Comparison of drug-eluting balloon with repeat drug-eluting stent for recurrent drug-eluting stent in-stent restenosis Objective Approximately, 10–20% of patients with drug eluting stent (DES) in-stent restenosis (ISR) will develop recurrent ISR; yet, the optimal management of recurrent DES-ISR is unknown. We sought to compare the outcomes of recurrent DES-ISR treated with drug eluting balloons (DEB) to those with repeated implantation of new-generation DES. Methods A total of 172 patients with recurrent DES-ISR were enrolled and stratified into two cohorts: the repeated DES implantation (Re-DES) group and the DEB group. The primary endpoint was the 1-year incidence of major adverse cardiovascular events (MACE). Results Ninety-three patients treated with DEB and 79 patients with Re-DES implantation were analyzed. Both groups had comparable baseline characteristics. Lesser residual stenosis was achieved in the Re-DES group (11.3 ± 3.2% vs. 22.4 ± 4.3%; P = 0.00) than in the DEB group. However, the incidence of MACE and target lesion revascularization (TLR) were less in the DEB group (17.2% vs. 32.9%; P = 0.02 and 15.1% vs. 27.8%; P = 0.04, respectively). For the ≥3 metal-layered DES-ISR subgroup, DEB drastically reduced the incidences of MACE and TLR compared with Re-DES (20.0% vs. 57.9%; P = 0.02 and 16.0% vs. 47.4%; P = 0.04, respectively). Survival analysis demonstrated that MACE-free survival was significantly higher in the DEB group compared with the Re-DES group, whether the metal layers were ≥3 or 2. Multivariate analysis revealed that the risk factors of MACE were diabetes mellitus, ≥3 metal-layered DES ISR, and repeat DES deployment. Conclusions For recurrent DES-ISR, DEB may improve clinical outcomes compared with Re-DES implantation, especially for ≥3 metal-layered DES-ISR.

Outcomes after percutaneous coronary intervention and comparison among scoring systems in predicting procedural success in elderly patients (≥ 75 years) with chronic total occlusion Background Evidence-based data on percutaneous coronary intervention in elderly patients with chronic total occlusion (CTO) and comparison among different scoring systems have not been well established. Patients and methods A total of 246 consecutive patients were stratified into two groups according to the age: elderly group (age≥ 75 years, n = 68) and nonelderly group (age < 75 years, n = 178). Clinical and angiographic characteristics including the Synergy Between PCI With TAXUS and Cardiac Surgery score, in-hospital major adverse cardiac events, procedural success rates, and predictive capacity of four scoring systems [J-CTO, Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS CTO), clinical and lesion-related (CL), and ostial location, Rentrop grade < 2, age ≥ 75 years (ORA) scores] were examined. Results Triple-vessel disease and the Synergy Between PCI With TAXUS and Cardiac Surgery score in the elderly group were significantly higher than those in the nonelderly group (73.53 vs. 53.93%, P = 0.005; 31.39 ± 7.68 vs. 27.85 ± 7.16, P = 0.001, respectively). The in-hospital major adverse cardiac event rates, vascular access complication rates, and major bleeding rates were similar between the elderly and the nonelderly group (2.94 vs. 2.25%, P = 0.669; 1.47 vs. 0.56%, P = 0.477; 2.94 vs. 1.12%, P = 0.306, respectively). By contrast, the procedural success rate was statistically lower in the elderly group than that in the nonelderly group (73.53 vs. 84.83%, P = 0.040). All the four scoring systems showed a moderate predictive capacity [area under the curve (AUC) for J-CTO score: 0.806, P < 0.0001; AUC for PROGRESS CTO score: 0.727, P < 0.0001; AUC for CL score: 0.800, P < 0.0001; AUC for ORA score: 0.672, P < 0.0001, respectively]. Compared with the ORA score, the J-CTO score, and the CL score showed a significant advantage in predicting procedural success among overall patients (ΔAUC = 0.134, P = 0.0122; ΔAUC = 0.128, P = 0.0233, respectively). Conclusion Despite the lower procedural success rate, percutaneous coronary intervention in elderly patients with CTO is feasible and safe. J-CTO, PROGRESS, ORA, and CL scoring systems have moderate discriminatory capacity.

