Vascular reactivity to mental stress is associated with poor cardiovascular disease outcomes in females following acute coronary syndrome Background: We aimed to test the hypothesis that peripheral endothelial dysfunction induced by mental stress may predict cardiovascular events after acute coronary syndrome beyond traditional cardiovascular disease risk factors. Methods: This was a prospective study in which 417 patients who had acute coronary syndrome were enrolled in two sites at the US and Qatar. Cardiovascular disease risk factors such as past medical history, blood pressure, heart rate, peripheral endothelial dysfunction, and response to three different mental stress examinations (Stroop Color Word, Arithmetic, and Spiral Omnibus) as assessed by ratio of reactive hyperemia tonometry (EndoPAT) with stress over EndoPAT at rest were obtained at baseline. Major adverse cardiac events were then recorded at 1 year after the index event. Results: There were no differences in baseline peripheral endothelial dysfunction or vascular response to mental stress between the US vs. Qatar patients. Women were more likely to experience major adverse cardiac events in the year following acute coronary syndrome (relative risk 2.42, 95% confidence interval 1.53–3.84, P = 0.044), and had a significantly lower mental stress ratio compared to women who did not (1.0 ± 0.17 vs. 1.20 ± 0.17, P = 0.04). In multivariate analyses stratified by sex, baseline peripheral endothelial dysfunction (EndoPAT < 1.7) (χ2 = 8.0, P = 0.005) and mental stress ratio (χ2 = 7.7, P = 0.006), were independently predictive of major adverse cardiac events in women, but not men. Conclusion: The current study demonstrates that in women both baseline endothelial function and vascular function in response to mental stress ratio are predictive of worse cardiovascular disease outcomes 1 year after acute coronary syndrome. The study may suggest an important mechanism for adverse clinical outcomes in women following acute coronary syndrome. Received 1 July 2019 Accepted 16 September 2019 Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website, www.coronary-artery.com. Correspondence to Amir Lerman, MD, Department of Cardiovascular Medicine, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905, USA. Tel: +1 507 255 4152; fax: +1 507 255 2550; e-mail: lerman.amir@mayo.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Anatomical features and clinical outcome of a honeycomb-like structure in the coronary artery: reports from 16 consecutive patients Background: Recanalization of thrombus in coronary artery tree is defined as a honeycomb-like structure. However, the anatomic features and appropriate treatment of honeycomb-like structure still remain largely unclear. Methods and results: Between 2014 July and 2017 December, 17 honeycomb-like structure in 16 patients based on optical coherence tomography and intravascular ultrasound were included. Fractional flow reserve was measured for patients who had thrombolysis in myocardial infarction flow grade 3. Angiographic and optical coherence tomography/intravascular ultrasound-derived variables were studied. Clinical events (until to 2018 December) were collected. Honeycomb-like structures mostly involved left anterior descending artery (68.8%) and localized at proximal-mid (88.2%) segment of vessels. Eight patients had a side branch ≥ 2 mm in diameter taking from honeycomb-like structure. Only one patient had a normal fractional flow reserve. Fifteen patients underwent implantation of a stent. Stent implantation was associated with side branch compromise or closure (4 in each). Of 4 patients with side branch closure, all had a creatine kinase myocardial band > 5 times increase in hospital, with 3 deaths and 1 target lesion revascularization during follow-up. Conclusions: Despite the presence of recanalization, most honeycomb-like structure lesion have a positive fractional flow reserve. Further study is required to address how to protect a large side branch taking from honeycomb-like structure. Received 7 March 2019 Accepted 25 August 2019 * Dr. Tian Xu, Dr. Rajiv Shrestha and Dr. Tao Pan contributed equally to the writing of this article. Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website, www.coronary-artery.com. Correspondence to Shao-Liang Chen, MD, College of Pharmacy, Division of Cardiology of Nanjing First Hospital, Nanjing Medical University, 68 Changle Road, Nanjing 210006, China Tel: +86 25 52208048; fax: +86 25 52208048; e-mail: chmengx@126.