Diagnostic performance of intravascular ultrasound-based fractional flow reserve in evaluating of intermediate left main stenosis

BACKGROUND The recently introduced ultrasonic flow ratio(UFR),is a novel fast computational method to derive fractional flow reserve(FFR)from intravascular ultrasound(IVUS)images.In the present study,we evaluate the diagnostic performance of UFR in patients with intermediate left main(LM)stenosis.METHODS This is a prospective,single center study enrolling consecutive patients with presence of intermediated LM lesions(diameter stenosis of 30%-80%by visual estimation)underwent IVUS and FFR measurement.An independent core laboratory assessed offline UFR and IVUS-derived minimal lumen area(MLA)in a blinded fashion.RESULTS Both UFR and FFR were successfully achieved in 41 LM patients(mean age,62.0±9.9 years,46.3%diabetes).An acceptable correlation between UFR and FFR was identified(r=0.688,P<0.0001),with an absolute numerical difference of 0.03(standard difference:0.01).The area under the curve(AUC)in diagnosis of physiologically significant coronary stenosis for UFR was 0.94(95%CI:0.87-1.01),which was significantly higher than angiographic identified stenosis>50%(AUC=0.66,P<0.001)and numerically higher than IVUS-derived MLA(AUC=0.82;P=0.09).Patient level diagnostic accuracy,sensitivity and specificity for UFR to identify FFR≤0.80 was 82.9%(95%CI:70.2-95.7),93.1%(95%CI:82.2-100.0),58.3%(95%CI:26.3-90.4),respectively.CONCLUSION In patients with intermediate LM diseases,UFR was proved to be associated with acceptable correlation and high accuracy with pressure wire-based FFR as standard reference.The present study supports the use of UFR for functional evaluation of intermediate LM stenosis.

The prognostic value of collateral circulation in coronary chronic total occlusion underwent percutaneous coronary intervention

BACKGROUND The prognostic value of coronary collateral circulation(CC)in patients undergoing chronic total occlusion(CTO)percutaneous coronary intervention(PCI)is underdetermined.The purpose of the study was to assess the prognostic value of current two CC grading systems and their association with long-term outcomes in patients with CTO underwent PCI.METHODS We consecutively enrolled patients with single-vessel CTO underwent PCI between January 2010 and December2013.All patients were categorized into well-developed or poor-developed collaterals group according to angiographic Werner's CC(grade 2 vs.grade 0–1)or Rentrop(grade 3 vs.grade 0–2)grading system.The primary endpoint was 5-year cardiac death.RESULTS Of 2452 enrolled patients,the overall technical success rate was 74.1%.Well-developed collaterals were present in686 patients(28.0%)defined by Werner's CC grade 2,and in 1145 patients(46.7%)by Rentrop grade 3.According to Werner's CC grading system,patients with well-developed collaterals had a lower rate of 5-year cardiac death compared with those with poordeveloped collaterals(1.6%vs.3.3%,P=0.02),those with suboptimal recanalization was associated with higher rate of 5-year cardiac death compared with optimal recanalization(4.7%vs.0.8%,P=0.01)and failure patients(4.7%vs.1.6%,P=0.12).However,the similar effect was not shown in Rentrop grading system.CONCLUSIONS In patients with the single-vessel CTO underwent PCI,well-developed collaterals by Werner's CC definition were associated with lower rate of 5-year cardiac death.Werner's CC grading system had a greater prognostic value than Rentrop grading system in patients with CTO underwent PCI.

Invasive versus conservative strategy in consecutive patients aged 80 years or older with non-ST-segment elevation myocardial infarction: a retrospective study in China

Objective To investigate whether the very elderly patients with non-ST-segment elevation myocardial infarction (NSTEMI) will benefit from an invasive strategy versus a conservative strategy. Methods 190 consecutive patients aged 80 years or older with NSTEMI were included in the retrospective study from September 2014 to August 2017, of which 69 patients received conservative strategy and 121 patients received invasive strategy. The primary outcome was death. Multivariate Cox regression models were used to assess the statistical association between strategies and mortality. The survival probability was further analyzed. Results The primary outcome occurred in 17.4% patients in the invasive group and in 42.0% patients in the conservative group (P = 0.0002). The readmission rate in the invasive group (14.9%) was higher than that in the conservative group (7.2%). Creatinine level (OR = 1.01, 95% CI: 0.10–1.03, P = 0.05) and use of diuretic (OR = 3.65, 95% CI: 1.56–8.53, P = 0.003) were independent influential factors for invasive strategy. HRs for multivariate Cox regression models were 3.45 (95% CI: 1.77–6.75, P = 0.0003), 3.02 (95% CI: 1.52–6.01, P = 0.0017), 2.93 (95% CI: 1. 46–5.86, P = 0.0024) and 2.47 (95% CI: 1.20–5.07, P = 0.0137). Compared with the patients received invasive strategy, the conservative group had remarkably reduced survival probability with time since treatment (P < 0.001). Conclusions An invasive strategy is superior to a conservative strategy in reducing mortality of patients aged 80 years or older with NSTEMI. Our results suggest that an invasive strategy is more suitable for the very elderly patients with NSTEMI in China.

