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Background: Cerebrovascular disease often coexists with coronary artery disease (CAD), and it has been associated with worse clinical outcomes in CAD patients. However, the prognostic effect of prior stroke on long-term outcomes in patients with acute coronary syndrome (ACS) is still unclear. Methods and Results: An observational cohort study of ACS patients who underwent emergency percutaneous coronary intervention (PCI) between January 1999 and May 2015 was conducted. Patients were divided into 2 groups according to their history of stroke. We evaluated both all-cause death and cardiac death. Of the 2,548 consecutive ACS patients in the current cohort, 268 (10.5%) had a history of stroke at the onset of ACS. Patients with a history of stroke were older and had a higher prevalence of comorbidities such as hypertension or renal deficiency. The cumulative incidences of all-cause death and cardiac death were significantly higher in patients with a history of stroke (both log-rank P

Aims Living alone is reported as an independent risk factor for cardiovascular disease. However, little is known about the association between clinical outcomes and living alone in patients with acute coronary syndrome (ACS). The aim of this study was to determine whether living alone is an independent prognostic risk factor for long-term mortality stratified by age in patients with ACS who were treated with primary percutaneous coronary intervention (PCI). Methods and results We conducted an observational cohort study of ACS patients who underwent PCI between January 1999 and May 2015 at Juntendo University Shizuoka Hospital, Japan. The primary endpoint was all-cause death. Among 2547 ACS patients, 381 (15.0%) patients were living alone at the onset of ACS. The cumulative incidence of all-cause death was comparable between living alone and living together (34.8% vs. 34.4%, log-rank P = 0.63). However, among younger population (aged Conclusion Although living alone was not significantly associated with long-term clinical outcomes in patients with ACS, it was a predictive risk factor among younger ACS patients. Careful attention should be paid to patients’ lifestyle, especially younger patients with ACS.

Background: Although short-term mortality of acute myocardial infarction (AMI) has decreased dramatically, sudden cardiac arrest is still one of serious complication. We assessed the clinical characteristics and prognosis’ predictors of AMI patients with out-of-hospital cardiac arrest (OHCA). Methods: We retrospectively analyzed consecutive patients with AMI who were treated with emergency percutaneous coronary intervention between 2004 and 2017. Patients with OHCA were compared with those without OHCA. Results: Among 2,101 AMI patients, 95 (4.7%) presented OHCA. Younger age (odds ratio [OR]: 0.95; 95% confidence interval [CI]: 0.93-0.97; p Conclusions: About 1 of 20 AMI patients presented with OHCA and younger age, absence of coronary risk factors, and anterior wall infarction were associated with OHCA occurrence.

The left intermammary artery (LIMA) graft is commonly used in coronary artery bypass grafting (CABG) to left anterior descending (LAD) because of its superior long-term patency. Acute occlusion of the LIMA causing ST-elevation myocardial infarction (STEMI) in the late postoperative period is rare, and its pathological mechanism is unclear. We present a case of acute occlusion of the LIMA in a 87-year-old woman who underwent CABG surgery 13 years previously. She was transferred to our hospital because of acute chest pain. Electrocardiography showed ST-elevation in anterior leads. Emergency coronary angiography revealed total occlusion of proximal LAD segment and the ostial LIMA (Figure). Therefore, we judged that the LIMA occlusion was causing anterior STEMI, and performed emergency percutaneous intervention. We successfully implanted a drug eluting stent at the culprit lesion and final angiography showed good reperfusion. Although the LIMA graft is expected long-term patency, early recognition of the possibility of LIMA occlusion might be necessary in patients with AMI after CABG surgery.

Left ventricular thrombus (LVT) is known as a life-threatening complication of acute myocardial infarction, in terms of sequential systemic embolization. When an LVT is found to be sufficiently large or mobile, not only anticoagulation therapy but also surgical thrombectomy should be administered immediately to prevent embolic events. Generally, since infarcted myocardium is comparatively fragile, ventriculotomy may result in anastomotic failure or further deterioration of LV function. We report herein a case of transmitral removal of LVT by which we successfully avoided ventriculotomy. A 50-year-old Japanese man was hospitalized due to ST-segment elevation myocardial infarction and emergency coronary angiography revealed total occlusion at the proximal left anterior descending artery. On hospital day 9, transthoracic echocardiography detected a massive LVT at the apex, protruding into the left ventricle. Considering the risk of embolization, urgent thrombectomy via a transmitral approach was performed. The LVT was easily removed through the mitral valve under endoscopic support, without any embolic events or postoperative complications.

