generally stronger in women than men. However, gender differences in the prognostic value of UA in patients with acute coronary syndrome (ACS) are unknown. We investigated gender differences in the relationship between UA level and the prognosis in patients with ACS.MethodThis was an observational analysis of patients with ACS undergoing percutaneous coronary intervention enrolled in the Ibaraki Cardiac Assessment Study (ICAS) registry. We analyzed 1380 patients (330 women, 1050 men) with ACS who had information on UA. We assessed the association between UA and the incidence of major cardiovascular adverse events (MACE), defined as all-cause death, congestive heart failure, reinfarction, and stroke. Patients were divided according to gender-specific UA quartile.ResultsThe mean UA level in women was significantly lower than that in men (4.9mg/dl vs 5.9mg/dl, p

Objectives This study aimed to validate the clinical implications of audiovisual telesupport system use. Background An audiovisual telesupport system with supervisors has been effective in guiding procedures when surgeons have limited experience with the technique. However, cardiovascular catheter interventions using an audiovisual telesupport system has not been previously reported. Methods Starting in September 2017, two cardiologists in Kamisu Saiseikai Hospital (Kamisu, Japan, with limited cardiologists) began performing cardiovascular catheter interventions using an audiovisual telesupport system. This system enabled them to perform catheter interventions with the support of advisors in the University of Tsukuba (Tsukuba, Japan). We retrospectively assessed procedure time and complications of percutaneous coronary intervention (PCI) and catheter ablation (CA). Results In the first 10 months, 21 patients with coronary artery disease underwent PCI using this system. The mean procedure duration of PCI was 42 ± 10 min. Nine patients with tachyarrhythmia including supraventricular tachycardia (SVT), ventricular premature contraction (VPC), common atrial flutter, and paroxysmal atrial fibrillation (AF) underwent CA using this system. The mean CA procedure time was 134 ± 31 min for SVT, 100 ± 14 min for VPC, and 200 min for AF. All PCI and CA procedures were successfully performed without any complications. Conclusions The audiovisual telesupport system enabled cardiologists with limited human resources to provide safe and high-quality catheter interventions.

A 61-year-old man underwent modified Bentall operation with a long interposed graft to left coronary artery for DeBakey Type I aortic dissection 4 years ago. He had residual descending aortic dissection with pseud-lumen extending to left subclavian artery and right iliac artery ( Panel A ; Supplementary material online, Movie S1 ). He presented with acute ST-segment elevation …

A 65-year-old woman, who was treated with a sirolimus-eluting stent (SES) (CYPHER) for the left anterior descending coronary artery (LAD) 36 months previously, presented with ST-segment elevation myocardial infarction, showing an acute thrombotic occlusion of the LAD stent ([Figure 1A][1]).

Background The prophylactic benefit of statins in reducing the incidence of contrast-induced acute kidney injury (CI-AKI) has been investigated in several studies with conflicting results. We sought to investigate whether statin pretreatment prevents CI-AKI in coronary artery disease (CAD) patients undergoing percutaneous coronary intervention (PCI). Methods A total of 2198 CAD patients who underwent PCI, except for those undergoing dialysis or who died within 7 days after angioplasty, were analyzed from the ICAS (Ibaraki Cardiovascular Assessment Study) multicenter registry. Analyzed subjects were divided into 2 groups according to statin pretreatment: statin pretreatment (n = 839) and non-statin pretreatment (n = 1359). Selection bias of statin pretreatment was adjusted by propensity score-matching method: pretreatment statin (n = 565) and non-statin pretreatment (n = 565). CI-AKI was defined as an increase in serum creatinine of ≥ 25% or 0.5 mg/dl from baseline within 1 week of contrast medium exposure. Results A total of 192 (8.7%) patients developed CI-AKI. No significant differences were observed in baseline patient characteristics between the statin and non-statin pretreatment groups after propensity score matching. In the propensity score-matched groups, the incidence of CI-AKI was significantly lower in patients with statin pretreatment than in those without statin pretreatment (3.5% vs.10.6%, odds ratio [OR]: 0.31, 95% confidence interval [CI]: 0.18–0.52, P < 0.001). Multivariate logistic regression analysis showed that statin pretreatment remained an independent negative predictor of CI-AKI (OR: 0.31, 95% CI: 0.18–0.53, P < 0.001) among propensity score-matched subjects. Conclusions Statin pretreatment was associated with a significant decrease in the risk of CI-AKI in CAD patients undergoing PCI in the ICAS Registry.