The effectiveness and safety of the RESTORE R drug-eluting balloon versus a drug-eluting stent for small coronary vessel disease： study protocol for a multi-center, randomized, controlled trial

bjective Small coronary vessel disease （disease affecting coronary vessels with main branch diameters of 〈 2.75 mm） is a common and intractable problem in percutaneous coronary intervention （PCI）. This study was designed to test the theory that the effectiveness and safety of drug-eluting balloons for the treatment of de novo lesions in small coronary vessels are non-inferior to those of drug-eluting stents. Methods We designed a prospective, multicenter, randomized, controlled clinical trial aiming to assess the effectiveness and safety of the RESTORE R （Cardionovum, Bonn, Germany） drug-eluting balloon （DEB） versus the RESOLUTE R （Medtronic, USA） drug-eluting stent （DES） in the treatment of small coronary vessel disease. This trial started in August 2016. A total of 230 patients with a reference vessel diameter （RVD） 〉 2.25 mm and 〈 2.75 mm were randomly assigned to treatment with a DEB or a DES at a 1：1 ratio. The study was also designed to enroll 30 patients with an RVD 〉 2.00 mm and 〈 2.25 mm in the tiny vessel cohort. Results The key baseline data include demographic characteristics, relative medical history, baseline angiographic values and baseline procedural characteristics. The primary endpoint is in-segment diameter stenosis at nine months after the index procedure. Secondary endpoints include acute success, all-cause death, myocardial infarction, target vessel revascularization, target lesion revascularization and stent thrombosis. Conclusions The study will evaluate the clinical efficacy, angiographic outcomes, and safety of DEBs compared to DESs in the treatment of de novo coronary artery lesions in small vessels.

Factors Associated with Coronary Artery Disease in Young Population(Age≤40):Analysis with 217 Cases

Objective To investigate the relevant factors of coronary artery disease （CAD） in young people under 40 years of age. Methods The study population was 292 young patients accepting coronary angiography in Fuwai Hospital from July to December 2006, including 272 men and 20 women, with the mean age being 36.7±3.7 years. The diagnosis of CAD was made in the cases presenting ~ 50% stenosis in coronary lumen in coronary angiography. Based on the diagnosis, 217 patients （204 men, 13 women） were assigned to CAD group, and 75 （68 men, 7 women） to non-CAD group. Clinical data and metabolic characteristics of the patients were collected and analyzed using t-test, Z2 test, and multinomial logistic regression with SPSS 8.0 software. Results Most study subjects were current smokers （209/292, 71.6%）, and more than half had body mass index （BMI）〉24 kg/m2 （230/292, 78.8%） and usually took high-fat diet （162/292, 55.5%）. The proportion of heavy smokers （smoking history ≥10 years and t〉20 cigarettes per clay） were significantly higher in the CAD group than in the non-CAD group [20.7% （45/217） vs. 9.3% （7/75）, P=0.015）]. Heavy smoking [odds ratio （OR）, 1.89; 95% confidence interval （CI）, 1.74-2.05], hypertension （OR, 1.56; 95% CI, 1.48-1.65）, alcohol （OR, 1.37; 95% CI, 1.30-1.46）, type 2 diabetes mellitus （OR, 1.37; 95% CI, 1.25-1.50）, high-fat diet （OR, 1.35; 95% CI, 1.28-1.43）, and BMI〉24 kg/m2 （OR, 1.09; 95% CI, 1.03-1.17） were factors related to CAD in the young patients （all P〈0.05）. Total cholesterol （4.56_±1.46 mmol/L vs. 4.09_±1.00 mmol/L）, low-density lipoprotein cholesterol （2.38±1.11 mmol/L vs. 2.14±0.63 rnmol/L）, lipoprotein a （134.97±109.70 mg/L vs. 101.58±58.39 mg/L）, uric acid （359.89_±100.09 μmol/L vs. 336.75±94.36 μmol/L）, erythrocyte sedimentation rate （9.98± 12.19 ram/hour vs. 4.89_±4.92 mm/hour）, high-sensitivity C-reactive protein （3.42±4.39 mg/L vs. 2.80±_3.77 mg/L） and Big endothelin-1 （1.41±1.50 fmol/mL vs. 0.77_±1.13 fmol/mL） in plasma were significantly increased in the CAD group compared with the non-CAD group （all P〈0.05）. Conclusions Heavy smoking, hypertension, alcohol consumption, type 2 diabetes mellitus, high-fat diet and BMI〉24 kg/m2 were significantly related to CAD in patients aged ≤40, with heavy smoking presenting the highest OR. Metabolic syndrome and inflammation were also more common in young CAD patients than in non-CAD patients.

