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Coronary artery spasm (CAS) is a well-known endothelial dysfunction, which can induce acute coronary syndrome (ACS) or vasospastic angina (VSA). Impaired glycemic control is risk factor for cardiovascular disease. In this study, we evaluated the impact of insulin resistance on CAS in patients

Coronary artery spasm (CAS) refers to an abnormal condition where the epicardial coronary artery contracts. The relationship between alcohol consumption and CAS is even more ambiguous. Therefore, we evaluated drinking patterns such as current drinking status, weekly drinking amount, and drinking

Left ventricular ejection fraction (LVEF) is a powerful predictor of prognosis in patients with coronary artery disease. The benefit of successful percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) patients with reduced EF has been investigated, however, there are very

Myocardial infarction (MI) can lead to worsening cardiovascular morbidity and mortality. However, there are limited data regarding the impact of MI on long-term clinical outcomes of coronary chronic total occlusion (CTO). A total of 640 consecutive CTO pts who underwent diagnostic coronary

Ambient air pollution is well-known to be a serious risk factor for cardiovascular diseases, stroke, and death. However, the association between air pollutants (AP) exposure and coronary artery spasm (CAS) by acetylcholine (Ach) provocation test is not well elucidated yet. A total of 5,822

Drug-eluting stent (DES) has reduced repeat revascularization, especially target lesion revascularization (TLR). However, there were limited data regarding non-TLR after DES implantation. The aim of this study was to evaluate whether here are differences in the incidence and predictors between TLR

Nowadays, population is fast growing into older age group, and the number of older patients (pts) with complex coronary artery disease (CAD) including unprotected left main (LM) disease undergoing revascularization is increasing. The aimof this study is to investigate the impact of age on the

There are limited data regarding long-term clinical outcomes of patients (Pts) with coronary chronic total occlusion (CTO) lesions according to gender. A total of 822 consecutive CTO pts who underwent diagnostic coronary angiography, receiving either percutaneous coronary intervention (PCI) or

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

PURPOSE Angiotensin converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB) are associated with a decreased incidence of new-onset diabetes mellitus (NODM). The aim of this study was to compare the protective effect of ACEI versus ARBs on NODM in an Asian population. MATERIALS AND METHODS We investigated a total of 2817 patients who did not have diabetes mellitus from January 2004 to September 2009. To adjust for potential confounders, a propensity score matched (PSM) analysis was performed using a logistic regression model. The primary end-point was the cumulative incidence of NODM, which was defined as having a fasting blood glucose ≥126 mg/dL or HbA1c ≥6.5%. Multivariable cox-regression analysis was performed to determine the impact of ACEI versus ARB on the incidence of NODM. RESULTS Mean follow-up duration was 1839±1019 days in all groups before baseline adjustment and 1864±1034 days in the PSM group. After PSM (C-statistics=0.731), a total 1024 patients (ACEI group, n=512 and ARB group, n=512) were enrolled for analysis and baseline characteristics were well balanced. After PSM, the cumulative incidence of NODM at 3 years was lower in the ACEI group than the ARB group (2.1% vs. 5.0%, p=0.012). In multivariate analysis, ACEI vs. ARB was an independent predictor of the lower incidence for NODM (odd ratio 0.37, confidence interval 0.17-0.79, p=0.010). CONCLUSION In the present study, compared with ARB, chronic ACEI administration appeared to be associated with a lower incidence of NODM in a series of Asian cardiovascular patients.