Background Although short-term mortality of acute myocardial infarction (AMI) has decreased dramatically in the past few decades, sudden cardiac arrest remains a serious complication. The aim of the study was to assess the clinical characteristics and predictors of prognosis in AMI patients who experienced out-of-hospital cardiac arrest (OHCA). Methods We retrospectively registered consecutive AMI patients who were treated with emergency percutaneous coronary intervention (PCI) between 2004 and 2017. Clinical characteristics and outcomes were compared between patients with OHCA and those without OHCA. Results Among 2101 AMI patients, 95 (4.7%) presented with OHCA. Younger age (odds ratio [OR]: 0.95; 95% confidence interval [CI]: 0.93–0.97; p p = 0.01) or dyslipidemia (OR, 0.56; 95% CI, 0.36–0.88; p = 0.01), left main trunk (LMT) or left anterior descending artery (LAD) as the culprit lesion (OR, 3.26; 95% CI, 1.99–5.33; p p p = 0.004), glucose level (OR, 1.01; 95% CI, 1.00–1.01; p = 0.01), and renal deficiency (OR, 3.35; 95% CI, 1.07–10.53; p = 0.04) as independent predictors of 30-day mortality among AMI patients with OHCA. Conclusions In patients with AMI who underwent emergency PCI, 30-day mortality was six times greater in those having presented initially with OHCA compared with those without OHCA. Younger age, absence of diabetes mellitus or dyslipidemia, LMT or LAD as the culprit lesion, and renal deficiency were independent predictors of OHCA. OHCA patient with higher blood glucose level on admission, LMT or LAD as the culprit lesion, or renal deficiency showed worse clinical outcomes.

IntroductionPacing-induced cardiomyopathy occasionally occurs in patients undergoing pacemaker implantation. Although compared with right ventricular (RV) apical pacing, RV septal pacing can attenuate left ventricular dyssynchrony; the success rate of lead placement on the RV septum using the stylet system is low. Additionally, no randomised controlled trial has addressed the issue regarding the accuracy of RV lead placement on the RV septum using the stylet and delivery catheter systems. This study hypothesises that a newly available delivery catheter system can improve the accuracy of RV lead placement on the RV septum.Methods and analysisIn a multicentre, prospective, randomised, single-blind, controlled trial, 70 patients with pacemaker indication owing to atrioventricular block will be randomised to either the delivery catheter or stylet group before the pacemaker implantation procedure. The position of the RV lead tip will be assessed using ECG-gated cardiac CT in all patients within 4 weeks after pacemaker implantation. Lead tip positions are classified into three groups: (1) RV septum, (2) anterior/posterior edge of the RV septal wall and (3) RV free wall. The primary endpoint will be the success rate of RV lead tip placement on the RV septum, which will be evaluated using cardiac CT.Ethics and disseminationThis study will be conducted according to the stipulations of the Helsinki Declaration and the institutional review board of Hamamatsu University School of Medicine. The results of the study will be disseminated at several research conferences and will be published in peer-reviewed journals.Trial registration numberjRCTs042200014; Pre-results.

Aims: Cardiovascular risk persists despite intensive lipid lowering therapy using statins. Serum levels of lipoprotein (a) [Lp(a)] can be a residual cardiovascular risk for adverse events. Aim of the present study was to evaluate the impact of Lp(a) on long-term clinical outcomes in patients treated with statin after percutaneous coronary intervention. Methods: We prospectively enrolled 3507 consecutive CAD patients who underwent a first percutaneous coronary intervention (PCI) between 1997 and 2011 at our institution. We identified 1768 patients (50.4%) who had treated with statin during PCI. Eligible 1336 patients were stratified to two groups according to Lp(a) levels (median Lp (a) 21.5 mg/dL). The primary outcome was major adverse cardiac events (MACE) including cardiac death and non-fatal acute coronary syndrome. Results: MACE occurred 144 (10.8%) including 34 (2.5%) cardiac death and 110 (8.7%) non-fatal ACS during median follow-up period of 1920 days. The cumulative rate of MACE was significantly higher in group with high Lp(a) group (log-rank p = 0.0460). Multivariate Cox regression analysis showed a significant correlation between Lp (a) levels treated as a natural logarithm-transformed continuous variable and increased MACE (adjusted HR for MACE 1.28, 95%CI 1.04–1.58, p = 0.0184) Conclusion: Elevated levels of Lp(a) is significantly associated with long-term adverse clinical outcomes among CAD patients who received statin therapy after PCI.

Background and objective A prior history of stroke is associated with increased adverse cardiovascular outcomes in patients with acute coronary syndrome (ACS), however the prognostic impact on long-term outcomes remains unclear. Methods We conducted an observational cohort study of ACS patients underwent primary percutaneous coronary intervention (PCI) between January 1999 and May 2015 at our hospital. The aim of the present study is to evaluate the overall prevalence and clinical impact of a history of stroke. The primary outcome was cardiac death during the median follow-up period of 5yrs. Results Among 2562 ACS patients of the current cohort, 268 patients (10.5%) had a history of stroke at the onset of ACS. The cumulative incidence of cardiac death was higher in patients with a history of stroke (11.4% vs. 19.7%, log-rank p Kaplan-Meier curve Conclusion Among ACS patients treated with primary PCI, a history of stroke was not rare and was associated with increased long term cardiac mortality.

