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Purpose: Asians often face the problems of clopidogrel resistance and East Asian paradox. This study aimed to evaluate the effects of P2Y 12 inhibitors, including low-dose prasugrel 2.5 mg, on the P2Y 12 reaction unit (PRU) in the chronic phase after percutaneous coronary intervention (PCI)., Methods: A total of 348 patients were studied. PRU was measured 6-12 months after PCI and subsequently, 6 months later using a P2Y 12 assay, respectively. This study evaluated the proportion of bleeding risk (PRU ≤ 85) and ischemic risk (PRU ≥ 239) as primary endpoints, and the prediction of bleeding risk and ischemic risk using multivariable logistic regression analysis., Results: At baseline, 136 patients (39%) received prasugrel 3.75 mg, 48 patients (14%) received prasugrel 2.5 mg, and 164 patients (47%) received clopidogrel 75 mg. Clopidogrel 75 mg had a significantly higher proportion of ischemic risk within one year after PCI than the other groups, and was an independent predictor for ischemic risk with reference of prasugrel 3.75 mg. In addition, switching from clopidogrel 75 mg to prasugrel 2.5 mg significantly lowered and aggregated the PRU value. Whereas, dose reduction of prasugrel had a significantly lower proportion of bleeding risk over one year after PCI than the continuation of prasugrel 3.75 mg, and was an independent predictor for bleeding risk with reference of continuation of prasugrel 3.75 mg., Conclusions: Prasugrel 2.5 mg has a lower ischemic risk and a more stable PRU value compared with clopidogrel treatment. Prasugrel also contributes to a decline in bleeding risk with concomitant dose reduction., Trial Registration: University Hospital Medical Information Network (UMIN), ID: UMIN000029541, Date: October 16, 2017 ( https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000033395 )., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

There are few reports on the association between apolipoprotein C-III (ApoC-III) and coronary calcification using intravascular modalities. This study aimed to investigate the impacts of ApoC-III levels on coronary calcification using grayscale intravascular ultrasound (IVUS). Consecutive 263 culprit lesions for 202 patients who underwent percutaneous coronary intervention using grayscale IVUS were included in this study and divided into four groups based on quartile ApoC-III values. This study assessed plaque characteristics, including severe calcification (>180° arc) at the minimum lumen area site and presence of calcified nodules within the culprit lesion using grayscale IVUS, and evaluated whether ApoC-III levels were associated with coronary calcified plaques. The highest ApoC-III quartile [Quartile 4 (Q4)] had a higher proportion of complex lesions, calcified plaques, severe calcification, calcified nodules, plaque burden, and total atheroma volume than the lowest ApoC-III quartile [Quartile 1 (Q1)]. Additionally, multivariable logistic regression analysis showed that Q4 was significantly associated with severe calcification and calcified nodules, with Q1 as the reference (odds ratio [OR]: 2.70, 95% confidence intervals [CIs]: 1.04-7.00, p  = 0.042; and OR: 3.72, 95% CIs 1.26-11.0, p  = 0.017, respectively). Furthermore, ApoC-III level (1-mg/dl increase) was a strong significant predictor of severe calcification (OR: 1.07, 95% CIs: 1.00-1.15, p  = 0.040) and calcified nodules (OR: 1.09, 95% CIs: 1.01-1.19, p  = 0.034) according to the multivariable logistic regression analysis. This study is the first to verify that elevated ApoC-III levels are associated with the development of severe calcification and progression to calcified nodules as detected by grayscale IVUS., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Fukase, Dohi, Nishio, Takeuchi, Takahashi, Chikata, Endo, Doi, Nishiyama, Okai, Iwata, Koga, Okazaki, Miyauchi, Daida and Minamino.)

Introduction: The long-term impact of renin-angiotensin system (RAS) inhibitors for secondary prevention in patients with chronic kidney disease (CKD) and coexisting coronary artery disease remains unclear., Methods: Altogether, 1,160 consecutive patients with CKD (mean age, 70 ± 9 years; 78% men) who underwent their first percutaneous coronary intervention (PCI) between 2000 and 2018 were included and analyzed. Based on their RAS inhibitor use, 674 patients (58%) were allocated to the RAS inhibitor group, and 486 patients (42%) were allocated to the non-RAS inhibitor group. This study evaluated the incidence of 3-point major adverse cardiovascular events (3P-MACE), including cardiovascular death, nonfatal acute coronary syndrome and nonfatal stroke, admission for heart failure (HF), target vessel revascularization (TVR), and all-cause death., Results: During a median follow-up duration of 7.8 years, 280 patients (24.1%) developed 3P-MACE, 134 patients (11.6%) were hospitalized for HF, 171 patients (14.7%) underwent TVR, and 348 patients (30.0%) died of any causes. The cumulative incidence rate of 3P-MACE in the RAS inhibitor group was significantly lower than in the non-RAS inhibitor group (31.7% vs. 39.0%, log-rank test, p = 0.034); however, that of admission for HF in the RAS inhibitor group was significantly higher than in the non-RAS inhibitor group (28.1% vs. 13.3%, log-rank test, p < 0.001). The subgroup of preserved ejection fraction, non-acute myocardial infarction, and non-proteinuria tended to promote the onset of HF rather than cardiovascular prevention by RAS inhibitors., Conclusion: The long-term RAS inhibitor use for patients with CKD after PCI might prevent cardiovascular events but increase the risk of HF., Competing Interests: The authors declare no conflicts of interest., (© 2023 The Author(s). Published by S. Karger AG, Basel.)

Aim: Apolipoprotein E (ApoE) strongly affects arteriosclerosis but has atheroprotective effects in combination with high-density lipoprotein cholesterol (HDL-C). The impact of the quantitative relationship between serum ApoE and HDL-C levels in patients with coronary artery disease (CAD) remains unclear., Methods: A total of 3632 consecutive patients who underwent their first intervention between 2000 and 2016 were included. They were categorized into normal and abnormal HDL-C groups based on the normal HDL-C value, and each group was subdivided into high and low ApoE subgroups based on the group-specific median ApoE value. We evaluated the incidence of major adverse cardiac and cerebrovascular events (MACCE), including cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, and all-cause deathResults: During a 6.4-year follow-up, 419 patients developed MACCE and 570 patients died. The interaction term between ApoE levels and HDL-C status in MACCE and all-cause death proved to be statistically significant. Kaplan-Meier analysis revealed that the cumulative incidence of MACCE was significantly higher for elevated pre-procedural ApoE levels than for reduced preprocedural ApoE levels in the normal HDL-C group. Conversely, the cumulative incidence of MACCE was significantly higher for reduced pre-procedural ApoE levels than for elevated pre-procedural ApoE levels in the abnormal HDL-C group. After adjustment for important covariates, multivariable Cox hazard analysis revealed that the serum ApoE level was a strongly independent predictor of MACCE; this was inversely related in both groups., Conclusions: Serum ApoE levels may have a paradoxical impact on the future cardiovascular risk depending on the HDL-C status in patients with CAD.

Background: This study aimed to compare the coronary plaque characterization by cardiovascular magnetic resonance (CMR) and near-infrared spectroscopy (NIRS)-intravascular ultrasound (IVUS) (NIRS-IVUS), and to determine whether pre-percutaneous coronary intervention (PCI) evaluation using CMR identifies high-intensity plaques (HIPs) at risk of peri-procedural myocardial infarction (pMI). Although there is little evidence in comparison with NIRS-IVUS findings, which have recently been shown to identify vulnerable plaques, we inferred that CMR-derived HIPs would be associated with vulnerable plaque features identified on NIRS-IVUS., Methods: 52 patients with stable coronary artery disease who underwent CMR with non-contrast T1-weighted imaging and PCI using NIRS-IVUS were studied. HIP was defined as a signal intensity of the coronary plaque-to-myocardial signal intensity ratio (PMR) ≥ 1.4, which was measured from the data of CMR images. We evaluated whether HIPs were associated with the NIRS-derived maximum 4-mm lipid-core burden index (maxLCBI 4mm ) and plaque morphology on IVUS, and assessed the incidence and predictor of pMI defined by the current Universal Definition using high-sensitive cardiac troponin-T., Results: Of 62 lesions, HIPs were observed in 30 lesions (48%). The HIP group had a significantly higher remodeling index, plaque burden, and proportion of echo-lucent plaque and maxLCBI 4mm  ≥ 400 (known as large lipid-rich plaque [LRP]) than the non-HIP group. The correlation between the maxLCBI 4mm and PMR was significantly positive (r = 0.51). In multivariable logistic regression analysis for prediction of HIP, NIRS-derived large LRP (odds ratio [OR] = 5.41; 95% confidence intervals [CIs] 1.65-17.8, p = 0.005) and IVUS-derived echo-lucent plaque (OR = 5.12; 95% CIs 1.11-23.6, p = 0.036) were strong independent predictors. Furthermore, pMI occurred in 14 of 30 lesions (47%) with HIP, compared to only 5 of 32 lesions (16%) without HIP (p = 0.005). In multivariable logistic regression analysis for prediction of incidence of pMI, CMR-derived HIP (OR = 5.68; 95% CIs 1.53-21.1, p = 0.009) was a strong independent predictor, but not NIRS-derived large LRP and IVUS-derived echo-lucent plaque., Conclusions: There is an important relationship between CMR-derived HIP and NIRS-derived large LRP. We also confirmed that non-contrast T1-weighted CMR imaging is useful for characterization of vulnerable plaque features as well as for pre-PCI risk stratification. Trial registration The ethics committee of Juntendo Clinical Research and Trial Center approved this study on January 26, 2021 (Reference Number 20-313)., (© 2023. The Author(s).)

