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Background and objectives The hemodynamic evaluation of coronary stenoses undergoes a transition from wire-based invasive measurements to image-based computational assessments. However, fractional flow reserve (FFR) values derived from coronary CT angiography (CCTA) and angiography-based quantitative flow ratio have certain limitations in accuracy and efficiency, preventing their widespread use in routine practice. Hence, we aimed to investigate the diagnostic performance of FFR derived from the integration of CCTA and invasive angiography (FFRCT-angio) with artificial intelligence assistance in patients with stable coronary artery disease (CAD). Methods Forty stable CAD patients with 67 target vessels (50%–90% diameter stenosis) were included in this single-center retrospective study. All patients underwent CCTA followed by coronary angiography with FFR measurement within 30 days. Both CCTA and angiographic images were combined to generate a three-dimensional reconstruction of the coronary arteries using artificial intelligence. Subsequently, functional assessment was performed through a deep learning algorithm. FFR was used as the reference. Results FFRCT-angio values were significantly correlated with FFR values (r = 0.81, P < 0.001, Spearman analysis). Per-vessel diagnostic accuracy of FFRCT-angio was 92.54%. Sensitivity and specificity in identifying ischemic lesions were 100% and 88.10%, respectively. Positive predictive value and negative predictive value were 83.33% and 100%, respectively. Moreover, the diagnostic performance of FFRCT-angio was satisfactory in different target vessels and different segment lesions. Conclusions FFRCT-angio exhibits excellent diagnostic performance of identifying ischemic lesions in patients with stable CAD. Combining CCTA and angiographic imaging, FFRCT-angio may represent an effective and practical alternative to invasive FFR in selected patients.

Objective There exist conflicting data on the efficacy and safety of ticagrelor and clopidogrel in East Asian patients with acute coronary syndrome (ACS). We performed a meta-analysis to evaluate whether ticagrelor or clopidogrel produces better outcomes for East Asian patients with ACS. Methods We searched for randomized controlled trials reporting associations between ticagrelor and clopidogrel in East Asian patients with acute coronary syndrome in PubMed, EMBASE, web of science and Cochrane central register of controlled trials. Results Ten studies involving 3 715 participants were qualified for our analysis. The major adverse cardiovascular events (MACE) were significantly decreased in patients with ticagrelor treatment compared to those with clopidogrel (risk ratio [RR]: 0.61; 95% confidence interval [CI]: 0.38–0.98; P = 0.042). There was no significant difference in all-cause death (RR: 0.89; 95% CI: 0.61–1.29; P = 0.540), cardiovascular death (RR: 0.86; 95% CI: 0.58–1.27; P = 0.451), myocardial infarction (RR: 0.91; 95% CI: 0.65–1.27; P = 0.575) and stroke (RR: 0.77; 95% CI: 0.44–1.36; P = 0.372) between ticagrelor and clopidogrel. Ticagrelor was associated with a significantly higher risk of bleeding compared to clopidogrel (RR: 1.71; 95% CI: 1.37–2.13; P = 0.000). Conclusion The present meta-analysis demonstrates that ticagrelor reduced the incidence of MACE in ACS patients from East Asia compared with clopidogrel. However, it increased the risk of bleeding.