The purpose of this study was to find a safe dosing regimen for landiolol, an ultra-short-acting β-adrenergic blocking agent, to rapidly control supraventricular tachyarrhythmias (SVTs) in patients with heart failure (HF). Landiolol is reported to have good effects in the treatment of SVTs after cardiac surgery. We evaluated 52 patients with SVT and symptoms of HF (NYHA class III/IV, 10/42; EF 32 ± 12 %) on admission because of ischaemic disease (n = 10), non-ischaemic cardiomyopathy (n = 32), or valvular disease (n = 10). Paroxysmal/persistent atrial fibrillation and atrial tachycardia were present in 16 (30 %), 23 (45 %), and 13 (25 %) patients, respectively. The patients first underwent conventional therapy with carperitide, dobutamine, or milrinone. Intravenous landiolol was administered at an infusion rate of 1 μg/kg/min and, if no adverse effects developed, the maintenance dose, titrated to HR and blood pressure response, was increased. At an average dose of 10.8 ± 9.4 μg/kg/min, mean HR significantly decreased significantly from 133 ± 27 to 82 ± 15 beats/min (P < 0.01), whereas systolic blood pressure did not differ from baseline to attainment of an effective dose level (105 ± 21 vs. 101 ± 19 mmHg, P = ns). Within 60 min after initiation of therapy, all patients had achieved a 20 % reduction in HR at the maintenance dose. Transient asymptomatic hypotension requiring cessation of landiolol therapy occurred in three patients. Intravenous administration of landiolol was both effective in rapidly controlling HR for up to 24 h and useful as bridging treatment to additional therapy of oral β blockade, pulmonary vein catheter ablation, or cardiac resynchronisation therapy in patients with HF.

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome and its etiology and pathogenesis have not been well understood. Intracoronary imaging modalities with intravascular ultrasound and optical coherence tomography would enable a precise diagnosis in this entity. Coronary angioscopy is also a unique tool for allowing direct visualization of the luminal surface of a vessel. We described an interesting case of SCAD documented with multimodality intracoronary imaging showing the presence of superficial lipid plaque nearby the coronary dissection entry point, which might have been associated with fragility of the arterial wall and the subsequent development of SCAD.

Plasma norepinephrine (NE) level can be a guide to mortality in patients with heart failure. This study aimed to evaluate the significance of plasma NE level compared with plasma natriuretic peptides (atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP)) levels in patients with atrial fibrillation (AF).Included in this study were 137 consecutive patients referred for catheter ablation of lone AF (paroxysmal in 90 and persistent in 47 patients). Blood samples for measurements of ANP, BNP and NE were drawn in the supine position before the procedure.ANP, BNP and NE levels were greater in patients with persistent AF than in patients with paroxysmal AF (median (25th-75th centile)=28 (18-49) vs 69 (36-106), p0.0001; 28 (15-50) vs 94 (39-156), p0.0001; and 315 (223-502) vs 382 (299-517) pg/mL, p=0.04, respectively). NE level correlated weakly with ANP and BNP levels (r=0.28 and r=0.23, respectively, p0.01 for both). BNP and NE levels differed between patients with and without recurrence of AF (55 (26-135) vs 35 (18-64), p=0.005 and 431 (323-560) vs 302 (225-436) pg/mL, p0.001, respectively). Of note, only NE level was significantly greater in patients with symptomatic sick sinus syndrome (SSS) (n=21) than in those without SSS (560 (466-632) vs 321 (242-437) pg/mL, p0.0001). Logistic regression analysis showed NE level to be the only independent discriminator for SSS (OR 1.006, 95% CI 1.002 to 1.010, p=0.001).An increase in plasma NE level was observed in patients with AF and SSS. Although this implies a pathophysiological link between clinical manifestation of SSS and the autonomic nervous dysfunction, further studies are needed to clarify the mechanisms for this novel finding.