Background: Sarcopenia, which is evaluated based on appendicular skeletal muscle mass (ASM) using dual-energy X-ray absorptiometry and bioelectrical impedance analysis, is a prognostic predictor for adverse outcomes in patients with coronary artery disease (CAD). However, a simple equation for estimating ASM is yet to be validated in clinical practice., Methods: We enrolled 2211 patients with CAD who underwent percutaneous coronary intervention at our hospital between 2010 and 2017. The mean age was 68 years and 81.5 % were men. Patients were divided into 2 groups based on each ASM index (ASMI): low; male < 7.3 and female < 5.0 and high; male ≥ 7.3 and female ≥ 5.0. ASM was calculated using the following equation: 0.193 × bodyweight + 0.107 × height - 4.157 × gender - 0.037 × age - 2.631. Primary endpoints were major adverse cardiac events (MACE, which includes cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, and hospitalization for heart failure), and all-cause mortality., Results: During the median follow-up period of 4.8 years, cumulative incidence of events were significantly higher in the low ASMI group. Cox proportional hazards model revealed that the low ASMI group had a significantly higher risk of primary endpoints than the high ASMI group (all-cause mortality; hazard ratio (HR): 2.13, 95 % confidence interval [CI]: 1.40-3.22, p < 0.001 and 4-point MACE; HR: 1.72, 95 % CI: 1.12-2.62, p = 0.01). Similar trends were observed after stratification by age of 65 years., Conclusion: Low ASMI, evaluated using the aforementioned equation, is an independent predictor of MACE and all-cause mortality in patients with CAD., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Author(s).)

Background In-stent restenosis, especially for neoatherosclerosis, is a major concern following percutaneous coronary intervention. This study aimed to elucidate the association of features of in-stent restenosis lesions revealed by optical coherence tomography (OCT)/optical frequency domain imaging (OFDI) and the extent of lipid-rich neointima (LRN) assessed by near-infrared spectroscopy (NIRS) and intravascular ultrasound, especially for neoatherosclerosis. Methods and Results We analyzed patients undergoing percutaneous coronary intervention for in-stent restenosis lesions using both OCT/OFDI and NIRS-intravascular ultrasound. OCT/OFDI-derived neoatherosclerosis was defined as lipid neointima. The existence of large LRN (defined as a long segment with 4-mm maximum lipid core burden index ≥400) was evaluated by NIRS. In 59 patients with 64 lesions, neoatherosclerosis and large LRN were observed in 17 (26.6%) and 21 lesions (32.8%), respectively. Naturally, large LRN showed higher 4-mm maximum lipid core burden index (median [interquartile range], 623 [518-805] versus 176 [0-524]; P <0.001). In OCT/OFDI findings, large LRN displayed lower minimal lumen area (0.9±0.4 versus 1.3±0.6 mm 2 ; P =0.02) and greater max lipid arc (median [interquartile range], 272° [220°-360°] versus 193° [132°-247°]; P =0.004). In the receiver operating characteristic curve analysis, 4-mm maximum lipid core burden index was the best predictor for neoatherosclerosis, with a cutoff value of 405 (area under curve, 0.92 [95% CI, 0.83-1.00]). In multivariable logistic analysis, only low-density lipoprotein cholesterol (odds ratio, 1.52 [95% CI, 1.11-2.08]) was an independent predictor for large LRNs. Conclusions NIRS-derived large LRN was significantly associated with neoatherosclerosis by OCT/OFDI. The neointimal characterization by NIRS-intravascular ultrasound has potential as an alternative method of OCT/OFDI for in-stent restenosis lesions.

Previous studies showed that elevated apolipoprotein A1 (ApoA1) and high-density lipoprotein cholesterol (HDL-C) predicted reduced risk of cardiovascular-related (CV) mortality in patients following percutaneous coronary intervention (PCI). Nevertheless, as the association between ApoA1 and cancer mortality in this population has been rarely addressed, our study aimed to evaluate prognostic impact of ApoA1 on multiple types of cancer mortality after PCI. This is a retrospective analysis of a single-center prospective registry database of patients who underwent PCI between 2000 and 2018. The present study enrolled 3835 patients whose data of serum ApoA1 were available and they were divided into three groups according to the tertiles of the preprocedural level of ApoA1. The outcome measures were total, gastrointestinal, and lung cancer mortalities. The median and range of the follow-up period between the index PCI and latest follow-up were 5.9 and 0-17.8 years, respectively. Consequently, Kaplan-Meier analyses showed significantly higher rates of the cumulative incidences of total, gastrointestinal, and lung cancer mortality in the lowest ApoA1 tertile group compared to those in the highest. In contrast, there were no significant differences in all types of cancer mortality rates in the groups divided by the tertiles of HDL-C. Multivariable Cox proportional hazard regression analysis adjusted by cancer-related prognostic factors, such as smoking status, identified the elevated ApoA1 as an independent predictor of decreased risk of total and gastrointestinal cancer mortalities. Our study demonstrates the prognostic implication of preprocedural ApoA1 for predicting future risk of cancer mortality in patients undergoing PCI., (© 2022 The Authors. International Journal of Cancer published by John Wiley & Sons Ltd on behalf of UICC.)

Background and Aims: The relationship of apolipoprotein A-I (ApoA-I) and renal function in patients after intervention remain unclear, thus, we aimed to evaluate the combined impacts of ApoA-I and kidney disease (K D )., Material and Methods: Altogether, 4101 consecutive patients who underwent intervention between 2000 and 2016 were included. The patients were divided into four groups based on the median ApoA-I values and presence of K D . We evaluated the incidence of major adverse cardiac and cerebrovascular events (MACCE), including cardiovascular death, non-fatal acute coronary syndrome and non-fatal stroke, and all-cause death., Results: During the median follow-up period of 6.2 years, 618 patients (15.1%) developed MACCE, and 627 patients (15.3%) died. ApoA-I level was significantly related to estimated glomerular filtration rate, and ApoA-I levels and K D status interaction term was statistically significant. Kaplan-Meier analysis revealed that the low ApoA-I with K D had the significantly highest cumulative incidence rate of MACCE and all-cause death compared to the other three groups. Additionally, ApoA-I levels and K D status were independent predictors of MACCE and all-cause death in multivariable Cox hazard analysis., Conclusion: The combined impacts of ApoA-I and renal function could be useful for evaluating cardiovascular and life prognoses in patients undergoing intervention., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier B.V. All rights reserved.)

In-stent restenosis (ISR) remains the primary concern after a percutaneous coronary intervention (PCI) and is considered to be associated with worse clinical outcomes. However, comparative data on ISR and de novo lesions are rare. Therefore, we aimed to compare PCI-related clinical outcomes between patients with de novo lesions and those with ISR lesions. We undertook a retrospective analysis of patients who had undergone a PCI between 2013 and 2020. The incidences of major adverse cardiac and cerebrovascular events (MACCE) and all-cause death over a 2-year follow-up period were evaluated. In total, 1538 patients were enrolled and divided into two groups: a de novo lesions group (n = 1258, 81.8%) and an ISR lesions group (n = 280, 18.2%). Patients in the ISR lesions group were significantly older, with a higher prevalence of hypertension, diabetes mellitus, dyslipidemia, and chronic kidney disease than those in the de novo lesions group. Kaplan-Meier curves showed no significant between-group differences in the incidence of MACCE (log-rank, p = 0.93) and all-cause death (p = 0.09). After adjustment for other covariates, PCIs for ISR lesions were not found to be significantly associated with MACCE (hazard ratio [HR], 1.10; 95% confidential interval [CI] 0.49-2.49; p = 0.81) and all-cause death (HR, 0.58; 95% CI 0.26-1.31; p = 0.19). PCIs for ISR lesions were not associated with worse clinical outcomes compared with PCIs for de novo lesions., (© 2021. Japanese Association of Cardiovascular Intervention and Therapeutics.)

Background: Inflammatory status is associated with cardiovascular events in patients with coronary artery disease (CAD) and renal function impairment. Chronic kidney disease (CKD) increases the incidence of cardiovascular events. However, whether the presence of residual inflammatory risk (RIR) and CKD together has a synergistic effect on the long-term clinical outcomes of patients with stable CAD undergoing percutaneous coronary intervention (PCI) remains unclear., Methods: We assessed 2,948 consecutive patients with stable CAD who underwent the first PCI from 2000 to 2016. Of these, we analyzed the data of patients (2,087) with measurements of high-sensitivity C-reactive protein (hs-CRP) available at follow-up (6-9 months later). High RIR was defined as hs-CRP of >0.6 mg/L according to the median value at follow-up. Patients were classified into four groups: Group 1 (low RIR, non-CKD), Group 2 (high RIR, non-CKD), Group 3 (low RIR, CKD), and Group 4 (high RIR, CKD). We evaluated all-cause mortality and major adverse cardiac events (MACE). The median follow-up period was 5.2 (interquartile range, 1.9-9.9) years., Results: In total, 189 (16.1%) and 128 (11.2%) cases of all-cause mortality and MACE, respectively, were identified during follow-up. The rates of all-cause mortality and MACE were significantly higher in Group 4 than those in the other groups (p<0.001). There was a stepwise increase in the incidence of all-cause mortality and MACE. Upon adjustment for important covariates, the presence of high RIR and/or CKD showed an independent association with a high incidence of MACE and all-cause mortality., Conclusions: The presence of high RIR and CKD conferred a synergistic adverse effect on the long-term clinical outcomes of patients undergoing PCI., Competing Interests: Disclosure The authors declare that there is no conflict of interest., (Copyright © 2021. Published by Elsevier Ltd.)