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Efficacy of nicorandil on the prevention of contrast-induced nephropathy in patients with coronary heart disease undergoing percutaneous coronary intervention Objectives: The purpose of this study was to explore the effect of nicorandil on the incidence of contrast-induced nephropathy in patients with coronary heart disease undergoing percutaneous coronary intervention. Methods: This study randomized 300 patients undergoing percutaneous coronary intervention to receive conventional treatment in the control group (hydration only; n = 150) vs. nicorandil therapy (nicorandil 10 mg three times daily plus hydration; n = 150). The primary endpoint was the incidence of contrast-induced nephropathy, defined as rise in serum creatinine ≥44.2 μmol/L or >25% above baseline within 72 hours after exposure to contrast administered during percutaneous coronary intervention. Secondary endpoints included differences in post-percutaneous coronary intervention serum creatinine, blood urea nitrogen, creatinine clearance rate, cystatin-C, and occurrence of major adverse events. Results: Contrast-induced nephropathy incidence was 3.3% (5/150) in the nicorandil group vs. 10.7% (16/150) in the control group (P < 0.05). At 48 and 72 hours after contrast administration, cystatin-C levels were significantly lower and creatinine clearance rate were significantly higher with nicroandil therapy compared to conventional treatment (all P values <0.05). No statistical difference was observed in the incidence of major post-procedure side effect events in hospital and fourteen days of follow-up period between the nicorandil group and control group (3.3% vs. 4.0%, P > 0.05). Conclusion: Compared to conventional treatment, oral nicorandil therapy was associated with less contrast-induced nephropathy and improved renal function following contrast administration during percutaneous coronary intervention. Received 21 June 2019 Accepted 10 September 2019 * Xue Zhang and Shicheng Yang are co-authors. Correspondence to Naikuan Fu, PhD, Department of Cardiology, Tianjin Chest Hospital, No. 261, Taierzhuang South Road, Jinnan District, Tianjin 300222, China Tel: +86 13820663179; fax: +86 2288185013; e-mail: cdrfnk@163.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Six months follow-up of protected high-risk percutaneous coronary intervention with the microaxial Impella pump: results from the German Impella registry Background: Percutaneous coronary intervention (PCI) represents an important alternative to coronary bypass surgery for the treatment of patients with complex coronary artery disease and high perioperative risk. Protected percutaneous coronary intervention applies temporary percutaneous ventricular assist devices to mitigate potential hemodynamic compromise in high-risk patients. The Impella system is currently the most commonly used device for protected percutaneous coronary intervention and showed improved hemodynamic parameters in earlier trials. Methods: This study was designed as a retrospective, observational multi-center registry conducted in ten hospitals in Germany. We included consecutive patients undergoing protected high-risk percutaneous coronary intervention with Impella support. The primary endpoint was defined as the occurrence of a major adverse cardiac event defined as all-cause mortality, ST-elevation myocardial infarction, or stroke during a postprocedural 180-day follow-up period. Results: In total, 157 patients (80.3% male; mean age 71.8 ± 10.8 years) were included in the present study, and 180-day follow-up was complete for 149 patients (94.9%). At baseline, the patients had a median left ventricular ejection fraction of 39.0% (interquartile range, 25.0–50.0%). The median SYNergy between PCI with TAXUS and Cardiac Surgery-Score I was 33.0 (interquartile range, 24.0–40.5) and the median EuroSCORE II was 7.2% (interquartile range, 3.2-17.1%). During postprocedural follow-up, 34 patients (22.8%) suffered a major adverse cardiac event. All-cause mortality was 18.1% (27 patients). Nine patients (6.0%) sustained a ST-elevation myocardial infarction, while 4 patients (2.7%) had a stroke. Conclusions: Patients undergoing protected high-risk percutaneous coronary intervention with Impella support showed an acceptable 180-day clinical outcome regarding major adverse cardiac event and mortality. Received 9 May 2019 Accepted 10 September 2019 Correspondence to Stefan Baumann, MD, First Department of Medicine, Faculty of Medicine Mannheim, University Medical Centre Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany Tel: +49 621 383 1417; fax: +49 621 383 2025; e-mail: stefan.baumann@umm.de Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Coronary artery dissection due to severe coronary vasospasm during ergonovine provocation test No abstract available

