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Background: After coronary stent implantation, prolonged dual antiplatelet therapy (DAPT) increases bleeding risk, requiring personalization of DAPT duration. The aim of this study was to develop and validate a machine learning model to predict optimal DAPT duration after contemporary drug-eluting stent implantation in patients with coronary artery disease., Methods and Results: The One-Month DAPT, RESET (Real Safety and Efficacy of 3-Month Dual Antiplatelet Therapy Following Endeavor Zotarolimus-Eluting Stent Implantation), and IVUS-XPL (Impact of Intravascular Ultrasound Guidance on Outcomes of Xience Prime Stents in Long Lesion) trials provided a derivation cohort (n=6568). Using the X-learner approach, an individualized DAPT score was developed to determine the therapeutic benefit of abbreviated (1-6 months) versus standard (12-month) DAPT using various predictors. The primary outcome was major bleeding; the secondary outcomes included 1-year major adverse cardiac and cerebrovascular events and 1-year net adverse clinical events. The risk reduction with abbreviated DAPT (3 months) in the individualized DAPT-determined higher predicted benefit group was validated in the TICO (Ticagrelor Monotherapy After 3 Months in the Patients Treated With New Generation Sirolimus-Eluting Stent for Acute Coronary Syndrome) trial (n=3056), which enrolled patients with acute coronary syndrome treated with ticagrelor. The validation cohort comprised 1527 abbreviated and 1529 standard DAPT cases. Major bleeding occurred in 25 (1.7%) and 45 (3.0%) patients in the abbreviated and standard DAPT groups, respectively. The individualized DAPT score identified 2582 (84.5%) participants who would benefit from abbreviated DAPT, which was significantly associated with a lower major bleeding risk (absolute risk difference [ARD], 1.26 [95% CI, 0.15-2.36]) and net adverse clinical events (ARD, 1.59 [95% CI, 0.07-3.10]) but not major adverse cardiac and cerebrovascular events (ARD, 0.63 [95% CI, -0.34 to 1.61]), compared with standard DAPT in the higher predicted benefit group. Abbreviated DAPT had no significant difference in clinical outcomes of major bleeding (ARD, 1.49 [95% CI, -1.74 to 4.72]), net adverse clinical events (ARD, 2.57 [95% CI, -1.85 to 6.99]), or major adverse cardiac and cerebrovascular events (ARD, 1.54 [95% CI, -1.26 to 4.34]), compared with standard DAPT in the individualized DAPT-determined lower predicted benefit group., Conclusions: Machine learning using the X-learner approach identifies patients with acute coronary syndrome who may benefit from abbreviated DAPT after drug-eluting stent implantation, laying the groundwork for personalized antiplatelet therapy.

Background: The impact of rosuvastatin versus atorvastatin on new-onset diabetes mellitus (NODM) among patients treated with high-intensity statin therapy for coronary artery disease (CAD) remains to be clarified. This study aimed to evaluate the risk of NODM in patients with CAD treated with rosuvastatin compared to atorvastatin in the randomized LODESTAR trial., Methods: In the LODESTAR trial, patients with CAD were randomly assigned to receive either rosuvastatin or atorvastatin using a 2-by-2 factorial randomization. In this post-hoc analysis, the 3-year incidence of NODM was compared between rosuvastatin and atorvastatin treatment in the as-treated population with high-intensity statin therapy as the principal population of interest., Results: Among 2932 patients without diabetes mellitus at baseline, 2377 were included in the as-treated population analysis. In the as-treated population with high-intensity statin therapy, the incidence of NODM was not significantly different between the rosuvastatin and atorvastatin groups (11.4% [106/948] versus 8.8% [73/856], hazard ratio [HR] = 1.32, 95% confidence interval [CI] = 0.98 to 1.77, P = 0.071). When the risk of NODM with rosuvastatin versus atorvastatin was assessed according to the achieved low-density lipoprotein cholesterol (LDL-C) level, the risk of NODM began to increase at a LDL-C level below 70 mg/dL. The incidence of NODM was significantly greater in the rosuvastatin group than it was in the atorvastatin group when the achieved LDL-C level was < 70 mg/dL (13.9% versus 8.0%; HR = 1.79, 95% CI 1.18 to 2.73, P = 0.007)., Conclusions: Among CAD patients receiving high-intensity statin therapy, the incidence of NODM was not significantly different between rosuvastatin and atorvastatin. However, a drug effect of the statin type on NODM was observed when the achieved LDL-C level was < 70 mg/dL., Trial Registration: ClinicalTrials.gov, Identifier: NCT02579499., (© 2024. The Author(s).)

Background: The optimal statin treatment strategy that is balanced for both efficacy and safety has not been clearly determined in older adults with coronary artery disease (CAD)., Methods: In the post hoc analysis of the LODESTAR (low-density lipoprotein cholesterol-targeting statin therapy versus intensity-based statin therapy in patients with coronary artery disease) trial, the impact between a treat-to-target strategy versus a high-intensity statin therapy strategy was compared in older adults (aged 75 years or older). The goal of treat-to-target low-density lipoprotein cholesterol (LDL-C) level was 50-70 mg/dl. The primary endpoint comprised the three-year composite of all-cause death, myocardial infarction, stroke or coronary revascularisation., Results: Among 4,400 patients with CAD enrolled in the LODESTAR trial, 822 (18.7%) were aged 75 years or older. Poor clinical outcomes and risk factors for atherosclerosis were more frequently observed in older adults than in younger population (<75 years old). Among these older adults with CAD, the prescription rate of high-intensity statin was significantly lower in the treat-to-target strategy group throughout the study period (P < 0.001). The mean LDL-C level for three years was 65 ± 16 mg/dl in the treat-to-target strategy group and 64 ± 18 mg/dl in the high-intensity statin group (P = 0.34). The incidence of primary endpoint occurrence was 10.9% in the treat-to-target strategy group and 12.0% in the high-intensity statin group (hazard ratio 0.92, 95% confidence interval 0.61-1.38, P = 0.69)., Conclusions: High-intensity statin therapy is theoretically more necessary in older adults because of worse clinical outcomes and greater number of risk factors for atherosclerosis. However, the primary endpoint occurrence with a treat-to-target strategy with an LDL-C goal of 50-70 mg/dl was comparable to that of high-intensity statin therapy and reduced utilisation of a high-intensity statin. Taking efficacy as well as safety into account, adopting a tailored approach may be considered for this high-risk population., Trial Registration: ClinicalTrials.gov, NCT02579499., (© The Author(s) 2024. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objective: To compare the long term efficacy and safety of rosuvastatin with atorvastatin treatment in adults with coronary artery disease., Design: Randomised, open label, multicentre trial., Setting: 12 hospitals in South Korea, September 2016 to November 2019., Participants: 4400 adults (age ≥19 years) with coronary artery disease., Interventions: Participants were assigned to receive either rosuvastatin (n=2204) or atorvastatin (n=2196) using 2×2 factorial randomisation., Main Outcome Measures: The primary outcome was a three year composite of all cause death, myocardial infarction, stroke, or any coronary revascularisation. Secondary outcomes were safety endpoints: new onset diabetes mellitus; hospital admissions due to heart failure; deep vein thrombosis or pulmonary thromboembolism; endovascular revascularisation for peripheral artery disease; aortic intervention or surgery; end stage kidney disease; discontinuation of study drugs owing to intolerance; cataract surgery; and a composite of laboratory detected abnormalities., Results: 4341 of the 4400 participants (98.7%) completed the trial. Mean daily dose of study drugs was 17.1 mg (standard deviation (SD) 5.2 mg) in the rosuvastatin group and 36.0 (12.8) mg in the atorvastatin group at three years (P<0.001). The primary outcome occurred in 189 participants (8.7%) in the rosuvastatin group and 178 (8.2%) in the atorvastatin group (hazard ratio 1.06, 95% confidence interval 0.86 to 1.30; P=0.58). The mean low density lipoprotein (LDL) cholesterol level during treatment was 1.8 mmol/L (SD 0.5 mmol/L) in the rosuvastatin group and 1.9 (0.5) mmol/L in the atorvastatin group (P<0.001). The rosuvastatin group had a higher incidence of new onset diabetes mellitus requiring initiation of antidiabetics (7.2% v 5.3%; hazard ratio 1.39, 95% confidence interval 1.03 to 1.87; P=0.03) and cataract surgery (2.5% v 1.5%; 1.66, 1.07 to 2.58; P=0.02). Other safety endpoints did not differ between the two groups., Conclusions: In adults with coronary artery disease, rosuvastatin and atorvastatin showed comparable efficacy for the composite outcome of all cause death, myocardial infarction, stroke, or any coronary revascularisation at three years. Rosuvastatin was associated with lower LDL cholesterol levels but a higher risk of new onset diabetes mellitus requiring antidiabetics and cataract surgery compared with atorvastatin., Trial Registration: ClinicalTrials.gov NCT02579499., Competing Interests: Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/disclosure-of-interest/ and declare: the study was funded by a grant from Sam Jin Pharmaceutical and Chong Kun Dang Pharmaceutical. M-KH has received speaker’s fees from Medtronic, Edward Lifesciences, and Viatris Korea, and institutional research grants from Sam Jin Pharmaceutical and Chong Kun Dang Pharmaceutical; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Importance: In patients with coronary artery disease, some guidelines recommend initial statin treatment with high-intensity statins to achieve at least a 50% reduction in low-density lipoprotein cholesterol (LDL-C). An alternative approach is to begin with moderate-intensity statins and titrate to a specific LDL-C goal. These alternatives have not been compared head-to-head in a clinical trial involving patients with known coronary artery disease., Objective: To assess whether a treat-to-target strategy is noninferior to a strategy of high-intensity statins for long-term clinical outcomes in patients with coronary artery disease., Design, Setting, and Participants: A randomized, multicenter, noninferiority trial in patients with a coronary disease diagnosis treated at 12 centers in South Korea (enrollment: September 9, 2016, through November 27, 2019; final follow-up: October 26, 2022)., Interventions: Patients were randomly assigned to receive either the LDL-C target strategy, with an LDL-C level between 50 and 70 mg/dL as the target, or high-intensity statin treatment, which consisted of rosuvastatin, 20 mg, or atorvastatin, 40 mg., Main Outcomes and Measures: Primary end point was a 3-year composite of death, myocardial infarction, stroke, or coronary revascularization with a noninferiority margin of 3.0 percentage points., Results: Among 4400 patients, 4341 patients (98.7%) completed the trial (mean [SD] age, 65.1 [9.9] years; 1228 females [27.9%]). In the treat-to-target group (n = 2200), which had 6449 person-years of follow-up, moderate-intensity and high-intensity dosing were used in 43% and 54%, respectively. The mean (SD) LDL-C level for 3 years was 69.1 (17.8) mg/dL in the treat-to-target group and 68.4 (20.1) mg/dL in the high-intensity statin group (n = 2200) (P = .21, compared with the treat-to-target group). The primary end point occurred in 177 patients (8.1%) in the treat-to-target group and 190 patients (8.7%) in the high-intensity statin group (absolute difference, -0.6 percentage points [upper boundary of the 1-sided 97.5% CI, 1.1 percentage points]; P < .001 for noninferiority)., Conclusions and Relevance: Among patients with coronary artery disease, a treat-to-target LDL-C strategy of 50 to 70 mg/dL as the goal was noninferior to a high-intensity statin therapy for the 3-year composite of death, myocardial infarction, stroke, or coronary revascularization. These findings provide additional evidence supporting the suitability of a treat-to-target strategy that may allow a tailored approach with consideration for individual variability in drug response to statin therapy., Trial Registration: ClinicalTrials.gov Identifier: NCT02579499.