Aims Aging is the most significant contributor to the increasing prevalence of atrial fibrillation (AF). The gut microbiota dysbiosis is involved in age-related diseases. However, whether the aged-associated dysbiosis contributes to age-related AF is still unknown. Direct demonstration that the aged gut microbiota is sufficient to transmit the enhanced AF susceptibility in a young host via microbiota-intestinal barrier-atria axis has not yet been reported. This study aimed to determine whether gut microbiota dysbiosis affects age-related AF. Methods and results Herein, by using a fecal microbiota transplantation (FMT) rat model, we demonstrated that the high AF susceptibility of aged rats could be transmitted to a young host. Specially, we found the dramatically increased levels of circulating lipopolysaccharide (LPS) and glucose led to the up-regulated expression of NLR family pyrin domain containing 3 (NLRP3)-inflammasome, promoting the development of AF which depended on the enhanced atrial fibrosis in recipient host. Inhibition of inflammasome by a potent and selective inhibitor of the NLRP3 inflammasome, MCC950, resulted in a lower atrial fibrosis and AF susceptibility. Then we conducted cross-sectional clinical studies to explore the effect of aging on the altering trends with glucose levels and circulating LPS among clinical individuals in two China hospitals. We found that both of serum LPS and glucose levels were progressively increased in elderly patients as compared with those young. Furthermore, the aging phenotype of circulating LPS and glucose levels, intestinal structure and atrial NLRP3-inflammasome of rats were also confirmed in clinical AF patients. Finally, aged rats colonized with youthful microbiota restored intestinal structure and atrial NLRP3-inflammasome activity, which suppressed the development of aged-related AF. Conclusions Collectively, these studies described a novel causal role of aberrant gut microbiota in the pathogenesis of age-related AF, which indicates that the microbiota-intestinal barrier-atrial NLRP3 inflammasome axis may be a rational molecular target for the treatment of aged-related arrhythmia disease. Translational perspective The current study demonstrates that aged-associated microbiota dysbiosis promotes AF in part through a microbiota-gut-atria axis. Increased AF susceptibility due to enhanced atrial NLRP3-inflammasome activity by LPS and high glucose was found in an aged FMT rat model, and also confirmed within elderly clinical individuals. In a long-term FMT rat study, the AF susceptibility was ameliorated by treatment with youthful microbiota. The present findings can further increase our understanding of aged-related AF and address a promising therapeutic strategy that involves modulation of gut microbiota composition.

Aging plays a critical role in the genesis of atrial fibrillation (AF) and also changes the gut microbes. Whether the aging-associated gut dysbiosis contributes to the development of aging-related AF and whether the gut microbes can be a target to prevent aging-related AF remains unknown.16S rRNA gene sequencing was performed to reveal the changes of gut microbes in elderly patients with AF, and the result showed that the intestinal abundance of B. fragilis was significantly decreased in elderly patients with AF. Subsequently, we examined the impact of B. fragilis supplementation on AF promotion, atrial structural remodeling and inflammation response in D-galactose induced aging rats. We found that oral administration of B. fragilis prevented AF inducibility and duration, which was associated with attenuation of atrial senescence, apoptosis and fibrosis. Furthermore, B. fragilis significantly diminished the systemic and atrial inflammation, which is accompanied by an increase in the number of Treg cells in the spleen and blood. More importantly, we found that the circulation level of polysaccharide A (PSA), the metabolite synthesized by B. fragilis, was reduced in elderly patients with AF and could predict the occurrence of AF, and B. fragilis increased the circulation concentration of PSA in D-galactose induced aging rats.The abundance of B. fragilis was lower in elderly patients with AF. Oral administration of B. fragilis significantly attenuated inflammatory response by increasing Treg cells, thereby preventing atrial structural remodeling and inhibiting AF promotion in D-galactose induced aging rats. This study provides experimental evidence for the effectiveness of targeting gut microbes in the prevention of aging-related AF.

Background: Aging is the most significant contributor to the increasing prevalence of atrial fibrillation (AF). The gut microbiota dysbiosis is involved in age-associated diseases. However, whether age-associated gut microbial dysbiosis contributes to AF is still unknown. The aim of this study was to evaluate the effect of gut microbiota on the susceptibility of aging-induced AF and to elucidate the underlying mechanisms. Results: The gut microbiota profiling of fecal samples in aged (22-24 months old) and young (2-3 months old) rats was performed by 16S ribosomal RNA gene analysis. A rat model of fecal microbiota transplantation (FMT) was established for analyzing the possible role of age-associated gut microbial dysbiosis in AF. Here, we found that aging process led to marked shift of the microbiota spectrum. The microbiota in young rats following FMT resembled that of aged microbiota and transmitted the increased AF susceptibility by elevation of circulating lipopolysaccharide (LPS). The mechanism for LPS-driven atrial pro-arrhythmic action was dependent on the activation of atrial nucleotide binding and oligomerization domain-like receptor family pyrin domain-containing (NLRP3)-inflammasome. Inhibition of inflammasome by MCC950 resulted in lower atrial fibrosis and AF susceptibility. In addition, atrial fibrosis, plasma LPS concentration, plasma glucose to oral glucose tolerance test (OGTT), intestinal permeability, and gut pathology were significantly increased in elderly human subjects. Finally, altering the microbiota in aged recipient to resemble that of young restored the intestinal barrier dysfunction and LPS and impaired glucose tolerance, and the worse outcomes of aged dysbiosis on atrial fibrosis and AF susceptibility were abrogated. Conclusions: These data suggest that age-associated microbial dysbiosis induces circulating LPS and impairs glucose tolerance, and thereby promotes AF susceptibility through enhanced activity of atrial NLRP3-inflammasome.

