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We sought to compare the angiographic findings and mortality in patients with non-ST-segment elevation (NSTEMI) versus ST-segment elevation myocardial infarction (STEMI) undergoing early invasive intervention. Of 11,872 patients enrolled in the Korean Acute Myocardial Infarction Registry from November 2005 to January 2008, we studied patients with NSTEMI undergoing early invasive intervention (n = 1,486) and those with STEMI undergoing primary percutaneous coronary intervention (n = 4,392). Multivessel coronary disease, baseline Thrombolysis In Myocardial Infarction (TIMI) flow grade 3, and the left circumflex artery as a culprit lesion occurred more frequently in patients with NSTEMI than in those with STEMI. Those with NSTEMI had a significantly lower mortality rate than those with STEMI during a median follow-up of about 12 months (3.8% vs 6.7%, p

Objectives The aim of this study was to evaluate the relative efficacy and safety of zotarolimus-eluting stents (ZES) in comparison with the established and widely used sirolimus- (SES) and paclitaxel-eluting stents (PES) in routine clinical practice. Background Whether ZES might provide similar clinical and angiographic outcomes in a broad spectrum of patients compared with SES or PES is undetermined. Methods We performed a single-blind, multicenter, prospectively randomized trial to compare ZES with SES and PES in 2,645 patients undergoing percutaneous coronary intervention. The primary end point was a composite of major adverse cardiac events (MACE) (death, myocardial infarction, and ischemia-driven target vessel revascularization) at 12 months. A noninferiority comparison (ZES vs. SES) and a superiority comparison (ZES vs. PES) were performed for the primary end point. Results Baseline clinical and angiographic characteristics were similar in the 3 groups. At 12 months, the ZES group showed noninferior rates of MACE compared with the SES group (10.2% vs. 8.3%, p for noninferiority = 0.01, p for superiority = 0.17) and significantly fewer MACE than the PES group (10.2% vs. 14.1%, p for superiority = 0.01). The incidence of death or myocardial infarction was similar among the groups (ZES vs. SES vs. PES, 5.8% vs. 6.9% vs. 7.6%, respectively, p = 0.31). The incidence of stent thrombosis was significantly lower in the SES group (ZES vs. SES vs. PES, 0.7% vs. 0% vs. 0.8%, respectively, p = 0.02). Conclusions In this large-scale, practical randomized trial, the use of ZES resulted in similar rates of MACE compared with SES and in fewer MACE compared with PES at 12 months. (Comparison of the Efficacy and the Safety of Zotarolimus-Eluting Stent Versus Sirolimus-Eluting Stent and PacliTaxel-Eluting Stent for Coronary Lesions; NCT00418067 )

Background The potential benefits and risks of the use of dual antiplatelet therapy beyond a 12-month period in patients receiving drug-eluting stents have not been clearly established. Methods In two trials, we randomly assigned a total of 2701 patients who had received drugeluting stents and had been free of major adverse cardiac or cerebrovascular events and major bleeding for a period of at least 12 months to receive clopidogrel plus aspirin or aspirin alone. The primary end point was a composite of myocardial infarction or death from cardiac causes. Data from the two trials were merged for analysis. Results The median duration of follow-up was 19.2 months. The cumulative risk of the primary outcome at 2 years was 1.8% with dual antiplatelet therapy, as compared with 1.2% with aspirin monotherapy (hazard ratio, 1.65; 95% confidence interval [CI], 0.80 to 3.36; P = 0.17). The individual risks of myocardial infarction, stroke, stent thrombosis, need for repeat revascularization, major bleeding, and death from any cause did not differ significantly between the two groups. However, in the dual-therapy group as compared with the aspirin-alone group, there was a nonsignificant increase in the composite risk of myocardial infarction, stroke, or death from any cause (hazard ratio, 1.73; 95% CI, 0.99 to 3.00; P = 0.051) and in the composite risk of myocardial infarction, stroke, or death from cardiac causes (hazard ratio, 1.84; 95% CI, 0.99 to 3.45; P = 0.06). CONCLUSIONS The use of dual antiplatelet therapy for a period longer than 12 months in patients who had received drug-eluting stents was not significantly more effective than aspirin monotherapy in reducing the rate of myocardial infarction or death from cardiac causes. These findings should be confirmed or refuted through larger, randomized clinical trials with longer-term follow-up. (ClinicalTrials.gov numbers, NCT00484926 and NCT00590174.)

Purpose Obesity is often associated with better clinical outcomes in heart failure (HF). This so-called obesity paradox remains controversial. The aim of present study was to investigate the prognostic value of obesity in patients hospitalized for systolic HF. Materials and methods We performed a pooled analysis of data from two multicenter, observational HF studies. Patients hospitalized for systolic HF were eligible for the present study. We divided the subjects into two groups, a normal body mass index (BMI) group and a high BMI group. Study endpoints included all-cause mortality and any re-hospitalization within 1 year. Results We enrolled 3145 patients (male, 1824; female, 1321). The high BMI group was significantly associated with lower 1-year mortality rate [odds ratio (OR), 0.543; 95% confidence interval (CI), 0.355-0.832] after adjusting for age, hypertension, diabetes, ischemic HF, previous myocardial infarction, serum creatinine level, anemia, and ejection fraction in men. After adjustment for clinical characteristics, high BMI was not significantly associated with 1-year mortality (OR, 0.739; 95% CI, 0.450-1.216) or 1-year re-hospitalization (OR, 0.958; 95% CI, 0.696-1.319) in women. Conclusion In pooled analysis of data from two Korean HF registries, the high BMI group was independently associated with lower 1-year mortality rate from systolic HF, especially in men.