Although posterior wall of left atrium (LA) is known to be arrhythmogenic focus, little is known about the effect of posterior wall isolation (PWI) in patients who undergo radiofrequency catheter ablation (RFCA) for persistent atrial fibrillation (PeAF).We randomly assigned 120 consecutive PeAF patients to additional PWI [PWI (+), n=60] or control [PWI (-), n=60] groups. In all patients, linear ablation was performed after circumferential pulmonary vein isolation (PVI). Linear lesions included roof, anterior perimitral, and cavotricuspid isthmus lines with conduction block. In PWI (+) group, posterior inferior linear lesion was also conducted. Creatine kinase-MB (CK-MB) and troponin-T levels were measured 1day after RFCA. LA emptying fraction (LAEF) was assessed before and 12 months after RFCA.A total of 120 subjects were followed for 12 months after RFCA. There were no significant differences between two groups in baseline demographics and LA volume (LAV). The levels of CK-MB and troponin-T and procedure time were not significantly different between the groups. AF termination during RFCA was more frequently observed in PWI (+) than control (P=0.035). During follow-up period, recurrence occurred in 10 (16.7%) patients in PWI (+) and 22 (36.7%) in control (P=0.02). The change in LAEF was not significantly different between the groups. On multivariate analysis, smaller LAV and additional PWI were independently associated with procedure outcome.PWI in addition to PVI plus linear lesions was an efficient strategy without deterioration of LA pump function in patients who underwent RFCA for PeAF.

Background There have been few randomized control trials comparing the incidence of stent fracture and primary patency among different self-expanding nitinol stents to date. The SMART™ CONTROL stent (Cordis Corp, Miami Lakes, Florida, United States) has a peak-to-valley bridge and inline interconnection, whereas the COMPLETE™-SE stent (Medtronic Vascular, Santa Rosa, California, United States) crowns have been configured to minimize crown-to-crown interaction, increasing the stent's flexibility without compromising radial strength. Further, the 2011 ESC (European society of cardiology) guidelines recommend that dual antiplatelet therapy with aspirin and a thienopyridine such as clopidogrel should be administered for at least one month after infrainguinal bare metal stent implantation. Cilostazol has been reported to reduce intimal hyperplasia and subsequent repeat revascularization. To date, there has been no randomized study comparing the safety and efficacy of two different antiplatelet regimens, clopidogrel and cilostazol, following successful femoropopliteal stenting. Methods/Design The primary purpose of our study is to examine the incidence of stent fracture and primary patency between two different major representative self-expanding nitinol stents (SMART™ CONTROL versus COMPLETE™-SE) in stenotic or occlusive femoropopliteal arterial lesion. The secondary purpose is to examine whether there is any difference in efficacy and safety between aspirin plus clopidogrel versus aspirin plus cilostazol for one month following stent implantation in femoropopliteal lesions. This is a prospective, randomized, multicenter trial to assess the efficacy of the COMPLETE™-SE versus SMART™ CONTROL stent for provisional stenting after balloon angioplasty in femoropopliteal arterial lesions. The study design is a 2x2 randomization design and a total of 346 patients will be enrolled. The primary endpoint of this study is the rate of binary restenosis in the treated segment at 12 months after intervention as determined by catheter angiography or duplex ultrasound. Discussion This trial will provide powerful insight into whether the design of the COMPLETE™-SE stent is more fracture-resistant or effective in preventing restenosis compared with the SMART™ CONTROL stent. Also, it will determine the efficacy and safety of aspirin plus clopidogrel versus aspirin plus cilostazol in patients undergoing stent implantation in femoropopliteal lesions. Trial registration Registered on 2 April 2012 with the National Institutes of Health Clinical Trials Registry (ClinicalTrials.gov identifier# NCT01570803).

Background Coronary artery spasm (CAS) is known to be a risk factor of acute coronary syndrome and angina pectoris. However, there is no currently available data with larger study population regarding long-term clinical outcomes of CAS in real world clinical practice. Objectives We evaluated the prevalence of CAS and the impact of CAS on 5-year clinical outcomes in a series of Asian CAS patients documented by intracoronary acetylcholine (Ach) provocation test. Methods A total of 1413 consecutive patients without significant coronary artery disease (CAD) who underwent Ach provocation test between Nov. 2004 and Oct. 2008 were enrolled. Significant CAS was defined as >70% of narrowing by incremental intracoronary injection of 20, 50 and 100μg. Patients were divided into two groups based on the presence of significant CAS (the non-CAS group: n=640, the CAS group; n=773). To adjust potential confounders, a propensity score matched (PSM) analysis was performed using the logistic regression model. Results A total of 54.7% (773/1413) patients were diagnosed as CAS documented by Ach provocation test. After PSM analysis, 2 propensity-matched groups (451 pairs, n=902, C-statistic=0.677) were generated. Despite of similar incidence of individual hard endpoints including mortality, myocardial infarction and revascularization, the CAS group showed the higher trend of recurrent angina requiring follow up angiography than the non-CAS group up to 5years (HR; 1.56, 95% C.I.; 0.99–2.46, p=0.054). Conclusions The prevalence of CAS was 54.7%. Although the cumulative incidence of recurrent angina requiring follow up coronary angiography seems to be increased up to 5years in CAS patients, CAS patients was not associated with major individual and composite clinical outcomes such as mortality, MI, PCI, CVA with optimal medical therapy as compared with patients without CAS.