Effects of chronic obstructive pulmonary disease on longterm prognosis of patients with coronary heart disease postpercutaneous coronary intervention

BACKGROUND Chronic obstructive pulmonary disease(COPD)and cardiovascular diseases are often comorbid conditions,their co-occurrence yields worse outcomes than either condition alone.This study aimed to investigate COPD impacts on the five-year prognosis of patients with coronary heart disease(CHD)after percutaneous coronary intervention(PCI).METHODS Patients with CHD who underwent PCI in 2013 were recruited,and divided into COPD group and non-COPD group.Adverse events occurring among those groups were recorded during the five-year follow-up period after PCI,including all-cause death and cardiogenic death,myocardial infarction,repeated revascularization,as well as stroke and bleeding events.Major adverse cardiac and cerebral events were a composite of all-cause death,myocardial infarction,repeated revascularization and stroke.RESULTS A total of 9843 patients were consecutively enrolled,of which 229 patients(2.3%)had COPD.Compared to non-COPD patients,COPD patients were older,along with poorer estimated glomerular filtration rate and lower left ventricular ejection fraction.Five-year follow-up results showed that incidences of all-cause death and cardiogenic death,as well as major adverse cardiac and cerebral events,for the COPD group were significantly higher than for non-COPD group(10.5%vs.3.9%,7.4%vs.2.3%,and 30.1%vs.22.6%,respectively).COPD was found under multivariate Cox regression analysis,adjusted for confounding factors,to be an independent predictor of all-cause death[odds ratio(OR)=1.76,95%CI:1.15-2.70,P=0.009]and cardiogenic death(OR=2.02,95%CI:1.21-3.39,P=0.007).CONCLUSIONS COPD is an independent predictive factor for clinical mortality,in which CHD patients with COPD are associated with worse prognosis than CHD patients with non-COPD.

Long-term follow-up of antithrombotic management patterns in patients with acute coronary syndrome in China

Objective To describe the long-term antithrombotic management patterns(AMPs)and clinical outcomes of Chinese patients with acute coronary syndrome(ACS).Methods This was an observational,multicenter,longitudinal cohort extension study of Chinese patients who had completed the EPICOR Asia 2-year follow-up study post-hospitalization for an ACS event.Changes in AMP and clinical outcomes for up to 5 years post-ACS event were evaluated.Results Overall,2334 patients with ACS were enrolled at 49 sites.The mean age was 61.6 years and 76.3%were men.By study end,2093 patients completed the 3-year follow-up.At baseline(2 years post-ACS event),72.4%of patents received one antiplatelet(AP)medication,with aspirin being the preferred one.A small proportion of patients(21.5%)was treated with two or more APs(2+AP),and even fewer patients(6.1%)did not receive any AP medication at baseline.Upon study completion,the proportion of patients without AP therapy increased to 13.6%,while the percentage of patients on one AP and 2+AP decreased to 69.3%and 17.1%,respectively.Numerically,a higher incidence of clinical events(composite of all-cause mortality,myocardial infarction,stroke)was observed for the 2+AP(13.2%)subgroup than for the no AP(10.5%)and one AP(8.6%)subgroups.Furthermore,the 2+AP subgroup exhibited the greatest number of bleeding events,outpatient visits,and hospitalization rates.Unlike myocardial infarction or stroke,bleeding events prompted an adjustment in AMP.Conclusion Most patients in China received at least one AP medication up to 5 years after an ACS event.

Effects of metabolic syndrome on onset age and long-term outcomes in patients with acute coronary syndrome

BACKGROUND: We aim to investigate effects of metabolic syndrome on onset age and long-termoutcomes in patients with acute coronary syndrome (ACS).METHODS: Patients with ACS (n=6,431) who underwent percutaneous coronary interventionfrom January to December 2013 were enrolled. After excluding patients with previous coronary arterydisease, 1,558 patients were diagnosed with early-onset ACS (men aged ≤50 years;women aged≤60 years) and 3,044 patients with late-onset ACS. Baseline characteristics and five-year clinicaloutcomes were measured.RESULTS: Body mass index, triglyceride, low-density lipoprotein cholesterol, and uric acidconcentrations were significantly higher, while the high-density lipoprotein cholesterol (HDL-C)concentration was lower in the early-onset ACS group (P<0.001). Multivariate logistic regression revealedobesity (odds ratio [OR] 1.590, 95% confi dence interval [CI] 1.345–1.881), hypertriglyceridemia (OR 1.403,95% CI 1.185–1.660), and low HDL-C (OR 1.464, 95% CI 1.231–1.742) as independent risk factorsfor early-onset ACS (all P<0.001). The fi ve-year follow-up showed that the incidences of all cause death(1.5% vs. 3.8%, P<0.001), cardiac death (1.1% vs. 2.0%, P=0.023), and recurrent stroke (2.2% vs. 4.2%,P<0.001) were lower, while bleeding events were more frequent in the early-onset ACS group. A subgroupanalysis showed higher incidences of recurrent myocardial infarction (MI) and revascularization in patientswith early-onset ACS and metabolic syndrome.CONCLUSIONS: Obesity, hypertriglyceridemia, and lower HDL-C level are independent riskfactors for early-onset ACS, recurrent MI, and revascularization. The control of metabolic syndromemay reduce the incidence of early-onset ACS and improve the long-term prognosis.