Background Reducing delay to percutaneous coronary intervention improves functional outcome and reduces long-term mortality. Transportation by helicopter is often quicker than ground transport and thus may improve overall prognosis through reduced ischemic injury and infarction size. Our hospital is located on the medically-depopulated peninsula surrounded by mountain. The journey from the southern tip of the peninsula to the critical care medical center of our hospital take 1.5 hour by a ground ambulance but only 15 minutes by helicopter. We compared the clinical characteristics and long-term mortality between air and ground transport of ACS patients for primary PCI. Methods We conducted an observational cohort study evaluating 2324 patients (mean age 68.5±12.0, male 75.2%) with ACS underwent primary PCI between April 2004 and December 2017 at our hospital. We divided into three groups according to transportation system type (air, ground, walk-in). The primary outcome was defined as all-cause death during the long-term follow-up. Results Among the entire cohort, 577 patients (24.8%) were transported by air. 1326 (57.1%) patients by ambulance, 421 (18.1%) patients by walk. Baseline characteristics were comparable, but patients by air had a higher prevalence of ST-elevation myocardial infarction. The rate of long-term mortality was comparable during the median follow up of 6 years (air, 21.1% vs. ground, 21.4% vs. walk-in, 21.1%, respectively, log-rank p=0.72). Multivariate Cox regression analysis showed no significant association between air transportation and long-term mortality (Adjusted HR [vs ground] 1.05, 95% CI 0.60–1.78, p=0.85 and [vs walk-in] 0.94, 95% CI 0.62–1.43, respectively, p=0.77). Kaplan-Meier curve Conclusions The rate of long-term mortality in patients with ACS transported by air was comparable with those transported by ground.

Acute coronary syndrome (ACS) is an important cause of mortality and morbidity in the general population. Recent advances in percutaneous coronary intervention (PCI) and optimal medical treatment have helped to improve the prognosis of patients with ACS. The previous reports indicated that women with ACS have a higher risk of adverse outcomes. However, sex differences in clinical outcomes with contemporary coronary revascularization and medical therapy for ACS have not been elucidated. We analyzed data from 676 consecutive patients with ACS (female, n = 166; male, n = 510) who were treated by emergency PCI between 2011 and 2014 at Juntendo Shizuoka Hospital. The patients were grouped according to sex. We defined major adverse cardiovascular events as a composite of all-cause death and ACS recurrence at 1 year and compared rates of major adverse cardiac events (MACE) between the groups. Women were older (75.4 ± 11.0 vs. 66.2 ± 12.2 years) and had a higher rate of multi-vessel disease, chronic kidney disease, and Killip IV at presentation. The cumulative rate of MACE at 1 year was significantly higher among women than men (17.5 vs. 10.2 %, p = 0.02, log-rank test). However, the association between women and a higher risk of MACE was attenuated after adjusting for age (HR 1.25, 95 % CI 0.77-2.00, p = 0.36) and other variables (HR 0.93, 95 % CI 0.36-2.44, p = 0.88). Adjustment for age and other risk factors attenuated sex differences in mid-term clinical outcomes among patients with ACS after emergency PCI.

Introduction: Several studies have shown that patients with acute coronary syndrome (ACS) presenting during off-hours have higher mortality, however, the impact of off-hour presentation on short-term mortality in patients with cardiogenic shock complicating ACS is uncertain. Hypothesis: Off-hour presentation may affect the short-term mortality in ACS patients with cardiogenic shock. Methods: We investigated consecutive 499 patients with cardiogenic shock complicating ACS from prospective and national-wide multicenter registry (JCS Shock Registry) database from March 2012 to April 2014. The primary outcomes of the present study were 30-day mortality among patients presenting either during regular-hours (defined as week-day from 8:00 AM to 8:00 PM) and off-hour (defined as weekdays from 8:01 PM to 7:59 AM, weekends and holidays). Results: Fifty-three percent of patients were presented in off-hour. Baseline characteristics were comparable including symptom onset to presentation time (off-hour; 65 min, interquartile range 39 to 180 vs. regular hour; 59 min, interquartile range 38 to 143, p = 0.22). Eighty percent of patients underwent urgent percutaneous coronary intervention and door to balloon time was also comparable between groups (off-hour; 86 min, interquartile range 60 to 110 vs. regular hour; 80 min, interquartile range 60 to 110, p = 0.74). The rate of 30-day mortality were comparable (off-hour; 35.1 % vs. regular hour 31.7 %, log-rank p = 0.48). In multivariate cox regression analysis, off-hours presentation did not affect the 30-day mortality (age- and gender-adjusted HR 1.12, 95% CI 0.82-1.52, p = 0.46). Conclusions: The clinical impact of either off-hours or regular-hours presentation is comparable in patients with cardiogenic shock complicating acute coronary syndrome (ACS) in Japan.