Introduction and Objectives: There are scarce data on the optimal duration and prognostic impact of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with second-generation drug-eluting stents for left main coronary artery (LMCA) disease. The aim of this study was to investigate the practice pattern and long-term prognostic effect of DAPT duration in patients undergoing PCI with second-generation drug-eluting stents for LMCA disease., Methods: Using individual patient-level data from the IRIS-MAIN and KOMATE registries, 1827 patients undergoing PCI with second-generation drug-eluting stents for LMCA disease with valid information on DAPT duration were included. The efficacy outcome was major adverse cardiovascular events (MACE, a composite of cardiac death, myocardial infarction, and stent thrombosis) and the safety outcome was TIMI major bleeding., Results: DAPT duration was <6 months (n=273), 6 to 12 months (n=477), 12 to 24 months (n=637), and ≥ 24 months (n=440). The median follow-up duration was 3.9 [interquartile range, 3.01-5.00] years. Prolonged DAPT duration was associated with lower incidences of MACE. In multigroup propensity score analysis, adjusted HR for MACE were significantly higher for DAPT <6 months and DAPT 6 to 12 months than for DAPT 12 to 24 months (HR, 4.51; 95%CI, 2.96-6.88 and HR 1.92; 95%CI, 1.23-3.00). There was no difference in HR for major bleeding among the assessed groups., Conclusions: DAPT duration following PCI for LMCA disease is highly variable. Although the duration of DAPT should be considered in the context of the clinical situation of each patient, <12 months of DAPT was associated with higher incidence of MACE. Registration identifiers: NCT01341327; NCT03908463., (Copyright © 2022 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Background: The impact of 1-month dual antiplatelet therapy (DAPT) followed by aspirin monotherapy according to clinical presentation has not been elucidated., Aims: This study aimed to compare the impact of 1-month DAPT followed by aspirin monotherapy after polymer-free drug-coated stent (PF-DCS) implantation (1-month DAPT after PF-DCS) vs 6-12-month DAPT followed by aspirin monotherapy after biodegradable polymer drug-eluting stent (BP-DES) implantation (6-12-month DAPT after BP-DES) according to clinical presentation., Methods: This is a post hoc analysis of the One-Month DAPT trial. The primary outcome was the composite of major adverse cardiac and cerebrovascular events (MACCE; a composite of cardiac death, non-fatal myocardial infarction, target vessel revascularisation, and stroke) and major bleeding., Results: Among 1,828 patients with stable coronary artery disease (CAD), 1-month DAPT after PF-DCS resulted in lower rates of the primary outcome than 6-12-month DAPT after BP-DES (3.9% vs 6.5%; hazard ratio [HR] 0.59, 95% confidence interval [CI]: 0.39-0.90; p=0.012). However, among 1,192 patients with acute coronary syndrome (ACS), the rates of the primary outcome were not significantly different between the two therapy groups (5.6% vs 3.6%; HR 1.57, 95% CI: 0.91-2.70; p=0.102) and a significant interaction was observed between therapy and clinical presentation regarding the primary outcome (P int =0.005). A significant interaction was observed in MACCE (P int =0.016), but not in major bleeding (P int =0.276)., Conclusions: In patients undergoing drug-eluting stent implantation for non-complex lesions, the benefits of 1-month DAPT followed by aspirin monotherapy for a composite of ischaemic and bleeding outcomes were found in patients with stable CAD, but not in those with ACS., Clinicaltrials: gov: NCT02513810.

Background Despite the clinical benefits to intravascular ultrasound (IVUS) guidance for percutaneous coronary intervention (PCI), most patients with coronary artery disease undergo angiography-guided PCI alone in the real-world setting. We sought to investigate the procedural characteristics of IVUS-guided PCI and their clinical outcomes, as compared with angiography-guided PCI. Methods and Results This was a cohort study using patient-level data from the IVUS-XPL (Impact of Intravascular Ultrasound Guidance on the Outcomes of Xience Prime Stents in Long Lesions) and ULTIMATE (Intravascular Ultrasound Guided Drug Eluting Stents Implantation in All-Comers Coronary Lesions) clinical trials. A total of 2848 patients with 3872 native coronary lesions were included and procedural characteristics assessed by quantitative coronary angiography (QCA) were compared between IVUS and angiography guidance. Stent-to-reference vessel diameter ratio (ie, QCA stent sizing) was greater (1.11±0.16 versus 1.07±0.14, P <0.001) and high-pressure postdilation was more frequently performed (83.7% versus 75.4%, P <0.001) with IVUS guidance, whereas residual stent edge dissections were more frequent in lesions treated with IVUS guidance (4.6% versus 0.7%, P <0.001). Given the dissection risk, optimal QCA stent sizing for IVUS guidance was a stent-to-QCA reference vessel diameter ratio ≥1.1 to <1.3. Among 1424 patients (1969 lesions) treated with angiography guidance, QCA stent sizing <1.0 was observed in 651 (33.1%) lesions, while QCA stent sizing ≥1.1 to <1.3 was observed in only 526 (26.7%) lesions. Under angiography guidance, patients with both QCA stent sizing ≥1.1 to <1.3 and high-pressure postdilation (235 of 1424, 16.5%) had a lower risk of 3-year target lesion failure compared with others (hazard ratio, 0.532; 95% CI, 0.293-0.966 [ P =0.038]). Conclusions IVUS-guided PCI resulted in larger QCA-assessed stent sizing and more frequent postdilation with high-pressure inflations. These procedures may further improve long-term clinical outcomes in patients undergoing PCI without IVUS. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01308281 (IVUS-XPL); NCT02215915 (ULTIMATE).