Weighing the potential late benefits versus early hazard associated with bioresorbable vascular scaffolds in percutaneous coronary interventions: a Markov decision analytic model Objective Use of poly-L-lactic acid-based bioresorbable scaffolds (BRS) has been associated with increased risk of device thrombosis during the first 3 years after implantation as compared to metallic everolimus-eluting stents (EES). The long-term performance of BRS relative to EES remains unknown. Methods We used a Markov decision analysis model to evaluate the effectiveness of BRS vs. EES over a lifetime horizon. In addition to one-way sensitivity analyses of key variables, we evaluated the impact of optimal implantation technique and limiting procedures to larger vessels (>2.6 mm in diameter) on model results. Results Assuming no risk of target lesion revascularization for BRS after 3 years, we found a small increment in quality-adjusted life expectancy (QALE) of 0.02 with the use of BRS relative to EES, with benefit being observed after 21.8 years. Optimal implantation technique and limiting to larger vessels resulted in larger gains in QALE (0.08 and 0.06, respectively) with BRS and shorter times to equipoise (6.7 and 8.3 years, respectively). Model results were highly sensitive to variations in the relative risk of stent thrombosis (BRS vs. EES). Conclusions Based on currently available data, it would take approximately 21.8 years for the presumed late benefits of current BRS relative to EES to overcome the early hazard associated with their use under favorable assumptions. Optimal implantation technique and limiting procedures to larger vessels improved BRS performance and reduced time to equipoise. Eliminating the higher BRS thrombosis risk is necessary in developing future generations of BRS as an acceptable alternative to EES. Received 30 July 2019 Accepted 8 September 2019 Correspondence to Reza Fazel, MD, MSc, Beth Israel Deaconess Medical Center, Division of Cardiolovascular Medicine, 185 Pilgrim Rd, Baker 4, Boston, Massachusetts, USA. Tel: +1 617 667 8800; fax: +1 617 667 1753; e-mail: rfazel@bidmc.harvard.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

CHA2DS2-Vasc score and saphenous vein graft disease in patients with coronary artery bypass graft surgery Background Saphenous vein grafts (SVGs) are still frequently used in coronary artery bypass graft surgery (CABG). However, the patency rate of SVGs is lower than arterial grafts. CHA2DS2-VASc score gives important information about the prognosis of various cardiovascular diseases. In this study, we aimed to investigate the association between CHA2DS2-VASc score and saphenous vein graft disease (SVGD) in patients with history of CABG surgery. Methods A total of 241 patients who had undergone CABG surgery and who underwent coronary angiography due to stable angina pectoris symptoms were reviewed retrospectively. SVGD was defined as ≥50% stenosis in at least one SVG. Patients were divided into two groups according to the presence or absence of SVGD. Results It was found that CHA2DS2-VASc scores were significantly higher in SVGD group. In multivariate logistic regression analysis, time interval after CABG [odds ratio (OR) = 1.077, 95% confidence interval (CI) 1.004–1.155; P = 0.037], and CHA2DS2-VASc score ≥ 4 (OR = 10.10, 95% CI 4.739–21.276; P < 0.001) were found to be independent predictors of SVGD. Conclusion For the first time, our results have suggested that CHA2DS2-VASc score, which is commonly used in daily clinical practice and easy to calculate, can provide useful information for the risk assessment of patients with SVGs. Received 8 August 2019 Accepted 8 September 2019 Correspondence to Mikail Yarlioglues, MD, Department of Cardiology, Ankara Education and Research Hospital, Altindag, Ankara 06340, Turkey. Tel: +0090545 476 63 20; fax: +0090312 363 33 96; e-mail: drmikailyar@gmail.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Automated external defibrillator use and outcomes after out-of-hospital cardiac arrest: an Israeli cohort study Background Out-of-hospital cardiac arrests (OHCA) are a serious healthcare situation with low survival rates. Application of an automated external defibrillator (AED) by bystanders shortens time to defibrillation and increases survival. In Israel, a regulation ensuring the presence of AED in public places was issued and implemented since 2014. We investigated whether this regulation had an impact on the outcomes of OHCA patients. Methods We performed a retrospective, single-center observational study. Included in the cohort were patients who were admitted to the department of intensive care cardiac unit with OHCA. Patients were stratified into two groups according to the year the regulation was introduced: group 1 (2009–2013) and group 2 (2014–2018). Results A total of 77 patients were included in group 1 and 61 in group 2. The utilization of AED was significantly higher in group 2 compared to group 1 (42% vs. 27%; P = 0.04). Compared to group 1 patients, group 2 had lower 48 h (0% vs. 8%; P = 0.02) and 30-day mortality (28% vs. 42%; P = 0.02). Cognitive damage following recovery was less frequent in group 2 (55% vs. 81%; P = 0.01). Conclusion Deployment of AEDs in public places by mandatory regulations increased utilization for OHCA and may improve outcomes. Received 21 August 2019 Accepted 2 September 2019 Correspondence to Ilan Merdler, MD MHA, Department of Cardiology, Tel-Aviv Sourasky Medical Center, 6 Weizzman St, Tel-Aviv, 64239, Israel. Tel: +97236972720; fax: +97236974808; e-mail: ilanmerdler@gmail.