The impact of preinfarct angina on the incidence of acute kidney injury in patients with myocardial infarction: interaction with pre-existent chronic kidney disease Aim Remote ischemic conditioning may reduce acute kidney injury (AKI) in patients undergoing a coronary intervention. As preinfarct angina (PIA) might act as a preconditioning stimulus in patients with ST-elevation myocardial infarction (STEMI), we aimed to study whether PIA reduces AKI in accordance to pre-existing chronic kidney disease. Patients and methods We conducted a retrospective study including 891 consecutive STEMI patients who underwent primary coronary intervention from January 2008 to March 2016. AKI was determined on the basis of KDIGO criteria. The impact of PIA was evaluated in three groups according to the baseline glomerular filtration rate: less than 45 ml/min/1.73 m2 (group 1, n = 89), 45–59 ml/min/1.73 m2 (group 2, n = 117), and greater than or equal to 60 ml/min/1.73 m2 (group 3, n = 642). Univariate and multivariate predictors for AKI were determined. Results AKI developed in 13.8% of patients (n = 117) and was more prevalent in patients with worse baseline renal function (35% in group 1; 22% in group 2; and 9% in group 3, P < 0.01). The prevalence of PIA was similar across groups (28–34%, P = 0.2). Only in group 1 did patients with PIA have a significantly lower rate of AKI than patients without PIA (19 vs. 42%, P = 0.033). In multivariate analysis, the absence of PIA in group 1 patients conferred an almost three-fold risk of developing AKI (odds ratio = 2.92, P = 0.009), whereas no differences were found for the other groups. Age, total ischemic time, and intra-aortic balloon pump utilization were also related independently to AKI. Conclusion In our series, STEMI patients with at least stage 3B chronic kidney disease had a three-fold risk of developing AKI in the absence of PIA. These findings suggest that patients with worse renal function may be more susceptible to the renoprotective effect of myocardial ischemic preconditioning.

Bacterial footprints in aspirate of infarct-related artery in ST-elevation myocardial infarction patients underwent primary percutaneous coronary intervention Background Bacterial infections can trigger acute coronary syndromes. This study aimed to examine bacterial footprints in the aspirate of infarct-related artery. Patients and methods We studied 140 patients with ST-elevation myocardial infarction who underwent a primary coronary intervention using thrombus aspiration catheters. The aspirate was sent for bacteriological and pathological examinations and immunoassay for pneumolysin toxin. Results Bacterial culture showed different bacteria in 14 samples. Leukocyte infiltrate was detected in all pathologically examined samples. Pneumolysin toxin was detected in only two samples. Patients with bacteria had similar baseline data as those without, except for the median age [46 (44–50) vs. 55 (47–62) years, P = 0.001, respectively], and white blood cells (WBCs) (16670 vs. 7550 cells/µl, P < 0.0001, respectively). In hospital-major clinical events (death, stroke, reinfarction, lethal arrhythmia, and heart failure) were not significantly different between the 2 groups with and without bacteria [4 (28.6%) vs. 20 (18.6%) events, respectively, odds ratio (OR) 1.8 (95% CL: 06–6.3), P = 0.5]. Patients with bacteria, heavy infiltration, and pneumolysin had insignificant higher events compared with those without [10/35 (28.6%) vs. 16/105 (15.2%) events, OR 2.2 (95% CL: 0.92–5.43), P = 0.13]. However, the difference was not significant. By multivariate analysis, bacteria, leukocyte infiltration, and pneumolysin were not predictors for in-hospital clinical events. Higher WBCs and younger age were significant predictors of bacterial footprints (P < 0.0001 and P = 0.04, respectively). Conclusion Bacterial footprints existed in the aspirate of infarct-related artery of ST-elevation myocardial infarction patients. Predictors were higher WBCs and younger age. Bacterial markers were not predictors for in-hospital clinical events. The presence of bacterial footprints supports the infectious hypothesis of atherosclerosis.

The predictive value of PRECISE-DAPT score for arrhythmic complications in patients with ST-elevation myocardial infarction Objective: To investigate the predictive value of the PRECISE-DAPT score for the development of arrhythmias in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. Method: A total of 706 patients with a diagnosis of ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention were enrolled to the study. The patients were divided into two groups according to the PRECISE-DAPT score (PRECISE-DAPT score ≥25 and PRECISE-DAPT score <25). The patients were compared in terms of in-hospital arrhythmia. Results: High-degree atrioventricular block (second-degree Mobitz II or third-degree atrioventricular block) (17.2% vs. 4.9%; P < 0.001), ventricular tachycardia (11.2% vs. 4.6%; P = 0.005) and atrial fibrillation (13.8% vs. 3.1%; P < 0.001) rates were statistically higher in patients with higher PRECISE-DAPT score (≥25). There was no difference between the groups in terms of ventricular fibrillation (9.5% vs. 8.3%; P = 0.678). In multivariable logistic regression analysis; PRECISE-DAPT Score was independently associated with high-degree atrioventricular block (odds ratio: 6.38, P < 0.001) and atrial fibrillation (odds ratio: 4.33, P < 0.001). Conclusion: The PRECISE-DAPT score was associated with high-degree atrioventricular block and atrial fibrillation in patients with ST-segment elevation myocardial infarction underwent percutaneous coronary intervention.