Background and Aims: The optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with drug-eluting stent in patients with chronic kidney disease (CKD) is not clearly established. This study purposed to compare clinical outcomes of patients with 6-12 (standard) versus 12-24 months (prolonged) DAPT according to CKD., Methods: Using a nationwide, claim-based database, we retrospectively evaluated association between DAPT duration and clinical outcomes including death, composite ischemic event, and composite bleeding event between 1 and 3 years after PCI. CKD was defined as estimated glomerular filtration rate <60 mL/min/1.73 m 2 . Of 73,941 eligible patients, 13,425 (18.2%) had CKD and 49,019 (66%) were prescribed prolonged DAPT. Prolonged DAPT had no significant impact on the risk of clinical outcomes in patients with normal renal function., Results: In patients with CKD, prolonged DAPT was associated with a lower risk of all-cause death (HR 0.85, 95% CI 0.76-0.95) and composite ischemic events (HR 0.87, 95% CI 0.78-0.96) and a higher risk of composite bleeding events (HR 1.18, 95% CI 1.02-1.37). Benefit of prolonged DAPT on reducing composite ischemic event increased significantly in patients with worsened renal dysfunction (p interaction  = 0.02) while there was no significant interaction between its bleeding risk and renal dysfunction (p interaction  = 0.22)., Conclusions: While standard DAPT would be recommended in patients with normal renal function, tailored decision for DAPT duration would be considered in those with CKD to balance between ischemic and bleeding risks., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Objectives: The present study aimed to evaluate long-term cardiac survival benefit for intravascular ultrasound (IVUS)- versus angiography-guided long drug-eluting stent (DES) implantation., Background: Although the long-term benefit of IVUS guidance for DES implantation has been reported from recent randomized trials, this benefit was primarily driven by the reduction in repeat revascularization. Thus, it remains uncertain whether IVUS guidance improved survival during long-term follow-up., Methods: We pooled the data of 2 randomized trials (IVUS-XPL [Impact of Intravascular Ultrasound Guidance on the Outcomes of Xience Prime Stents in Long Lesions] and ULTIMATE [Intravascular Ultrasound Guided Drug Eluting Stents Implantation in All-Comers Coronary Lesions]) and compared IVUS guidance versus angiography guidance in 2,577 patients with long lesions treated with an implanted stent length ≥28 mm. The primary end point was cardiac death at 3 years., Results: A 3-year clinical follow-up was completed in 96%. The primary end point of cardiac death occurred in 12 patients (1.0%) in the IVUS-guided group vs 28 patients (2.2%) in the angiography-guided group (HR: 0.43; 95% CI: 0.22-0.84; P = 0.011). In addition, target lesion-related myocardial infarction occurred in 3 patients (0.2%) in the IVUS-guided group and in 9 patients (0.7%) in the angiography-guided group (HR: 0.33; 95% CI: 0.09-1.22; P = 0.081), stent thrombosis developed in 3 patients (0.2%) in the IVUS-guided group and 9 patients (0.7%) in the angiography-guided group (HR: 0.33; 95% CI: 0.09-1.23; P = 0.082), and ischemia-driven target lesion revascularization was observed in 47 patients (3.8%) in the IVUS-guided group and 80 patients (6.5%) in the angiography-guided group (HR: 0.57; 95% CI: 0.40-0.82; P = 0.002)., Conclusions: In this post hoc pooled patient-level analysis, the use of IVUS-guided long DES implantation compared with angiography-guided stent implantation improved long-term patient cardiac survival., Competing Interests: Funding Support and Author Disclosures Supported by the Cardiovascular Research Center, Seoul, Korea. Dr Mintz has received honoraria (lecture fees) from Boston Scientific, Philips/Volcano, Abiomed, and Medtronic. Dr Chen has received lecture fees from Microport, Boston Scientific, and Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: This study sought to evaluate the impact of poststent optical coherence tomography (OCT) findings, including severe malapposition, on long-term clinical outcomes., Background: Suboptimal OCT findings following percutaneous coronary intervention (PCI) are highly prevalent; however, their clinical implications remain controversial., Methods: Of the patients registered in the Yonsei OCT registry, a total of 1,290 patients with 1,348 lesions, who underwent OCT immediately poststenting, were consecutively enrolled for this study. All patients underwent implantation of drug-eluting stents. Poststent OCT findings were assessed to identify predictors of device-oriented clinical endpoints (DoCE), including cardiac death, target vessel-related myocardial infarction (MI) or stent thrombosis, and target lesion revascularization (TLR). Significant malapposition criteria associated with major safety events (MSE) were also investigated, such as cardiac death, target vessel-related MI, or stent thrombosis., Results: The median follow-up period was 43.0 months (interquartile range [IQR] 21.4 to 56.0 months). The incidence rates of stent edge dissection, tissue prolapse, thrombus, and malapposition after intervention were not associated with occurrence of DoCE. However, patients with significant malapposition (total malapposition volume [TMV] ≥7.0 mm 3 ] exhibited more frequent MSE. A smaller minimal stent area (MSA) was identified as an independent predictor for DoCE (hazard ratio [HR]: 1.20 [95% confidence interval [CI]: 1.00 to 1.43]; p = 0.045). Malapposition with TMV ≥7.0 mm 3 was found to be an independent predictor of MSE (HR: 6.12 [95% CI: 1.88 to 19.95]; p = 0.003). Follow-up OCT at 3, 6, or 9 months after PCI showed that poststent TMV ≥7.0 mm 3 was related to a greater occurrence of late malapposition and uncovered struts., Conclusions: Although most suboptimal OCT findings were not associated with clinical outcomes, a smaller MSA was associated with DoCE, driven mainly by TLR, and significant malapposition with TMV ≥7.0 mm 3 was associated with more MSE after PCI. (Yonsei OCT [Optical Coherence Tomography] Registry for Evaluation of Efficacy and Safety of Coronary Stenting; Yonsei OCT registry; NCT02099162)., Competing Interests: Funding Support and Author Disclosures This research was supported by the Technology Innovation Program (20012442, MultiPhase Implant with Biodegradable and Magnetic Features for Biological Flow Organs), funded by the Ministry of Trade, Industry and Energy (MOTIE, Korea), by a National Research Foundation of Korea grant funded by the Korean government (MSIT) (2017R1A2B2003191) and the Cardiovascular Research Center (Seoul, Korea). Dr. Jung-Sun Kim has received proctoring fees from Abbott Vascular and Occlutech. Dr. Guagliumi is a consultant for St. Jude Medical and Boston Scientific; and has received institutional research grants from Abbott Vascular, Boston Scientific, and St. Jude Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: There are 2 competing approaches to optimize drug-eluting stent implantation: angiography-guided routine postdilation or intravascular ultrasound (IVUS) guidance., Methods: From the pooled data of 2 randomized trials, IVUS-XPL (Impact of Intravascular Ultrasound Guidance on the Outcomes of Xience Prime Stents in Long Lesions) and ULTIMATE (Intravascular Ultrasound Guided Drug Eluting Stents Implantation in All-Comers Coronary Lesions), that compared IVUS- versus angiography-guided drug-eluting stent implantation, we compared 1037 patients (1265 lesions) with IVUS-guided postdilation, 905 patients (1170 lesions) with angiography-guided postdilation, and 383 patients (397 lesions) with angiography-guided drug-eluting stent implantation without postdilation as a reference group; all patients required ≥28 mm long stents. The primary end point was composite of cardiac death, target lesion-related myocardial infarction, or ischemia-driven target lesion revascularization at 3 years., Results: Postintervention quantitative coronary angiography-based minimum lumen diameter was not different between the angiography guidance with postdilation versus the angiography guidance without postdilation group (2.5±0.4 mm versus 2.5±0.4 mm; P =0.367). However, it was larger in the IVUS guidance with postdilation versus the angiography guidance without postdilation group (2.6±0.5 mm versus 2.5±0.4 mm; P =0.046), and also in the IVUS guidance with postdilation versus the angiography guidance with postdilation group (2.6±0.5 mm versus 2.5±0.4 mm; P <0.001). The rate of the primary end point was not different between the angiography guidance with postdilation versus the angiography guidance without postdilation group (8.6% versus 9.8%; hazard ratio, 0.86 [95% CI, 0.58-1.29]; P =0.473). However, it was lower after IVUS guidance with postdilation versus angiography guidance without postdilation (4.5% versus 9.8%; hazard ratio, 0.44 [95% CI, 0.28-0.68]; P <0.001) and also after IVUS guidance with postdilation versus angiography guidance with postdilation (4.5% versus 8.6%; hazard ratio, 0.51 [95% CI, 0.35-0.74]; P <0.001)., Conclusions: In patients undergoing long drug-eluting stent implantation, IVUS-guided postdilation was associated with improved long-term clinical outcomes, unlike angiography-guided postdilation.

[Figure: see text].

Objectives: To evaluate the safety and technical utility of the short track sliding (STS) balloon catheter., Background: An STS balloon catheter is designed to ensure a low profile at the shaft and perform distal anchoring using a single guidewire. However, its clinical practice with the STS balloon catheter has not been reported., Methods: This prospective multi-center registry enrolled 100 patients with significant coronary artery disease who had undergone percutaneous coronary intervention using an STS balloon catheter at three hospitals in Korea from March 2019 to July 2020. Overall safety was assessed as any occurrences of device-related malfunction during the pre-dilation of the lesions. Its technical success rates of the kissing balloon technique or the distal anchoring technique using a single guidewire were also evaluated., Results: Of the 118 lesions pre-dilated using the STS balloon, no significant complication was observed except for three significant coronary dissections, which were completely covered with stents. There was no incidence of balloon catheter malfunction, such as fracture, entrapment, or perforation. With 13 attempts of kissing ballooning techniques with the STS balloon with a 6F guiding catheter, all cases were successful. The distal anchoring techniques were attempted in 10 cases, the stent was successfully crossed to the target lesion in all 10 cases., Conclusions: The novel STS balloon catheter can be safely applied in routine coronary intervention with minimal complications. In addition, this catheter could be useful for performing the kissing balloon technique with a small-caliber guiding catheter and distal anchoring technique with a single guidewire., (© 2021 Wiley Periodicals LLC.)

Background: Clinical implications of systemic atherosclerosis in patients with cardiogenic shock (CS) remain unclear. This study investigated the association between polyvascular disease (PVD) and clinical outcome in CS patients., Methods: A total of 1247 CS patients was enrolled from the RESCUE registry, a multicenter, observational cohort between January 2014 and December 2018. They were divided into two groups according to presence of PVD, defined as ≥2 coexistence of coronary artery disease, peripheral arterial disease, or cerebrovascular disease. Primary outcome was all-cause death during 12 months of follow-up., Results: 136 (10.9%) patients were diagnosed with PVD. The risk of 12-month all-cause death was significantly higher in the PVD group than in the non-PVD group (54.4% versus 40.4%, adjusted hazard ratio [HR] 1.31, 95% confidence interval [CI] 1.02-1.69, p = 0.034). There was a significant interaction between PVD and vasoactive inotropic score (VIS) (p for interaction = 0.014). Among the 945 patients with VIS <84, PVD was associated with a higher risk of 12-month all-cause death (unadjusted HR 1.77, 95% CI 1.30-2.41, p = 0.030); among the 302 patients with VIS ≥84, the incidence of 12-month all-cause death was similar between the PVD and non-PVD groups (unadjusted HR 1.03, 95% CI 0.68-1.56, p = 0.301)., Conclusions: Presence of PVD was associated with 12-month all-cause mortality in patients with CS, especially for less severe forms of CS patients with VIS <84. Clinicaltrials.govnumber:NCT02985008., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Uncertainty remains regarding the associations of angiographic optimization and intravascular ultrasound (IVUS) optimization after new-generation drug-eluting stent (DES) implantation., Methods: From four randomized trials comparing outcomes between IVUS and angiography-guidance for long or chronic total occlusion (CTO) lesions, 1396 patients who underwent IVUS-guided new-generation DES implantation were enrolled. Of these, 1112 patients (80%) met angiographic optimization criteria (postprocedural diameter stenosis, ≤20%) and were further classified into the matched (same results for angiographic optimization and IVUS optimization) and the mismatched group (opposite results for angiographic optimization and IVUS optimization) according to the meeting of IVUS optimization criteria (minimal stent area, ≥5.5 mm2 or ≥80% of mean reference lumen area). The major adverse clinical events (MACE) were compared., Results: Of 1112 patients with angiographic optimization, 675 patients met the IVUS optimization criteria (61%; matched), but 437 patients (39%; mismatched) failed to meet IVUS optimization criteria (false-positive rate = 76%). On multivariate analyses, age >60 years, reference vessel diameter ≤2.7 mm, left circumflex artery and lesion length ≥33 mm were significant predictors for the mismatched. When comparing the 12-month MACE rates, the mismatched group (6.8%) showed a significantly higher rate than the matched group (1.5%; hazard ratio = 2.62; 95% confidence interval = 1.20-5.72; P = 0.012), mainly driven by a higher target-vessel revascularization rate (6.4 vs 1.4%; P = 0.021)., Conclusion: Despite meeting angiographic optimization criteria in long or CTO lesions, more than one-third of the patients with IVUS-guided new-generation DES implantation failed to meet the IVUS optimization criteria and had worse clinical outcomes. Therefore, IVUS optimization should be considered for patients who had predictors of mismatch., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Pre-stenting intravascular ultrasound (IVUS) assessment is helpful for appropriate stent sizing and determination of the stent landing zone during percutaneous coronary intervention., Aims: The aim of this meta-analysis was to investigate the effect of pre-stenting IVUS evaluation on procedural and clinical outcomes for diffuse lesions treated with drug-eluting stents (DES)., Methods: In four randomised trials comparing IVUS- and angiography-guided DES placement, a total of 1,396 patients who underwent DES implantation with IVUS guidance were identified. Pre-stenting IVUS assessment was performed in 905 patients along with post-stenting IVUS (65%; pre-stenting IVUS(+) group). Post-stenting IVUS evaluation alone was conducted on 491 patients (35%; pre-stenting IVUS(-) group)., Results: The pre-stenting IVUS(+) group had a larger angiographic minimal lumen diameter and IVUS-derived minimal stent area (MSA) than did the pre-stenting IVUS(-) group. After adjusting, these findings were consistent. The one-year composite of cardiac death, myocardial infarction, and target vessel revascularisation did not differ between the groups. In subgroup analysis, the pre-IVUS(+) group was significantly favoured over the pre-IVUS(-) group in the subset of patients with acute myocardial infarction and lesions with small vessels in terms of larger MSA, and in the subset of patients with chronic total occlusions in terms of better clinical outcomes., Conclusions: Pre-stenting IVUS assessment prior to DES placement was associated with better acute procedural outcomes, though this did not translate into one-year clinical outcomes in the context of post-stenting IVUS assessment. Visual summary. Acute and one-year outcomes of pre-stenting intravascular ultrasound: a meta-analysis of randomised clinical trials.