Aims: Little is known about the long-term outcomes of β-blockers use in patients with coronary artery disease (CAD) without myocardial infarction (MI) and reduced ejection fraction (rEF). However, more attention should be paid to the oral administration of β-blockers in elderly patients who are susceptible to heart failure (HF), sinus node dysfunction, or rate response insufficiency. We aimed to evaluate the long-term impact of β-blockers in elderly patients with CAD without MI or systolic HF who have undergone percutaneous coronary intervention., Methods and Results: A total of 1018 consecutive elderly patients with CAD (mean age, 72 ± 7 years; 77% men) who underwent their first intervention between 2010 and 2018 were included in this study. According to the presence or absence of the use of β-blockers, 514 patients (50.5%) were allocated to the β-blocker group, and 504 (49.5%) to the non-β-blocker group. We evaluated the incidence of 4-point major adverse cardiovascular events (4P-MACE), including cardiovascular death, non-fatal MI, non-fatal stroke, admission for HF, target vessel revascularization (TVR), and all-cause death. We focused on the association between chronotropic incompetence of β-blockers and incidence of a new HF and analysed the results using an exercise electrocardiogram regularly performed in the outpatient department after percutaneous coronary intervention. During a median follow-up duration of 5.1 years, 83 patients (8.3%) developed 4P-MACE, including cardiovascular death in 17, non-fatal MI in 13, non-fatal stroke in 25, and admission for HF in 39 patients. Additionally, 124 patients (12.2%) had a TVR and 104 (10.2%) died of other causes. Kaplan-Meier analysis showed that the cumulative incidence rate of 4P-MACE in the β-blocker group was significantly higher than that in the non-β-blocker group (15.4% vs. 10.0%, log-rank test, P = 0.015). Above all, the cumulative incidence rate of admission for HF in the β-blocker group was significantly higher (8.8% vs. 3.2%, log-rank test, P < 0.001). The β-blocker group had significantly lower resting heart rate, stress heart rate, and stress-rest Δ heart rate on exercise electrocardiogram. Multivariate Cox hazard analysis revealed that EF, β-blocker use, stress-rest Δ heart rate, and CKD were strong independent predictors of admission for HF., Conclusions: Long-term β-blocker use was significantly associated with an increased risk of adverse cardiovascular events in elderly patients with CAD without MI or systolic HF. In particular, the chronotropic incompetence action of β-blockers could increase the risk of admission for HF in elderly patients with CAD without MI and systolic HF, and the present findings warrant further investigation., (© 2021 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Background: Patients with end-stage renal disease (ESRD) on chronic hemodialysis who are complicated by coronary artery disease (CAD) are at very high risk of cardiovascular (CV) events and mortality. However, the prognostic benefit of statins, which is firmly established in the general population, is still under debate in this particular population., Methods: As a part of a prospective single-center percutaneous coronary intervention (PCI) registry database, this study included consecutive patients on chronic hemodialysis who underwent PCI for the first time between 2000 and 2016 ( n = 201). Participants were divided into 2 groups by following 2 factors, such as (1) with or without statin, and (2) with or without high LDL-C (> and ≤LDL-C = 93 mg/dL, median) at the time of PCI. The primary endpoint was defined as CV death, and the secondary endpoints included all-cause and non-CV death, and 3 point major cardiovascular adverse events (3P-MACE) which is the composite of CV death, non-fatal myocardial infarction and stroke. The median and range of the follow-up period were 2.8, 0-15.2 years, respectively., Results: Kaplan-Meier analyses showed significantly lower cumulative incidences of primary and secondary endpoints other than non-CV deaths in patients receiving statins. Conversely, no difference was observed when patients were divided by the median LDL-C at the time of PCI ( p = 0.11). Multivariate Cox proportional hazard analysis identified statins as an independent predictor of reduced risk of CV death (Hazard ratio of statin use: 0.43, 95% confidence interval 0.18-0.88, p = 0.02), all-cause death (HR: 0.50, 95%CI 0.29-0.84, p = 0.007) and 3P-MACE (HR: 0.50, 95%CI 0.25-0.93, p = 0.03)., Conclusions: Statins were associated with reduced risk of adverse outcomes in patients with ESRD following PCI.

Little is known about the prognostic impact of high-sensitivity C-reactive protein (hs-CRP) levels on causes of death during long-term follow-up. We, therefore, investigated the associations between hs-CRP and clinical outcomes in the patients with intermittent claudication. Three hundred thirty-five consecutive patients (mean age, 72 ± 8 years, 82% men) undergoing first intervention for de novo iliac and/or femoropopliteal artery lesions from 2009 to 2020 were studied. Patients were divided into 2 groups based on the optimal cutoff value of hs-CRP (> or ≤ 0.15 mg/dL). The median follow-up duration was 3.6 years (interquartile range, 1.0-6.2 years). Although the cumulative incidence rate of major adverse cardiovascular limb events was not significantly different between the higher and lower hs-CRP groups (29.0 and 22.1%, respectively; log-rank test, p = 0.410), that of all-cause death was significantly higher in the higher hs-CRP group than in the lower hs-CRP group (18.7 vs. 5.8%, log-rank test, p = 0.007), even in cardiovascular-related death and malignancy-related death (log-rank test, p = 0.030 and 0.046, respectively). Higher hs-CRP levels at the time of intervention were significantly associated with higher frequency of all-cause death, even after adjusting for other risk factors (hazard ratio 2.79; 95% confidence interval 1.66-7.17, p = 0.024). In addition, malignancy-related death was most frequent as high as 60% (21/35 deaths), and elevated hs-CRP levels and the Brinkman index were strongly independent predictors of malignancy-related death. In conclusion, elevated hs-CRP levels were significantly associated with cardiovascular-related and malignancy-related deaths in patients with intermittent claudication. Furthermore, the result that cancer mortality exceeds cardiovascular mortality is different from previous reports, so the present findings warrant further investigation., (© 2021. Springer Japan KK, part of Springer Nature.)

Objectives: This study was conducted to use optical coherence tomography (OCT) to compare vascular healing between bioresorbable polymer (BP) and durable polymer (DP) everolimus-eluting stents (EES) in patients with acute coronary syndromes (ACS)., Background: Whether BP-EES induce better vascular healing compared to contemporary DP-EES remains controversial, especially for ACS., Methods: In this prospective, randomized, non-inferiority trial, we used OCT to compare 6-month vascular healing in patients with ACS randomized to BP versus DP-EES: percent strut coverage (primary endpoint, non-inferiority margin of 2.0%) and neointimal thickness and percent neointimal hyperplasia (NIH) volume. As an exploratory analysis, morphological factors related to the endpoints and the effect of underlying lipidic plaque on stent healing were evaluated., Results: A total of 104 patients with ACS were randomly assigned to BP-EES (n = 52) versus DP-EES (n = 52). Of these, 86 patients (40 BP-EES and 46 DP-EES) were included in the final OCT analyses. Six-month percent strut coverage of BP-EES (83.6 ± 11.4%) was not non-inferior compared to those of DP-EES (81.6 ± 13.9%), difference 2.0% (lower 95% confidence interval-2.6%), p non-inferiority  = 0.07. There were no differences in neointimal thickness 70.0 ± 33.9 μm versus 67.2 ± 33.9 μm, p = 0.71; and percent NIH volume 7.5 ± 4.7% versus 7.3 ± 5.3%, p = 0.85. By multivariable linear regression analysis, stent type was not associated with percent strut coverage or percent NIH volume; however, percent baseline embedded struts or stent expansion was positively associated with percent NIH volume. Greater NIH volume was observed in lipidic compared with non-lipidic segments (8.7 ± 5.6% vs. 6.1 ± 5.2%, p = 0.005)., Conclusions: Six-month strut coverage of BP-EES was not non-inferior compared to those of DP-EES in ACS patients. Good stent apposition and expansion were independently associated with better vascular healing., (© 2021 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.)

Although on-site workstation-based CT fractional flow reserve (CT-FFR) is an emerging method for assessing vessel-specific ischemia in coronary artery disease, severe calcification is a significant factor affecting CT-FFR's diagnostic performance. The subtraction method significantly improves the diagnostic value with respect to anatomic stenosis for patients with severe calcification in coronary CT angiography (CCTA). We evaluated the diagnostic capability of CT-FFR using the subtraction method (subtraction CT-FFR) in patients with severe calcification. This study included 32 patients with 45 lesions with severe calcification (Agatston score >400) who underwent both CCTA and subtraction CCTA using 320-row area detector CT and also received invasive FFR within 90 days. The diagnostic capabilities of CT-FFR and subtraction CT-FFR were compared. The sensitivities, specificities, positive predictive values (PPVs), and negative predictive values (NPVs) of CT-FFR vs. subtraction CT-FFR for detecting hemodynamically significant stenosis, defined as FFR ≤ 0.8, were 84.6% vs. 92.3%, 59.4% vs. 75.0%, 45.8% vs. 60.0%, and 90.5% vs. 96.0%, respectively. The area under the curve for subtraction CT-FFR was significantly higher than for CT-FFR (0.84 vs. 0.70) ( p = 0.04). The inter-observer and intra-observer variabilities of subtraction CT-FFR were 0.76 and 0.75, respectively. In patients with severe calcification, subtraction CT-FFR had an incremental diagnostic value over CT-FFR, increasing the specificity and PPV while maintaining the sensitivity and NPV with high reproducibility.

Competing Interests: H.D. is a member of Circulation Reports’ Editorial Team. The remaining authors have no conflicts of interest to disclose.