Assessment of the relationship between C-reactive protein-to-albumin ratio and slow coronary flow in patients with stable angina pectoris Background The relationship between severity of coronary artery disease and inflammatory parameters has been previously demonstrated. However, there is a lack of data regarding the role of C-reactive protein-to-albumin ratio (CAR) in slow coronary flow (SCF) in patients with stable angina pectoris (SAP). In this study, we aimed to investigate the relationship between CAR and presence of SCF in patients with SAP. Patients and methods This study enrolled 217 patients undergoing coronary angiography for SAP. SCF was detected in 81 (37.3%) patients, and the control group included 136 patients. All clinical, demographical, and laboratory parameters were entered into a dataset and compared between SCF group and the controls. Results The mean age of the patients was 66.1 ± 12.1 years (male: 57.1%). C-reactive protein and CAR were significantly higher in patients with SCF compared with controls (P = 0.004 and < 0.001, respectively). Logistic regression analysis demonstrated that high CAR level was an independent determinant of SCF (odds ratio: 1.023; 95% confidence interval: 1.013–1.034; P < 0.001). Conclusion Higher CAR level may be a valuable predictor of SCF in patients with SAP who undergo coronary angiography. Inflammation may play an important role in the pathogenesis of SCF.

Clinical utility of coronary computed tomography angiography in patients diagnosed with high-grade stenosis of the coronary arteries Objectives We purposed to evaluate the reliability of coronary computed tomography angiography (CCTA) in patients with a CCTA finding of high-grade stenosis. Patients and methods Between May 2015 and March 2017, patients who underwent invasive coronary angiography (ICA) because of detection of high-grade stenosis by CCTA ( ≥ 70% stenosis of epicardial arteries or ≥ 50% of the left main coronary artery; Coronary Artery Disease Reporting and Data System grade 4 or 5) were selected for this study from our prospective registry cohort. Results Among 646 eligible patients, only 263 (41%) patients were correctly diagnosed with significant coronary artery disease on ICA as same as CCTA findings. The per-vessel analysis revealed that 620 (68%) of 916 affected vessels had confirmed concordant significant stenosis between the CCTA and ICA results. The concordance rate was 49% among the segments with identified plaques in the per-segment analysis. Revascularization of the target vessel identified with severe stenosis by CCTA was performed in 228 (35%) patients. A logistic regression analysis revealed that smoking [odds ratio (OR): 1.59, 95% confidence interval (CI): 1.04–2.42, P = 0.03], taller height (OR: 1.02, 95% CI: 1.00–1.05, P = 0.016), and presence of typical symptoms of angina (OR: 1.86, 95% CI: 1.34–2.59, P < 0.001) were found to increase the probability of diagnostic concordance. A greater calcified segment involvement score (OR: 0.88, 95% CI: 0.82–0.94, P < 0.001) was associated with a lower diagnostic concordance. Conclusion The diagnostic discordance between CCTA and ICA was frequently observed in patients who were diagnosed with a CCTA finding of high-grade stenosis.

End-stage renal failure is associated with impaired coronary microvascular function Background Cardiovascular disease is the leading cause of death in patients with chronic kidney disease. Studies investigating the disproportionate burden of cardiovascular disease have occurred predominantly in the peripheral vasculature, often used noninvasive imaging modalities, and infrequently recruited patients receiving dialysis. This study sought to evaluate invasive coronary dynamic vascular function in patients with end-stage renal failure (ESRF). Patients and methods Patients referred for invasive coronary angiography prior to renal transplantation were invited to participate. Control patients were recruited in parallel. Baseline characteristics were obtained. Coronary diameter (via quantitative coronary angiography) and coronary blood flow (via Doppler Flowire) were measured; macrovascular endothelial-dependent and independent effects were evaluated in response to intracoronary acetylcholine infusion (10−7 and 10−6 mol/l) and intracoronary glyceryl trinitrate, respectively. Microvascular function was evaluated by response to adenosine and expressed as coronary flow velocity reserve. Mean values were compared. Results Thirty patients were evaluated: 15 patients with ESRF (mean age 52.1 ± 9, male 73%) and 15 control patients (mean age 53.3 ± 13, male 60%). Comorbidity profile, aside from ESRF, was well matched. Baseline coronary blood flow was similar between groups (101.6 ± 10.3 vs. 103.4 ± 9.1 ml/min, P = 0.71), as was endothelial-dependent response to acetylcholine (159.1 ± 16.9 vs. 171.1 ± 16.8 ml/min, P = 0.41). Endothelial-independent response to glyceryl trinitrate was no different between groups (14.3 ± 3.1 vs. 13.1 ± 2.3%, P = 0.73. A significantly reduced coronary flow velocity reserve was observed in the ESRF cohort compared to controls (2.34 ± 0.4 vs. 3.05 ± 0.3, P = 0.003). Conclusion Patients with ESRF had preserved endothelial-dependent function however compared to controls, demonstrated significantly attenuated microvascular reserve. An impaired response to adenosine may not only represent a component of the pathophysiological milieu in patients with ESRF but may also provide a basis for the suboptimal diagnostic performance of vasodilatory stress in this population.