Effect of Intracoronary Infusion of Bone Marrow Mononuclear Cells or Peripheral Endothelial Progenitor Cells on Myocardial Ischemia-reperfusion Injury in Mini-swine

Objective To simulate and assess the clinical effect of intracoronary infusion of bone marrow mononuclear cells or peripheral endothelial progenitor cells on myocardial reperfusion injury in mini-swine model. Methods Twenty-three mini-swine with myocardial reperfusion injury were used as designed in the study protocol. About （3.54±0.90）×10^7 bone marrow mononuclear cells （MNC group, n=9） or （1.16± 1.07）× 10^7 endothelial progenitor cells （EPC group, n=7） was infused into the affected coronary segment of the swine. The other mini-swine were infused with phosphate buffered saline as control （n=7）. Echocardio- graphy and hemodynamic studies were performed before and 4 weeks after cell infusion. Myocardium infarc- tion size was calculated. Stem cell differentiation was analyzed under a transmission electromicroscope. Results Left ventricular ejection fraction dropped by 0% in EPC group, 2% in MNC group, and 10% in the control group 4 weeks after cell infusion, respectively （P〈0.05）. The systolic parameters increased in MNC and EPC groups but decreased in the control group. However, the diastolic parameters demonstrated no significant change in the three groups （P〉0.05）. EPC decreased total infarction size more than MNC did （1.60±0.26 cm2 vs. 3.71±1.38 cm2, P〈0.05）. Undermature endothelial cells and myocytes were found under transmission electromlcroscope. Conclusions Transplantation of either MNC or EPC may be beneficial to cardiac systolic function, but might not has obvious effect on diastolic function. Intracoronary infusion of EPC might be better than MNC in controlling infarction size. Both MNC and EPC may stimulate angiogenesis, inhibit flbrogenesis, and differentiate into myocardial cells.

IMPLANTATION OF AUTOLOGOUS BONE MARROW MONONUCLEAR CELLS INTO ISCHEMIC MYOCARDIUM ENHANCES CORONARY CAPILLARIES AND SYSTOLIC FUNCTION IN MINISWINE

Objective To investigate the therapeutic effectiveness of intracoronary implantation of autologous bone marrow mononuclear cells (BM-MNC) in miniswine model of reperfused myocardial infarction. Methods Sixteen miniswine myocardial ischemic reperfusion injury models made by ligation of the distal one third segment of left anterior descending artery for 90 minutes were randomized into 2 groups. In BM-MNC group (n = 9), (3.54±0.90)×108 BM-MNC were intracoronary injected, and in the control group (n = 7), phosphate buffered saline was injected by the same way. Echocardiographic and hemodynamic results, vessel density, and myocardial infarction size were evaluated and compared before and 4 weeks after cell transplantation. Results In BM-MNC group, there were no differences between before and 4 weeks after transplantation in aspects of left ventricular ejection fraction (LVEF), interventricular septal thickness, left ventricular lateral and anterior septal wall thickness, cardiac output, or +dp/dtmax. In control group, LVEF, interventricular septal thickness, left ventricular lateral and anterior septal wall thickness, cardiac output, and +dp/dtmax decreased significantly 4 weeks after transplantation (P < 0.05). Left ventricular end-diastolic pressure and –dp/dtmax did not change significantly before and after cell transplantation in both groups. Capillary density in BM-MNC group was greater than that in control group [(13.39 ± 6.96)/high power field vs. (3.50 ± 1.90)/high power field, P < 0.05]. Infarction area assessed by tetrazolium red staining and the infarction percentage decreased in BM-MNC group compared with those in control group (P < 0.05). Conclusions Transplantation of BM-MNC into myocardium with ischemic reperfusion injury increases capillary density and decreases infarction area. It has significantly beneficial effect on cardiac systolic function rather than on diastolic function.