Background and Aims: The prognosis of stented lesions differs according to in-stent neointimal characteristics on optical coherence tomography (OCT). In particular, patients who show in-stent heterogeneous neointima are associated with a higher incidence of target lesion revascularization (TLR) compared with those who show in-stent non-heterogeneous neointima. However, the relationship between in-stent neointimal characteristics and native coronary atherosclerosis progression has not been clearly elucidated. The study aimed to investigate the relationship between in-stent neointimal characteristics and progression of native atherosclerosis., Methods: The neointimal characteristics of 377 patients with 377 drug-eluting stents (DESs) were quantitatively and qualitatively assessed using OCT. The OCT-based neointima was categorized as homogeneous (n = 207), heterogeneous (n = 93), and layered (n = 77). The relationship of non-target lesion revascularization (non-TLR) with neointimal characteristics was evaluated after OCT examination of the stents., Results: After a median follow-up duration of 40.0 months, patients with heterogeneous neointima showed significantly higher non-TLR rates than those with homogeneous neointima and tended to have higher non-TLR rates than those with layered neointima (heterogeneous vs. homogeneous:14.0% vs. 8.7%, p = 0.046; heterogeneous vs. layered neointima:14.0% vs. 7.8%, p = 0.152). Multivariate analysis showed that the independent determinants for non-TLR were heterogeneous neointima (HR: 2.237, 95% CI: 1.023-4.890, p = 0.044) and chronic kidney disease (hazard ratio [HR]: 8.730, 95% CI: 2.175-35.036, p = 0.002)., Conclusions: The heterogeneous neointima in DES-treated lesions was associated with a higher incidence of non-TLR and target lesion failure. This finding suggests that the neointimal pattern may reflect the progression of the native lesion., Competing Interests: The authors have declared that no competing interests exist.

Background Although antiplatelet therapy (APT) has been recommended to balance ischemic-bleeding risks, it has been left to an individualized decision-making based on physicians' perspectives before non-cardiac surgery. The study aimed to assess the advantages of a consensus among physicians, surgeons, and anesthesiologists on continuation and regimen of preoperative APT in patients with coronary drug-eluting stents. Methods and Results A total of 3582 adult patients undergoing non-cardiac surgery after percutaneous coronary intervention with second-generation stents was retrospectively included from a multicenter cohort. Physicians determined whether APT should be continued or discontinued for a recommended period before non-cardiac surgery. There were 3103 patients who complied with a consensus decision. Arbitrary APT, not based on a consensus decision, was associated with urgent surgery, high bleeding risk of surgery, female sex, and dual APT at the time of preoperative evaluation. Arbitrary APT independently increased the net clinical adverse event (adjusted odds ratio [OR adj ], 1.98; 95% CI, 1.98-3.11), major adverse cardiac event (OR adj , 3.11; 95% CI, 1.31-7.34), and major bleeding (OR adj , 2.34; 95% CI, 1.45-3.76) risks. The association was consistently noted, irrespective of the surgical risks, recommendations, and practice on discontinuation of APT. Conclusions Most patients were treated in agreement with a consensus decision about preoperative APT based on a referral system among physicians, surgeons, and anesthesiologists. The risk of perioperative adverse events increased if complying with a consensus decision was failed. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03908463.

We evaluated early vascular responses after new-generation drug-eluting stent (DES) implantation. From 2 randomized trials, we identified 471 patients (138 patients with acute myocardial infarction [AMI] vs 333 patients with stable angina or unstable angina [SA/UA]) treated by DESs who underwent serial optical coherence tomography (OCT) from postprocedure to 3 months. At 3-month follow-up OCT, malapposed strut percentage was higher in AMI than in SA/UA (5.3% vs 0.7%, P < .001); it was markedly increased from postprocedure in AMI (2.0%-5.3%, P < .001), whereas it decreased in SA/UA (1.7%-0.7%, P < .001). Patients with AMI showed a higher risk of persistent (59% vs 37%; P < .001) or late-acquired malapposition (15% vs 8%; P = .04). Uncovered strut percentage at 3 months was also higher in AMI than in SA/UA (13.1% vs 6.7%, P < .001). The AMI presentation was the significant risk factor for both significant stent malapposition (SM, ≥200 μm; odds ratio [OR] = 3.45, CI = 1.85-7.14, P < .001) and uncovered stent (% uncovered struts >6.0%; OR = 2.44, CI = 1.35-4.76, P = .004), together with malapposed distance and postprocedural thrombi. Further, AMI presentation was the predictor for the occurrence of early period late-acquired and persistent malapposition. Serial OCT comparison analyses showed that patients with AMI compared with patients with SA/UA showed more delayed strut coverage, more severe degree SM or uncovered stents, and higher incidences of early period persistent or late-acquired SM.

Background: Coronary interventions using drug-eluting stents (DESs) of left main coronary artery (LMCA) lesions have shown favorable clinical outcomes. However, duration of dual antiplatelet therapy (DAPT) after LMCA interventions has not yet been investigated., Methods and results: From a multicenter Korean Multicenter Angioplasty Team (KOMATE) registry, 1,004 patients who received DES implantations for LMCA lesions and did not experience major adverse cardiovascular events (including major bleeding) for 1 year after coronary intervention were analyzed. Patients were divided into 2 groups; DAPT ≤12 (n=503) and >12 months (n=501). The primary endpoint was number of net clinical adverse events (NACEs), composite of cardiac deaths, myocardial infarctions, stent thrombosis and major bleeding events. During a 4.5-year follow-up period after LMCA interventions, the DAPT >12 months group showed a lower NACE rate than the DAPT ≤12 months group (adjusted-HR 0.53 [0.29-0.99], P=0.045). For patients who maintained DAPT >12 months, rate of cardiac deaths, myocardial infarctions, and stent thrombosis events were lower than in patients who had DAPT ≤12 months (adjusted-HR 0.35 [0.17-0.73], P=0.005) without increased major bleeding (P=0.402)., Conclusions: For patients who can continue DAPT without major bleeding events, prolonged DAPT (>12 months) after LMCA stenting demonstrated better long-term efficacy outcomes than DAPT ≤12 months with comparable safety.

Purpose: Although current guidelines recommend the administration of dual antiplatelet therapy (DAPT) for up to 12 months after the implantation of a drug-eluting stent (DES), extended DAPT is frequently used in real-world practice., Materials and Methods: From the Korean Multicenter Angioplasty Team registry, we identified a total of 1414 patients who used DAPT for >3 years after DES implantation (extended-DAPT group) and conducted a landmark analysis at 36 months after the index procedure. We evaluated the determinants for and long-term outcomes of extended DAPT and compared the occurrence of major adverse cardiovascular and cerebrovascular events (MACCE), defined as the composite of all-cause death, myocardial infarction, stent thrombosis, and stroke, between the extended-DAPT group and the guideline-DAPT group [DAPT <1 year after DES implantation (n=1273)]., Results: Multivariate analysis indicated the occurrence of acute coronary syndrome as the most significant clinical determinant of the use of extended DAPT. Bifurcation, stent diameter ≤3.0 mm, total stented length ≥28 mm, and use of first-generation DESs were also significant angiographic and procedural determinants. MACCE rates were similar between the extended-DAPT group and the guideline-DAPT group in crude analysis [hazard ratio (HR), 1.08; 95% confidence interval (CI), 0.69-1.68; p =0.739] and after propensity matching (HR, 1.22; 95% CI, 0.72-2.07; p =0.453). Major bleeding rates were comparable between the two groups., Conclusion: In patients undergoing percutaneous coronary intervention, indefinite use of DAPT does not show superior outcomes to those of guideline-DAPT. Major bleeding rates are also similar., Competing Interests: The authors have no potential conflicts of interest to disclose., (© Copyright: Yonsei University College of Medicine 2020.)