Background and Aims: Little is known about the long-term impact of apolipoprotein E (apoE) on residual cardiovascular risk in patients with chronic coronary syndrome (CCS) receiving statin treatment., Methods: A total of 1109 consecutive patients (mean age, 67 ± 10 years; 83% men) with CCS who underwent their first intervention between 2000 and 2016 were included in this study. All patients had achieved low-density lipoprotein cholesterol (LDL-C) <100 mg/dL on statin treatment and were divided into two groups based on median serum apoE values. We evaluated the incidence of major adverse cardiovascular events (MACEs), including cardiovascular death, non-fatal acute coronary syndrome, and target vessel revascularization., Results: A total of 552 and 557 patients were categorized to the higher and lower apoE groups, respectively. There were significant relationships between apoE levels and total cholesterol levels, triglyceride levels, high-density lipoprotein cholesterol levels, and estimated remnant cholesterol, except for LDL-C levels. During the median follow-up period of 5.1 years, 195 patients (17.6%) developed MACEs. Kaplan-Meier analysis revealed that the cumulative incidence of MACEs in the higher apoE group was significantly higher than in the lower apoE group (29.5% vs.23.8% log-rank test, p = 0.019). Using multivariable Cox hazard analysis, serum apoE level (1-mg/dL increase) (hazard ratio 1.15; 95% confidence interval 1.03-1.29, p = 0.013) was the strongest independent predictor of MACEs., Conclusions: Serum apoE level could be a strong predictor of residual cardiovascular risk in patients with CCS long-term, even if LDL-C levels are controlled with statin treatment., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Aim: Pneumococcal and influenza infections can cause serious morbidity and mortality in patients with cardiovascular diseases. The purpose of this study was to investigate the safety and efficacy of simultaneous inoculations of 23-valent pneumococcal polysaccharide vaccine (PPSV23) and trivalent influenza vaccine (TIV) in patients with coronary artery disease (CAD)., Methods: This was a prospective, randomized, single-blind, placebo-controlled study. A total of 40 patients with CAD were randomly assigned to the TIV＋PPSV23 (simultaneous inoculations of TIV and PPSV23) and TIV＋Placebo (inoculations of TIV and placebo) groups. Primary outcomes were the safety of simultaneous vaccinations and the changing of circulating cardiovascular biomarkers before, at 4-, and at 12-weeks after vaccinations., Results: The baseline characteristics between the two groups were identical. The prevalence of injection-site pain, swelling, and reddening were 47%, 37%, and 37% in the TIV＋PPSV23 group, and 10%, 5%, and 0% in the TIV＋Placebo group, respectively. All reactions were self-limited. Body temperature ＞37.0℃ or serious injection-related reaction was not observed. The levels of white blood cells, high-sensitivity C-reactive protein, N-terminal pro-B-type natriuretic peptide, pentraxin-3, and malondialdehide-modified low-density lipoprotein (LDL), were not significantly different between the two groups before and after vaccinations. The levels of anti-oxidized LDL were significantly and step-wisely decreased from baseline, to 4-, and 12-weeks vaccinations in the both groups. No significant changes of other markers were observed in both groups at each time point., Conclusion: Simultaneous inoculations of TIV and PPSV23 were safety in patients with CAD, suggesting that dual vaccinations can be considered even in patients with CAD.

Chronic kidney disease (CKD) and anemia are each individually associated with worse clinical outcomes in patients with coronary artery disease (CAD). However, the prognostic impact of both CKD and anemia on clinical outcomes, when they coexist, remains unclear in CAD patients after percutaneous coronary intervention (PCI). We studied 2484 CAD patients who underwent their first PCI and had available date on preprocedural hemoglobin between 2000 and 2016. The patients were divided into four groups according to the presence of CKD and/or anemia. We evaluated the incidences of all-cause death and major adverse cardiac and cerebrovascular events (MACCEs), including cardiovascular death, non-fatal myocardial infarction, and stroke. Among the patients, 310 patients (12.5%) had both CKD and anemia (CKD with anemia group), 309 (12.4%) had CKD only, 461(18.6%) had anemia only, and 1404 (56.5%) had neither CKD nor anemia. Patients in the CKD with anemia group were older and had a higher incidence of hypertension and diabetes mellitus. During a median follow-up period of 3.7 years, Kaplan-Meier curves showed that patients in the CKD with anemia group had significantly higher incidences of MACCE and all-cause death than the CKD only and anemia only group (both log-rank p < 0.001). Using patients with the no CKD or anemia group as a reference, the adjusted hazard ratios (HRs), 95% confidence interval for MACCE were 1.51 (0.92-2.47) for the CKD only, 1.48 (0.94-2.32) for the anemia only and 2.00 (1.18-3.38) for the CKD with anemia group. Moreover, the adjusted HR for all-cause death were 1.42 (0.96-2.10) for the CKD only, 1.79 (1.28-2.51) for the anemia only, and 1.92 (1.30-2.84) for the CKD with anemia group. In conclusion, the combined effects of both CKD and anemia on outcomes after PCI were worse than either of their individual effects.

Little is known about the association between limb prognosis in peripheral artery disease and apolipoprotein E (apoE). We evaluated the long-term impact of apoE on adverse limb events in patients with intermittent claudication receiving statin treatment.A total of 218 consecutive patients (mean age, 73 ± 8 years; 81% men) with intermittent claudication who underwent their first intervention between 2009 and 2020 were included in this study. All patients had achieved LDL-C < 100 mg/dL on statin treatment and were divided into two groups based on the apoE value (≥ 4.7 or < 4.7 mg/dL). We evaluated the incidence of major adverse limb events (MALEs), including vessel revascularization and limb ischemia development.A total of 39 and 179 patients were allocated to the higher and lower apoE groups, respectively. Compared to the lower apoE group, the higher apoE group had a significantly higher total cholesterol level, triglyceride level, and non-high-density lipoprotein cholesterol level. During the median follow-up period of 3.6 years, 30 patients (13.8%) developed MALEs. Kaplan-Meier analysis revealed that the cumulative incidence of MALEs in the higher apoE group was significantly higher than that in the lower apoE group (44.0% versus 21.6%, log-rank test, P = 0.002). During multivariable Cox hazard analysis, higher apoE level (≥ 4.7 mg/dL) (hazard ratio, 2.61; 95% confidence interval, 1.18-5.70, P = 0.019) was the only strong independent predictor of MALEs.ApoE levels could be a strong predictor and residual risk for long-term limb prognosis in patients with intermittent claudication and achieving LDL-C < 100 mg/dL with statin treatment.

Background: Computed tomography fractional flow reserve (CT-FFR), which can be acquired on-site workstation using fluid structure interaction during the multiple optimal diastolic phase, has an incremental diagnostic value over conventional coronary computed tomography angiography (CCTA). However, the appropriate location for CT-FFR measurement remains to be clarified., Method: A total of 115 consecutive patients with 149 vessels who underwent CCTA showing 30-90% stenosis with invasive FFR within 90 days were retrospectively analyzed. CT-FFR values were measured at three points: 1 and 2 cm distal to the target lesion (CT-FFR 1cm, 2cm ) and the vessel terminus (CT-FFR lowest ). The diagnostic accuracies of CT-FFR ≤ 0.80 for detecting hemodynamically significant stenosis, defined as invasive FFR ≤ 0.80, were compered., Result: Fifty-five vessels (36.9%) had invasive FFR ≤ 0.80. The accuracy and AUC for CT-FFR 1cm and 2cm were comparable, while the AUC for CT-FFR lowest was significantly lower than CT-FFR 1cm and 2cm . (lowest/1cm, 2 cm = 0.68 (95 %CI 0.63-0.73) vs 0.79 (0.72-0.86, p = 0.006), 0.80 (0.73-0.87, p = 0.002)) The sensitivity and negative predictive value of CT-FFR lowest were 100%. The reclassification rates from positive CT-FFR lowest to negative CT-FFR 1cm and 2cm were 55.7% and 54.2%, respectively., Conclusion: The diagnostic performance of CT-FFR was comparable when measured at 1-to-2 cm distal to the target lesion, but significantly higher than CT-FFR lowest . The lesion-specific CT-FFR could reclassify false positive cases in patients with positive CT-FFR lowest , while all patients with negative CT-FFR lowest were diagnosed as negative by invasive FFR., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr. Fujimoto has a research agreement with Canon Medical Systems Corporation that is related to this study. This research was supported by Canon Medical Systems Corporation. All other authors report no conflicts to the work., (© 2021 The Authors.)

Background: Endovascular treatment (EVT) for femoropopliteal artery disease is common in clinical practice. However, little is known about its prognostic factors, causes of death, and long-term clinical outcomes., Methods: Two hundred eighty-five consecutive patients (mean age, 72±8 years, 73% men) undergoing their first EVT for de-novo femoropopliteal artery disease from 2009 to 2018 were studied. Patients were divided in two groups according to the presence of critical limb ischemia (CLI). We evaluated the incidence of major adverse limb events (MALE) including clinically driven target vessel revascularization and target limb major amputation, and all-cause death., Results: The procedure was successful in 97.9% of cases. The non-CLI group comprised 205 patients (72%), and the CLI group comprised 80 patients (28%). The CLI group exhibited higher high-sensitivity C-reactive protein (hs-CRP) levels and a higher rate of hemodialysis than the non-CLI group. During the median follow-up period of 3.5 years, there were 62 deaths (21.8%) including cardiovascular (32.3%), infection (32,3%), and malignancy-related (22.6%) deaths. Kaplan-Meier analysis revealed that the CLI group had a significantly higher incidence of MALE and all-cause death (log-rank, both p<0.001, respectively). The leading causes of death in the CLI group were cardiovascular- and infection-related death; the leading cause of death in the non-CLI group was malignancy-related. On multivariate Cox hazard analysis, hemodialysis, TASC II classification C/D lesions, and CLI were significant predictors of MALE (p<0.001, p=0.005, and p=0.012, respectively). Hemodialysis, age, higher hs-CRP levels, and CLI were significant predictors of all-cause death (p<0.001, p=0.003, p=0.009, and p=0.021, respectively)., Conclusions: Although EVT for femoropopliteal artery disease appears feasible with a high rate of procedural success, a high incidence of MALE and all-cause death was observed. Further studies are needed to improve the outcomes in patients with CLI., (Copyright © 2020. Published by Elsevier Ltd.)