Nine-year clinical outcomes of drug-eluting stents vs. bare metal stents for large coronary vessel lesions

Objectives To evaluate the very long-term safety and effectiveness of drug-eluting stents （DES） compared to bare-metal stents （BMS） for patients with large coronary vessels. Methods From April 2004 to October 2006, 2407 consecutive patients undergoing de novo lesion percutaneous coronary intervention with reference vessel diameter greater than or equal to 3.5 mm at Fu Wai Hospital in Beijing, China, were prospectively enrolled into this study. We obtained 9-year clinical outcomes including death, myocardial infarction （MI）, thrombosis, target lesion revascularization （TLR）, target vessel revascularization （TVR）, and major adverse cardiac events （MACE, the composite of death, MI, and TVR）. We performed Cox＇s proportional-hazards models to assess relative risks of all the outcome measures after propensity match. Results After propensity scoring, 514 DES-treated patients were matched to 514 BMS-treated patients. The patients treated with BMS were associated with higher risk ofTLR （HR： 2.55, 95%CI： 1.520-4.277, P = 0.0004） and TVR （HR： 1.889, 95%CI： 1.185-3.011, P = 0.0075）, but the rates of death/MI and MACE were not statistically different. All Academic Research Consortium definition stent thrombosis at 9-year were comparable in the two groups. Conclusions During long-term follow-up through nine years, use of DES in patients with large coronary arteries was still associated with significant reductions in the risks of TLR and TVR.

Prolonged dual antiplatelet therapy after drug-eluting stent implantation improves long-term prognosis for acute coronary syndrome:five-year results from a large cohort study

BACKGROUND:To investigate the most appropriate dual antiplatelet therapy(DAPT)duration for patients with acute coronary syndrome(ACS)after drug-eluting stent(DES)implantation in the largest cardiovascular center of China.METHODS:We enrolled 5,187 consecutive patients with ACS who received DES from January to December 2013.Patients were divided into four groups based on DAPT duration:standard DAPT group(11-13 months,n=1,568)and prolonged DAPT groups(13-18 months[n=308],18-24 months[n=2,125],and>24 months[n=1,186]).Baseline characteristics and 5-year clinical outcomes were recorded.RESULTS:Baseline characteristics were similar across the four groups.Among the four groups,those with prolonged DAPT(18-24 months)had the lowest incidence of major adverse cardiovascular and cerebrovascular events(MACCEs)(14.1%vs.11.7%vs.9.6%vs.24.2%,P<0.001),all-cause death(4.8%vs.3.9%vs.2.1%vs.2.6%,P<0.001),cardiac death(3.1%vs.2.6%vs.1.4%vs.1.9%,P=0.004),and myocardial infarction(MI)(3.8%vs.4.2%vs.2.5%vs.5.8%,P<0.001).The incidence of bleeding was not different among the four groups(9.9%vs.9.4%vs.11.0%vs.9.4%,P=0.449).Cox multivariable analysis showed that prolonged DAPT(18-24 months)was an independent protective factor for MACCEs(hazard ratio[HR]0.802,95%confidence interval[CI]0.729-0.882,P<0.001),all-cause death(HR 0.660,95%CI 0.547-0.795,P<0.001),cardiac death(HR 0.663,95%CI 0.526-0.835,P<0.001),MI(HR 0.796,95%CI 0.662-0.957,P=0.015),and target vessel revascularization(HR 0.867,95%CI 0.755-0.996,P=0.044).Subgroup analysis for high bleeding risk showed that prolonged DAPT remained an independent protective factor for all-cause death and MACCEs.CONCLUSION:For patients with ACS after DES,appropriately prolonging the DAPT duration may be associated with a reduced risk of adverse ischemic events without increasing the bleeding risk.

Comparison of outcomes for percutaneous coronary intervention in men and women with unprotected left main disease

BACKGROUND Percutaneous coronary intervention(PCI)in patients with unprotected left main coronary artery disease(ULMCAD)is increasing strategy in coronary artery patients.However,there is a lack of knowledge on the impact of sex on outcomes of patients undergoing ULMCAD PCI.METHODS From January 2004 to December 2015,there were 3,960 patients undergoing ULMCAD PCI at our institution,including 3,121(78.8%)men and 839(21.2%)women.The clinical outcome included the incidence of major adverse cardiac events(MACE)(the composite of all-cause death,myocardial infarction(MI),and revascularization),all-cause death,MI,revascularization at three years follow-up.RESULTS Compared with men,women had not significantly different MACE(14.7%vs.14.6%,P=0.89),all-cause death(3.5%vs.3.7%,P=0.76),MI(5.0%vs.4.3%,P=0.38),revascularization(9.1%vs.8.9%,P=0.86),respectively.After adjustment,rates of MACE(HR=1.49;95%CI:1.24−1.81;P<0.0001)and all-cause death(HR=1.65;95%CI:1.09−2.48;P=0.017)occurred more frequently in male patients,as well as revascularization(HR=1.46;95%CI:1.16−1.85;P=0.001).CONCLUSION In this analysis,compared to men,women undergoing ULMCAD PCI have better outcomes of MACE,allcause death,and revascularization.