Background: The optimal duration of dual antiplatelet therapy remains controversial. Methods and Results: Between December 2006 and March 2008, 823 patients were enrolled in a prospective multicenter registry for 3-month dual antiplatelet therapy (aspirin 100-200mg+clopidogrel 75mg daily) followed by aspirin mono-therapy after zotarolimus-eluting stents (ZES). Major exclusion criteria were: cardiogenic shock, stent thrombosis (ST)-segment elevation myocardial infarction (MI) within 48h, previous drug-eluting stent implantation, severe left ventricular dysfunction, bifurcation lesions requiring 2-stenting, left main and graft lesions. The primary outcome was a composite of cardiac death, MI, or ST at 1 year. The median duration of dual antiplatelet therapy was 95 days (interquartile range 90-101). At 1 year, 3 patients (0.4%) had cardiac deaths, 3 patients (0.4%) had MI, and 4 patients (0.5%) had definite or probable ST, leading to the primary outcome in 5 patients (0.6%). Death, MI, or any revascularization occurred in 68 patients (8.3%). Among patients who were event-free at 3 months (n=812), clopidogrel was discontinued at 3 months in 661 patients and was continued for longer than 3 months in 151 patients. Discontinuation of clopidogrel at 3 months did not increase the primary outcome (HR 0.90; 95%CI, 0.09-9.02), death, MI, or any revascularization (HR 0.89; 95%CI, 0.48-1.67) after adjustment for the propensity score. Conclusions: Three-month dual antiplatelet therapy seems to be feasible after ZES implantation in relatively low-risk patients. (Circ J 2010; 74: 2314-2321)

Drug-eluting stents (DESs) are increasingly used for treatment of acute ST-segment elevation myocardial infarction (STEMI), but there are few comparisons of outcomes of various types of DES. We compared the efficacy and safety of zotarolimus-eluting stents (ZESs), sirolimus-eluting stents (SESs), and paclitaxel-eluting stents (PESs) in primary intervention for STEMI. This multicenter, prospectively randomized ZEST-AMI trial included 328 patients at 12 medical centers who were randomly assigned to ZES (n = 108), SES (n = 110), or PES (n = 110) deployment. The primary end point was major adverse cardiac events (death, MI, and ischemia-driven target vessel revascularization) at 12 months. Secondary end points included the individual components of the primary end point, late loss, angiographic restenosis, and stent thrombosis. Baseline clinical and angiographic characteristics were well matched. In-segment late loss (0.28 +/- 0.42 vs 0.46 +/- 0.48 vs 0.47 +/- 0.50 mm, respectively, p = 0.029) and restenosis rate (2.7% vs 15.9% vs 12.3%, respectively, p = 0.027) at 8 months were lowest in the SES group compared to the ZES and PES groups. At 12 months, cumulative incidence rates of primary end points in the ZES, SES, and PES groups were 11.3%, 8.2%, and 8.2%, respectively (p = 0.834). There were 2 acute (in the SES group) and 5 subacute (2 in the SES group and 3 in the PES group) stent thromboses. Incidence of death, recurrent MI, or ischemia-driven target vessel revascularization did not differ among the 3 groups. In conclusion, despite the difference in restenosis rate, the efficacy and safety of the 3 different DESs showed similar, acceptable results in the treatment of STEMI.

Background Distal protection during primary angioplasty in acute myocardial infarction (AMI) is the subject of recent controversy. The present study was designed to determine whether the distal embolic protection preserves myocardial microvascular integrity and improves clinical outcomes in patients with AMI. Methods A total of 116 AMI patients presenting within 12 h of onset of symptoms were enrolled at 7 angioplasty centers. They were randomly assigned to either primary angioplasty with distal protection group (DP; n =60) or angioplasty alone group (Controls; n =56). Results After primary angioplasty, achievement of final Thrombolysis In Myocardial Infarction (TIMI) grade 3 and TIMI Myocardial Perfusion (TMP) grade 3 were more frequent in the DP group than in the control group [58/60 (96%) vs. 43/56 (81%), p =0.016; and 39/60 (65%) vs. 20/56 (38%), p =0.001, respectively]. After primary angioplasty, the baseline and hyperemic averaged peak velocities were significantly higher (23.2±11.5 vs. 18.0±6.9 cm/s, p =0.029; and 39.2±16.7 vs. 30.6±10.8 cm/s, p =0.014, respectively) and the baseline and hyperemic microvascular resistance indices were significantly lower (4.18±2.22 vs. 5.34±2.25 mm Hg cm −1 s, p =0.036; and 2.38±1.39 vs. 3.11±1.32 mm Hg cm −1 s, p =0.030, respectively) in the DP group. Patients in the DP group showed more favorable phasic coronary flow pattern in diastolic deceleration time (679±262 vs. 519±289 ms, p =0.035; and 751±246 vs. 616±269 ms, p =0.035, respectively). Major adverse cardiac events at 6 months occurred with similar frequency in both groups (8.7% vs. 11.1%, p =0.400). Conclusions Distal protection device effectively preserves microvascular integrity during primary angioplasty in AMI. Distal protection, however, did not improve clinical outcomes.

As few studies have reported the impact of transradial interventions (TRIs) versus transfemoral interventions (TFIs) on percutaneous coronary interventions using real-world registry data, we compared the clinical and procedural outcomes between TRIs and TFIs in the Korean Transradial Intervention Prospective Registry. Patients undergoing percutaneous coronary interventions were consecutively registered from February 2014 to July 2014 in this multicenter registry. Composite events were evaluated for all-cause deaths, nonfatal myocardial infarctions, and repeat revascularizations within 30 days. Nonlesion complications included access site complications and bleeding events. A total of 1,225 patients (232 for TFIs and 993 for TRIs) were analyzed. All-cause deaths and composite events were more frequent in the TFI group than in the TRI group. Procedure failures and nonlesion complications were also more frequent in the TFI group, whereas lesion complication rates were similar in the 2 groups. Procedure times were not different between the 2 groups, whereas fluoroscopy times were longer and contrast volumes were larger in the TFI group. However, in a propensity score-matched cohort, all-cause deaths, composite events, procedure failures, and lesion and nonlesion complications were not different between the 2 groups. In contrast, in the matched cohort, the procedure and fluoroscopy times were longer and the contrast volumes were larger in the TFI group. In conclusion, TRI was as effective and safe as TFI in terms of short-term clinical outcomes, procedure success rates, and complication rates, whereas TRI was more effective for reducing procedure times and hazardous exposure to radiation and contrast media.

