Incremental predictive value of the combined use of the neutrophil-to-lymphocyte ratio and systolic blood pressure difference after successful drug-eluting stent implantation

Background: Previous work has highlighted the importance of the neutrophil-to-lymphocyte ratio (NLR) and the difference in the ward-to-catheterization laboratory systolic blood pressure (ΔSBP) in prognostic stratification after acute coronary syndrome. However, there is paucity of data regarding the added value of combining these two variables to predict 5-year major clinical outcomes after percutaneous coronary intervention. Methods: A total of 1188 patients were classified into four groups according to the NLR and ΔSBP (high vs. low) using cutoffs derived from an analysis of receiver operating characteristic curves. A NLR > 3.0 and a ΔSBP > 25 mmHg were considered high values. The primary endpoint was the composite of all-cause death, cardiac death, and non-fatal myocardial infarction. The secondary endpoint was the composite of target lesion revascularization, target vessel revascularization, and incidence of cerebrovascular accidents. Results: The incidence of the primary endpoint was significantly higher in the high NLR and ΔSBP group than in the other three groups (2.2% vs. 4.7% vs. 4.3% vs. 13.2%, p < 0.001). The incidence of the secondary endpoint was similar among the four groups. Incorporation of high NLR and high ΔSBP into a model with conventional and meaningful clinical and procedural risk factors increased the C-statistics in predicting the primary endpoint (0.575 to 0.635, p = 0.002). Conclusions: The power to predict the primary endpoint after drug-eluting stent implantation at the 5-year follow-up was improved by combining NLR and ΔSBP

Monotherapy versus combination therapy of statin and renin–angiotensin system inhibitor in ST-segment elevation myocardial infarction

Background: The beneficial effects of statin and renin–angiotensin system inhibitor (RASI) are well-known. In this retrospective cohort study,  2-year clinical outcomes were compared between monotherapy and combination therapy with statin and RASI in ST-segment elevation myocardial infarction (STEMI) patients after stent implantation. Methods: A total of 17,414 STEMI patients were enrolled and divided into the three groups (group A: 2448 patients, statin alone; group B: 2431 patients, RASI alone; and group C: 12,535 patients, both statin and RASI). The principal clinical endpoint was the occurrence of major adverse cardiac events (MACEs) defined as all-cause death, recurrent myocardial infarction, and any repeat revascularization. Results: After adjustment, the cumulative incidences of MACEs in group A (adjusted hazard ratio [aHR] 1.337; 95% confidence interval [CI] 1.064–1.679; p = 0.013) and in group B (aHR 1.375; 95% CI 1.149–1.646; p = 0.001) were significantly higher than in group C. The cumulative incidence of all-cause death in group A was significantly higher than that in group C (aHR 1.539; 95% CI 1.014–2.336; p = 0.043). The cumulative incidences of any repeat revascularization (aHR 1.317; 95% CI 1.031–1.681; p = 0.028), target lesion vascularization, and target vessel vascularization in group B were significantly higher than in group C. Conclusions: A Statin and RASI combination therapy significantly reduced the cumulative incidence of MACEs compared with a monotherapy of these drugs. Moreover, the combination therapy showed a reduced all-cause death rate compared with statin monotherapy, and a decreased repeat revascularization rate compared with RASI monotherapy

A Clinical Risk Score to Predict In-hospital Mortality from COVID-19 in South Korea

Background: Early identification of patients with coronavirus disease 2019 (COVID-19) who are at high risk of mortality is of vital importance for appropriate clinical decision making and delivering optimal treatment. We aimed to develop and validate a clinical risk score for predicting mortality at the time of admission of patients hospitalized with COVID-19. Methods: Collaborating with the Korea Centers for Disease Control and Prevention (KCDC), we established a prospective consecutive cohort of 5,628 patients with confirmed COVID-19 infection who were admitted to 120 hospitals in Korea between January 20, 2020, and April 30, 2020. The cohort was randomly divided using a 7:3 ratio into a development (n = 3,940) and validation (n = 1,688) set. Clinical information and complete blood count (CBC) detected at admission were investigated using Least Absolute Shrinkage and Selection Operator (LASSO) and logistic regression to construct a predictive risk score (COVID-Mortality Score). The discriminative power of the risk model was assessed by calculating the area under the curve (AUC) of the receiver operating characteristic curves. Results: The incidence of mortality was 4.3% in both the development and validation set. A COVID-Mortality Score consisting of age, sex, body mass index, combined comorbidity, clinical symptoms, and CBC was developed. AUCs of the scoring system were 0.96 (95% confidence interval [CI], 0.85-0.91) and 0.97 (95% CI, 0.84-0.93) in the development and validation set, respectively. If the model was optimized for > 90% sensitivity, accuracies were 81.0% and 80.2% with sensitivities of 91.7% and 86.1% in the development and validation set, respectively. The optimized scoring system has been applied to the public online risk calculator (https://www.diseaseriskscore.com). Conclusion: This clinically developed and validated COVID-Mortality Score, using clinical data available at the time of admission, will aid clinicians in predicting in-hospital mortality

Provisional drug-coated balloon treatment guided by physiology on de novo coronary lesion