Comparing of Light Transmittance Aggregometry and Modified Thrombelastograph in Predicting Clinical Outcomes in Chinese Patients Undergoing Coronary Stenting with Clopidogrel

Background:Several platelet function tests are currently used to measure responsiveness to antiplatelet therapy.This study was to compare two tests,light transmittance aggregometry (LTA) and modified thrombelastography (mTEG),for predicting clinical outcomes in Chinese patients after percutaneous coronary intervention (PCI).Methods:Prospective,observational,single-center study of 789 Chinese patients undergoing PCI was enrolled.This study was investigated the correlations between the two tests and performed receiver operating characteristic curve (ROC) analysis for major adverse cardiovascular events (MACEs) at 1-year follow-up.Results:MACEs occurred in 32 patients (4.1％).Correlations were well between the two tests in the adenosine diphosphate induced platelet reactivity (Spearman r =0.733,P ＜ 0.001).ROC-curve analysis demonstrated that LTA (area under the curve [AUC]:0.677; 95％ confidence interval [CI]:0.643-0.710; P =0.0009),and mTEG (AUC:0.684; 95％ CI:0.650-0.716; P =0.0001) had moderate ability to discriminate between patients with and without MACE.MACE occurred more frequently in patients with high on-treatment platelet reactivity (HPR) when assessed by LTA (7.4％ vs.2.7％; P ＜ 0.001),and by TEG (6.7％ vs.2.6％; P ＜ 0.001).Kaplan-Meier analysis demonstrated that HPR based on the LTA and mTEG was associated with almost 3-fold increased risk of MACE at 1-year follow-up.Conclusions:The correlation between LTA and mTEG is relatively high in Chinese patients.HPR measured by LTA and mTEG were significantly associated with MACE in Chinese patients undergoing PCI.

Relationship between fibrinogen levels and cardiovascular events in patients receiving percutaneous coronary intervention:a large single-center study

Background:It is currently unclear if fibrinogen is a risk factor for adverse events in patients receiving percutaneous coronary intervention(PCI)or merely serves as a marker of pre-existing comorbidities and other causal factors.We therefore investigated the association between fibrinogen levels and 2-year all-cause mortality,and compared the additional predictive value of adding fibrinogen to a basic model including traditional risk factors in patients receiving contemporary PCI.Methods:A total of 6293 patients undergoing PCI with measured baseline fibrinogen levels were enrolied from January to December 2013 in Fuwai Hospital.Patients were divided into three groups according to tertiles of baseline fibrinogen levels:low fibrinogen,<2.98 g/L;medium fibrinogen,2.98 to 3.58 g/L;and high fibrinogen,≥3.58 g/L.Independent predictors of 2-year clinical outcomes were determined by multivariate Cox proportional hazards regression modeling.The increased discriminative value of fibrinogen for predicting all-cause mortality was assessed using the C-statistic and integrated discrimination improvement(IDI).Results:The 2-year all-cause mortality rate was 1.2%.It was significantly higher in the high fibrinogen compared with the low and medium fibrinogen groups according to Kaplan-Meier analyses(1.7%vs.0.9%and 1.7%vs.1.0%,respectively;log-rank,P=0.022).Fibrinogen was significantly associated with all-cause mortality according to multivariate Cox regression(hazard ratio 1.339,95%confidence interval:1.109-1.763,P=0.005),together with traditional risk factors including age,sex,diabetes mellitus,left ventricular ejection fraction,creatinine clearance,and low-density lipoprotein cholesterol.The area under the curve for all-cause mortality in the basic model including traditional risk factors was 0.776,and this value increased to 0.787 when fibrinogen was added to the model(IDI=0.003,Z=0.140,P=0.889).Conclusions:Fibrinogen is associated with 2-year all-cause mortality in patients receiving PCI,but provides no additional information over a model including traditional risk factors.

Risk Factors of Contrast-induced Acute Kidney Injury in Patients Undergoing Emergency Percutaneous Coronary Intervention

Background： Previous studies of contrast-induced acute kidney injury （CI-AK1） were mostly based on selective percutaneous coronary intervention （PCI） cases, and risk factors of CI-AKI after emergency PCI are unclear. The aim of this study was to explore the risk factors of CI-AKi in a Chinese population undergoing emergency PCI. Methods： A total of 1061 consecutive patients undergoing emergency PCI during January 2013 and June 2015 were enrolled and divided into CI-AK1 and non-CI-AKl group. Univariable and multivariable analyses were used to identity the risk factors of CI-AKI in emergency PCI patients. CI-AKI was defined as an increase in serum creatinine ≥25% or ≥0.5 mg/dl （44.2 μmol/L） above baseline within 3 days alter exposure to contrast medium. Results： The incidence of C1-AKI in patients undergoing emergency PCI was 22.7% （241/1061）. Logistic multivariable analysis showed that body surface area （BSA） （odds ratio [OR] 0.213, 95% confidence interval [CI]： 0.075-0.607, P = 0.004）, history, of myocardial infarction （MI） （OR 1.642, 95% CI. 1.079-2.499, P- 0.021 ）, left ventricular ejection fraction （LVEF） （OR 0.969, 95% CI： 0.944-0.994, P = 0.015）, hemoglobin （Hb） （OR 0.988, 95% CI. 0.976-1.000, P 1.018 1.037, P 〈 0.001 ）, left anterior descending （LAD） stented （OR 1 0.009 0.987, P- 0.049）, and diuretics use （OR 1.850, 95% CI： 1.233-2 0.045）, estimated glomerular filtration rate （OR 1.027, 95% CI： 464, 95% CI： 1.000 2.145, P 0.050）, aspirin （OR 0.097, 95%CI： .777, P - 0.003） were independent predictors of CI-AKI in patients undergoing emergency PCI. Conclusion： History of MI, low BSA, LVEF and Hb level, LAD stented, and diuretics use are associated with increased risk of CI-AK1 in patients undergoing emergency PCI.