Introduction: The use of radial artery is gradually increasing because transradial approach have shown less mortality and bleeding complications compared to transfermoral approach. But, there is little known about the differences according to radial access site except for fluoroscopic time and learning curve. Hypothesis: We aimed to compare the success rate, procedural factors and radiation exposure according to radial access site in patients who performed coronary angiography (CAG). Methods: The study population was derived from TRI prospective registry from 20 institutes in Korea from Feb 2013 to Sep 2013. Exclusion criteria were patients with data missing≥30%, invalid data, less than 19-year old patients, patient received interventional treatment, and patient who performed CAG via femoral approach. A total of 3496 among 5779 patients was assessed for data analysis. Success rate for CAG, crossover rate, procedural factors, fluoroscopic time and fluoroscopic dose were compared between right radial (RR) and left radial (LR) approach. Results: Mean age was 62.9±11.6 years and male was 1974 patients (56.5%). The use or EMLA cream was higher in LR group (29.2% vs. 14.0%, p Conclusions: In KOTRI analysis, success rate for CAG was higher in RR group, but radiation time and dose were lower in LR group. Most common cause of crossover was puncture failure.

Objectives The aim of this study was to investigate the predictive accuracy of invasive coronary microvascular indexes for identifying microvascular obstruction (MVO) on cardiac magnetic resonance imaging (CMR) in patients treated with primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI). Background We hypothesized that a combination of the index of microcirculatory resistance (IMR) and the thermodilution-derived coronary flow reserve (CFRthermo) will enhance the predictive accuracy of detecting MVO compared with either index alone. Methods The IMR and CFRthermo were measured using a single pressure sensor/thermistor-tipped guidewire in 40 STEMI patients immediately after PCI and related to MVO assessed by CMR day 7. The primary endpoint was the predictive accuracy of the IMR for detecting MVO. Results Patients with an IMR >36 (upper tertile) had a higher rate of MVO compared with those with an IMR ≤36 (93% vs. 39%; p = 0.001). MVO occurred in all patients with an IMR >36 and a CFRthermo ≤1.7 and in no patients with an IMR ≤36 and a CFRthermo >1.7. The IMR remained an independent predictor of MVO (odds ratio: 1.212, 95% confidence interval [CI]: 1.004 to 1.464; p = 0.045) after adjustment for age, creatine kinase-myocardial band, myocardial blush grade, thrombus burden, and CFRthermo. Both the IMR (area under the curve, 0.868, 95% CI: 0.719 to 0.956; p = 0.001) and the CFRthermo (area under the curve, 0.706, 95% CI: 0.536 to 0.842; p = 0.03) were predictive of MVO. Combined IMR and CFRthermo increased the area under the curve for MVO to 0.941. Conclusions In patients who underwent primary PCI for STEMI, an increased IMR has an independent predictive value for MVO detection, and combined high IMR and low CFRthermo are highly predictive of MVO. These indexes could be used to further risk-stratify patients and guide regional and systemic therapies.

Background and Objectives Although increasing evidence has indicated that radial access is a beneficial technique, few studies have focused on Korean subjects. The aim of this study was to evaluate current practice of coronary angiography (CAG) and percutaneous coronary intervention (PCI) using radial access in South Korea. Subjects and Methods A total of 6338 subjects were analyzed from Korean Transradial Intervention prospective registry that was conducted at 20 centers in Korea. After evaluating the initial access, subjects intended for radial access were assessed for their baseline, procedure-related, and complication data. Subjects were categorized into three groups: group of overall subjects (n=5554); group of subjects who underwent PCI (n=1780); and group of subjects who underwent primary percutaneous coronary intervention (PPCI) (n=167). Results The rate of radial artery as an initial access and the rate of access site crossover was 87.6% and 4.4%, respectively, in overall subjects. Those rates were 82.4% and 8.1%, respectively, in subjects who underwent PCI, and 60.1% and 4.8%, respectively, in subjects who underwent PPCI. For subjects who underwent CAG, a 6-F introducer sheath and a 5-F angiographic catheter was the most commonly used. During PCI, a 6-F introducer sheath (90.6%) and a 6-F guiding catheter were standardly used. Conclusion The large prospective registry allowed us to present the current practice of CAG and PCI using radial access. These data provides evidence to achieve consensus on radial access in CAG and PCI in the Korean population.

Objective: This study compared the efficacy of the sirolimus-eluting stent (SES), the paclitaxel-eluting stent (PES), and the bare metal stent (BMS) for long coronary lesions. Background: The outcome of drug-eluting stent (DES) implantation in long coronary lesions remains unclear. Methods: The study involved 527 patients with de novo long coronary lesions (≥24 mm), which were treated with long (≥28 mm) SESs (223 lesions), PESs (194 lesions), or BMSs (201 lesions). Results: Lesions in the SES (36.0 ± 14.9 mm, P < 0.001) and PES (36.3 ± 14.5 mm, P < 0.001) groups were longer than those in the BMS group (32.0 ± 12.3 mm), meaning the two DES groups had longer stented segments than did the BMS group. Six-month angiographic follow-up showed the SES (9.3%, P < 0.001) and PES (21.3%, P < 0.001) groups had lower in-segment restenosis rates than that of the BMS group (42.5%). The rate of major adverse cardiac events (MACE) including death, myocardial infarction, and target lesion revascularization at 9 months was higher in the BMS group (26.6%) than that in the SES (13.0%, P < 0.001) and PES (15.7%, P < 0.001) groups. Posthoc analysis of the two DES groups showed that the in-segment restenosis rate was lower for the SES than that for the PES group (P = 0.002), while the MACE rate was similar. Conclusions: The use of DESs for long coronary lesions appears to be safe and more effective than the use of BMSs in terms of restenosis and adverse clinical events. SES use was associated with lower late luminal loss and a lower angiographic restenosis rate compared with PES use. © 2006 Wiley-Liss, Inc.