Association between new circulating proinflammatory and anti-inflammatory adipocytokines with coronary artery disease Background The aim of this study was to evaluate the diagnostic and risk predictive value of emerging proinflammatory and anti-inflammatory adipocytokines on coronary artery disease (CAD). Patients and methods The study involved 259 inpatients suspected acute coronary syndrome who underwent coronary angiography. Demographic, clinical characteristics, and coronary artery stenosis rated by Gensini score were collected by cardiovascular doctors. The levels of serum inflammatory adipocytokines were evaluated by ELISA. The correlations of the cytokines with clinical parameters were assessed. Receiver operating characteristic curves were constructed for the diagnosis of CAD. Results The 259 inpatients were assigned to the CAD (n = 180) and control groups (n = 79). Compared with the control group, the CAD group displayed significantly higher serum levels of retinol-binding protein-4 (RBP4), pentraxin 3 (PTX3), galectin-3 (GAL-3), and plasminogen activator inhibitor (PAI-1), and significantly lower levels of netrin-1 (NTN1), interleukin-37 (IL-37), and adiponectin (ADP) (all P < 0.05). PAI-1 was significantly upregulated, and IL-37 and ADP were significantly downregulated in the three-vessels CAD subgroup compared to the one- and two-vessels CAD subgroups (P < 0.05). The RBP4, PTX3, GAL-3, PAI-1, and IL-37 inflammatory cytokines were significantly positively correlated with Gensini score, and ADP was negatively correlated (all P < 0.001). IL-37 was a more accurate anti-inflammatory biomarker than NTN1 and ADP. Combining cytokines significantly increased the sensitivity and specificity. Conclusion The inflammatory adipocytokines GAL-3, RBP4, PTX3, NTN1, and IL-37 were more effective than the classical biomarkers PAI-1 and ADP in the diagnosis and risk assessment of CAD patients.

Effect of ischemic preconditioning on cardiovascular outcomes in patients with symptomatic coronary artery disease: a cohort study Background Despite the powerful myocardial protection of ischemic preconditioning (IP) observed in experimental studies, it remains a challenge to observe such protection in humans. Thus, the aim of this study was to evaluate the possible effects of IP on clinical outcomes in patients with coronary artery disease (CAD). Patients and methods In this cohort study, patients with multivessel CAD, preserved systolic ventricular function, and stable angina were prospectively selected. They underwent two sequential exercise stress tests (EST) to evaluate IP presence. IP was considered present if patients had an improvement in the time to the onset of 1.0-mm STsegment deviation in the second EST. The primary end point was the composite rate of cardiac death, nonfatal myocardial infarction, or revascularization during 1-year follow-up. Patients with (IP+) and without (IP−) the cardioprotective mechanism were compared regarding clinical end points. Results A total of 229 patients completed EST and had IP evaluated: 165 (72%) were IP+ and 64 (28%) were IP − patients. Of these, 218 patients had complete follow-up. At 1-year, event-free survival regarding the primary end point was 95.5 versus 83.6% (P = 0.0024) and event-free survival regarding cardiac death or myocardial infarction was 99.4 versus 91.7% (P=0.0020), respectively, in IP + and IP − groups. The unadjusted hazard ratio (IP + /IP−) for the primary end point was 4.63 (1.52–14.08). After multivariate analysis, IP was still significantly associated with better clinical outcomes (P = 0.0025). Conclusion This data suggest that IP may contribute to better clinical outcomes in patients with ischemic heart disease.