High dose atorvastatin is known to be associated with new onset diabetes mellitus (NODM) in patients with high risk for developing diabetes mellitus (DM). However, low dose atorvastatin is more commonly used as compared with high dose atorvastatin. The aim of this study is to investigate the impact of low dose atorvastatin (LDA, 10mg or 20mg) on the development of NODM up to three years in Asian patients.From January 2004 to September 2009, we investigated a total of 3566 patients who did not have DM. To adjust for potential confounders, a propensity score matching (PSM) analysis was performed using the logistic regression model. After PSM (C-statistics: 0.851), a total of 818 patients (LDA group, n=409 patients and control group, n=409 patients) were enrolled for analysis.Before PSM, the cumulative incidence of NODM (5.8% vs. 2.1%, p0.001), myocardial infarction (0.5% vs. 0.1%, p-value=0.007), and major adverse cardio-cerebral event (MACCE, 1.8% vs. 0.7%, p-value=0.012) at three-years were higher in the LAD group. However, after PSM, there was a trend toward higher incidence of NODM (5.9% vs. 3.2%, p=0.064) in the LDA group, but the incidence of MACCE (1.2% vs. 1.5%, p-value=1.000) was similar between the two groups. In multivariable analysis, the LDA administration was tended to be an independent predictor of NODM (OR: 1.99, 95% CI: 1.00-3.98, p-value 0.050).In this study, the use of LDA tended to be a risk factor for NODM in Asian patients and reduced clinical events similar to the control group. However, large-scale randomized controlled trials will be needed to get the final conclusion.

Both diabetes mellitus (DM) and coronary artery spasm (CAS) are associated with endothelial dysfunction. Thus, a higher incidence of CAS is expected in diabetic patients (pts). We evaluated the impacts of DM and the status of blood sugar control on CAS with intracoronary acetylcholine (ACh) provocation test.A total of 986 pts (106 DM vs 880 non-DM pts) with angiographically normal coronary artery received ACh provocation test. Significant CAS was defined as a transient90% luminal narrowing with concurrent chest pain and/ or ST-segment changes. HbA1c7% was considered a controlled blood sugar level.The incidence of CAS was similar between patients with versus without DM (30.2% vs 23.5%; P=.13). Multivariable analysis showed that DM was not an independent risk factor for significant CAS (odds ratio [OR], 1.29; 95% confidence interval [CI], 0.81-2.07; P=.28). The angiographic characteristics of CAS were also similar between these two groups. Subgroup analysis regarding the impact of the status of blood sugar control on CAS showed that the incidence of CAS was similar between diabetic pts with versus without controlled blood sugar levels (35.4% vs 25.9%; P=.29). Multivariable analysis showed that the uncontrolled blood sugar level was not an independent risk factor for CAS (OR, 0.79; 95% CI, 0.29-2.13; P=.64).Despite the expected endothelial dysfunction, DM and the status of blood sugar control are not associated with CAS, suggesting the existence of different mechanisms for CAS and coronary artery disease.

Heart failure is known to be associated with increased adverse clinical outcomes in coronary artery diseases. The impact of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) in patients (pts) with new onset heart failure is not clear. We compared the 12-month clinical

Background: High dose atrovastatin is known to be associated with new onset diabetes mellitus (DM) in patients (pts). However, there have been limited data whether low dose atrovastatin can be asso...