BACKGROUND Limited data are available on the clinical significance of residual thrombi after thrombectomy and prestenting reduced epicardial coronary flow in ST-segment elevation myocardial infarct (STEMI) patients. MATERIALS AND METHODS The incidence of the no-reflow phenomenon, defined as a final thrombolysis in myocardial infarction (TIMI) flow grade of up to 2 or a myocardial blush grade of up to 1, was compared in 260 STEMI patients undergoing primary percutaneous coronary intervention according to thrombotic burden. Large thrombotic burden (LTB), defined as a thrombus score of at least 3, was observed in 134 patients, among whom 66 (49.3%) underwent aspiration thrombectomy. No-reflow incidence was compared on the basis of thrombectomy treatment, thrombus residue after thrombectomy, and prestenting TIMI flow grade. RESULTS The no-reflow phenomenon occurred most frequently in LTB patients without thrombectomy, followed by those who underwent thrombectomy and the small thrombus burden group (33.8 vs. 21.2 vs. 10.3%, respectively, P

We report here on a case of accidental aortocoronary dissection that occurred during the engagement of a guiding catheter. This resulted in an antegrade dissection into the right coronary artery, and a retrograde extension of the dissection into the Sinus of Valsalva and the ascending aorta up to the aortic arch. It was successfully treated with a stent deployment at the RCA ostium; this restored optimal coronary blood flow and there was a complete resolution of the aortic dissection as was documented by coronary angiography and the follow-up CT scan.

We aimed to evaluate the feasibility of transradial primary percutaneous coronary intervention (PCI) in patients with ST elevation myocardial infarction (STEMI) by comparing the procedural results and complications with those of transfemoral intervention. From April 1997 to October 2004, we enrolled 352 consecutive cases of STEMI who underwent primary PCI. The femoral route was used in 132 cases (TFI group) and the radial route was used in 220 cases (TRI group). Cases with Killips class IV, a negative Allen test or a non-palpable radial artery were excluded from our study. Baseline clinical and angiographic profiles were comparable in both groups. Vascular access time was 3.8 +/- 3.5 min in the TFI group and 3.6 +/- 3.1 min in the TRI group, and cath room to reperfusion time was 25 +/- 11 min in the TRI group and 26 +/- 13 min in the TRI group. The procedural success rate was 89% in the TFI group and 88% in the TRI group. Crossover occurred in 9 cases (4%) due to approaching vessel tortuosity in the TRI group. Major access site complications occurred in 7 cases (5%) in the TFI group, and there were no complications in the TRI group (p0.001). Although radial occlusion occurred in 5 cases of the TRI group, there was no evidence of hand ischemia. The total hospital stay was significantly shorter in TRI group than in TFI group. In conclusion, use of the radial artery might be a potential vascular access route in performing primary PCI in selected cases.

The commercially available formulation of amlodipine is conjugated with besylate salt to increase water solubility. Recently, a new amlodipine salt formulation has been developed in which the free base of amlodipine is conjugated with a chemically different salt, adipate.The goal of this study was to compare the antihypertensive effect and tolerability of amlodipine adipate with those of amlodipine besylate in patients with mild to moderate hypertension.This was a multicenter, randomized, doubleblind, parallel-group study in which patients received 8 weeks of treatment with either amlodipine adipate or amlodipine besylate. The primary efficacy variable was noninferiority of the difference in mean changes from baseline in trough diastolic blood pressure (DBP) after 8 weeks of treatment. Secondary efficacy variables included mean changes in DBP, systolic blood pressure (SBP), and response rate (defined as the proportion of patients whose DBP was90 mm Hg or whose DBP had decreased from baseline byor =10 mm Hg). The incidence of adverse events (AEs) was also assessed.Two hundred eleven patients were randomly assigned to receive amlodipine adipate (n = 106) or amlodipine besylate (n = 105). Study patients were primarily female (54.5%), with a mean (SD) age of 52.2 (9.6) years and a mean body weight of 67.1 (10.2) kg; there were no between-group differences in demographic profiles. After 4 weeks of randomized treatment, 58 (27.5%) patients (29 [27.4%] amlodipine adipate, 29 [27.6%] amlodipine besylate) had not achieved a mean DBP90 mm Hg, and their dose was doubled. Mean DBP changes at 8 weeks were -15.2 (7.3) mm Hg in the amlodipine adipate group and -14.2 (7.4) mm Hg in the amlodipine besylate group (P = NS). Because the 95% CI for the difference in mean DBP changes between groups (-0.53 to 2.55) was within the prespecified lower limit (-4 mm Hg), amlodipine adipate was considered noninferior to amlodipine besylate. Mean SBP changes were -24.9 (12.1) mm Hg in the amlodipine adipate group and -22.0 (14.7) mm Hg in the amlodipine besylate group (P = NS). The response rates were 92.0% for amlodipine adipate and 95.4% for amlodipine besylate (P = NS). The overall incidence of clinical AEs was 20.8% in the amlodipine adipate group and 25.7% in the amlodipine besylate group (P = NS). Drug-related clinical AEs occurred in 5.7% and 12.4% of patients in the respective treatment groups (P = NS). Serum uric acid levels decreased significantly from base-line in both groups (P0.001).Eight weeks of treatment with amlodipine adipate produced significant reductions from baseline in blood pressure in these patients with mild to moderate hypertension. The efficacy of amlodipine adipate was not inferior to that of amlodipine besylate. Tolerability was comparable between the 2 treatment groups.