Background: Fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) are useful in determining indications for revascularization of coronary artery disease (CAD). Although the discordance of FFR and iFR was noted in approximately 20%, this cause has not been well established. We investigated patient background and features on coronary CT angiography (CCTA) showing not only FFR- and iFR-positive findings but also discordance between FFR ≤ 0.8 and iFR ≤ 0.89., Methods: Subjects were consecutively treated in 83 cases with 105 vessels in which stenosis of 30-90% was detected at one vessel of at least 2 mm or more in the major epicardial vessels and FFR and iFR was performed within subsequent 90 days, among suspected CAD which underwent CCTA. The factors affecting not only FFR- and iFR-positive findings, respectively, but also discordance between FFR and iFR was evaluated using logistic regression analysis on per-patient and per-vessel basis., Results: FFR- and iFR-positive findings were observed in 42 vessels (40.0%) and 34 vessels (32.3%), respectively. Discordance between FFR ≤ 0.8 and iFR ≤ 0.89 was observed in 22 vessels (21.0%) of 21 patients. In multivariate logistic analysis, LAD (OR 3.55; 95%CI 1.20-11.71; p = 0.0217) and lumen volume/myocardial weight (L/M) ratio (OR 0.93; 0.86-0.99, p = 0.0290) were significant predictors for FFR-positive findings. For iFR-positive findings, LAD (OR 3.86; 95%CI 1.12-13.31; p = 0.0236) was only significant predictor. In FFR ≤ 0.8 and iFR > 0.89 group (15 vessels, 14.3%), positive remodeling (PR) (OR 5.03, 95%CI 1.23-20.48, p = 0.0205) was significant predictor. In FFR > 0.8 and iFR ≤ 0.89 group (7 vessels, 6.7%), there were no significant predictors., Conclusion: On CCTA characteristics, a relevant predictor for FFR-positive findings included low L/M ratio. PR was significant predictor in FFR-positive, iFR-negative patients among those with discordance between the FFR and iFR.

Background: A common complication of endovascular treatment for femoropopliteal lesions is bleeding at the vascular access site. Although risk factors of bleeding-associated complications at the approach site have been reported, the results have been inconclusive. Hence, this study aimed to assess the predictors of bleeding-associated complications at the approach site in patients undergoing endovascular treatment for femoropopliteal lesions., Methods: This retrospective, single-center, observational study included consecutive patients who underwent endovascular treatment (n = 366, 75% male, 72.4±9.9 year) for peripheral arterial disease with claudication and critical limb ischemia in our hospital from January 2010 to December 2017. We divided the patients into bleeding and non-bleeding groups, depending on whether bleeding-associated complications occurred at the approach site. Bleeding-associated complications were defined according to the Bleeding Academic Research Consortium criteria types 2, 3, and 5., Results: Altogether, 366 endovascular treatment procedures and 404 arterial accesses were performed for femoropopliteal lesions in 335 peripheral arterial disease patients with claudication and 69 critical limb ischemia patients. We recorded 35 postprocedural bleeding-associated complications at the approach site (9%), all of which were hematomas. The predictors of increased bleeding-associated complications were age ≥ 80 years (bleeding vs. non-bleeding group, 43% vs. 25%, p<0.05) and antegrade cannulation of the common femoral artery (48% vs. 69%, p<0.05). Ultrasound-guided puncture reduced bleeding-associated complications (odds ratio, 0.28; 95% confidence interval, 0.004-0.21; p<0.05). In contrast, there was no significant difference in puncture site calcification between the groups (bleeding vs. non-bleeding groups, 29% vs. 21%, p = 0.29)., Conclusion: Ultrasound-guided puncture is associated with a decrease in bleeding-associated complications at the approach site, regardless of the presence of calcified plaque. It is particularly effective and should be more actively used in patients aged ≥80 years and for antegrade cannulation of the common femoral artery., Competing Interests: The authors have declared that no competing interests exist.

Background: Asians have a much lower incidence of adverse coronary events than Caucasians. We sought to evaluate the characteristics of coronary lipid-rich plaques (LRP) in Asian patients with acute coronary syndrome (ACS) and stable angina (SA). We also aimed to identify surrogate markers for the extent of LRP., Methods: We evaluated 207 patients (ACS, n = 75; SA, n = 132) who underwent percutaneous coronary intervention under near infrared spectroscopy intravascular ultrasound (NIRS-IVUS). Plaque characteristics and the extent of LRP [defined as a long segment with a 4-mm maximum lipid-core burden index (maxLCBI 4mm )] on NIRS in de-novo culprit and non-culprit segments were analyzed., Results: The ACS culprit lesions had a significantly higher maxLCBI 4mm (median [interquartile range (IQR)]: 533 [385-745] vs. 361 [174-527], p  < 0.001) than the SA culprit lesions. On multivariate logistic analysis, a large LRP (defined as maxLCBI 4mm  ≥ 400) was the strongest independent predictor of the ACS culprit segment (odds ratio, 3.87; 95% confidence interval, 1.95-8.02). In non-culprit segments, 19.8% of patients had at least one large LRP without a small lumen. No significant correlation was found between the extent of LRP and systematic biomarkers (hs-CRP, IL-6, TNF-α), whereas the extent of LRP was positively correlated with IVUS plaque burden (r = 0.24, p  < 0.001)., Conclusions: We confirmed that NIRS-IVUS plaque assessment could be useful to differentiate ACS from SA culprit lesions, and that a threshold maxLCBI 4mm  ≥ 400 was clinically suitable in Japanese patients. No surrogate maker for a high-risk LRP was found; consequently, direct intravascular evaluation of plaque characteristics remains important., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2021 The Authors.)

Background: Fractional flow reserve (FFR) is an established method for assessing functional myocardial ischemia. Recently, the resting full-cycle ratio (RFR) has been introduced as a non-hyperemic index of functional coronary stenosis. However, the effects of clinical characteristics on discordance between RFR and FFR have not been fully evaluated. We aimed to identify clinical characteristics that influence FFR-RFR concordance., Methods: We included 410 patients with 573 intermediate coronary lesions who underwent clinically indicated invasive coronary angiography, as well as assessments of FFR and RFR. Receiver-operating characteristic (ROC) curves were created to assess the optimal cut-off values of RFR for predicting FFR ≤0.80., Results: RFR exhibited a strong correlation with FFR (r = 0.66, p < 0.0001). ROC analysis identified an optimal RFR cut-off value of 0.92 for categorization based on an FFR cut-off value of 0.8. The discordance of FFR >0.8 and RFR ≤0.92 (high FFR/low RFR) was observed in 112 lesions (20.9%), whereas the discordance of FFR ≤0.8 and RFR >0.92 (low FFR/high RFR) was observed in 35 lesions (6.5%). Higher rate of hemodialysis and lower hemoglobin levels were observed in the high FFR/low RFR group. Multivariate analyses identified female sex, left anterior descending artery (LAD) lesions, and hemodialysis as significant predictors of high FFR/low RFR. Conversely, body surface area and non-LAD lesions were significantly associated with low FFR/high RFR. Hemodialysis [odds ratio (OR): 2.41, 95% confidence interval (CI) 1.31-4.41; p = 0.005] and LAD lesions (OR: 1.86, 95% CI: 1.25-2.79; p = 0.002) were identified as independent predictors of overall FFR-RFR discordance., Conclusions: RFR exhibited good diagnostic performance in the identification of functionally significant stenosis. However, RFR may overestimate functional severity in patients undergoing hemodialysis or in those with LAD lesions. Further prospective trials are required to demonstrate the non-inferiority of RFR to FFR., (Copyright © 2020. Published by Elsevier Ltd.)

Background: Recent improvements in devices and medications may diminish the risk of adverse events following percutaneous coronary intervention (PCI) in women. However, complex calcified coronary lesions are increasingly being encountered in clinical practice, which remain challenging for contemporary PCI. Rotational atherectomy (RA) of severely calcified lesions is an option that facilitates the technical success of PCI. We aimed to examine sex differences in long-term clinical prognoses after PCI with RA in the drug-eluting stent (DES) era., Methods and Results: We evaluated J2T ROTA registry data from 1,090 patients with severely calcified de novo coronary artery stenoses who underwent PCI using RA at 3 hospitals between 2004 and 2015. After excluding patients who received regular hemodialysis, 788 patients, including 570 men and 218 women, were ultimately analyzed. The primary endpoint was major adverse cardiovascular and cerebrovascular events (MACCE), which included death, acute coronary syndrome (ACS), and stroke. The women were significantly older, and presented more frequently with chronic kidney disease, ACS, atrial fibrillation, lower body mass indexes, and worse lipid profiles than the men. During the observation period, MACCE occurred in 197 patients (25%) (118 deaths, 29 strokes, and 50 ACS). In the unmatched population, women had a higher MACCE rate than men (hazard ratio: 1.48, [95% confidence interval: 1.07-2.06]). However, sex was not associated with MACCE in the propensity score-matched population., Conclusion: In the DES era, differences between sexes were not observed in relation to long-term MACCE in patients undergoing PCI with RA for severely calcified coronary artery stenoses., Competing Interests: Juntendo University School of Medicine (Dr. Okai, Dr. Dohi, Dr. Okazaki, Dr. Tamura, Dr. Miyauchi, and Dr. Daida) and Teikyo University School of Medicine (Dr. Nakashima, Dr. Okabe, Dr. Nagura, Dr. Nara, Dr. Kawashima, Dr. Kyono, and Dr. Kozuma) received institutional research funds from Boston Scientific Japan. Dr. H. Kyono and K Kozuma have received modest honorarium for lecture from Boston Scientific Japan. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (AJCD Copyright © 2021.)