Clinical benefits of bioresorbable vascular scaffold (BVS) implantation for long coronary lesions were not sufficiently evaluated. The efficacy and safety of BVS and metallic everolimus-eluting stent (EES) were compared for the treatment of long coronary narrowings. A total of 341 patients with diffuse long lesions (requiring device length ≥28 mm) were randomized to receive either BVS (n = 171) or EES (n = 170) implantation. The primary endpoint was major adverse cardiovascular events which included death from cardiac cause, myocardial infarction, device thrombosis, or ischemia-driven target-lesion revascularization at 12 months. The trial was terminated early because the manufacturer stopped supplying BVS. The mean lesion length was 32.2 ± 13.1 mm in the BVS group and 35.3 ± 13.0 mm in the EES group. The 12-month follow-up was completed in 332 patients (97.4%). At 12 months, the primary endpoint events occurred in 2 patients (1.2%) in the BVS group and in 4 patients (2.4%) in the EES group (hazard ratio = 0.49, 95% confidence interval = 0.09 to 2.67, p = 0.398). Definite or probable device thrombosis occurred in 1 patient (0.6%) in the BVS group and 1 patient (0.6%) in the EES group (hazard ratio = 1.00, 95% confidence interval = 0.06 to 15.94, p = 0.998). In conclusion, in patients with long native coronary artery disease, significant differences between BVS and EES were not observed regarding the primary composite endpoint of death from cardiac cause, myocardial infarction, device thrombosis, or target-lesion revascularization at 12 months. However, due to the early termination of this trial and a low number of events, the results cannot be considered clinically relevant (clinicalTrials.gov Identifier: NCT02796157)., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background and Aims: The long-term comparative results between culprit-only percutaneous coronary intervention (C-PCI) and multivessel PCI (M-PCI) or those between complete revascularization (CR) and incomplete revascularization (IR) in patients with non-ST-elevation myocardial infarction (NSTEMI) and multivessel disease (MVD) after successful newer-generation drug-eluting stent (DES) implantation are limited. Therefore, we compared the 2-year clinical outcomes in such patients., Methods: A total of 4588 patients with NSTEMI and MVD (C-PCI, n = 2055; M-PCI, n = 2533; CR, n = 2029; IR, n = 504) were evaluated. The primary outcome was major adverse cardiac events (MACEs) defined as all-cause death, recurrent myocardial infarction MI, and any repeat coronary revascularization. The secondary outcome was stent thrombosis (ST)., Results: The cumulative incidences of the primary and secondary outcomes were similar in the three comparison groups (C-PCI vs. M-PCI, CR vs. IR, or CR vs. C-PCI). However, the cumulative incidence of non-target vessel revascularization (non-TVR) was higher in the C-PCI group than in the M-PCI group (adjusted hazard ratio [aHR]: 2.011; 95% confidence interval [CI]: 1.942-3.985; p = 0.012), higher in the IR group than in the CR group (aHR: 2.051; 95% CI: 1.216-4.183; p = 0.043), and higher in the C-PCI group than in the CR group (aHR: 2.099; 95% CI: 1.237-3.564; p = 0.006)., Conclusions: Regarding the higher cumulative incidence of non-TVR, M-PCI and CR were preferred compared to C-PCI or IR in patients with NSTEMI and MVD. However, further randomized studies are required to confirm these findings., Competing Interests: Declaration of competing interest The authors declared they do not have anything to disclose regarding conflict of interest with respect to this manuscript., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: For diabetic patients with multivessel coronary artery disease (MVD), limited data exist on the long-term outcomes of percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) according to clinical presentation [stable coronary artery disease (SCAD) or non-ST-elevation acute coronary syndrome (NSTE-ACS)]., Patients and Methods: From a Korean multicenter registry, we analyzed 1135 diabetic patients with MVD treated with PCI (n = 660) or CABG (n = 475). After propensity score matching, 8-year major adverse cardiovascular and cerebrovascular events [MACCE; composite of all-cause death, myocardial infarction (MI), or stroke] were compared between PCI and CABG according to clinical presentation., Results: After matching, MACCE was not different between PCI and CABG for SCAD patients [15.6 vs. 17.2%, hazard ratio (HR)  = 0.94, 95% confidence interval (CI)  = 0.55-1.63, P = 0.837], whereas it was higher in PCI than in CABG for NSTE-ACS patients (31.1 vs. 22.4%, HR = 1.63, 95% CI = 1.03-2.59, P = 0.036), mainly driven by the higher MI occurrence (HR = 2.18, 95% CI = 1.04-4.59, P = 0.035). A significant interaction between revascularization strategy and clinical presentation was observed for MACCE (P-interaction = 0.022). However, when PCI was further classified according to revascularization completeness, the treatment gap between PCI and CABG with respect to MI in NSTE-ACS patients was improved by complete-revascularization PCI., Conclusion: Among diabetic patients with MVD, the long-term outcomes of PCI versus CABG differed according to clinical presentation. CABG may be more beneficial for NSTE-ACS patients with MVD in reducing MACCE and MI, whereas PCI was as effective as CABG for SCAD patients with MVD. Therefore, clinical presentation must be considered when choosing revascularization strategies in these patients.

Limited data exist on the long-term efficacy of extended dual antiplatelet therapy (DAPT) after left main coronary artery (LMCA) bifurcation stenting. This study investigated the long-term clinical outcomes associated with long-term DAPT after LMCA bifurcation stenting. Using data from the multicenter KOMATE and COBIS registries, we analyzed 1,142 patients who received a drug-eluting stent for a LMCA bifurcation lesion and who experienced no adverse events for 12 months after the index procedure. Patients were divided into 2 groups: DAPT >12 months (n = 769) and DAPT ≤12 months (n = 373). The primary end point was major adverse cardiovascular events (MACEs), as a composite of cardiac death, myocardial infarction, stroke, and stent thrombosis, over 5 years of follow-up. We further performed propensity score adjustment for clinical outcomes. DAPT >12 months afforded a lower MACE rate than DAPT ≤12 months (2.3% vs 5.4%, adjusted hazard ratio [HR] 0.37; 95% confidence interval [CI] 0.19 to 0.71; p = 0.003). The use of DAPT for >12 months was an independent predictor of a reduced likelihood of MACEs (HR 0.34; 95% CI 0.17 to 0.67; p = 0.002). A DAPT score ≥2, chronic kidney disease, and age >75 years were significant independent predictors of MACEs. In subgroup analysis, the use of DAPT for >12 months consistently resulted in better clinical outcomes across all subgroups, especially among patients with ACS, compared with the use of DAPT for ≤12 months. In conclusion, an extended duration of DAPT reduces MACE rates after LMCA bifurcation stenting., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Data concerning the impact of stent generation on long-term outcomes in ST-segment elevation myocardial infarction (STEMI) patients with multivessel disease (MVD) who underwent primary percutaneous coronary intervention (PCI) with culprit-only PCI (C-PCI) or multivessel PCI (M-PCI) are limited., Methods: A total of 7,266 patients were separated into the two groups, a C-PCI (n = 4,901) or M-PCI group (n = 2,365). The primary endpoint was the occurrence of major adverse cardiac events (MACE) defined as all-cause death, recurrent myocardial infarction, and any repeat revascularization. The secondary endpoint was the cumulative incidence of stent thrombosis (ST) at 2 years., Results: The cumulative incidence of MACE was significantly higher in the bare-metal stents (BMS) group than the first-generation (1G)-drug-eluting stents (DES) (C-PCI: adjusted hazard ratio [aHR], 1.940; 95% confidence interval [CI], 1.389-2.709; p < .001; M-PCI: aHR, 1.544; 95% CI, 1.099-2.074; p = .038), and the second-generation (2G)-DES group (C-PCI: aHR, 2.271; 95% CI, 1.657-3.114; p < .001; M-PCI: aHR, 2.999; 95% CI, 1.899-4.704; p < .001). In the M-PCI group, 1G-DES showed a higher incidence of MACE compared with 2G-DES (aHR, 1.639; 95% CI, 1.028-2.614; p = .004). The cumulative incidences of ST in the both groups were similar., Conclusion: The cumulative incidence of MACE was the lowest for 2G-DES, the highest for BMS, and intermediate for 1G-DES in the STEMI patients with MVD after C-PCI or M-PCI. However, cumulative incidence of ST in the two different reperfusion strategy groups was similar regardless of stent generation., (© 2019 Wiley Periodicals, Inc.)

Background: Evaluate the safety and efficacy of guideline-recommended risk score-directed dual antiplatelet therapy (GD-DAPT) based on THE PRECISE-DAPT score after 2nd-generation drug-eluting stent (DES) implantation.Methods and Results:We analyzed 5,131 patients pooled from 4 clinical trials. Patients were divided into 3 groups according to current recommendations on the duration of DAPT and their actual DAPT duration: GD-DAPT (n=2,183), shorter DAPT (n=1,540), longer DAPT (n=1,408). The primary endpoint was the rate of net adverse clinical events (NACE) during the first 12 months. The secondary endpoints were ischemic or bleeding events. Overall, GD-DAPT did not affect NACE (1.2% vs. 1.2% for shorter DAPT and 1.7% for longer DAPT) or bleeding events (0.6% vs. 0.5% and 0.9%), and there were fewer ischemic events (2.8% vs. 4.4% and 4.0%, P=0.03) than with shorter DAPT. Especially in acute coronary syndrome (ACS) patients, GD-DAPT had fewer NACE (1.5% vs. 1.4% and 4.2%; P=0.006) and bleeding events (0.8% vs. 0.5% and 2.8%; P=0.001) than longer DAPT as well as fewer ischemic events (2.8% vs. 4.4% and 4.7%; P=0.03) than shorter DAPT., Conclusions: GD-DAPT did not affect NACE or bleeding events and reduced the number of ischemic events at 12 months compared with shorter DAPT. For ACS, GD-DAPT was associated with favorable outcomes compared with non-GD-DAPT. Therefore, GD-DAPT may optimize efficacy and safety.

