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There have been no previous attempts to assess coronary plaque morphology in statin-treated patients with combined residual cholesterol and inflammatory risk. The aim of this study was to characterize the morphology using optical coherence tomography (OCT) and to investigate the underlying molecular mechanisms. Two hundred seventy statin-treated patients with stable coronary artery disease who underwent OCT imaging prior to elective percutaneous coronary intervention were included in this single-center retrospective analysis. Subjects were stratified into four groups based on low-density lipoprotein cholesterol (LDL-C) and high-sensitivity C-reactive protein (hs-CRP) levels using 70 mg/dl and 2 mg/L as cut-offs, respectively. OCT images of the target lesions were assessed. For a subset of patients, peripheral blood mononuclear cells (PBMC) were isolated, and gene expression was characterized using microarray analysis. Patients with high LDL-C and high hs-CRP demonstrated a higher frequency of lipid-rich plaques (LRP) (91%, P?=?0.03) by OCT. LRPs in these patients had a greater maximal lipid arc (186.6?±?92.5°, P?=?0.047). In addition, plaques from patients who did not achieve dual-target were less frequently calcified (P?=?0.003). If calcification was present, it was characterized by a lower maximal arc (P?=?0.016) and shorter length (P?=?0.025). PBMC gene expression analysis demonstrated functional enrichment of toll-like receptors (TLRs) 1–9 to be associated with high LDL-C and hs-CRP. Obstructive coronary lesions in patients on statin therapy with combined residual cholesterol and inflammatory risk demonstrated a higher prevalence of LRP with greater maximal lipid arcs and more frequent spotty calcifications. PBMC from these patients revealed functional enrichment of TLR 1–9.

Purpose:To investigate the impact on restenosis rates of deep injury to the adventitial layer during directional atherectomy. Methods:Between 2007 and 2010, 116 consecutive patients (mean age 69.6 years; 56 men) with symptomatic femoropopliteal stenoses were treated with directional atherectomy at a single center. All patients had claudication and TASC A/B lesions in the superficial femoral or popliteal arteries. Histopathology analysis of atherectomy specimens was performed to identify adventitial injury. Clinical follow-up included physical examination and duplex ultrasound scans at 3, 6, and 12 months in all patients. The primary endpoint was the duplex-documented 1-year rate of restenosis, which was determined by a peak systolic velocity ratio <2.4. Patients were dichotomized by the presence or absence of adventitial or medial cuts as evaluated by histopathology. Results:Adventitial injury were identified in 62 (53%) of patients. There were no differences in baseline demographic and clinical features (p>0.05), lesion length (58.7±12.8 vs 56.2±13.6 mm, p=0.40), or vessel runoff (1.9±0.6 vs 2.0±0.6, p=0.37) between patients with and without adventitial injury, respectively. The overall 1-year incidence of restenosis was 57%, but the rate was significantly higher (p<0.0001) in patients with adventitial or medial injury (97%, 60/62) as compared with those without (11%, 6/54). Conclusion:Lack of adventitial injury after atherectomy for femoropopliteal stenosis is strongly related to patency at 1 year.

Aneurysm of the aorta is largely a disease of the elderly. The incidence/prevalence of the disease has steadily increased in recent times, mainly because of the increase in awareness among patients/physicians and better imaging modalities. Early diagnosis and treatment of this disease holds the key to success and plays a part in prevention of catastrophic complications. With advancements in endovascular and surgical innovations, repair of aneurysmal disease has made significant progress, translating into better survival and long-term benefits. However, with significant morbidity and mortality associated with this disease, there is still a need for further research.

Introduction:The predictive value of high sensitivity C-reactive protein (hsCRP) after percutaneous coronary intervention (PCI) is well described in Caucasians, but understudied in minorities.Hypothesis:We hypophesized, that there were differences in prevalence and prognostic impact of hsCRP elevation according to race/ethnicity.Methods:We included all patients undergoing PCI between 2010-2017 in a single tertiary center, excluding those with acute coronary syndrome, cancer and hsCRP >10 mg/L. Race/Ethnicity was self-reported. hsCRP ?2 mg/L during index PCI was considered elevated. The association between hsCRP elevation and 1-year major adverse cardiac events (MACE), consisting of all-cause death, myocardial infarction (MI) and target lesion revascularization was assessed using Kaplan-Meier method and Cox models, adjusting for sex, age, diabetes, prior myocardial infarction, prior coronary artery bypass graft, peripheral artery disease and hemoglobin at baseline.Results:The analysis included 2,193 Asians, 5,592 Caucasians, 2,910 Hispanics and 1,202 African-Americans (total n= 11,843). Prevalence of hsCRP elevation differed widely between subgroups (p<0.01) and was highest in African-Americans and lowest in Asians (Figure 1). Comparing patients with normal vs. elevated hsCRP, 1-year rates of MACE were 7.6% vs. 12.9% in Asians, 6.6% vs. 9.7% in Caucasians, 8.3% vs. 11.3% in Hispanics and 6.0% vs. 13.4% in African-Americans, respectively. After adjustment, the association of elevated hsCRP and MACE was not significant in Asians (HR 1.33, 0.98-1.78 95% CI), moderate in Caucasians (HR 1.4, 1.12-1.76 95% CI), higher in Hispanics (HR 1.72, 1.21-2.5 95% CI) and highest in African-Americans (HR 2.35, 1.42-3.89 95% CI).Conclusions:hsCRP elevation varies between races/ethnicities, and in Hispanics and African-Americans its prevalence and prognostic impact is the highest.