Impact of Proton-pump Inhibitors on the Pharmacodynamic Effect and Clinical Outcomes in Patients Receiving Dual Antiplatelet Therapy after Percutaneous Coronary Intervention： A Propensity Score Analysis

Background：Prior studies have reported controversial conclusions regarding the risk of adverse cardiovascular events in patients using proton-pump inhibitors （PPIs） combined with clopidogrel therapy,causing much uncertainty in clinical practice.We sought to evaluate the safety of PPIs use among high-risk cardiovascular patients who underwent percutaneous coronary intervention （PCI） in a long-term follow-up study.Methods：A total of 7868 consecutive patients who had undergone PCI and received dual antiplatelet therapy （DAPT） at a single center from January 2013 to December 2013 were enrolled.Adenosine diphosphate （ADP）-induced platelet aggregation inhibition was measured by modified thromboelastography （mTEG） in 5042 patients.Propensity score matching （PSM） was applied to control differing baseline factors.Cox proportional hazards regression was used to evaluate the 2-year major adverse cardiovascular and cerebrovascular events （MACCEs）,as well as individual events,including all-cause death,myocardial infarction,unplanned target vessel revascularization,stent thrombosis,and stroke.Results：Among the whole cohort,27.2% were prescribed PPIs.The ADP-induced platelet aggregation inhibition by mTEG was significantly lower in PPI users than that in non-PPI users （42.0 ± 30.9% vs.46.4 ± 31.4%,t =4.435,P 〈 0.001）.Concomitant PPI use was not associated with increased MACCE through 2-year follow-up （12.7% vs.12.5%,x2 =0.086,P =0.769）.Other endpoints showed no significant differences after multivariate adjustment,regardless of PSM.Conclusion：In this large cohort of real-world patients,the combination of PPIs with DAPT was not associated with increased risk of MACCE in patients who underwent PCI at up to 2 years of follow-up.

Relationship between High Level of Estimated Glomerular Filtration Rate and Contrast-Induced Acute Kidney Injury in Patients who Underwent an Emergency Percutaneous Coronary Intervention

Background： Mounts of studies have shown that low estimated glomerular filtration rate （eGFR） is associated with increased risk of adverse outcomes in patients with coronary artery disease. However, high level of eGFR was less reported. In the study, we aimed to explore the relationship between the baseline eGFR, especially the high level, and contrast-induced acute kidney injury （CI-AKI） in a Chinese population who underwent an emergency percutaneous coronary intervention （PCI）. Methods： Patients who underwent an emergency PCI from 2013 to 2015 were enrolled and divided into five groups as eGFR decreasing. Baseline characteristics were collected and analyzed. The rates of CI-AKI and the composite endpoint （including nonfatal myocardial infarction, revascularization, stroke, and all-cause death） at 6- and 12-month follow-up were compared. Logistic analysis for CI-AKI was performed.Results： A total of 1061 patients were included and the overall CI-AKI rate was 22.7% （241 / 1061）. The separate rates were 77.8% （7/9） in Group 1 （eGFR 〉 120 ml·min^-1 -1.73 m^-2）, 26.0% （118/454） in Group 2 （120 ml·min^-1·min^-11.73 m^-2〉 eGFR≥90 ml·min^-1 1.73^-2）, 18.3% （86/469） in Group 3 （90 ml·min^-1 1.73 m^-2〉 eGFR 〉60 ml·min^-1·min^-11.73 m^-2）, 21.8% （26/119） in Group 4 （60 ml·min^-1·1.73 m^-2〉 eGFR≥30 ml·min^-1·min^-11.73 m^-2）, and 40.0% （4/10） in Group 5 （eGFR 〈30 ml·min^-1·min^-1·min^-11.73 m^-2）, with statistical significance （χ^2 = 25.19, P 〈 0.001）. The rates of CI-AKI in five groups were 77.8%, 26.0%, 18.3%, 21.8%, and 40.0%, respectively, showing a U-typed curve as eGFR decreasing （the higher the level of eGFR, the higher the CI-AKI occurrence in case ofeGFR_〉60 ml·min^-1·1.73 m^-2）. The composite endpoint rates in five groups were 0, 0.9%, 2.1%, 6.7%, and 0 at 6-month follow-up, respectively, and 0, 3.3%, 3.4%, 16.0%, and 30.0% at 12-month follow-up, respectively, both with significant differences （χ^2 = 16.26, P = 0.009 at 6-month follow-up, and χ^2 = 49.05, P 〈 0.001 at 12-month follow-up）. The logistic analysis confirmed that eGFR was one of independent risk factors of CI-AKI in emergency PCI patients. Conclusions： High level ofeGFR might be associated with increased risk of CI-AKI in patients with emergency PCI, implying for future studies and risk stratification in clinical practice.