Aims Non-contrast T 1-weighted imaging (T1WI) has emerged as a novel non-invasive imaging for vulnerable coronary plaque showing a high-intensity plaque (HIP). However, the association between HIP and percutaneous coronary intervention (PCI) has not been evaluated. We investigated the association between the presence of HIP and the incidence of myocardial injury after PCI. Methods and results A total of 77 patients with stable angina were imaged with non-contrast T1WI by using a 1.5 T magnetic resonance system (HIP and non-HIP group, N = 31 and 46 patients, respectively). We defined HIP as a coronary plaque to myocardium signal intensity ratio (PMR) of ≥1.4. High-sensitive cardiac troponin-T (hs-cTnT) was measured at baseline and 24 h after PCI. Percutaneous coronary intervention-related myocardial injury (PMI) was defined as an elevation of hs-cTnT >5× 99th percentile upper reference limit. High-intensity plaque was associated with the characteristics of ultrasound attenuation and positive remodelling on intravascular ultrasound. Although baseline hs-cTnT was similar between the groups, increase in hs-cTnT was significantly greater in the HIP vs. non-HIP group (0.065 [0.023–0.304] vs. 0.017 [0.005–0.026], P < 0.001). Percutaneous coronary intervention-related myocardial injury occurred more frequently in the HIP than non-HIP group (58.1 vs. 10.9%, P < 0.001), and the cut-off value of PMR found to be 1.44 for predicting PMI (sensitivity 78.3% and specificity 81.5%). In multivariate analysis, a PMR of ≥1.4 was a significant predictor of PMI (odds ratio 5.63, 95% confidence interval 1.28–24.7, P = 0.022). Conclusion High-intensity plaque on non-contrast T1WI was characterized as vulnerable coronary plaque on IVUS and was associated with higher incidence of PMI.

BackgroundThe association of Mehran risk score (MRS) with long-term prognosis in patients treated with percutaneous coronary intervention (PCI) has not been fully reported. We investigated the association between MRS and clinical outcomes in patients who underwent PCI.MethodsStudy subjects comprised 2198 patients treated with PCI from the Ibaraki Cardiovascular Assessment Study multicenter registry, excluding patients receiving hemodialysis or who died within 7 days. We categorized them into 4 groups according to MRS (low-risk: ≤5; medium-risk: 6–10; high-risk: 11–16; and very high-risk: ≥16). Contrast-induced acute kidney injury (CI-AKI) was defined as an increase of 0.5mg/dL or 25% in pre-PCI serum creatinine within 1-week post procedure. We evaluated CI-AKI and major adverse cardiac and cerebrovascular events (MACCE), and defined as all-cause death, myocardial infarction, congestive heart failure, or cerebrovascular disorder (stroke or transient ischemic attack).ResultsA total of 192 (8.7%) patients developed CI-AKI. At multivariate analysis, odds ratio for CI-AKI was 4.09 (95% CI: 1.72–9.17, p=0.002) in the very high-risk group, 1.49 (95% CI: 0.89–2.42, p=0.120) in the high-risk group, and 1.08 (95% CI: 0.74–1.54, p=0.693) in the medium-risk group, as compared with the low-risk group. MACCE in the very high-risk group was more than 5-fold higher [hazard ratio (HR) 5.40, 95% CI: 2.96–9.28, p

