Differences in coronary plaque characteristics between patients with and those without peripheral arterial disease.

INTRODUCTION Cardiovascular mortality of patients with combined peripheral arterial disease (PAD) and coronary artery disease (CAD) is twice as high as that in those with either disease alone. It is known that patients with PAD undergoing percutaneous coronary intervention have a higher incidence of adverse cardiac events such as myocardial infarction or target vessel revascularization. OBJECTIVE In this study, we compared the detailed characteristics of culprit and nonculprit plaques between patients with and those without PAD using optical coherence tomography. PATIENTS AND METHODS We performed propensity score matching using the following variables: (i) age; (ii) sex; (iii) clinical presentation; (iv) diabetes mellitus; (v) hyperlipidemia; (vi) smoking; (vii) hypertension; (viii) BMI; and (ix) coronary lesion location. Finally, we matched 34 culprit lesions and 30 nonculprit lesions in patients with PAD to 68 culprit lesions and 60 nonculprit lesions in patients without PAD (1 : 2 ratio). RESULTS In culprit lesions, PAD patients when compared with those without PAD had a higher prevalence of lipid-rich plaque (73.5 vs. 51.5%; P=0.033), higher lipid index (1744±1110 vs. 1246±656; P=0.043), calcification (79.4 vs. 58.8%; P=0.039), macrophage accumulation (70.6 vs. 48.5%; P=0.034), and cholesterol crystals (32.4 vs. 10.3%; P=0.006). In nonculprit lesions, PAD patients had a higher prevalence of calcification (76.7 vs. 55.0%; P=0.046), macrophage accumulation (63.3 vs. 38.3%; P=0.025), and cholesterol crystals (36.7 vs. 16.7%; P=0.034). CONCLUSION Our study suggests greater coronary plaque vulnerability in both culprit and nonculprit lesions in patients with PAD. This observation underscores the need for more aggressive risk management in patients with combined PAD and coronary artery disease

Clinical and laboratory predictors for plaque erosion in patients with acute coronary syndromes

Background-—Plaque erosion is responsible for 25% to 40% of patients with acute coronary syndromes (ACS). Recent studies suggest that anti-thrombotic therapy without stenting may be an option for this subset of patients. Currently, however, an invasive procedure is required to make a diagnosis of plaque erosion. The aim of this study was to identify clinical or laboratory predictors of plaque erosion in patients with ACS to enable a diagnosis of erosion without additional invasive procedures. Methods and Results-—Patients with ACS who underwent optical coherence tomography imaging were selected from 11 institutions in 6 countries. The patients were classified into plaque rupture, plaque erosion, or calcified plaque, and predictors were identified using multivariable logistic modeling. Among 1241 patients with ACS, 477 (38.4%) patients were found to have plaque erosion. Plaque erosion was more frequent in non–ST-segment elevation-ACS than in ST-segment–elevation myocardial infarction (47.9% versus 29.8%, P=0.0002). Multivariable logistic regression models showed 5 independent parameters associated with plaque erosion: age 15.0 g/dL, and normal renal function. When all 5 parameters are present in a patient with non–ST-segment elevation-ACS, the probability of plaque erosion increased to 73.1%. Conclusions-—Clinical and laboratory parameters associatedwith plaque erosion are explored in this retrospective registry study. These parametersmay be useful to identify the subset ofACS patients with plaque erosion and guide themto conservativemanagement without invasive procedures. The results of this exploratory analysis need to be confirmed in large scale prospective clinical studiesDr. Jang has received an educational grant from Abbott Vascular and Medicure. Dr. Adriaenssens has received grants and consulting fees from Abbott Vascula

The ability of contemporary cardiologists to judge the ischemic impact of a coronary lesion visually

Background: Landmark trials showed that invasive pressure measurement (Fractional Flow Reserve, FFR) was a better guide to coronary stenting than visual assessment. However, present-day interventionists have benefited from extensive research and personal experience of mapping anatomy to hemodynamics. Aims: To determine if visual assessment of the angiogram performs as well as invasive measurement of coronary physiology. Methods: 25 interventional cardiologists independently visually assessed the single vessel coronary disease of 200 randomized participants in The Objective Randomized Blinded Investigation with optimal medical Therapy of Angioplasty in stable angina trial (ORBITA). They gave a visual prediction of the FFR and Instantaneous Wave-free Ratio (iFR), denoted vFFR and viFR respectively. Each judged each lesion on 2 occasions, so that every lesion had 50 vFFR, and 50 viFR assessments. The group consensus visual estimates (vFFR-group and viFR-group) and individual cardiologists' visual estimates (vFFR-individual and viFR-individual) were tested alongside invasively measured FFR and iFR for their ability to predict the placebo-controlled reduction in stress echo ischemia with stenting. Results: Placebo-controlled ischemia improvement with stenting was predicted by vFFR-group (p < 0.0001) and viFR-group (p < 0.0001), vFFR-individual (p < 0.0001) and viFR-individual (p < 0.0001). There were no significant differences between the predictive performance of the group visual estimates and their invasive counterparts: p = 0.53 for vFFR vs FFR and p = 0.56 for viFR vs iFR. Conclusion: Visual assessment of the angiogram by contemporary experts, provides significant additional information on the amount of ischaemia which can be relieved by placebo-controlled stenting in single vessel coronary artery disease

Dynamic neointimal pattern after drug-eluting stent implantation defined by optical coherence tomography.