Background: One of the most common medical problems associated with pregnancy is hypertension. Hypertensive disorders of pregnancy (HDP), which has been attributable to abnormal placentation may have adverse effects on both mother and foetus if left unchecked. The objective of this study was to determine the prevalence of this condition and its effect on placental morphology as well as maternal and perinatal outcomes., Materials and Methods: This was a prospective case-control study, conducted at Komfo Anokye Teaching Hospital (KATH), Ghana between February 2018 and July 2018. The progression of pregnancy in normotensive and hypertensive pregnant women, and the eventual perinatal outcomes were closely followed. Statistical analysis was performed using IMB-SPSS version 23. Associations were considered significant at p values of ≤ 0.05., Results: From a total of 214 deliveries recorded during the period of study, 84 (39.25%) were hypertensives. Forty four (52%) of the hypertensives had preeclampsia, 28 (33.3%) had gestational hypertension, 6 (7.1%) had eclampsia, 4 (4.8%) had chronic hypertension, and 2 (2.4%) had preeclampsia superimposed on chronic hypertension. The frequency of placental haematoma, placental infarction, and placental calcification in the normotensives were significantly (p = 0.001) lower than that of the hypertensives. The mean placental weight (p = 0.01), placental volume (p = 0.001), placental diameter (p = 0.03), and placental thickness (p = 0.001) of the normotensives were significantly higher than those of the hypertensives. The number of normotensives in whom labour was induced, who had their babies delivered by caesarean section, and who were admitted after they had given birth were significantly (p = 0.001) lower than that of hypertensives who underwent similar procedures. No stillbirths were recorded in the normotensives compared with four in the hypertensives. The number of babies delivered to the normotensives who were admitted to the NICU was significantly (p = 0.001) lower than those delivered by hypertensives., Conclusion: There was a high prevalence of hypertensive disorders of pregnancy in the study site. Pregnant women who developed HDP are at a risk of developing placental abnormalities that adversely affected perinatal outcomes. These adverse effects can be curtailed by embarking on a vigorous health education drive., Competing Interests: The authors have declared that no competing interests exist.

Background: Serum levels of lipoprotein (a) [Lp(a)] have been reported as a residual risk marker for adverse events in patients with coronary artery disease (CAD). However, the prognostic impact of Lp(a) on long-term clinical outcomes among diabetic patients on statin therapy after percutaneous coronary intervention (PCI) remains unclear., Methods: The present investigation was a single-center, observational, retrospective cohort study. Among consecutive patients with CAD who underwent first PCI in our institution from 2000 to 2016, we enrolled diabetic patients on statin treatment. As a result, 927 patients (81% men; mean age, 67 years) were enrolled and divided into 2 groups according to a median Lp(a) level of 19.5 mg/dL. The incidence of major adverse cardiac events (MACE), including all-cause death, non-fatal myocardial infarction (MI), and non-fatal cerebral infarction (CI), was evaluated., Result: No significant differences were seen in age, sex, smoking habits, hypertension, chronic kidney disease, or body mass index between high and low Lp(a) groups. During follow-up (median, 5.0 years; interquartile range, 1.9-9.7 years), MACE occurred in 90 cases (17.6%), including 40 (7.9%) cardiac deaths, 18 (3.6%) non-fatal MI, and 37 (7.9%) non-fatal CI. Frequency of MACE was significantly higher in the high-Lp(a) group than in the low-Lp(a) group (log-rank test, p = 0.002). Higher Lp(a) level at the time of PCI was significantly associated with higher frequency of MACE, even after adjusting for other covariates, including other lipid profiles (hazard ratio, 1.91; 95% confidence interval, 1.20-3.09; p = 0.006)., Conclusion: Our results demonstrated that in diabetic patients with CAD on statin treatment, increased Lp(a) levels could offer a good residual lipid risk marker. Assessing Lp(a) levels may be useful for risk stratification of long-term clinical outcomes after PCI, especially in diabetic patients., (Copyright © 2020 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

For the revascularization of patients with clinical and anatomical complexities, several technical skills are often required. However, the prognostic effect of complex percutaneous coronary intervention (C-PCI) on the clinical outcomes is not well known. The aim of this study was to investigate the relationship between the C-PCI and mid-term clinical outcomes. We assessed 1062 patients who underwent PCI with newer-generation drug-eluting stent and stratified the patients according to whether they had complex PCI (C-PCI, n = 358) or non-complex PCI (non-C-PCI, n = 704). C-PCI was defined as a procedure with at least 1 of the following features: 3 vessels treated, ≥ 3 stents per vessel implanted, ≥ 3 lesions treated, use of a 2-stent technique, the total stent length per vessel > 60 mm, chronic total occlusion, unprotected left main coronary artery stenting, and rotational atherectomy use. All-cause death and major adverse cardiac and cerebrovascular events (MACCE; cardiovascular death, non-fatal myocardial infarction, and non-fatal ischemic stroke) were evaluated. The median follow-up period was 1.9 (0.8-3.0) years. The baseline SYNTAX score was significantly higher in the C-PCI group than in the non-C-PCI group [20 (14-27) vs. 10 (6-17), p < 0.001]. Kaplan-Meier analysis showed that the cumulative incidences of all-cause death (log-rank p = 0.12) and MACCE (log-rank p = 0.64) did not differ between the two groups. On multivariable Cox analysis, C-PCI did not adversely affect the clinical outcomes. Despite a high rate of anatomically complex coronary lesions, the patients who underwent C-PCI had comparable "hard" clinical outcomes with those of non-C-PCI.

The aim of this study was to investigate the long-term clinical impact of residual inflammatory risk (RIR) by evaluating serial high-sensitivity C-reactive protein (hs-CRP) in Asian patients with coronary artery disease (CAD). We evaluated 2032 patients with stable CAD undergoing percutaneous coronary intervention (PCI) with serial hs-CRP measurements (2 measurements, 6-9 months apart) from the period 2000 to 2016. A high-RIR was defined as hs-CRP > 0.9 mg/L according to the median value. Patients were assigned to four groups: persistent-high-RIR, increased-RIR, attenuated-RIR, or persistent-low-RIR. Major adverse cardiac events (MACE) and all-cause death were evaluated. MACE rates in patients with persistent high, increased and attenuated RIR were significantly higher than in patients with persistent low RIR ( p < 0.001). Moreover, the rate of all-cause death was significantly higher among patients with persistent high and increased RIR than among patients with attenuated and persistent low RIR ( p < 0.001). After adjustment, the presence of persistent high RIR (hazard ratio (HR) 2.22; 95% confidence interval (CI) 1.37-3.67, p = 0.001), increased RIR (HR 2.25, 95%CI 1.09-4.37, p = 0.029), and attenuated RIR (HR 1.94, 95%CI 1.14-3.32, p = 0.015) were predictive for MACE. In addition, presence of persistent high RIR (HR 2.07, 95%CI 1.41-3.08, p < 0.001) and increased RIR (HR 1.94, 95%CI 1.07-3.36, p = 0.029) were predictive for all-cause death. A high RIR was significantly associated with MACE and all-cause death among Japanese CAD patients. An evaluation of changes in inflammation may carry important prognostic information and may guide the therapeutic approach.