Acute ST-segment elevation myocardial infarction (STEMI) remains a leading cause of morbidity and mortality around the world. A large number of STEMI patients after the infarction gradually develop heart failure due to the infarcted myocardium. Timely reperfusion is essential to salvage ischemic myocardium from the infarction, but the restoration of coronary blood flow in the infarct-related artery itself induces myocardial injury and cardiomyocyte death, known as ischemia/reperfusion injury (IRI). The factors contributing to IRI in STEMI are complex, and microvascular obstruction, inflammation, release of reactive oxygen species, myocardial stunning, and activation of myocardial cell death are involved. Therefore, additional cardioprotection is required to prevent the heart from IRI. Although many mechanical conditioning procedures and pharmacological agents have been identified as effective cardioprotective approaches in animal studies, their translation into the clinical practice has been relatively disappointing due to a variety of reasons. With new emerging data on cardioprotection in STEMI over the past few years, it is mandatory to reevaluate the effectiveness of “old” cardioprotective interventions and highlight the novel therapeutic targets and new treatment strategies of cardioprotection.

Inability to advance a balloon is a well-recognized cause leading to a failure in recanalization of chronic total occlusions (CTOs) despite successfully passing a guidewire. A few techniques and devices have been introduced to facilitate balloon passage, especially the use of Tornus catheter. However, complex manipulation, expensive cost, and availability limit the application of these methods. This study was to evaluate the efficiency and safety of "seesaw balloon-wire cutting" technique in comparison with Tornus catheter for balloon uncrossable CTOs.Eighty patients with balloon uncrossable CTOs were enrolled in this study. Among them, 40 patients treated with "seesaw balloon-wire cutting" technique were consecutively investigated and 40 patients treated with Tornus catheter before were matched retrospectively. A rotablator or retrograde strategy was taken as a bail-out strategy. Success rates of device and procedure and complication rate were assessed. Complications included coronary dissection, cardiac tamponade, death, Q-wave myocardial infarction (MI), non-Q-wave MI, emergency PCI and bypass surgery.Compared with the Tornus catheter, device success rate was significantly higher with the "seesaw balloon-wire cutting" technique (87.5% vs. 45.0%, P0.001), and the mean procedural time was much shorter (90.5±8.3min vs. 141.5±21.3min, P0.001). The procedural success rate was also higher with the "seesaw balloon-wire cutting" technique (92.5% vs.72.5%, P=0.037). There were no differences in complication rate.The "seesaw balloon-wire cutting" technique is superior to the Tornus catheter in treating balloon uncrossable CTOs.

Ticagrelor has been demonstrated to provide a more rapid and powerful inhibition of platelet aggregation compared with clopidogrel in coronary artery disease (CAD) patients. In our previous study, we found that half-dose ticagrelor produced similar inhibitory effects on platelet aggregation as standard-dose ticagrelor and exerted significantly stronger effects than clopidogrel in Chinese patients with non-ST-elevation ACS. Therefore, we performed this study to observe the efficacy of one-quarter standard-dose ticagrelor in comparison to standard-dose clopidogrel in Chinese patients with stable CAD.In a randomized, single-blind, crossover trial, 30 patients with stable CAD were randomized to one-quarter standard-dose ticagrelor (22.5mg BID for 7days) or standard-dose clopidogrel (75mg QD for 7days). Following a 2-week washout period, patients switched regimens. Light transmission aggregometry (LTA) and VerifyNow assay were used to measure platelet function.The platelet aggregation rate (PAgR) was obviously lower with ticagrelor than clopidogrel (17.70%±12.67% versus 27.63%±13.10%, P0.05). The % inhibition levels in the ticagrelor group exhibited significantly greater than that in the clopidogrel group (65.33%±21.31% versus 36.23%±23.01%, P0.01). PRU values in the ticagrelor group were dramatically lower than that in the clopidogrel group (87.03±51.38 versus 163.77±58.66, P0.01). High-platelet reactivity (HPR) (≥208 PRU) was 0% with ticagrelor and 16.67% with clopidogrel.One-quarter standard-dose ticagrelor provided greater degree of platelet inhibition than standard-dose clopidogrel in Chinese patients with stable CAD.