Background: Optical coherence tomography (OCT) was used to assess serial changes in severe acute stent malapposition (ASM) after drug-eluting stent (DES) implantation., Methods: The maximal depth and axial lengths of ASM after DES implantation were serially quantified at percutaneous coronary intervention (PCI), and at 3 and 12-month follow-up, for 100 lesions in 96 patients. Severe ASM was defined as a maximal malapposed depth ≥400 μm or maximal malapposed axial length ≥1 mm., Results: Of the 100 lesions, 23 lesions (23%) had a severe ASM depth at PCI. At 3 months, the maximal depth decreased to <400 μm in 12 of 23 lesions (52%). At 12 months, the maximal depth further decreased to <400 μm in 8 of the remaining 11 lesions (73%). Similarly, of 53 lesions (53%) with a severe ASM length at PCI, the maximal length decreased to 0 mm in 26 (49%) but remained severe in 17 lesions (32%) at 3 months. At 12 months, 9 of the 17 remaining lesions (53%) further decreased to 0 mm. The cut-off values for the maximal malapposed depth and length to predict the absence of stent malapposition at 12 months were 565 μm at PCI and 165 μm at 3 months, and were 2.7 mm at PCI and 0.1 mm at 3 months, respectively., Conclusion: Half of the severe ASM cases resolved within 3 months, and another half resolved during 3-12 months of follow-up. Our findings provide a better understanding of the time-dependent natural course of severe ASM using OCT., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objectives: The goal of this study was to evaluate whether the beneficial effect of use of intravascular ultrasound (IVUS) is sustained for long-term follow-up., Background: The use of IVUS promoted favorable 1-year clinical outcome in the IVUS-XPL (Impact of Intravascular Ultrasound Guidance on the Outcomes of Xience Prime Stents in Long Lesions) trial. It is not known, however, whether this effect is sustained for long-term follow-up., Methods: The IVUS-XPL trial randomized 1,400 patients with long coronary lesions (implanted stent length ≥28 mm) to receive IVUS-guided (n = 700) or angiography-guided (n = 700) everolimus-eluting stent implantation. Five-year clinical outcomes were investigated in patients who completed the original trial. The primary outcome was the composite of major adverse cardiac events, including cardiac death, target lesion-related myocardial infarction, or ischemia-driven target lesion revascularization at 5 years, analyzed by intention-to-treat., Results: Five-year follow-up was completed in 1,183 patients (85%). Major adverse cardiac events at 5 years occurred in 36 patients (5.6%) receiving IVUS guidance and in 70 patients (10.7%) receiving angiographic guidance (hazard ratio: 0.50; 95% confidence interval: 0.34 to 0.75; p = 0.001). The difference was driven mainly by a lower risk for target lesion revascularization (31 [4.8%] vs. 55 [8.4%]; hazard ratio: 0.54; 95% confidence interval: 0.33 to 0.89; p = 0.007). By landmark analysis, major adverse cardiac events between 1 and 5 years occurred in 17 patients (2.8%) receiving IVUS guidance and in 31 patients (5.2%) receiving angiographic guidance (hazard ratio: 0.53; 95% confidence interval: 0.29 to 0.95; p = 0.031)., Conclusions: Compared with angiography-guided stent implantation, IVUS-guided stent implantation resulted in a significantly lower rate of major adverse cardiac events up to 5 years. Sustained 5-year clinical benefits resulted from both within 1 year and from 1 to 5 years post-implantation. (Impact of Intravascular Ultrasound Guidance on the Outcomes of Xience Prime Stents in Long Lesions [IVUS-XPL Study]: Retrospective and Prospective Follow-Up Study; NCT03866486)., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: We investigated whether optical coherence tomography (OCT) guidance would reduce nonoptimal bioresorbable vascular scaffold (BVS) deployment., Methods: This was a randomized controlled trial. Patients who required percutaneous coronary intervention for ischemic heart disease were recruited from 2 centers in Korea. The enrolled patients were randomly assigned to receive either OCT-guided BVS (Absorb; Abbott Vascular) implantation or angiography-guided BVS implantation using an optimized technique. The primary outcome was nonoptimal deployment, which was a composite outcome of the following parameters assessed by OCT: a minimal scaffold area <5 mm 2 , residual area stenosis >20%, incomplete apposition of the scaffold struts >5%, major edge dissection, or scaffold disruption. The secondary outcome was a procedural complication defined by the occurrence of no reflow, coronary perforation, or flow-limiting dissection., Results: Between September 2016 and January 2018, 88 patients (90 lesions) were assigned to OCT guidance, while 88 patients (89 lesions) were assigned to angiography guidance. The recruitment was prematurely terminated in March 2018 because the manufacturer stopped supplying BVS. Postprocedural OCT data were available for 88 lesions with OCT guidance and for 88 lesions with angiography guidance. There was nonoptimal BVS deployment postprocedurally in 35.2% of patients in the OCT-guidance group and in 38.6% in the angiography-guidance group (absolute difference, -3.7% [95% CI, -19.0% to 11.6%]; P =0.64). There were no procedural complications in either group., Conclusions: OCT-guided BVS implantation did not reduce the incidence of nonoptimal deployment compared to that of angiography-guided BVS implantation (using optimized techniques)., Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02894697.

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.

Adverse effects have been reported in patients with preprocedural anemia after percutaneous coronary intervention (PCI), but data regarding the relation between elevated hemoglobin (Hb) level and post-PCI prognosis remain limited. This study assessed the impact of elevated Hb on major adverse cardiac and cerebrovascular event (MACCE) at 12 months, a composite of all-cause mortality, nonfatal myocardial infarction, and ischemic stroke after PCI. We pooled patient-level data from four Korean multicenter drug-eluting stent registries from 2010 to 2016. In total, 5,107 patients were divided into 5 categories according to the baseline Hb level (<10, 10 to 12.9, 13 to 14.9, 15 to 16.9 and ≥17 g/dl). Patients with higher Hb levels were significantly younger, predominantly male, current smokers with higher body mass index, and more frequent dyslipidemia. Hypertension, diabetes, chronic kidney disease, and cerebrovascular accident were more prevalent in lower Hb groups. Categorically, a U-shaped curvilinear relation was observed between baseline Hb and clinical outcomes showing significantly higher MACCE rate in <10g/dl (hazard ratio [HR], 4.62 [2.81 to 7.68]) and ≥17 g/dl (HR, 4.06 [1.57 to 10.5]) groups compared with the reference group (13 to 14.9 g/dl), especially in men. In nonanemic patients (Hb ≥13 g/dl), adjusted HRs of MACCE, mortality, and stroke were significantly higher in ≥17 g/dl group than in the reference group. Furthermore, ≥17 g/dl was an independent predictor for MACCE and all-cause mortality after PCI. In conclusion, not only low Hb but also elevated Hb of ≥17 g/dl was significantly associated with higher MACCE rates and all-cause mortality after PCI. An appropriate treatment strategy for patients with high Hb level should be identified through future studies., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Drug-coated balloon (DCB) angioplasty has been shown to be a promising option for the treatment of coronary in-stent restenosis (ISR). We compared the clinical outcomes of patients with ISR who were treated with two commonly used paclitaxel-containing DCBs, the Pantera Lux (PL) and SeQuent Please (SP). A total of 491 patients with 507 ISR lesions [PL-DCB in 127 (26%) patients and SP-DCB in 364 (74%) patients] underwent DCB angioplasty for ISR lesions. The major adverse cardiac events (MACEs), including cardiac death, target lesion-related myocardial infarction, and target lesion revascularization, were assessed. There were no significant differences in each occurrence of MACE and cardiac death: 16 MACEs (61 per 1000 person-years) in the PL-DCB group and 55 (60 per 1000 person-years) MACEs in the SP-DCB group, log-rank p = 0.895, and three cardiac deaths (11 per 1000 person-years) in the PL-DCB group and ten cardiac deaths (11 per 1000 person-years) in the SP-DCB group, log-rank p = 0.849. Diabetes mellitus under insulin treatment [hazard ratio (HR) 2.71; 95% confidence interval (CI) 1.31-5.60; p = 0.007], chronic kidney disease (HR 1.99; 95% CI 1.01-3.92; p = 0.045), early-onset ISR (HR 1.99; 95% CI 1.18-3.36; p = 0.010), and recurrent ISR (HR 1.89; 95% CI 1.08-3.32; p = 0.026) were associated with the occurrence of MACE after DCB angioplasty. There was no significant difference of MACE between PL-DCB and SP-DCB treatment in patients with ISR. Patients with insulin-treated diabetes, chronic kidney disease, early-onset ISR, and recurrent ISR were at a higher risk of MACE after DCB angioplasty.

Background and Aims: The impact of late drug-eluting stent (DES) malapposition detected by optical coherence tomography (OCT) on long-term clinical outcomes has not been clearly established. We evaluated long-term clinical outcomes of late stent malapposition (LSM) detected by OCT in a qualified study population., Methods: A total of 428 patients were selected from previous randomized OCT studies that evaluated the degree of strut coverage of different DESs at a 3-12-month follow-up OCT examination. These patients were assigned to one of two groups based on the presence (n = 136) or absence (n = 292) of LSM on follow-up OCT images (performed at 7.0 ± 3.4 months after DES implantation). The cumulative rates of composite events (cardiac death, target-vessel-related myocardial infarction, target-vessel revascularization, and stent thrombosis) were compared between the two groups., Results: During 73.7 ± 18.3 months of follow-up, cardiac death or (very) late stent thrombosis did not occur in either group. The cumulative rate of composite events was similar among the patients in each group (6.2% in patients with LSM vs. 11.7% in those without LSM) [hazard ratio (HR) = 0.569, 95% confidence interval (CI) = 0.257-1.257, p = 0.163]. Target vessel-related myocardial infarction occurred in 0.7% of patients with LSM vs. 1.5% of those without LSM (HR = 0.521, 95% CI = 0.058-4.670, p = 0.560). Target-vessel revascularization was performed in 5.4% of patients with LSM vs. 10.2% of those without LSM (HR = 0.574, 95% CI = 0.246-1.343, p = 0.201)., Conclusions: Cardiac death or (very) late stent thrombosis did not occur in patients with OCT-detected LSM during long-term follow-up. The presence of OCT-detected LSM was not associated with adverse clinical events., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background The effects of severe acute stent malapposition ( ASM ) after drug-eluting stent implantation on long-term clinical outcomes are not clearly understood. We evaluated long-term clinical outcomes of severe ASM using optical coherence tomography. Methods and Results We pooled patient- and lesion-level data from 6 randomized studies. Five studies investigated follow-up drug-eluting stent strut coverage and one investigated ASM . In this data set, a total of 436 patients with 444 lesions underwent postintervention optical coherence tomography examination and these data were included in the analysis. Severe ASM was defined as lesions with ≥400 μm of maximum malapposed distance or ≥1 mm of maximum malapposed length. Composite events (cardiac death, target lesion-related myocardial infarction, target lesion revascularization, and stent thrombosis) were compared between patients with and without severe ASM . The postintervention optical coherence tomography findings indicated that 62 (14.2%) patients had lesions with ≥400 μm of maximum malapposed distance and 186 (42.7%) patients had lesions with ≥1 mm of maximum malapposed length. The 5-year clinical follow-up was completed in 371 (86.1%) of the eligible 431 patients. The cumulative rate of composite events was similar among the patients in each group during 5-year follow-up: 3.3% in patients with ASM ≥400 μm of maximum malapposed distance versus 3.1% in those with no ASM or ASM <400 μm of maximum malapposed distance ( P=0.89), and 1.2% in patients with ASM ≥1 mm of maximum malapposed length versus 4.6% in those with no ASM or ASM <1 mm of maximum malapposed length ( P=0.06). Conclusions During the 5-year follow-up, ASM severity was not associated with long-term clinical outcomes in patients treated with drug-eluting stents.