Background -We evaluated the prognosis of deferred and revascularized coronary stenoses after FFR measurement to assess its revascularization threshold in clinical practice. Methods -The IRIS-FFR registry prospectively enrolled 5846 patients with at least one coronary lesion with FFR measurement. Revascularization was deferred in 6468 lesions and performed in 2165 lesions after FFR assessment. The primary endpoint was major adverse cardiac events (MACE; cardiac death, myocardial infarction, and repeat revascularization) at a median follow-up of 1.9 years and analyzed on a per-lesion basis. A marginal Cox model accounted for correlated data in patients with multiple lesions, and a model to predict per-lesion outcomes was adjusted for confounding factors. Results -For deferred lesions, the risk of MACE demonstrated a significant, inverse relationship with FFR (adjusted hazard ratio [aHR], 1.06; 95% confidence interval [CI], 1.05-1.08; P < 0.001). However, this relationship was not observed in revascularized lesions (aHR, 1.00; 95% CI, 0.98-1.02; P = 0.70). For lesions with FFR ≥ 0.76, the risk of MACE was not significantly different between deferred and revascularized lesions. Conversely, in lesions with FFR ≤ 0.75, the risk of MACE was significantly lower in revascularized lesions than in deferred lesions (for FFR 0.71-0.75, aHR, 0.47; 95% CI, 0.24-0.89; P = 0.021, and for FFR ≤ 0.70, aHR 0.47; 95% CI, 0.26-0.84; P = 0.012). Conclusions -This large, prospective registry showed that the FFR value was linearly associated with the risk of cardiac events in deferred lesions. In addition, revascularization for coronary artery stenosis with a low FFR (≤ 0.75) was associated with better outcomes than the deferral, while for a stenosis with a high FFR (≥ 0.76), medical treatment would be a reasonable and safe treatment strategy. Clinical Trial Registration -clinicaltrials.gov Identifier: NCT01366404.

Since ST-elevation myocardial infarction (STEMI) occurs due to plaque rupture rather than atherosclerotic stenosis, it could be concerned that atherosclerotic lesion length itself and number of stents according to lesion length are matter indeed. There are not enough large studies reveals whether

Background and Objectives Experimental protocols for remote ischemic conditioning (RIC) utilize models in which a tourniquet is placed around the hindlimb or effluent is collected from an isolated heart. In analyzing the humoral factors that act as signal transducers in these models, sampled blood can be influenced by systemic responses, while the effluent from an isolated heart might differ from that of the hindlimb. Thus, we designed a new isolated hindlimb model for RIC and tested whether the effluent from this model could affect ischemia/reperfusion (IR) injury and if the reperfusion injury salvage kinase (RISK) and survivor activating factor enhancement (SAFE) pathways are involved in RIC. Materials and Methods After positioning needles into the right iliac artery and vein of rats, Krebs-Henseleit buffer was perfused using a Langendorff apparatus, and effluent was collected. The RIC protocol consisted of 3 cycles of IR for 5 minutes. In the RIC effluent group, collected effluent was perfused in an isolated heart for 10 minutes before initiating IR injury. Results Compared with the control group, the infarct area in the RIC effluent group was significantly smaller (31.2%±3.8% vs. 20.6%±1.8%, p

Purpose Transradial intervention (TRI) shows anatomical and technical differences between the right radial approach (RRA) and left radial approach (LRA). The aim of this study was to evaluate the efficacy and safety using LRA, compared with RRA. Materials and Methods A total of 1653 consecutive patients who underwent TRI from November 2004 to October 2010 were enrolled in the Korean multicenter TRI registry. The patients were divided into two groups: the RRA group (n=792 patients) and the LRA group (n=861 patients). To adjust for any potential confounders, propensity score matched (PSM) analysis was performed (C-statistic: 0.726). After PSM, a total of 1100 patients were enrolled for analysis. Results After PSM, the RRA group exhibited a larger contrast volume (259.3±119.6 mL vs. 227.0±90.7 mL, p

Introduction: The efficacy of prasugrel and ticagrelor has not been well evaluated in East Asian. We sought to compare the pharmacodynamic efficacy of prasugrel and ticagrelor by using VerifyNow P2Y12 assay (Accumetrics, San Diego, CA, USA). Methods: From 2012 January to 2014 April, we selected 83 patients who were administered ticagrelor 90 mg twice daily (n = 24), prasugrel 10 mg daily (n = 39), or prasugrel 5 mg daily (n = 20) after percutaneous coronary intervention due to acute coronary syndrome in our institute. After 3-4 weeks, on-treatment platelet reactivity (OPR) was measured by VerifyNow assay. According to the previous studies, we used 2 different criteria for the therapeutic window of OPR (East Asian criteria: 275≥PRU>85; Western criteria: 208 ≥PRU>85). We compared the OPR and the proportion of the therapeutic window between 3 groups. Results: The OPR was the lowest in the ticagrelor group, followed by the prasugrel 10 mg and prasugrel 5 mg groups (49.1 ± 29.9 vs. 83.7 ± 57.1 vs. 168.5 ± 60.8, p < 0.001).When we used the East Asian criteria, the prasugrel 5 mg group had the highest proportion of patients in the therapeutic window of OPR followed by prasugrel 10mg and ticagrelor groups ( 90.0% vs. 46.2% vs. 12.5%, p < 0.001). When using Western criteria, the prasugrel 5mg group still showed the highest proportion of patients with therapeutic window followed by prasugrel 10mg and ticagrelor groups (60.0% vs. 43.6% vs. 12.5%, p Conclusion: Short-term administration of prasugrel 5mg highly led the patients into the therapeutic window of OPR (in both of East Asian and Western criteria), compared with prasugrel 10mg and ticagrelor 180mg group. The prasugrel 5mg daily might be the optimal maintenance regimen for East Asian patients.