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Interaction of CYP2C19 G681A polymorphism and omeprazole on clopidogrel responsiveness and impact in patients with acute coronary syndrome Objective The aim of this study was to explore the individual effects of the CYP2C19 G681A polymorphism and omeprazole use and their interaction on clopidogrel responsiveness in acute coronary syndrome (ACS). The CYP2C19 G681A polymorphism and omeprazole use were both known for retarding the effects of clopidogrel under broad cardiovascular conditions; however, data from ACS patients were limited. Methods We conducted a cross-sectional study of 102 ACS patients who received clopidogrel before percutaneous coronary intervention. The platelet function was assessed by a Platelet Function Analyzer-200, in which clopidogrel hyporesponsiveness was defined as a closure time (CT) of ≤106 s. The CYP2C19 G681A polymorphism was investigated using the PCR-RFLP technique. Statistical analysis was performed by using χ2 test, Student’s t-test, binary logistic regression, and receiver-operating characteristic (ROC) curve. Results Carriages of the CYP2C19 681A allele and omeprazole use were present in 47.1 and 37.3% patients, respectively. The mean CT ± SD was 103.1 ± 1.7 s and the prevalence of clopidogrel hyporesponsiveness was 66.7%. The CT was significantly shorter in carriages of the 681A allele compared with the 681G allele (P = 0.002), but had no significant difference in patients with vs. without omeprazole use (P = 0.467). The ROC analysis of an effect on clopidogrel hyporesponsiveness of CYP2C19 G681A alone and combination with omeprazole use had area under the curve values of 0.654 and 0.672, respectively. Conclusion In ACS patients, the effect of the CYP2C19 G681A polymorphism on clopidogrel responsiveness, but not omeprazole use, is strong. However, a combination of both factors enhances clopidogrel hyporesponsiveness. Received 15 August 2019 Accepted 8 September 2019 * Sornsith Jirungda and Burabha Pussadhamma contributed equally to the writing of this article. Correspondence to Nantarat Komanasin, PhD, Cardiovascular Research Group, School of Medical Technology, Faculty of Associated Medical Sciences, Khon Kaen University, 123 Moo 16 Mittraphap Road, Nai-Muang District, Khon Kaen 40002, Thailand. Tel: +66 43 202087; fax: +66 43 202087; e-mail: nankom@kku.ac.th Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Characteristic findings of acute spontaneous coronary artery dissection by cardiac computed tomography Background: Spontaneous coronary artery dissection (SCAD) is an infrequent cause of acute coronary syndrome (ACS); however, its detection carries relevant clinical implications. Cardiac computed tomography (CCT) has been found to be useful for follow-up, but data during the acute phase are scarce. Thus, our aim was to evaluate the early diagnostic ability of CCT to detect SCAD. Methods: We retrospectively analyzed all the in-hospital CCT performed in a prospective cohort of patients with SCAD from 2012 to 2016. An independent expert blindly evaluated the studies and described the radiologic characteristics of the lesions. These features were compared with the invasive coronary angiography (ICA) and optical coherence tomography (OCT) findings. Results: 18 lesions were analyzed from 12 episodes identified in 11 patients (100% females; median age of 57 years old). CCT recognized the presence of SCAD in 14 (78%) of the lesions, with four different morphological patterns. Most commonly (10, 71%) SCAD presented as a diffuse lumen narrowing surrounded by a ‘sleeve-like’ wall thickening, which corresponded to intramural hematoma in OCT evaluation. When compared with ICA, CCT showed a positive correlation (Spearman’s Rho = 0.775; P = 0.001) and excellent concordance (ICC = 0.8; P = 0.004) in stenosis grading, but not for lesion length and minimal luminal area. Conclusion: CCT was able to identify the presence of SCAD in most of the patients in the acute phase of this elusive and challenging clinical entity. In addition, in this setting, CCT revealed unique and distinct radiologic features and provided a precise assessment of lesion severity. Received 24 April 2019 Accepted 7 September 2019 Correspondence to Fernando Alfonso, MD, PhD, Cardiology Department, Hospital Universitario de La Princesa, Calle de Diego León, 62, 28006 Madrid, Spain. Tel: +34686668539; fax: +34 915202201; e-mail: falf@hotmail.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.