Background and Aims: There are limited data comparing clinical outcomes among new-generation drug-eluting stents (DES) in ST-segment elevation myocardial infarction (STEMI) patients with multivessel coronary artery disease (MVD) who underwent primary percutaneous coronary intervention (PCI) with culprit-only or multivessel PCI. We investigated 1-year clinical outcomes between biodegradable-polymer (BP)-coated biolimus-eluting stent (BES) and durable-polymer (DP)-coated DES in STEMI patients with MVD who underwent two different reperfusion strategies., Methods: A total of 4255 patients were enrolled and divided into two groups, a culprit-only (n = 2571, BP- [n = 264] or DP-DES [n = 2307]) or a multivessel PCI group (n = 1684, BP- [n = 145] or DP-DES [n = 1539]). The primary endpoint was major adverse cardiac events (MACE) defined as all-cause death, recurrent myocardial infarction (re-MI), and total repeat revascularization. The secondary endpoint was the incidence of definite or probable stent thrombosis (ST)., Results: BP-BES and DP-DES showed a similar 1-year adjusted hazard ratio (HR) for MACE (culprit-only, adjusted hazard ratio [HR], 1.114; p = 0.740; multivessel, HR, 0.564; p = 0.167) and ST (culprit-only, HR, 1.110, p = 0.891; multivessel, HR, 0.375; p = 0.402). The adjusted HR for all-cause death, re-MI, and repeat revascularization were similar between the two groups. In the total population, the culprit-only PCI group showed a higher incidence of total repeat revascularization than the multivessel PCI group., Conclusions: BP-BES and DP-DES showed comparable safety and efficacy in STEMI patients with MVD who underwent primary PCI with two different reperfusion strategies during a 1-year follow-up period., (Copyright © 2019 Elsevier B.V. All rights reserved.)

We investigated the association of perioperative antiplatelet therapy (APT) and outcomes in patients with drug-eluting stent (DES) placement for noncardiac surgery (NCS). In consecutive 23,358 patients who underwent percutaneous coronary interventions between 2005 and 2016, total of 2,179 patients that required 2,179 elective NCS after DES placement were retrospectively analyzed. A net adverse clinical event (NACE), composite of death, myocardial infarction, stent thrombosis, and major bleeding, was assessed at 30 days. Of 2,179 patients, 937 patients (43%) underwent NCS with discontinuation of APT. For overall, NACE occurred in 10 patients who discontinued APT (1.1%) and 22 patients who continued APT (1.8%) without significant differences (hazard ratio [HR] 0.60, 95% confidence interval [CI] 0.28 to 1.27, p = 0.182). Also, adjusted NACE event rates were not different between groups for overall NCSs (adjusted HR 0.76, 95% CI 0.38 to 1.52, p = 0.440), for NCSs >1, ≤12 months after DES, and for NCSs >12 months after DES. Our findings persisted (adjusted HR 1.26, 95% CI 0.51 to 3.10, p = 0.618) when those who continued dual-APT were excluded from the continuation of APT group due to a higher tendency of NACE compared with those who continued single-APT (adjusted HR 2.26, 95% CI 0.98 to 5.21, p = 0.055). However, the patients who discontinued APT for >7 days had a significantly higher NACE than those who discontinued for ≤7 days (adjusted HR 6.93, 95% CI 2.16 to 22.24, p = 0.001). In conclusion, discontinuation of APT may not be associated with higher NACEs 30 days postsurgery compared with continuation of APT, when APT was discontinued for ≤7 days in patients undergoing elective NCS after DES implantation., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background The relationship between late stent malapposition ( LSM ) and adverse cardiovascular events is controversial. Studies are needed to evaluate long-term (>5 years) clinical outcomes of LSM detected by optical coherence tomography ( OCT ) after drug-eluting stent implantation. Methods and Results We investigated long-term clinical outcomes of OCT -detected LSM in 351 patients who received drug-eluting stents and were examined by both poststent and follow-up OCT (175±60 days after drug-eluting stent implantation) from January 2009 to December 2011. LSM was observed in 99 patients (28%). We evaluated the cumulative rate of composite events (cardiovascular death, target-vessel-related myocardial infarction, target-vessel revascularization, and stent thrombosis). During 80.1±24.5 months of follow-up, very late stent thrombosis did not occur in any patients with LSM . The cumulative 8-year rate of composite events was 7.3% in patients with LSM and 10.5% in patients without LSM ( P=0.822, log-rank test). We further divided patients into the following 4 groups: patients with both late-persistent and late-acquired stent malapposition (n=23), patients with late-persistent stent malapposition alone (n=45), patients with late-acquired stent malapposition alone (n=31), and patients without LSM (n=252). The cumulative 8-year rates of composite events were similar among these 4 groups (0%, 9.6%, 9.7%, and 10.5%, respectively; P=0.468 by log-rank test). Conclusions During long-term follow-up (>5 years), very late stent thrombosis did not occur in patients with OCT -detected LSM . The rates of adverse clinical events were similar between patients with LSM versus those without LSM . Presence of OCT -detected LSM was not associated with unfavorable clinical outcomes.

Objectives: The impact of age on the incidence and timing of non-cardiac surgery after coronary stent implantation is unknown. We evaluated the incidence and timing of non-cardiac surgery after drug-eluting stent (DES) implantation according to patient age., Methods: A total of 37,915 consecutive patients treated by DES implantation between February 2003 and April 2014 were included in this study. The number of patients who underwent non-cardiac surgery were as follows: 4263 (11.2%) within 1 year, 5357 (14.1%) within 2 years, and 6311 (16.6%) within 3 years of DES implantation. Patients were divided into four groups according to age: <50 years (n = 5785), between 50 and 59 years (n = 9639), between 60 and 69 years (n = 13,566), and between 70 and 79 years (n = 8925)., Results: The rates of non-cardiac surgery within 1 year among patients aged <50 years, 50-59 years, 60-69 years, and 70-79 years were 8.0% (461/5785), 8.9% (855/9639), 12.1% (1636/13,566), and 14.7% (1311/8925), respectively (P-value for trend <.01). The cut-off age at which non-cardiac surgery was more likely to occur within 1 year of DES implantation was 62 years. The rate of non-cardiac surgery within 3 years of DES implantation reached a peak among patients who were 73 years old (23.9%)., Conclusions: Non-cardiac surgery with requests for cessation of dual-antiplatelet treatment was frequently performed in patients ≥62 years old who were treated with DES implantation in a real-world clinical practice.

Patient preference plays an important role in daily practice; however, its implication has not been well investigated regarding treatment strategy for complex coronary artery disease. We prospectively evaluated a trend of patient-centered decision-making of revascularization strategy in patients with multivessel or unprotected left main coronary artery disease. A standardized protocol that favors coronary artery bypass graft surgery (CABG) as the primary treatment of choice, rather than percutaneous coronary intervention, was adopted. According to the protocol, patients decided whether or not they received CABG. Among the 763 consecutively enrolled patients, 293 patients (38%) consented to receive CABG. Fifty-six percent of patients with a high Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) score chose CABG. SYNTAX score was independently correlated with consent to receive CABG in each patient SYNTAX score stratum. In-stent restenosis was an independent predictor of choosing CABG in patients with low and intermediate SYNTAX scores. Unprotected left main coronary artery disease was negatively correlated with the decision to choose CABG in patients with intermediate SYNTAX score. Reasons for declining CABG included refusal of open-heart surgery in 318 patients (68%), mild presentation of angina symptoms in 132 patients (28%), low self-confidence to expect long-term survival in 120 patients (26%), and economic factors in 10 patients (2%). Short-term major adverse cardiac and cerebrovascular events occurred in about 1% of patients without significant differences between the 2 groups. In conclusion, despite the preferred use of the CABG protocol, more than half of the patients declined CABG. Patient-centered decision-making as well as heart team approach should be considered in real-world practice situations., (Copyright © 2018. Published by Elsevier Inc.)

Background: Using optical coherence tomography, we evaluated early follow-up findings of significant stent malapposition (SSM) in patients treated with second-generation drug-eluting stent., Methods and Results: From the DETECT-OCT randomized trial (Determination of the Duration of the Dual Antiplatelet Therapy by the Degree of the Coverage of the Struts on Optical Coherence Tomography From the Randomized Comparison Between Everolimus- Versus Biolimus-Eluting Stent), a total of 386 patients (390 lesions) who underwent both postintervention and 3-month follow-up optical coherence tomography examinations were included for the present analysis. SSM was defined as a stent that had a strut with a maximal wall-to-strut distance of ≥200 μm. Postintervention, SSM was detected in 175 lesions (44.9%), including 117 lesions with a maximal wall-to-strut distance of ≥200 to <400 μm and 58 lesions with a maximal wall-to-strut distance of ≥400 μm. As the implanted stent diameter-to-reference vessel diameter ratio grew, the risk of postintervention SSM dropped (odds ratio, 0.587; 95% CI, 0.367-0.941; P=0.0398). The optimal value that best separated SSM from non-SSM postintervention was a stent diameter-to-reference vessel diameter ratio of 1.0. At 3 months follow-up, the frequency of SSM decreased from 44.9% to 33.6% (131 lesions; P=0.0001), mainly driven by the decrease in lesions with a maximal wall-to-strut distance of ≥200 to <400 μm. As the maximal wall-to-strut distance on postintervention optical coherence tomography was larger, the risk of 3-month SSM increased (odds ratio, 1.607; 95% CI, 1.131-2.286; P=0.0284). The optimal value that best separated SSM from non-SSM at 3 months follow-up was a maximal wall-to-strut distance postintervention of 230 μm., Conclusions: A spontaneous decrease in SSM was observed early in this qualified study with a large number of study patients treated with second-generation drug-eluting stent., Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT01752894.