Background/Aims: Newer P2Y12 inhibitors, such as prasugrel and ticagrelor, have greater antiplatelet efficacy but may increase the risk of bleeding. In this study, we compared the pharmacodynamic efficacy of prasugrel and ticagrelor in East Asian patients with acute coronary syndrome (ACS). Methods: We selected 83 ACS patients undergoing percutaneous coronary intervention who were discharged with 90 mg ticagrelor twice daily (n = 24), 10 mg prasugrel daily (n = 39) or 5 mg prasugrel daily (n = 20). After 2 to 4 weeks, on-treatment platelet reactivity (OPR) was assessed in terms of P2Y12 reaction units (PRUs) using the VerifyNow P2Y12 assay (Accumetrics). We compared East Asian (85 < PRU ≤ 275) and Caucasian (85 < PRU ≤ 208) criteria for assessing the therapeutic window of OPR. Results: OPR was lowest in the ticagrelor group, followed by the 10 mg prasugrel and 5 mg prasugrel groups (49.1 ± 29.9 vs. 83.7 ± 57.1 vs. 168.5 ± 60.8, respectively; p < 0.001). The 5 mg prasugrel group had the highest proportion of patients with OPR values within the therapeutic window, followed by the 10 mg prasugrel and ticagrelor groups (90.0% vs. 46.2% vs. 12.5%, respectively; p < 0.001 for East Asian criteria; 60.0% vs. 43.6% vs. 12.5%, respectively; p < 0.001 for Caucasian criteria). Conclusions: Short-term administration of 5 mg prasugrel facilitated maintenance within the therapeutic window of OPR compared with the 10 mg prasugrel and ticagrelor groups. Thus, 5 mg prasugrel daily may be the optimal antiplatelet regimen for stabilized East Asian ACS patients.

We investigated and compared the clinical outcomes between biodegradable polymer biolimus-eluting stents (BES) and durable polymer everolimus-eluting stents (EES) in a single-center prospective registry.There is limited data regarding the safety and efficacy of the biodegradable BES compared to second-generation drug-eluting stents.From January 2010 to April 2012, a total of 1,279 patients were treated with BES (n = 647) or EES (n = 632) in a single center. We included 1,231 patients (BES = 625, EES = 606) after excluding 48 patients (BES = 22, EES = 26) with acute myocardial infarction accompanied by cardiogenic shock. The 1-year incidences of target lesion failure (TLF), patient-oriented composite outcomes (POCO), and stent thrombosis (ST) after the index procedure were compared in propensity score-matched analyses.Propensity score matching yielded 406 well-balanced pairs (EES = 406, BES-B = 406). In the propensity-matched population, the 1-year incidence of TLF (BES = 3.0% vs. EES = 2.5%, P = 0.666) and POCO (BES = 5.4% vs. EES = 6.4%, P = 0.552) were similar between the 2 groups. In addition, the incidence of definite or probable ST was also similar (BES = 0.74% vs. EES = 0.74%, P = 1.000). In subgroup analysis, the number of patients who reached the primary end-point did not differ significantly between the 2 groups.In a single-center registry with unrestricted use of EES and BES-B, these stents showed comparable efficacy and safety in terms of TLF, POCO, and ST at 1-year follow-up.

The utility of electrocardiography (ECG) in screening for left ventricular hypertrophy (LVH) in general populations is limited mainly because its low sensitivity. B-type natriuretic peptide (BNP) is released due to the remodeling processes of LVH and could improve the diagnostic accuracy for the ECG criteria for LVH. We hypothesized that addition of BNP levels to ECG criteria could aid LVH detection compared with ECG alone in a general population. We enrolled consecutive 343 subjects from a community-based cohort. LVH was defined as LV mass index > 95 g/m2 for females and > 115 g/m2 for males according to echocardiography. The area under the receiver operator characteristic (ROC) curve to detect LVH was 0.55 (95% confidence interval [CI], 0.50-0.61) in Sokolow-Lyon criteria and 0.53 (0.47-0.59) in the Cornell voltage criteria. After addition of N-terminal-proBNP levels to the model, the corresponding areas under the ROC were 0.63 (0.58-0.69) and 0.64 (0.59-0.69), respectively. P values for the comparison in areas under the ROC for models with and without N-terminal-proBNP levels were < 0.001. These data suggest that addition of N-terminal-proBNP levels to ECG criteria could significantly improve the diagnostic accuracy of LVH in general populations. Graphical Abstract

Besides poor clinical outcomes, female gender has been known as a high-risk factor for bleeding complications. This study aimed to investigate the impact of gender on clinical outcomes and bleeding complications after transradial coronary intervention (TRI). The Korean TRI registry is a retrospective multicenter registry with 4,890 patients who underwent percutaneous coronary intervention in 2009 at 12 centers. To compare clinical outcomes and bleeding complications between the male and female groups, we performed a propensity score matching in patients who received TRI. A total of 1,194 patients (597 in each group) were studied. The primary outcome was 1-year major adverse cardiac events, including all-cause mortality, myocardial infarction, target vessel revascularization, and stroke. The secondary outcome was major bleeding (composite of bleeding requiring transfusion of ≥2 units of packed cells or bleeding that was fatal). The proportion of major adverse cardiac events was similar between the 2 groups (6.2% vs 4.7%, p = 0.308). The female group had a greater incidence of major bleeding (0.3% vs 3.2%, p0.001). On multivariate analysis, female gender (odds ratio [OR] 7.748, 95% confidence interval [CI] 1.767 to 13.399), age ≥75 years (OR 5.824, 95% CI 2.085 to 16.274), and chronic kidney disease (OR 7.264, 95% CI 2.369 to 12.276) were independent predictors of major bleeding. In conclusion, the female gender had a tendency for more bleeding complications than male gender after TRI without difference in the clinical outcome.