Background: We aimed to assess the impact of scoring balloon angioplasty (SBA) after rotational atherectomy (RA) on long-term clinical outcomes in patients who underwent percutaneous coronary intervention (PCI) using second-generation drug-eluting stents (DES). The long-term outcomes associated with SBA after RA in severely calcified lesions is unknown., Methods: Using the J2T ROTA registry data, we evaluated the clinical events of patients who underwent PCI using RA for heavily calcified lesions from January 2004 to December 2015. A total of 307 patients who underwent PCI with second-generation DES were analyzed and divided into the SBA (n = 96) and conventional balloon angioplasty (CBA) groups (n = 211). Eighty-two and 189 patients comprised the "SBA after small burr (SBA-SB)" and "CBA after small burr (CBA-SB)" subgroups, respectively, for the subgroup analysis. Study endpoints were incidence of 3-year major adverse cardiac events (MACE), target vessel revascularization (TVR), and target lesion revascularization (TLR)., Results: Kaplan-Meier analysis revealed that the incidence of 3-year cumulative MACE, TVR, and TLR were comparable between groups, and that the incidences of 3-year cumulative MACE, TVR, and TLR were significantly lower in the SBA-SB subgroup than in the CBA-SB subgroup (log-rank p = 0.008; log-rank p = 0.047; log-rank p = 0.045; respectively). Multivariate Cox regression model indicated that SBA after RA was an independent predictor of MACE (hazard ratio: 0.337; 95% confidence interval: 0.139 to 0.817; p = 0.016)., Conclusions: Additional SBA following RA was associated with lower MACE incidence in patients undergoing RA with a small-sized burr., Competing Interests: Declaration of Competing Interest None., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The purpose of the study was to evaluate the optimal cut-off value of CT-Fractional Flow Reserve (CT-FFR) using fluid-structure interaction and how to adjust the CT-FFR's underestimation from a standpoint of minimize 1-year cardiac events. Subjects were 38 cases with 44 vessels in which stenosis of 30-90% was detected using one-rotation scanning by 320-row coronary CT angiography (CCTA) and invasive FFR (i-FFR) was performed within subsequent 90 days. CT-FFR was calculated using on-site from the multiple cardiac phases. A hypothetical 1-year cardiac event incidence was estimated using previous evidences when revascularization was decided based on CT-FFR. We assessed the optimal cut-off value of CT-FFR and how to correct the CT-FFR to minimize hypothetical cardiac events under four different disease prevalence (20%, 25%, 30%, 35%, and 40%). A total of 16 vessels had i-FFR ≤ 0.8. On per-patient basis, the sensitivity, specificity, positive predict value, negative predict value, and diagnostic accuracy of CT-FFR ≦ 0.8 vs CCTA > 50% to detect functional stenosis defined as invasive FFR ≦ 0.80 were 93.3% vs 73.3%, 73.9% vs 26.1%, 70.0% vs 39.3%, 94.4% vs 60.0%, and 81.6% vs 44.7%, respectively. For minimize 1-year cardiac events, the optimal cut-off value for more than 30% of disease prevalence was 0.80. However, the optimal cut-off value for 20, 25, and 30% was 0.54 in any cases. After the adjustment of CT-FFR using a formula of 0.3X + 0.634 for CT-FFR < 0.7 to counteract its underestimation, the % reduction of the events for 20, 25, 30, 35, and 40% at a 0.80 cut-off were 19.0%, 15.6%, 12.6%, 10.0%, and 7.7% respectively. It was reasonable to support that the optimal cut-off value was 0.80 in disease prevalence of more than 30% for minimize 1-year cardiac events. However, underestimation should be adjusted to reduce cardiac events, especially when disease prevalence is low.

Thrombocytopenia is a frequent complication in patients requiring intra-aortic balloon pumping (IABP) counterpulsation. However, its prognostic impact has not been fully addressed. The objective of this study is to evaluate the impact of the change in the platelet number during IABP use on the prognosis after device removal.This is a retrospective observational study. Patients in the intensive cardiac care unit at three Juntendo University hospitals who underwent percutaneous implantation of IABP with or without veno-arterial extracorporeal membrane oxygenation (V-A ECMO), since 2012-2016, were enrolled in the study (n = 439). Patients who died during mechanical circulatory support (n = 47) were excluded. We evaluated the prognostic impact of the ratio of platelet reduction from the baseline (% PLT reduction) during IABP use on cardiovascular mortality after device removal.The median and the range of follow-up period were 298 days and 0-1,869 days, respectively. Unadjusted Kaplan-Meier analysis demonstrated that patients with a higher % PLT reduction had higher cardiovascular (CV) mortality. An adjusted Cox proportional hazard analysis demonstrated that a 10% higher % PLT reduction was associated with higher cardiovascular (CV) mortality (Hazard ratio: 1.3, 95% Confidence interval: 1.1-1.6, P < 0.001). Moreover, % PLT reduction and the maximum C-reactive protein (CRP) level during IABP use were positively correlated (r = 0.326, P < 0.001).The reduced number of platelets during IABP use was associated with an increased risk of CV mortality.

Background: The use of serial intravascular ultrasound (IVUS) for coronary atherosclerosis has offered valuable insight into plaque regression (PR) or progression. However, the beneficial effects of PR on the long-term clinical outcomes in patients with acute coronary syndrome (ACS) remain unclear. We aimed to evaluate the impact of coronary plaque change in patients following primary percutaneous coronary intervention., Methods: We retrospectively analyzed data from 4 prospective clinical trials involving 173 patients with ACS who underwent serial IVUS of non-culprit lesions on statin treatment at baseline and at 6 or 8 months of follow-up. The relationship of the IVUS findings with the change in percent atheroma volume (PAV), on-treatment low-density lipoprotein cholesterol (LDL-C), and major adverse cardiac and cerebrovascular events (MACCE) were investigated., Results: In our serial IVUS analysis, baseline plaque volume and PAV were 79.6mm 3 and 46.0%, respectively. The overall change in PAV was -1.5% [interquartile range (IQR): -4.1% to 1.0%], and PR (i.e. PAV change from baseline <0) was observed in 67.1% of patients. They were followed up observationally for a mean of 3.5 years and a total of 37 MACCE occurred. The rate of MACCE tended to be lower in patients with PR than in those without PR (18.1% vs. 28.7%, p=0.14). A multivariate Cox hazard model analysis demonstrated that achievement of both PR and on-treatment low LDL-C levels (<70mg/dL) was the only significant independent predictor of MACCE (hazard ratio: 0.42, 95% confidence interval: 0.19-0.88; p=0.02)., Conclusions: Achievement of both PR and sufficient lowering of the LDL-C was clinically important in post-ACS management., (Copyright © 2019 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

The co-existence of expansive arterial remodelling in both coronary arteries (CAs) and the abdominal aorta has already been reported, although the clinical indicators and quantitative analysis have not been well studied. We therefore aimed to clarify the clinical and anatomical characteristics of patients with abdominal aortic aneurysms (AAAs). 123 AAA patients who underwent coronary angiography were compared to 123 control patients selected by propensity score matching. CA diameters of all 3 vessels were measured by quantitative coronary angiographic analysis. Coronary artery ectasia (CAE) was defined as local or generalized aneurysmal change of the CAs. Excessive expansive CA remodelling was defined as the maximal diameter of the right or left circumflex artery in the upper 75th percentile (>4.8 mm). Multivariable logistic regression analyses were used to determine predictors of CAE and excessive expansive CA remodelling. The prevalences of CAE and excessive expansive CA remodelling were significantly higher in the AAA group than in the non-AAA group (28% vs. 8% and 31% vs. 19%; both p<0.05). On multivariable analysis, the presence of AAA (odds ratio (OR), 4.56; 95% confidence intervals (95%CI) 2.18-10.4) and body mass index (BMI) (OR, 1.11; 95%CI 1.03-1.21) were independently associated with CAE, and higher high-sensitivity C-reactive protein (OR, 2.19; 95%CI 1.08-4.52) and BMI (OR, 1.11; 95%CI 1.02-1.21) were independently associated with excessive expansive CA remodelling. In conclusions, this study showed a higher prevalence of ectatic CA disease in AAA patients and suggests that higher inflammation and obesity are associated with expansive arterial remodelling in coronary arteries., Competing Interests: The authors have declared that no competing interests exist.

Background: Hemodialysis (HD) patients have heavy calcium deposits in their stenotic coronary arteries and worse post-percutaneous coronary intervention (PCI) prognoses than those who do not undergo HD. Rotational atherectomy (RA) facilitates PCI success in severely calcified lesions. We aimed to identify clinical and procedural characteristics that predict HD patients' long-term prognoses after PCI that included RA in the drug-eluting stent (DES) era., Methods: This study included 302 patients who underwent regular HD from J2T Multicenter Registry database of 1090 consecutive patients who underwent RA to treat de novo calcified lesions at three university hospitals between 2004 and 2015. The primary endpoint was cardiovascular (CV) death., Results: During the 5-year observation period, 59 CV deaths (19.5%) occurred. The CV death group and non-CV death group had comparable profiles except significantly lower left ventricular ejection fraction, higher brain natriuretic peptide (BNP), lower rate of RA burr upsizing, and lower rate of final thrombolysis in myocardial infarction (TIMI) 3 flow achievement in the CV death group. Cox regression analysis revealed that increasing ablation burr size (hazard ratio [HR]: 0.33; 95% confidence interval [CI]: 0.13-0.81), final TIMI 3 flow (HR: 0.07; 95% CI: 0.02-0.28), lower BNP level, and optimal medication were independently associated with better CV mortality in HD patients., Conclusion: In the DES era, oral medications at the time of PCI and stepwise calcium ablation were associated with improved long-term CV mortality in HD patients who are scheduled to undergo RA to treat severely calcified coronary artery stenoses, as therapeutic strategies., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: A low 1,5-anhydro-D-glucitol (AG) blood level is considered a clinical marker of postprandial hyperglycemia. Previous studies reported that 1,5-AG levels were associated with vascular endothelial dysfunction and coronary artery disease (CAD). However, the association between 1,5-AG levels and coronary artery plaque in patients with CAD is unclear., Methods: This study included 161 patients who underwent percutaneous coronary intervention for CAD. The culprit plaque characteristics and the extent of coronary calcification, which was measured by the angle of its arc, were assessed by preintervention intravascular ultrasound (IVUS). Patients with chronic kidney disease or glycosylated hemoglobin ≥ 7.0 were excluded. Patients were divided into 2 groups according to serum 1,5-AG levels (< 14.0 μg/mL vs. ≥ 14 μg/mL)., Results: The total atheroma volume and the presence of IVUS-attenuated plaque in the culprit lesions were similar between groups. Calcified plaques were frequently observed in the low 1,5-AG group (p = 0.06). Compared with the high 1,5-AG group, the low 1,5-AG group had significantly higher median maximum calcification (144° vs. 107°, p = 0.03) and more frequent calcified plaques with a maximum calcification angle of ≥ 180° (34.0% vs. 13.2%, p = 0.003). Multivariate logistic regression analysis showed that a low 1,5-AG level was a significant predictor of a greater calcification angle (> 180°) (OR 2.64, 95% CI 1.10-6.29, p = 0.03)., Conclusions: Low 1,5-AG level, which indicated postprandial hyperglycemia, was associated with the severity of coronary artery calcification. Further studies are needed to clarify the effects of postprandial hyperglycemia on coronary artery calcification.