Objectives: This study sought to measure early strut coverage in patients receiving drug-eluting stents (DESs) and to explore the feasibility of short-term dual antiplatelet therapy (DAPT) based on the degree of early strut coverage., Background: Data for early strut coverage in patients receiving new-generation DESs, and its implications for DAPT continuation were limited., Methods: A randomized, multicenter trial was conducted in 894 patients treated with DESs. Patients were randomly assigned to everolimus-eluting stent (EES) (n = 444) or biolimus-eluting stent (BES) (n = 450) groups and optical coherence tomography (OCT)-guided (n = 445) or angiography-guided (n = 449) implantation groups using a 2-by-2 factorial design. Early strut coverage was measured as the percentage of uncovered struts on 3-month follow-up OCT examination. The primary outcome was the difference in early strut coverage between EES and BES groups and between OCT- and angiography-guided implantation groups. The secondary outcome was a composite of cardiac death, myocardial infarction, stent thrombosis, and major bleeding during the first 12 months post-procedure in patients receiving 3-month DAPT based on the presence of early strut coverage (≤6% uncovered) on 3-month follow-up OCT., Results: Three-month follow-up OCT data were acquired for 779 patients (87.1%). The median percentage of uncovered struts at 3 months was 8.9% and 8.2% in the EES and BES groups, respectively (p = 0.69) and was lower in the OCT-guided group (7.5%) than in the angiography-guided group (9.9%; p = 0.009). Favorable early strut coverage (≤6% uncovered strut) was observed in 320 of 779 patients (41.1%). At 12 months, the composite event rarely occurred in the 3-month (0.3%) or 12-month (0.2%) DAPT groups (p = 0.80)., Conclusions: OCT-guided DES implantation improved early strut coverage compared with angiography-guided DES implantation, with no difference in strut coverage between EES and BES groups. Short-term DAPT may be feasible in selected patients with favorable early strut coverage (Determination of the Duration of the Dual Antiplatelet Therapy by the Degree of the Coverage of The Struts on Optical Coherence Tomography From the Randomized Comparison Between Everolimus-eluting Stents Versus Biolimus A9-eluting Stents [DETECT-OCT]; NCT01752894)., (Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: We investigated the effects of coronary artery disease (CAD) or peripheral artery disease (PAD) on clinical outcomes of patients with abdominal aortic aneurysm (AAA) treated with endovascular aortic aneurysm repair (EVAR)., Methods: We retrospectively evaluated a total of 475 patients with AAA treated with EVAR at a single center. Patients were divided into three groups: group A (n = 166), patients without CAD or PAD; group B (n = 196), patients with CAD but without PAD; and group C (n = 113), patients with PAD regardless of CAD. The primary endpoint was the accumulated rate of major adverse cardiovascular and cerebrovascular event (MACCE), a composite of all-cause death, myocardial infarction (MI), or stroke., Results: The prevalence of CAD and PAD in patients with AAA was 55.8 and 23.8%, respectively. Patients were followed for 40.2 ± 35.3 months. Baseline characteristics were similar among the groups except for current smoking (A, 27.4%; B, 20.8%; C, 50.5%; p = 0.001). Three years after EVAR, the incidences of MACCE (A, 5.6%; B, 9.5%; C, 16.7%; p = 0.021) and stroke (A, 0%; B, 2.2%; C, 5.2%; p = 0.025) were highest in group C. All-cause death and aneurysm death did not differ among the groups. PAD [hazard ratio (HR) 2.88, 95% confidence interval (CI) 1.32-6.29, p = 0.008] and previous stroke (HR 4.39, 95% CI 1.94-9.93, p < 0.001) were independent predictors of MACCE., Conclusions: PAD was an independent risk factor of increased MACCE and stroke for patients with AAA undergoing EVAR. More intensive secondary prevention may be needed to reduce adverse cardiovascular events in AAA patients with PAD., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Purpose: The present study investigated the diagnostic accuracy and clinical implications of moderate stenosis (50-69%, Coronary Artery Disease Reporting and Data System, grade 3) on coronary computed tomography angiography (CCTA), compared with invasive coronary angiography (ICA)., Materials and Methods: Two hundred and seventy-six patients who underwent ICA due to moderate stenosis alone on CCTA were selected from our prospective registry cohort., Results: Diagnostic concordance between CCTA and ICA was found in only 50 (18%) patients. Among the 396 vessels and 508 segments with moderate stenosis, diagnostic concordance was found in 132 vessels (33%) and 127 segments (25%). Segments with calcified plaque had lower diagnostic concordance than those with mixed or non-calcified plaque (22% vs. 28% vs. 27%, respectively, p =0.001). While calcified plaque burden did not have an influence on severe stenosis (≥70%) on ICA, higher burden of non-calcified plaque was correlated with a greater incidence of ICA-based severe stenosis, which was more frequent in patients with ≥3 segments of non-calcified plaque (75%) than those without non-calcified plaque (22%, p <0.001). Typical angina and mixed or non-calcified plaque were correlated with a higher incidence of under-diagnosis, while the use of next-generation computed tomography scanners reduced the incidence of under-diagnosis. Increased body weight, left circumflex artery involvement, and calcified plaque were independent factors that increased the risk of over-diagnosis of CCTA., Conclusion: The diagnosis of moderate stenosis by CCTA may be limited in estimating the exact degree of ICA-based anatomical stenosis. Unlike calcific burden, non-calcific burden was positively correlated with the presence of severe stenosis on ICA., Competing Interests: The authors have no financial conflicts of interest., (© Copyright: Yonsei University College of Medicine 2018.)

Background and Aims: It is unclear whether the obesity paradox is still apparent in the new-generation drug-eluting stent (DES) era. Therefore, we assessed the impact of body mass index (BMI) on clinical outcome after percutaneous coronary intervention (PCI) with new-generation DESs., Methods: A total of 5264 consecutive patients from 4 new-generation DES registries were divided into 4 categories according to BMI: 1) underweight (BMI<18.5 kg/m 2 , n = 130), 2) normal weight (18.5 ≤ BMI <25 kg/m 2 , n = 2943), 3) overweight (25 ≤ BMI<30 kg/m 2 , n = 1932), and 4) obese (BMI≥30 kg/m 2 , n = 259). The primary endpoint was the occurrence of major adverse cardiac and cerebrovascular event (MACCE) at 12 months, including all-cause mortality, nonfatal myocardial infarction, stroke, and target-vessel revascularization., Results: The 12-month MACCE rates decreased according to increasing BMI categories. (underweight, 13.1%; normal, 6.0%; overweight, 4.8%; obese, 4.2%; p < 0.001). After adjustment for other confounders, the underweight group had significantly higher MACCE rates than the normal-weight (hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.33-0.99; p = 0.049), overweight (HR, 0.49; 95% CI, 0.27-0.88; p = 0.017), and obese (HR, 0.41; 95% CI, 0.18-0.98; p = 0.044) groups. These differences were mainly driven by all-cause mortality and target-vessel revascularization. When BMI was treated as a continuous variable, BMI per 1 kg/m 2 was also an independent predictor for MACCE (HR, 0.95; 95% CI, 0.91-0.99; p = 0.008) and a MACE increase began below a BMI of 24 kg/m 2 ., Conclusions: Lower BMI was significantly associated with higher rates of MACCE and all-cause mortality after PCI. The obesity paradox is manifested in Korean patients in the new-generation DES era., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objectives: This study sought to investigate the long-term clinical effects of stent generation and stent strategy for left main coronary artery (LMCA) bifurcation lesion treatment., Background: Limited data are available to assess long-term clinical outcomes after stenting, including use of current-generation drug-eluting stent (C-DES) for treatment of LMCA bifurcation lesions., Methods: A total of 1,353 patients who were recorded in 2 multicenter real-world registries were treated by either early-generation drug-eluting stent (E-DES) (n = 889) or C-DES (n = 464). Primary endpoint was major adverse cardiovascular events (MACE). MACE was defined as a composite of cardiac death or myocardial infarction, stent thrombosis, and target lesion revascularization rates during 3-year follow-up. The authors further performed propensity-score adjustment for clinical outcomes., Results: During 3-year follow-up, the overall MACE rate was 8.7%. Use of a 1-stent strategy resulted in better clinical outcomes than use of a 2-stent strategy (4.7% vs. 18.6%, hazard ratio [HR]: 3.71; 95% confidence interval [CI]: 2.55 to 5.39; p < 0.001). Use of C-DES resulted in a lower MACE rate compared with using E-DES (4.6% vs. 10.9%, HR: 0.55; 95% CI: 0.34 to 0.89; p = 0.014), especially for the 2-stent strategy. For patients with C-DES, the presence of chronic kidney disease and pre-intervention side branch diameter stenosis ≥50% were significant independent predictors of MACE., Conclusions: Intervention of LMCA bifurcation lesions using DES implantation demonstrated acceptable long-term clinical outcomes, especially in C-DES patients. Use of a 1-stent strategy resulted in better clinical benefits than using a 2-stent strategy., (Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Purpose: The present study aimed to evaluate the efficacy and safety of polymer-free drug-coated BioFreedom stent implantation in comparison to coronary artery bypass graft (CABG) before major noncardiac surgery., Materials and Methods: In a multicenter registry, 55 patients required revascularization before major noncardiac surgery that should not be delayed >6 months. Of them, 27 underwent BioFreedom stent implantation and 28 underwent CABG. Primary outcomes included rate of noncardiac surgery, time from revascularization to noncardiac surgery, and occurrence of composite outcomes (all-cause death, myocardial infarction, stent thrombosis, stroke, repeat revascularization, or major bleeding)., Results: The rate of major noncardiac surgery was significantly higher in the BioFreedom group (92.6%) than in the CABG group (64.3%; p=0.027). Time from revascularization to noncardiac surgery was significantly shorter in the BioFreedom group (38.0 days) than in the CABG group (73.0 days; p=0.042). During the hospitalization for revascularization period, the occurrence of primary outcomes did not differ between the groups. However, the BioFreedom group showed a shorter hospitalization period and lower total treatment cost than the CABG group. During the hospital stay for noncardiac surgery, the occurrence of composite outcome was not significantly different between groups (4% vs. 0%; p>0.999): stroke occurred in only 1 case, and there were no cases of death or stent thrombosis in the BioFreedom group., Conclusion: This study demonstrated that BioFreedom stenting as a revascularization strategy before major noncardiac surgery might be feasible and safe in selected patients with less severe coronary artery diseases., Competing Interests: The authors have no financial conflicts of interest., (© Copyright: Yonsei University College of Medicine 2018.)