Coronary plaques with positive remodeling (PR) and low-attenuation plaques (LAP) by computed tomography angiography (CTA) might be associated with plaque vulnerability. The purpose of this study was to assess the relation between coronary plaques with PR and LAP by CTA and fibrous cap thickness measured by optical coherence tomography (OCT).We used CTA and OCT to assess 102 coronary plaques in patients with coronary artery disease (unstable angina pectoris, n=24; stable angina pectoris, n=78). Plaque characteristics were divided into three groups: 2-feature-positive plaques (PR and LAP; n=32), 1-feature-positive plaques (PR or LAP; n=20), and 2-feature-negative plaques (neither PR nor LAP; n=50). PR was defined as remodeling index (RI) of1.05 and LAP was defined as CT density value50HU.There were significant differences between the three plaque groups with respect to fibrous cap thickness measured by OCT: 76±24μm in 2-feature-positive plaques, 154±51μm in 1-feature-positive plaques, and 192±49μm in 2-feature-negative plaques (P0.001). The RI (1.21±0.06, 1.14±0.05, P=0.011) and the presence of thin cap fibroatheroma (TCFA) (70-μm thickness) (75%, 15%, P=0.001) were significantly higher in UAP than in SAP patients with 2-feature-positive plaques, whereas fibrous cap thickness (68.9±24.1, 92.1±21.9μm, P0.001) was lower in the UAP patients. In UAP patients, the presence of ring-like enhancement showed higher accuracy of 88% for detection of TCFA.Coronary PR and LAP by CTA were associated with the degree of fibrous cap thickness measured by OCT. CTA can non-invasively provide promising information on plaque vulnerability by identifying coronary plaque with PR and LAP, especially ring-like enhancement.

To evaluate the incidence and clinical predictors of contrast-induced acute kidney injury (CI-AKI) in patients with ST-segment elevation myocardial infarction (STEMI), unstable angina pectoris/non-STEMI (UAP/NSTEMI), and stable AP (SAP) undergoing percutaneous coronary intervention (PCI).We enrolled 1,954 patients (SAP, n=1,222; UAP/NSTEMI, n=277; STEMI, n=455) who underwent PCI. Patients were categorized according to contrast media volume/estimated glomerular filtration rate ratio (CV/eGFR low:2.0, mid: 2.0-2.9, high: ≥3.0). CI-AKI was defined as an increase in serum creatinine of 0.5mg/dl or 25% within 1 week from contrast-medium injection. The incidence of CI-AKI was highest among the STEMI patients (SAP, 4.24%; UAP/NSTEMI, 10.7%; STEMI, 16.1%, P0.01). Significant predictors of CI-AKI were emergency PCI (odds ratio [OR] 3.70; 95% confidence interval [CI] 2.55-5.37; P0.001), ejection fraction40% (OR 2.04; 95% CI 1.24-3.36; P=0.005), and hemoglobin10g/dl (OR 0.02; 95% CI 1.17-4.55; P=0.02) after multivariate logistic regression analysis. In the SAP group, a CV/eGFR ratio ≥3.0 was a significant predictor of CI-AKI (P=0.048), but not in UAP/NSTEMI and STEMI patients.UAP/NSTEMI and STEMI patients undergoing emergency PCI were at high risk for CI-AKI regardless of CV/eGFR ratio. Minimizing the dose of contrast medium based on eGFR might be valuable in reducing the risk of CI-AKI in SAP patients.

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome and its etiology and pathogenesis have not been well understood. Intracoronary imaging modalities with intravascular ultrasound and optical coherence tomography would enable a precise diagnosis in this entity. Coronary angioscopy is also a unique tool for allowing direct visualization of the luminal surface of a vessel. We described an interesting case of SCAD documented with multimodality intracoronary imaging showing the presence of superficial lipid plaque nearby the coronary dissection entry point, which might have been associated with fragility of the arterial wall and the subsequent development of SCAD.