The mechanism of forward blood flow during cardiopulmonary resuscitation (CPR) remains controversial. We hypothesized that, if the heart acts as a pump, the proximal descending thoracic aorta would be distended during compression by forward blood flow, and would be constricted or remained unchanged if blood flow is generated by increased intrathoracic pressure. Fourteen patients with nontraumatic cardiac arrest underwent transesophageal echocardiography to verify changes in the descending thoracic aorta during standard manual CPR. The aortic dimensions, including cross-sectional area and diameter at the end of compression and relaxation, were measured proximal to, and at the maximal compression site of the descending thoracic aorta. At the maximal compression site, deformation of the descending thoracic aorta was observed during compression in all patients and the ratio of maximal to minimal diameter of the aorta (deformation ratio) decreased during compression compared with relaxation (0.58±0.15 vs. 0.81±0.11, P =0.001). This suggests eccentric compression of the descending thoracic aorta by external chest compression. The deformation ratio of the descending thoracic aorta proximal to the maximal compression site remained unchanged during compression and relaxation (1.0±0.88 vs. 1.0±0.9, P =0.345). The cross-sectional area of the descending thoracic aorta proximal to the maximal compression site increased 15% on average during compression compared with relaxation in 12 of 14 patients. In conclusion, deformation of the aorta at the maximal compression site and increase in the cross-sectional area of the proximal aorta suggests that cardiac pumping is the dominant mechanism in generating forward blood flow during CPR in humans.

No existing device for cardiopulmonary resuscitation (CPR) is designed to exploit both the "cardiac pump" and the "thoracic pump" effect simultaneously. The purpose of this study was to measure the haemodynamic effect of a new simultaneous sternothoracic cardiopulmonary resuscitation (SST-CPR) device that could compress the sternum and constrict the thoracic cavity simultaneously in a canine cardiac arrest model. After 4 min of ventricular fibrillation, 24 mongrel dogs were randomized to receive standard CPR (n=12) or SST-CPR (n=12). SST-CPR generated a new pattern of the aortic pressure curve presumed to be the result of both sternal compression and thoracic constriction. SST-CPR resulted in significantly higher mean arterial pressure than standard CPR (68.9+/-16.1 vs. 30.5+/-10.0 mmHg, P

We describe a first case of successful transcatheter management of guidewire-induced distal coronary artery perforation and impending cardiac tamponade, which developed during percutaneous coronary angioplasty, with transcatheter injection of polyvinyl alcohol form. This method may be an effective alternative in the management of distal coronary artery perforation requiring surgical repair.

We aimed to evaluate the mid-term outcomes of resolute zotarolimus-eluting stent (R-ZES) implantation for in-stent restenosis (ISR).There has been a paucity of data regarding the effects of new-generation drug-eluting stent to treat ISR.From 2009 to 2010, a total of 98 patients with 98 ISR lesions were prospectively enrolled after R-ZES implantation for the treatment of ISR. Among 98 patients, 73 patients underwent follow-up angiography at 9 months. Serial intravascular ultrasound (IVUS) at both postprocedure and 9 months was evaluated in 55 patients. The overlapped segment of R-ZES was defined as the portion of R-ZES superimposed on previous stent.Late loss and binary restenosis rate were 0.3 ± 0.5 mm and 5.5% at 9 months. On IVUS, the percentage of neointimal volume and maximum percentage of neointimal area were 3.9 ± 6.3% and 17.3 ± 15.5%, respectively. There was no significant change of vessel volume index between postprocedure and 9 months (16.9 ± 4.7 mm³ /mm vs. 17.1 ± 4.6 mm³ /mm, P = 0.251). Late-acquired incomplete stent apposition was observed in 5 (5/55, 9.1%) cases. Compared with nonoverlapped segments of R-ZES, the overlapped did not show larger neointimal volume index (0.3 ± 0.5 mm³ /mm vs. 0.2 ± 0.3 mm³ /mm, P = 0.187) on 9-month IVUS. During follow-up (median, 353 days), repeat target-lesion revascularization was performed in four cases, but there were no death or stent thrombosis.This study suggested that R-ZES implantation for the treatment of ISR was effective up to 9 months and showed favorable vascular responses on serial IVUS assessment.

We report our experience in coronary angioplasty and intravascular ultrasonography (IVUS) on a heavy, encircling, calcified lesion that was not dilated with the use of a cutting balloon and a non-compliant balloon. The angioplasty was successfully performed with a simple and inexpensive hugging balloon technique.

A case in which a 0.014" wire was broken during the sheath placement in the radial artery for transradial coronary procedure is described here, and a successful retrieval of it using conventional methods is also described. Through the left femoral artery, the 6 Fr guiding catheter was advanced down to the tip of the broken wire at the brachial artery, and the distal part of the broken guidewire was captivated into the guiding catheter. By inflating the balloon catheter inside of the guiding catheter, seized broken guidewire between the inflated balloon and the guiding catheter was removed successfully by withdrawing the whole system en bloc.