Background: Hyperuricemia is a well-known risk factor for diabetes mellitus (DM) and other cardiovascular diseases, but the relationship between hyperuricemia and the development of new-onset DM is...

Chronic total occlusion (CTO) intervention is still challenging because of the limited procedural success rate and high target failure. The impact of percutaneous coronary intervention (PCI) for CTO in elder patients is not clear. We evaluated the 12-month clinical outcomes between intervention and

A 55-year-old man with a previous history of cerebral infarct and hypertension presented to our cardiovascular center complaining of angina in November 2011. Chronic total occlusion in the proximal left anterior descending artery was identified by coronary angiography (Figure 1A). The patient subsequently underwent percutaneous coronary intervention. Wiring was done successfully with a tapered stiff wire (Conquest Pro 20; ASAHI INTECC). After multiple predilation, a single drug-eluting stent (3.0 × 18 mm) of an open-cell design and bioabsorbable polymer (Nobori; Terumo, Tokyo, Japan) was implanted using a 3.5-mm noncompliant balloon (inflation pressure, 24 atmospheric pressure; Quantum Maverick Balloon; Boston Scientific/Scimed, Maple Grove, MN) for application of final high-pressure postdilation (Figure 1B). The patient has been asymptomatic since percutaneous coronary intervention and on dual antiplatelet therapy. A 6-month scheduled angiographic follow-up demonstrated a structural misalignment at the stent implantation site with a change in focal aneurysm (Figure 1C). Digital subtraction imaging by StentBoost (Subtract; Philips Healthcare, Best, The Netherlands) was done under the suspicion of stent distortion, but the imaging was unclear to clarify the diagnosis (Figure 1D). To determine the precise configuration of the stent, we performed intravascular optical coherence tomography (OCT). Conventional 2-dimensional (2-D) OCT revealed a focal thrombus and 2 additional aneurysms …

In our previous study, hypertensive patients with uncontrolled blood pressure had a significantly lower incidence of coronary artery spasm (CAS) than those with controlled blood pressure. However, it is unknown whether hypertensive patients with target-organ damage have a lower incidence of CAS than

Background: The inflammatory biomarker high-sensitivity C-reactive protein (hsCRP) is known to be associated with the progression and worsening of heart failure (HF). We evaluated the clinical sign...

In previous studies, some clinical risk factors were found to be associated with adverse cardiac events in coronary artery spasm (CAS) patients, however, combinatorial effects of those risk factors have not been systematically evaluated yet. This study is to develop a novel scoring system which

Angiographic evidence of coronary artery perforation has been reported in about 0.1% to 3.0% of a variety of endovascular intervention, is one of the most life-threatening complication in contemporary percutaneous coronary intervention (PCI) [1]. The frequency of adjuvant balloon postdilation at the overlapping segment after multiple overlapping stenting to treat the diffuse long lesion is increasing in drug-eluting stent (DES) era. We experienced an unexpected devastating coronary perforation just after the adjuvant balloon postdilation at the overlapping stented area in curved proximal left anterior descending artery (LAD), which can be an emerging risk factor of coronary perforation in contemporary PCI with DES. Nonsurgical management such as prolonged balloon inflation and immediate reversal of anticoagulation often fails and emergency surgery can be needed. Polytetrafluoroethylene (PTFE)-covered stents (The JOSTENT coronary stent graft; Abbot Vascular Devices, Abbott Park, Illinois, USA) can provide a successful mechanical barrier using shielding mechanism of PTFE and is known to be a very effective, safe and easy treatment option for covering coronary perforations [2]. Thus, this PTFE-covered stent graft has emerged as a promising tool for the nonsurgical

We report a case of extensive exfoliative dermatitis in a patient appearing 3 days after intracoronary administration of non-ionic contrast medium Iodixanol (Visipaque) during the primary percutaneous coronary intervention. The patient presented with acute myocardial infarction and has never exposed to any X-ray contrast medium. The patient was successfully treated with corticosteroid, antihistamines and antibiotics for the prevention of secondary bacterial infection. The patient was recovered 8 days after the anti-allergic medical management. This case can be a rare example of late-onset allergic reaction to a non-ionic contrast medium Iodixanol presented with extensive exfoliative dermatitis.