Impacts of smoking status on the clinical outcomes of coronary non-target lesions in patients with coronary heart disease:a single-center angiographic study

Background:Coronary atherosclerotic plaque could go through rapid progression and induce adverse cardiac events.This study aimed to evaluate the impacts of smoking status on clinical outcomes of coronary non-target lesions.Methods:Consecutive patients with coronary heart disease who underwent two serial coronary angiographies were included.All coronary non-target lesions were recorded at first coronary angiography and analyzed using quantitative coronary angiography at both procedures.Patients were grouped into non-smokers,quitters,and smokers according to their smoking status.Clinical outcomes including rapid lesion progression,lesion re-vascularization,and myocardial infarction were recorded at second coronary angiography.Multivariable Cox regression analysis was used to investigate the association between smoking status and clinical outcomes.Results:A total of 1255 patients and 1670 lesions were included.Smokers were younger and more likely to be male compared with nonsmokers.Increase in percent diameter stenosis was significantly lower(2.7[0.6,7.1]%vs.3.5[0.9,8.9]%)and 3.4[1.1,7.7]%,P=0.020)in quitters than those in smokers and non-smokers.Quitters tended to have a decreased incidence of rapid lesions progression(15.8%[76/482]vs.21.6%[74/342]and 20.6%[89/431],P=0.062),lesion re-vascularization(13.1%[63/482]vs.15.5%[53/432]and 15.5%[67/431],P=0.448),lesion-related myocardial infarction(0.8%[4/482]vs.2.6%[9/342]and 1.4%[6/431],P=0.110)and all-cause myocardial infarction(1.9%[9/482]vs.4.1%[14/342]and 2.3%[10/431],P=0.128)compared with smokers and non-smokers.In multivariable analysis,smoking status was not an independent predictor for rapid lesion progression,lesion re-vascularization,and lesion-related myocardial infarction except that a higher risk of all-cause myocardial infarction was observed in smokers than non-smokers(hazards ratio:3.00,95%confidence interval:1.04-8.62,P=0.042).Conclusion:Smoking cessation mitigates the increase in percent diameter stenosis of coronary non-target lesions,meanwhile,smokers are associated with increased risk for all-cause myocardial infarction compared with non-smokers.

Validation of Predictive Value of Patterns of Nonadherence to Antiplatelet Regimen in Stented Patients Thrombotic Risk Score in Chinese Population Undergoing Percutaneous Coronary Intervention:A Prospective Observational Study

Background: The patterns of nonadherence to antiplatelet regimen in stented patients(PARIS) thrombotic risk score are a novel score for predicting the risk of coronary thrombotic events(CTEs) after percutaneous coronary intervention(PCI) with drug?eluting stents.However, the prognostic value of this score has not been fully evaluated in non?Euro?American PCI populations.Methods: We performed a prospective, observational study of 10,724 patients who underwent PCI in Fuwai hospital, China and evaluated the PARIS thrombotic risk score’s predictive value of CTEs in the PCI population. The area under the receiver operating characteristic curve(AUROC) was used to assess the predictive value of the PARIS score for CTE.Results: Among 9782 patients without in?hospital events, a total of 95 CTEs occurred during the 2?year follow?up. The PARIS score was significantly higher in patients with CTEs(3.38 ± 2.04) compared with patients without events(2.53 ± 1.70, P < 0.001).According to the risk stratification of the PARIS thrombotic score, the risk of CTEs in the high?risk group was 3.14 times higher than that in the low?risk group(hazard ratio [HR], 3.14; 95% confidence interval [CI], 1.92–5.13; P < 0.001). However, the risk of CTEs in the intermediate?risk and low?risk groups was not significant(HR, 1.39; 95% CI, [0.86–2.24]; P = 0.184). The PARIS score showed prognostic value in evaluating CTEs in the overall population(AUROC, 0.621; 95% CI, 0.561–0.681), the acute coronary syndrome(ACS) population(AUROC, 0.617; 95% CI, 0.534–0.700; P = 0.003), and the non?ACS population(AUROC, 0.647; 95%CI, 0.558–0.736; P = 0.001).Conclusions: In a real?world Chinese population, the PARIS thrombotic risk score shows a modest prognostic value for CTEs in patients after PCI. This score also has a predictive value for CTEs in the ACS and non?ACS subgroup populations.