Although drug-eluting stents (DES) have become the mainstay of percutaneous coronary intervention, late and very late stent thrombosis remains a concern. Drug-coated balloons (DCB) have the advantage of preserving the anti-restenotic benefits of DES while minimizing potential long-term safety concerns. Currently the two methods to ensure successful DCB treatment of a stenotic lesion are angiography or physiology-guided DCB application. This review will evaluate these two methods based on previous evidence and make suggestions on how to perform DCB treatment more efficiently and safely

Drug-coated balloon treatment in coronary artery disease: Recommendations from an Asia-Pacific Consensus Group

Coronary artery disease (CAD) is currently the leading cause of death globally, and the prevalence of thisdisease is growing more rapidly in the Asia-Pacific region than in Western countries. Although the useof metal coronary stents has rapidly increased thanks to the advancement of safety and efficacy of newergeneration drug eluting stent (DES), patients are still negatively affected by some the inherent limitationsof this type of treatment, such as stent thrombosis or restenosis, including neoatherosclerosis, andthe obligatory use of dual antiplatelet therapy (DAPT) with unknown optimal duration.Drug-coated balloon (DCB) treatment is based on a leave-nothing-behind concept and therefore it is notlimited by stent thrombosis and long-term DAPT; it directly delivers an anti-proliferative drug whichis coated on a balloon after improving coronary blood flow. At present, DCB treatment is recommendedas the first-line treatment option in metal stent-related restenosis linked to DES and bare metal stent.For de novo coronary lesions, the application of DCB treatment is extended further, for conditions suchas small vessel disease, bifurcation lesions, and chronic total occlusion lesions, and others. Recently,several reports have suggested that fractional flow reserve guided DCB application was safe for largercoronary artery lesions and showed good long-term outcomes. Therefore, the aim of these recommendationsof the consensus group was to provide adequate guidelines for patients with CAD based on objectiveevidence, and to extend the application of DCB to a wider variety of coronary diseases and guide theirmost effective and correct use in actual clinical practice

Effect of delayed hospitalization on 3-year clinical outcomes according to renal function in patients with non-ST-segment elevation myocardial infarction

Background: We evaluated the effect of delayed hospitalization (symptom-to-door time [STD] ≥ 24 h) on 3-year clinical outcomes according to renal function in patients with non-ST-segment elevation myocardial infarction (NSTEMI) undergoing new-generation drug-eluting stent (DES) implantation. Methods: A total of 4513 patients with NSTEMI were classified into chronic kidney disease (CKD) (estimated glomerular filtration rate [eGFR] < 60 mL/min/1.73 m2, n = 1118) and non-CKD (eGFR ≥ 60 mL/min/1.73 m2, n = 3395) groups. They were further sub-classified into groups with (STD ≥ 24 h) and without (STD < 24 h) delayed hospitalization. The primary outcome was the occurrence of major adverse cardiac and cerebrovascular events (MACCE), defined as all-cause death, recurrent myocardial infarction, any repeat coronary revascularization, and stroke. The secondary outcome was stent thrombosis (ST). Results: After multivariable-adjusted and propensity score analyses, the primary and secondary clinical outcomes were similar in patients with or without delayed hospitalization in both CKD and non-CKD groups. However, in both the STD < 24 h and STD ≥ 24 h groups, MACCE (p < 0.001 and p < 0.006, respectively) and mortality rates were significantly higher in the CKD group than in the non-CKD group. However, ST rates were similar between the CKD and non-CKD groups and between the STD < 24 h and STD ≥ 24 h groups. Conclusions: Chronic kidney disease appears to be a much more important determinant of MACCE and mortality rates than STD in patients with NSTEMI

Sex difference after acute myocardial infarction patients with a history of current smoking and long-term clinical outcomes: Results of KAMIR Registry

Background: The contribution of sex as an independent risk factor for cardiovascular disease still remains controversial. The present study investigated the impact of sex on long-term clinical outcomes in Korean acute myocardial infarction (AMI) patients with a history of current smoking on admission after drug-eluting stents (DESs). Methods: A total of 12,565 AMI patients (male: n = 11767 vs. female: n = 798) were enrolled. Major adverse cardiac events (MACEs) comprising all-cause death, recurrent myocardial infarction (Re-MI), and any repeat revascularization were the primary outcomes that were compared between the two groups. Probable or definite stent thrombosis (ST) was the secondary outcome. Results: After adjustment, the early (30 days) cumulative incidences of MACEs (adjusted hazard ratio [aHR]: 1.457; 95% confidence interval [CI]: 1.021–2.216; p = 0.035) and all-cause death (aHR: 1.699; 95% CI: 1.074–2.687; p = 0.023) were significantly higher in the female group than in the male group. At 2 years, the cumulative incidences of all-cause death (aHR: 1.561; 95% CI: 1.103–2.210; p = 0.012) and Re-MI (aHR: 1.880; 95% CI: 1.089–2.974; p = 0.022) were significantly higher in the female group than in the male group. However, the cumulative incidences of ST were similar between the two groups (aHR: 1.207; 95% CI: 0.583–2.497; p = 0.613). Conclusions: The female group showed worse short-term and long-term clinical outcomes compared with the male group comprised of Korean AMI patients with a history of current smoking after successful DES implantation. However, further studies are required to confirm these results