Despite the fact that the drug-eluting stents (DES) have markedly reduced neointimal proliferation, restenosis is still an open subject. Although DES fracture is very rare, it has been considered as one of the reasons for DES restenosis, however, the mechanism and proper management are not clearly elucidated yet. We describe two cases of sirolimus-eluting stent fracture combined with significant restenosis and suggest the possible revascularization strategies for successful management.

Stent thrombosis is a feared complication of percutaneous coronary intervention, although there is a low incidence of thrombotic events following drug-eluting stent implantation. We report a case with cardiogenic shock complicated by acute myocardial infarction due to simultaneous subacute stent thrombosis occurring 3 days after implantation of two sirolimus-eluting stents in the proximal left anterior descending artery (LAD) and in the proximal right coronary artery (RCA).

Hyperuricemia is known to be associated with cardiovascular complications. However, there are limited data whether there is a clear association between hyperuricemia and significant coronary artery spasm (CAS) as assessed with intracoronary Acetylcholine (Ach) provocation test. This study consisted

Coronary artery bypass grafting (CABG) using bilateral internal thoracic artery (BITA) has been proven to improve survival. Many surgeons use the composite Y-graft which is made of left ITA (LITA) and right ITA (RITA) grafts. The LITA is typically anastomosed to left anterior descending artery (LAD). However, we have used RITA for LAD instead of LITA and reviewed the patency of ITA grafts and their clinical outcomes.We analyzed 48 patients who underwent CABG using a BITA composite Y-graft from 2002 to 2012. In 30, LITA was anastomosed to LAD (Group L). The other 18 had RITA to LAD anastomosis (Group R).The mean age of Group R was higher than that of Group L (p = 0.009). Postoperative angiography was performed in 35 patients (73%). Two patients in Group L and none of the patients in Group R had an ITA graft failure. The incidence of ITA graft failure and new adverse cardiovascular events were not different between the two groups.The clinical outcome of RITA to LAD anastomosis is comparable with anastomosis of LITA to LAD in CABG using BITA composite Y-grafts. This technique may be useful when longer and larger ITA grafts are needed.

recurrence after radiofrequency catheter ablation in patients with atrial fibrillation☆ Sung Il Im , Seung Yong Shin , Jin Oh Na , Yong Hyun Kim , Cheol Ung Choi , Seong Hwan Kim , Jin Won Kim , Eung Ju Kim , SeongWoo Han , Seung-Woon Rha , Chang Gyu Park , Hong Seog Seo , Dong Joo Oh , Chun Hwang , Hong Euy Lim a,⁎,1 a Division of Cardiology, Cardiovascular Center, Korea University Guro Hospital, Seoul, South Korea b Division of Cardiology, Chung-Ang University Hospital, Seoul, South Korea c Division of Cardiology, Korea University Ansan Hospital, Ansan, South Korea d Division of Cardiology, Hallym University Hangang Sacred Heart Hospital, Seoul, South Korea e Division of Cardiology, Utah Valley Regional Medical Center, Provo, UT, USA

Background and objectives The intracoronary injection of acetylcholine (Ach) has been shown to induce coronary spasms in patients with variant angina. Clinical significance and angiographic characteristics of patients with a significant response to lower Ach dosages are as-yet non-clarified compared with patients responding to higher Ach doses. Subjects and methods A total of 3034 consecutive patients underwent coronary angiography with Ach provocation tests from January 2004 to August 2010. Ach was injected in incremental doses of 20, 50, 100 µg into the left coronary artery. Significant coronary artery spasm was defined as focal or diffuse severe transient luminal narrowing (>70%) with/without chest pain or ST-T change on the electrocardiogram (ECG). We compared the clinical and angiographic characteristics of patients who responded to a lower Ach dose (20 or 50 µg, n=556) to those that responded to a higher Ach dose (100 µg, n=860). Results The baseline clinical and procedural characteristics are well balanced between the two groups, except diabetes was higher in the lower Ach dose group and there were differences in medication history. After adjusting for confounding factors, the lower Ach dose group showed more frequent temporary ST elevation and atrioventricular block on the ECG. Furthermore, the group of patients who responded to the lower Ach dose was associated with a higher incidence of baseline and severe spasm than those who responded to a higher Ach dose. Conclusion Patients with a significant response to a lower Ach dose were associated with more frequent ST elevation, baseline spasm, and more severe spasm compared with those who responded to a higher Ach dose, suggesting more intensive medical therapy with close clinical follow-up is required for those patients.