Introduction:Elevated low-density lipoprotein cholesterol (LDL-C) levels are strongly associated with coronary risk in the general population. Chronic kidney disease (CKD) is a common co-morbidity in patients undergoing percutaneous coronary intervention (PCI), but the impact of high LDL-C in these subjects remains unclear. The present study aims to investigate the relation between LDL-C and adverse events after PCI according to the presence of CKD.Hypothesis:The prognostic relevance of LDL-C on cardiovascular outcomes is influenced by the presence of concomitant CKD.Methods:Data from all PCI procedures between 2009 and 2017 in a single tertiary center was prospectively collected. CKD was defined as an estimated glomerular filtration rate <60 ml/min/1.73m2. Exclusion criteria were end-stage renal failure (requiring dialysis or estimated glomerular filtration rate <15 mL/min/1.73m2) and conditions associated with pathologically lowered LDL-C (body mass index <18.5 kg/m2, ejection fraction <30%, and neoplastic disease). Baseline LDL-C levels were classified as either high (?90 mg/dl) or low (<90 mg/dl). The primary endpoint of interest was myocardial infarction (MI) at 1 year.Results:A total of 12,823 subjects were included, of which 3,253 (25.4%) had CKD. High baseline LDL-C was present in 22.7% and 27.6% of CKD and non-CKD patients, respectively. Overall, patients with high LDL-C levels experienced higher rates of MI at 1 year (Figure). However, while the risk of MI was significantly increased in non-CKD patients with high LDL-C as compared to low LDL-C (adjusted HR: 1.78 [95% CI, 1.22-2.60]; p=0.003), no such trend was observed among CKD patients (adjusted HR: 1.40 [0.78-2.49]; p=0.26).Conclusions:The impact of LDL-C levels on the risk of MI differs between CKD and non-CKD patients. Prognostic implications of high LDL-C may be attenuated in CKD patients undergoing PCI.

Introduction:Contrast-induced acute kidney injury (CI-AKI) after PCI predicts worse cardiovascular outcomes. Physiologic mechanisms, genetic predisposition and socioeconomic disparities related to ethnicity may contribute to the occurrence of CI-AKI.Hypothesis:We evaluated the risk of CI-AKI after PCI according to ethnicity and its subsequent impact on 1-year mortality.Methods:Patients undergoing PCI at our Institution from 2009-2018 were grouped by ethnicity into White (n=7,942), Asian (n=2,604), Hispanic (n=1,431) and African American (n=1,748). CI-AKI was defined as a peri-procedural creatinine increase of >0.3 mg/dL or >50% compared to baseline. The association between ethnicity and CI-AKI was assessed using logistic regression. A sensitivity analysis was performed by including only patients with baseline CKD, defined as eGFR <60 mL/min/1.73m2. The risk of 1-year mortality after CI-AKI was evaluated with multivariate Cox model.Results:The rate of CI-AKI was 5.8% in the overall population. Compared to White patients, the risk of CI-AKI was higher in African Americans (OR 1.45, 95% CI 1.19-1.76; p<0.001), lower in Asians (OR 0.78, 95% CI 0.65-0.98; p=0.03) and similar in Hispanics (OR 0.93, 95% CI 0.73-1.19; p=0.57). However, after adjustment for confounders, the association between ethnicity and CI-AKI was largely attenuated (Figure). Findings of sensitivity analysis in CKD patients were consistent with those in the general population. Overall, 1-year mortality was increased in patients who experienced CI-AKI (adjusted HR 1.92, 95% CI 1.39-2.66; p<0.001), but this risk was not uniform among the different subgroups (White: p<0.001, African American: p=0.05, Hispanic: p=0.06, Asian: p=0.37) (Figure).Conclusions:The risk of CI-AKI after PCI varies according to ethnicity, however, this might be explained by differences in risk factors observed in each group. The occurrence of CI-AKI is associated with an increased risk of mortality at 1 year.

Introduction:Efficacy of drug-eluting stent has been assessed in several trials with consistent effect between genders. However, patients undergoing PCI for left main (LM) stenosis tend to experience high rates of recurrent events, especially in anatomically complex cases. As women are generally underrepresented in most trials, gender differences in this high-risk population undergoing LM PCI are not well established.Hypothesis:We sought to evaluate predictors of patient- and device-oriented outcomes at 1 year in men and women receiving unprotected LM PCI.Methods:We included patients undergoing LM PCI at our institution from 2009 to 2017. Those with prior CABG, STEMI on presentation, or treated with bare metal stents were excluded. We assessed the predictors of major adverse cardiac and cerebrovascular events (MACCE; the composite of death, myocardial infarction or stroke) and target vessel revascularization (TVR) at 1 year separately for men and women, using multivariate Cox regression model.Results:Of the 641 patients undergoing unprotected LM PCI, 216 (34%) were female. Among women, the strongest predictor of MACCE was chronic kidney disease, followed by atrial fibrillation, NSTEMI on presentation and reduced left ventricular ejection fraction (by decrease of 10%). In men, NSTEMI on presentation was the strongest predictor of MACCE followed by bifurcation lesions, anemia, and reduced left ventricular ejection fraction (Table). In stent restenosis was the only predictor of 1-year TVR in both men (HR 2.22, 95% CI 1.10-4.48; p=0.026) and women (HR 7.47, 95% CI 2.18-25.57; p=0.001).Conclusions:Men and women undergoing unprotected LM PCI with drug-eluting stent present common as well as distinctive predictors of MACCE at 1 year. In-stent restenosis constitutes the only independent predictor of TVR after LM PCI in both genders.