Background: A novel algorithm has been developed for the on-site analysis of CT-fractional flow reserve (CT-FFR) using fluid structural interactions. There have been no reports on the factors affecting the diagnostic performance of CT-FFR using this algorithm. We evaluated the factors predictive of false-positive CT-FFR findings compared to invasive FFR as a reference standard., Methods: The subjects were 66 consecutive cases (81 vessels) who underwent invasive FFR assessment within 90 days of the detection of 30-90% stenosis of one vessel of the major coronary artery, from among patients with suspected coronary arterial disease who underwent one-rotation scanning by 320-row coronary CT angiography (CCTA). The prospective CCTA mode was used for all patients, with the X-ray exposure set in a range of 70-99% of the RR interval. The FFR was calculated on-site from multiple cardiac phases. Factors associated with a false-positive finding of functional stenosis on CT-FFR, defined as an invasive FFR of ≤0.80, were evaluated using logistic regression analysis., Results: Thirty-nine vessels (48.1%) had an invasive FFR of ≤0.80. CT-FFR and invasive FFR values disagreed in 13 vessels in 13 patients. The values were false positive in 12 of the vessels. In an analysis of patient characteristics, the body mass index (odds ratio, 1.33; 95%CI, 1.06-1.67; p = 0.01) and Image noise (odds ratio, 1.18; 95%CI, 1.01-1.40; p = 0.04) were predictive of false-positive findings. The presence of calcified plaque (odds ratio, 5.16; 95%CI, 1.06-20.85; p = 0.01) was the only significant predictive factor in a vessel-based analysis of lesion characteristics., Conclusions: The presence of calcified plaque exerted a significant effect on the diagnostic performance of CT-FFR, and did so independently of the degree of calcification indicated by the Agatston score.

Background: Sleep-disordered breathing (SDB) is a novel cardiovascular risk factor. To date, the effects of continuous positive airway pressure (CPAP) on coronary plaque atheroma in SDB patients with coronary artery disease (CAD) have remained unclear. The CPAP Effects on Atherosclerotic Plaques in Patients with Sleep-Disordered Breathing and Coronary Artery Disease (ENTERPRISE) trial was designed to evaluate the effects of CPAP treatment in addition to optimal medical treatment on coronary plaque regression in SDB patients., Methods: This study is planned as a prospective, randomized, open-label, single-center study. The presence of SDB is defined as a 3% oxygen desaturation index (ODI) of ≥15 events/h as measured by nocturnal pulse oximetry. A total of 100 eligible SDB patients undergoing intravascular ultrasound (IVUS)-guided percutaneous coronary intervention will be randomly assigned to either CPAP as add-on therapy or no CPAP for SDB (1:1 ratio for CPAP vs. no CPAP). The intervention will consist of 12 months of CPAP treatment. The primary endpoint will be percentage changes in plaque atheroma volume of the non-culprit lesion segment as measured by IVUS. A specialist sleep cardiology team will carefully monitor patients receiving CPAP treatment in order to quickly detect and resolve problems, and to motivate patients to continue treatment., Conclusion: This study will provide novel information on the effects of SDB and its treatment with CPAP on coronary plaque stability with regard to secondary prevention of CAD., (Copyright © 2018 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Background Sleep-disordered breathing ( SDB ) is a novel cardiovascular risk factor. However, the coronary plaque characteristics of patients with SDB with coronary artery disease are still unclear. Methods and Results This study included 289 consecutive patients with coronary artery disease undergoing percutaneous coronary intervention. Plaque characteristics of the culprit lesion were assessed by preintervention intravascular ultrasound. The presence of SDB was defined as a 3% oxygen desaturation index of ≥15 events per hour measured by nocturnal pulse oximetry. Of 289 patients, the median 3% oxygen desaturation index was 9.6 (interquartile range, 5.1-16.6), and 88 patients (30.4%) were defined as having SDB . Compared with the no- SDB group, the SDB group had a larger total atheroma volume of the culprit lesion (224.5 mm 3 versus 190.8 mm 3 , P=0.05). The median maximum attenuation and calcification angle were 140° and 130°, respectively. Attenuated plaque with a maximum attenuation angle >140° was more frequently observed in the SDB group compared with the no- SDB group (34.9% versus 22.6%; P=0.03). However, there were no statistically significant differences between groups in the maximum calcium angle and the frequency of calcific plaques with a maximum calcium angle >130°. Multivariable logistic regression analysis showed that the presence of SDB was a significant predictor of a greater ultrasound attenuation angle (>140°) (odds ratio, 1.86; 95% confidence interval, 1.02-3.39; P=0.04). Conclusions SDB was associated with larger atheroma plaque volume and a greater ultrasound attenuation, which are discriminators of plaque vulnerability. Further studies are needed to clarify the effects of SDB treatment on coronary plaque lesions.

ABO blood group and body mass index (BMI) have individually been appraised as risk factors for certain diseases. From statistical perspective, it may be important to examine the relationship between the ABO blood antigen and BMI. This cross-sectional study involved 412 participants aged 18 to 46 at the Kwame Nkrumah University of Science and Technology (KNUST), Kumasi. Weight and height of participants were measured for BMI calculation; blood group determination was done using antisera. Blood group O was the most prevalent (51.2%), while Rhesus-positive individuals constituted 90.3%. 6.3% of the participants were obese, while 18.7% were overweight. There was significant ( p =0.006) higher prevalence of obesity in females (10.3%) than in males (3.4%). The study did not observe any significant difference by association of ABO blood group with gender ( p =0.973), BMI ( p =0.307), or Rhesus status ( p =0.723). Regarding gender ( p =0.400) and BMI ( p =0.197), no statistically significant difference was observed between Rhesus blood groups. The prevalence of overweight, obesity, blood type O, and rhesus positive observed among students in this study is largely similar to what has been reported in published studies in Ghana and from other countries. Overweight and obesity were not associated with ABO blood groups or Rhesus in this study.

Background: Rotational atherectomy (RA) is an adjunct tool for the management of heavily calcified coronary lesions during percutaneous coronary intervention (PCI), but the long-term clinical outcomes of RA use remain unclear in this drug-eluting stent era.Methods and Results:This multi-center registry assessed the characteristics and outcomes of patients treated by RA for calcified coronary lesions between 2004 and 2015. Among 1,090 registered patients, mean age was 70±10 years and 815 (75%) were male. Sixty percent of patients had diabetes mellitus and 27.7% were receiving hemodialysis. The procedure was successful in 96.2%. In-hospital death occurred in 33 patients (3.0%), and 14 patients (1.3%) developed definite/probable stent thrombosis. During the median follow-up period of 3.8 years, the incidence of major adverse cardiac events (MACE), defined as all-cause death, acute coronary syndrome, stent thrombosis, target vessel revascularization and stroke, was 46.7%. On multivariable Cox hazard analysis, hemodialysis (HR, 2.08; 95% CI: 1.53-2.86; P<0.0001) and age (HR, 1.03; 95% CI: 1.01-1.04; P<0.0001) were strong independent predictors of MACE. Conversely, statin treatment was associated with lower incidence of MACE (P=0.035)., Conclusions: This study has provided the largest Japanese dataset for long-term follow-up of RA. Although RA in calcified lesions appears feasible with a high rate of procedural success, a high incidence of MACE was observed.

Rationale: Cases of severe disopyramide poisoning are rare and few have been reported. We report a case in which activated-charcoal column hemoperfusion was dramatically effective for life-threatening disopyramide poisoning., Patient Concerns: A teenage girl who had overdosed on disopyramide (total dose, 4950 mg) was brought to our hospital. She was resuscitated from short period cardiopulmonary arrest and subsequently showed severe cardiogenic shock and ventricular arrhythmia., Diagnoses: Disopyramide poisoning (self-evident)., Interventions: As hemodynamics remained unstable after providing percutaneous cardiopulmonary support and intra-aortic balloon pumping, we attempted direct hemoperfusion using a coated activated-charcoal hemoperfusion column., Outcomes: Hemodynamics including electrocardiography and serum disopyramide concentration were dramatically improved, and the patient was ambulatory by hospital day 14., Lessons: Because disopyramide has low molecular weight and a small distribution volume, blood purification is considered to be the most effective therapy. We selected direct hemoperfusion for relatively high protein-binding rate. In fact, clinical status was dramatically improved, and the calculated half-life of the direct hemoperfusion phase was the shortest of all phases. In cases of severe or life-threatening disopyramide poisoning, blood purification therapy including direct hemoperfusion using a coated activated-charcoal column should be performed.

For the last 25 years, it has been proven that the occurrence or recurrence of neural tube defects can be prevented with the administration of folic acid before and early pregnancy. At present, over 80 countries in the world, except Japan, have mandated the fortification of wheat flour and/or rice with folic acid, which has resulted in a significant reduction in the prevalence of neural tube defects. In 2000, the Japanese government recommended folic acid 400 μg daily for young women of childbearing age and women who are planning to conceive. In 2002, the government started to present information about the importance of folic acid in the development of fetuses in the Mother-Child Health Booklet annually. Despite these endeavors, the prevalence of neural tube defects has remained unchanged. We discuss the risk factors of neural tube defects and propose preventive measures to decrease the number of neonates with neural tube defects. We believe that the government should implement the fortification of staple food with folic acid very soon, which will eventually decrease not only the neonatal mortality and morbidity, but also the economic burden on our health care system., (© 2017 Japanese Teratology Society.)