β-Blocker use has been controversial for a long time in the management of hypertensive patients with obstructive sleep apnea (OSA). The aim of present study was to compare the effects of metoprolol on BP lowering with amlodipine in hypertensive OSA patients.Hypertensive subjects with OSA were randomly assigned to metoprolol and amlodipine groups, receiving 12 weeks of oral either metoprolol (47.5 mg once daily) or amlodipine (5 mg once daily) treatment. At baseline and after the 12-week treatment period, 24-h ambulatory blood pressure monitoring was performed in both groups.Both of metoprolol and amlodipine treatments significantly lowered 24-h blood pressure (BP) (from 143/88 to 132.3/81.6 mmHg; from 141.3/84.5 to 133.7/80.8 mmHg), daytime BP (from 146/90.2 to 136.4/84.6 mmHg; from 145.1/87.6 to 138.2/84.1 mmHg), and nighttime BP (from 139.1/83.9 to 125.7/76.2 mmHg; from 134.5/78.5 to 125.8/74.1 mmHg) (all P 0.05). But there were no significant differences between the groups in BP variability (P 0.05). Besides, metoprolol significantly reduced daytime heart rate (HR) (P 0.05), while 24-h and nighttime HR values had no remarkable changes compared with baseline (P 0.05).Metoprolol had similar therapeutic effects on BP lowering as amlodipine and could not decrease HR during the nighttime in hypertensive patients with OSA.

Coronary artery perforation (CAP) is an infrequent yet potentially life-threatening complication of percutaneous coronary intervention. We report, for the first time, two cases of successful closure of guidewire-induced distal CAP with silk suture embolization using a microcatheter. This technique appears to be safe, simple, and effective for the treatment of distal guidewire perforations, even in refractory cases.

Background: Previous studies revealed that culprit vessels of ST-segment elevation myocardial infarction (STEMI) were often related to mild or moderate stenosis. However, recent studies suggested that severe stenosis was primarily found in culprit lesions. The objective of this study was to analyze the stenosis severity of culprit lesions in STEMI patients and to clarify the paradoxical results. Methods: A total of 489 consecutive STEMI patients who underwent primary percutaneous coronary intervention were retrospectively studied from January 2012 to December 2014. The patients were divided into three groups based on stenosis severity using quantitative coronary analysis: Group A, 314 cases, stenosis ≥70%; Group B, 127 cases, stenosis 50–70%; and Group C, 48 cases, stenosis ≤50%. The clinical, demographic, and angiographic data of all groups were analyzed. Results: Patients in Group A exhibited a significantly higher prevalence of history of angina pectoris (95.9% vs. 62.5%, P < 0.001), multivessel disease (73.2% vs. 54.2%, P = 0.007), and lower cardiac ejection fraction (53.3 ± 8.6 vs. 56.8 ± 8.4, P = 0.009) than those in Group C. Multivariable analysis revealed that history of angina pectoris (odds ratio [OR]: 13.89, 95% confidence interval [CI]: 6.21–31.11) and multivessel disease (OR: 2.32, 95% CI: 1.25–4.31) were correlated with severe stenosis of the culprit lesion in Group A. Conclusions: Most culprit lesions in STEMI patients were severe stenosis. These patients exhibited a higher prevalence of angina history and multivessel diseases.