Background and Objectives: The aim of our study was to compare the values of brachial-ankle pulse wave velocity (baPWV) measured with two different non-invasive methods as predictors of coronary artery disease (CAD) in patients who had undergone coronary angiography. Subjects and Methods: From 6373 patients who visited our laboratory for non-invasive procedures, we enrolled 965 consecutive patients undergoing coronary angiography. Data for baPWV and peripheral augmentation index (pAI) were recorded. CAD was defined as greater than 50% stenosis of a major epicardial artery in a coronary angiogram. In addition, the severity of CAD was classified as: none/ minimal or 1-, 2-, or 3-vessel disease, based on previous or current angiographic findings. Results: Among 965 subjects, the mean age was 63.7±11.6 years, and 58.2% were male. Compared with subjects without CAD disease, those with CAD showed higher values of baPWV (16.6±3.5 m/sec vs. 15.9±3.4 m/sec, p

Large thrombotic burden is a well-known predictor of no-reflow phenomenon and mortality in ST-elevation myocardial infarction (STEMI). However, limited data are available on the clinical significance of residual thrombus after thrombectomy. Therefore, we aimed to investigate the effectiveness of

Purpose We aimed to investigate whether combination therapy using intracoronary (IC) abciximab and aspiration thrombectomy (AT) enhances myocardial perfusion compared to each treatment alone in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). Materials and methods We enrolled 40 patients with STEMI, who presented within 6 h of symptom onset and had Thrombolysis in MI flow 0/1 or a large angiographic thrombus burden (grade 3/4). Patients were randomly divided into 3 groups: 10 patients who received a bolus of IC abciximab (0.25 mg/kg); 10 patients who received only AT; and 20 patients who received both treatments. The index of microcirculatory resistance (IMR) was measured with a pressure sensor/thermistor-tipped guidewire following successful PCI. Microvascular obstruction (MVO) was assessed using cardiac magnetic resonance imaging on day 5. Results IMR was lower in the combination group than in the IC abciximab group (23.5±7.4 U vs. 66.9±48.7 U, p=0.001) and tended to be lower than in the AT group, with barely missed significance (23.5±7.4 U vs. 37.2±26.1 U, p=0.07). MVO was observed less frequently in the combination group than in the IC abciximab group (18.8% vs. 88.9%, p=0.002) and tended to occur less frequently than in the AT group (18.8% vs. 66.7%, p=0.054). No difference of IMR and MVO was found between the IC abciximab and the AT group (66.9±48.7 U vs. 37.2±26.1 U, p=0.451 for IMR; 88.9% vs. 66.7%, p=0.525 for MVO, respectively). Conclusion Combination treatment using IC abciximab and AT may synergistically improve myocardial perfusion in patients with STEMI undergoing primary PCI (Trial Registration: clinicaltrials. gov Identifier: NCT01404507).

Recent studies suggest that the intracoronary administration of bone marrow (BM)-derived mesenchymal stem cells (MSCs) may improve left ventricular function in patients with acute myocardial infarction (AMI). However, there is still argumentative for the safety and efficacy of MSCs in the AMI setting. We thus performed a randomized pilot study to investigate the safety and efficacy of MSCs in patients with AMI. Eighty patients with AMI after successful reperfusion therapy were randomly assigned and received an intracoronary administration of autologous BM-derived MSCs into the infarct related artery at 1 month. During follow-up period, 58 patients completed the trial. The primary endpoint was changes in left ventricular ejection fraction (LVEF) by single-photon emission computed tomography (SPECT) at 6 month. We also evaluated treatment-related adverse events. The absolute improvement in the LVEF by SPECT at 6 month was greater in the BM-derived MSCs group than in the control group (5.9% ± 8.5% vs 1.6% ± 7.0%; P=0.037). There was no treatment-related toxicity during intracoronary administration of MSCs. No significant adverse cardiovascular events occurred during follow-up. In conclusion, the intracoronary infusion of human BM-derived MSCs at 1 month is tolerable and safe with modest improvement in LVEF at 6-month follow-up by SPECT. (ClinicalTrials.gov registration number: NCT01392105).

OBJECTIVE Increased adiponectin levels may play a protective role in the development of metabolic abnormalities, but prospective studies of the predictive value of serum adiponectin to identify individuals at high risk of new-onset metabolic syndrome are lacking. We investigated whether serum adiponectin predicts incident cases of the metabolic syndrome in a population-based longitudinal study. RESEARCH DESIGN AND METHODS A prospective cohort study was conducted of 2,044 adults (831 men and 1,213 women) aged 40–70 years without metabolic syndrome examined in 2005–2008 (baseline) and 2008–2011 (follow-up). Baseline serum adiponectin concentrations were measured by radioimmunoassay. RESULTS During an average of 2.6 years of follow-up, 153 men (18.4%) and 199 women (16.4%) developed metabolic syndrome. In multivariable-adjusted models, the odds ratio for incident metabolic syndrome comparing the highest with the lowest quartiles of adiponectin levels was 0.25 (95% CI 0.14–0.47) in men and 0.45 (0.28–0.74) in women. While serum adiponectin did not improve the area under the ROC curve for predicting new-onset metabolic syndrome based on information from metabolic syndrome components, the net reclassification improvement and the integrated discrimination improvement of prediction models including adiponectin were significantly higher compared with those of models not including adiponectin among men, with a significant difference between men and women (P = 0.001). CONCLUSIONS Increased adiponectin is an independent protective factor for incident metabolic syndrome in men and women, and it may have a clinical role in predicting new-onset metabolic syndrome among men.

Although central obesity is a more powerful predictor of cardiovascular disease (CVD) than general obesity, there is limited information on structural and functional changes of the heart in central obesity. Therefore, we evaluated the association between abdominal obesity and geometric and functional changes of the heart in healthy males. A total of 1460 healthy males aged 40 to 70 years without known CVD from the Korean Genome and Epidemiology Study on Atherosclerosis Risk of Rural Areas in the Korean General Population were included. All individuals underwent conventional 2-dimensional echocardiography and tissue Doppler imaging to measure left atrial (LA) and left ventricle (LV) geometry and function. Increasing tertiles of waist circumference (WC) were associated with stepwise increases in LA volume, LV end-diastolic dimension, LV mass to height, deceleration time of E wave, and lower E/A ratio (all P trends 89 cm) to the lowest tertile (

Statin is a well-known agent which has a variety of pleiotropic effect for reducing incidence of major adverse cardiovascular events (MACE) among patients (pts) with acute myocardial infarction (AMI). However, there have been an issue related to higher incidence of new onset diabetes and glucose