There have been several reports that beta blocker (BB) therapy is associated with a slightly higher incidence of new-onset diabetes mellitus (DM). It is still controversial whether the chronic BB therapy is a risk factor of new onset DM, especially in Asian population. We investigated the 4,231

There are limited data regarding impact of chronic alcohol use on vasospastic angina. We evaluated the impact of alcohol use on coronary artery spasm (CAS) as assessed with intracoronary acetylcholine (Ach) provocation test. A total 3034 consecutive patients [pts, Men 1457 (48.0%), mean age 54.5±

Chronic total occlusion (CTO) intervention is still challenging because of the limited procedural success rate and higher recurrence. It is not clear whether the angiographic and clinical outcomes may different between patients (pts) with single vessel CTO (SV-CTO) and multi-vessel CTO (MV-CTO). A

Objectives: It is well known that myocardial bridge (MB) is a risk factor of vasospastic angina. However, clinical and angiographic characteristics according to different acetylcholine (ACh) dose in patients with MB are not clarified yet. Methods: A total 483 consecutive patients who had angiographically proven MB underwent the intracoronary ACh provocation test. ACh was injected by incremental doses of 20, 50 and 100 μg into the left coronary artery. We evaluated the clinical and angiographic characteristics of patients with MB according to 3 different ACh doses. Results: The baseline clinical and procedural characteristics are well balanced among the three groups. The MB patients who responded to the lower ACh dose (20 μg) had higher incidence of baseline spasm, severe vasospasm and diffuse long spasms (>30 mm) than those who responded to the higher doses (50 and 100 μg). The incidence of 12-month mortality and recurrent chest pain was higher in the lower ACh dose group (20 μg). Conclusion: The patients with MB significantly reacting at the low ACh dose had more pronounced baseline spasm, severe and diffuse long coronary artery spasm, higher 12-month mortality and recurrent chest pain than those reacting with the higher ACh doses, suggesting that more intensive medical therapy will be required.

Background In contrast to many studies comparing everolimus-eluting stent (EES) with paclitaxel-eluting stent (PES), data directly comparing EES with sirolimus-eluting stent (SES) are limited, especially in patients with acute myocardial infarction (AMI). Methods This study includes 2911 AMI patients treated with SES (n=1264) or EES (n=1701) in Korea Acute Myocardial Infarction Registry (KAMIR). Propensity score matching was applied to adjust for baseline imbalance in clinical and angiographic characteristics, yielding a total of 2400 well-matched patients (1200 receiving SES and 1200 receiving EES). One-year clinical outcomes were compared between the two propensity score matched groups. Results Baseline clinical and angiographic characteristics were similar between the two propensity score matched groups. One-year clinical outcomes of the propensity score matched cohort were comparable between the EES versus the SES groups including the rates of cardiac death (4.8% vs. 4.8%, P=1.000), recurrent myocardial infarction (1.4% vs. 1.7%, P=0.619), target lesion revascularization (1.4% vs. 1.6%, P=0.737), target lesion failure (7.0% vs. 7.3%, P=0.752), and probable or definite stent thrombosis (0.5% vs. 0.9%, P=0.224) except for a trend toward lower incidence of target vessel revascularization (1.9% vs. 3.0%, P=0.087) and a lower rate of total major adverse cardiac events (9.3% vs. 11.9%, P=0.034) in the EES group. Conclusions The present propensity score matched analysis performed in a large-scale, prospective, multicenter registry suggests that the second-generation drug-eluting stent EES has at least comparable or even better safety and efficacy profiles as compared with SES in the setting of AMI.