Ticagrelor is a novel direct-acting P2Y12 receptor antagonist used for preventing atherothrombotic events in patients with acute coronary syndromes (ACS). The current recommended dose is 90 mg bid, but a low dose of ticagrelor has not been previously studied in Chinese ACS patients. Therefore, we performed this study to observe the different effects of half- and standard-dose ticagrelor on platelet aggregation in Chinese patients with NSTE-ACS. Sixty-two NSTE-ACS subjects were assigned to half-dose ticagrelor (n = 20), standard-dose ticagrelor (n = 22) and clopidogrel (n = 20) groups. Five days after drug administration, VerifyNow P2Y12 assay was performed to test P2Y12 reaction units (PRU) and inhibition of platelet aggregation (IPA). High-platelet reactivity (HPR) was defined as a PRU > 208. The adverse events, including bleeding events and dyspnoea, were monitored throughout the study. PRU values in the half-dose (44.55 ± 32.88) and standard-dose (39.10 ± 40.02) ticagrelor were dramatically lower than those in the clopidogrel group (189.20 ± 65.22; P < 0.0001). The half-dose (84% ± 10%) and standard-dose (86% ± 13%) ticagrelor both showed greater IPA than clopidogrel (33% ± 20%; P < 0.0001). There were no significant differences in PRU and IPA between the two ticagrelor groups (P = 0.3085 and 0.4028, respectively). HPR rates were significantly lower in the two ticagrelor groups (0% for both) than those in the clopidogrel group (35%). In conclusion, half-dose ticagrelor had a similar inhibitory effect on platelet aggregation as standard-dose ticagrelor in Chinese patients with NSTE-ACS, which was significantly stronger than that of clopidogrel.

Excessive movement of coronary stents within the artery can make accurate stent placement difficult. This study assessed the use of the floating-wire technique to reduce stent motion to improve placement accuracy.During percutaneous coronary intervention, if excessive stent movement prevented accurate stent placement, the floating-wire technique was performed to reduce stent motion within the coronary artery during both stent positioning and deployment. Postprocedural angiograms were analyzed by two independent operators to measure the motion length of the stent delivery system relative to the coronary artery before and after using the floating-wire technique. The floating-wire technique was considered necessary in 19 patients. No procedural complications occurred. The extent of motion was markedly reduced by using the floating-wire technique (4.04 ± 1.25 mm to 1.11 ± 0.81 mm; P.001).The floating-wire technique is an effective and safe method to reduce stent movement and facilitate accurate stent deployment. This simple technique can be easily applied in any interventional cardiac catheterization laboratory without the need for additional training or equipment.

Balloon crossing failure after passing a guidewire usually leads to unsuccessful percutaneous recanalization of chronic total occlusions (CTOs). We sought to investigate a novel technique for solving this problem.Twenty-one patients with failed balloon crossing through CTOs after successful guidewire passing were treated with the "seesaw balloon-wire cutting" technique between July 2012 and May 2013. The main process of this technique was to insert two guidewires (guidewire A and guidewire B) into the distal true lumen of CTOs and then to advance two short and lowprofile balloons (balloon A and balloon B) over the two guidewires, respectively. Balloon A was first advanced over guidewire A as distally as possible, and then was inflated with high pressure (≥18 atm) to press guidewire B, producing a cutting power to crush the proximal fibrous cap of the CTO. Subsequently, balloon A was withdrawn slightly, and balloon B was advanced as distally as possible and then was inflated to press guidewire A, producing a similar cutting effect to crush the proximal fibrous cap on the other side. The two balloons were progressed alternatively until one of them was able to cross through the occluded segment.This new technique was successfully applied in 17 patients (81.0%), leading to procedural success of their CTOs. The technique failed in 4 patients (19.0%) due to heavy calcification. No complications occurred in all patients.The seesaw balloon-wire cutting technique is an effective and safe approach to facilitate balloon crossing during CTO interventions.

Objective To investigate whether microRNAs (miRs) can serve as novel biomarkers for in-stent restenosis (ISR). Methods This retrospective, observational single-centre study was conducted at the cardiovascular department of a tertiary hospital centre in the north of China. Follow-up coronary angiography at 6 to 12 months was performed in 181 consecutive patients implanted with drug-eluting stents. Fifty-two healthy volunteers served as the control group. The plasma miRs levels were analyzed by quantitative real-time PCR. Receiver-operating characteristic curve (ROC) analysis was performed to investigate the characters of these miRs as potential biomarkers of ISR. Results MiR-21 levels in ISR patients were significantly higher than those in non-ISR patients and healthy controls (P