OBJECTIVES Certain neointimal patterns including neoatherosclerosis (NA) are known to be associated with poor clinical outcome. The prevalence and time course of different neointimal patterns have not been studied systematically. The aim of this study was to investigate the serial changes in neointimal pattern after drug-eluting stent implantation. PATIENTS AND METHODS A total of 132 patients with 207 drug-eluting stents, who underwent two follow-up optical coherence tomography studies at 6 and 12 months, were included. Neointimal patterns were categorized as homogeneous, heterogeneous, layered, or NA using optical coherence tomography. Quantitative and qualitative analyses of neointima were carried out. RESULTS Both at 6 and at 12 months, the homogenous neointima was the predominant type (>75%), followed by the layered and the heterogeneous pattern. At 12 months, progression to NA was observed in 0.6% of the patients in the homogeneous group, in 5.6% of the patients in the heterogeneous group, and in 3.9% of the patients in the layered group. Regression to the homogeneous pattern was observed in 5.6% of the patients in the heterogeneous group and 11.5% of the patients in the layered group. CONCLUSION The homogenous neointima is the predominant pattern both at 6 and at 12 months. The neointimal pattern changed between 6 and 12 months in 10.6% of stents. Further studies are needed to understand the mechanisms of these neointimal changes and their clinical significance

Clinical, angiographic, IVUS, and OCT predictors for irregular protrusion after coronary stenting.

AIMS Irregular protrusion identified by optical coherence tomography (OCT) immediately following stent implantation has been reported as an independent predictor for adverse cardiac events at one year. However, baseline characteristics for the development of irregular protrusion are unknown. The aim of the study was to identify predictors for irregular protrusion following stent implantation. METHODS AND RESULTS A total of 900 lesions in 786 patients who had post-stent OCT imaging were analysed. The patients were divided into two groups: those with (484 lesions, 456 patients) and those without (416 lesions, 330 patients) irregular protrusion. Baseline characteristics (n=786) as well as pre-stent angiogram (n=786), intravascular ultrasound (IVUS; n=31) and OCT (n=159) findings were compared between the two groups. Multivariate analysis showed that patients with irregular protrusion had higher low-density lipoprotein (LDL) cholesterol levels and lesions with greater stent length, greater percent atheroma volume on IVUS, greater lipid content and a higher prevalence of thrombus on OCT before stent implantation. CONCLUSIONS Irregular protrusion was found more frequently in patients with higher LDL cholesterol levels. In addition, lesions treated with longer stents, with greater plaque burden, larger lipid content and a higher prevalence of thrombus were identified as predictors for irregular protrusion following stent implantation

SYNTAX score and pre- and poststent optical coherence tomography findings in the left anterior descending coronary artery in patients with stable angina pectoris

SYNTAX score (SS) has been reported to be an independent predictor of future cardiac events including target lesion revascularization. The aim of this study was to assess the relation between SS and plaque characteristics and poststent vascular response using optical coherence tomography in coronary artery tree and left anterior descending artery (LAD) in patients with stable angina. A total of 179 lesions among 165 patients, including 100 lesions in LAD, were analyzed. Patients were stratified into tertiles. In pre–percutaneous coronary intervention analysis of whole coronary tree and LAD, lesions of the third tertile had the highest prevalence of lipid-rich plaque. Compared with the first tertile, the third tertile had greater lipid index, thinner fibrous cap, and higher prevalence of thin-cap fibroatheroma. In poststent optical coherence tomography, the incidence of stent edge dissection and irregular protrusion was higher in the third tertile compared with the first tertile in coronary tree analysis. In LAD analysis, the prevalence of irregular protrusion was the highest in the third tertile. In conclusion, high SS may reflect higher plaque vulnerability. Stent edge dissection and irregular protrusion were more frequent in patients with higher SS, indicating poor vascular response to stenting. Our results may explain higher cardiac event rate and target lesion revascularization in patients with higher SS

Prognostic impact of atrial fibrillation in patients with acute myocardial infarction

Background: Atrial fibrillation (AF) is the most common supraventricular tachyarrhythmia in patients with acute myocardial infarction (AMI). However, little is known about the impact of AF on in-hospital and long-term mortalities in patients with AMI in the era of primary percutaneous coronary intervention (PCI). Methods: Six hundred ninety-four consecutive patients with AMI admitted within 48 h after symptom onset were analyzed. All patients successfully underwent primary PCI at the acute phase of AMI. Patients were divided into 2 groups according to the presence of AF at admission or during index hospitalization. We retrospectively evaluated the in-hospital and long-term all-cause mortalities between patients with and those without AF. Results: AF was detected in 38 patients (5.5%) at admission and in 51 patients (7.3%) during hospitalization. Patients with AF were older and had a higher heart rate, lower ejection fraction, higher prevalence of hypertension, worse renal function, higher peak level of creatine phosphokinase, and lower rate of final TIMI flow grade 3 than those without AF. Although patients with AF had a more complicated clinical course and higher in-hospital mortality (11.2% vs. 4.0%, P=0.009), there was no significant association between presenting AF and in-hospital death after adjustment for baseline confounders (odds ratio, 2.63; 95% confidence interval [CI], 0.91–5.47; P=0.076). During the follow-up period of 3.0±1.7 years, patients with AF had a higher all-cause mortality than those without AF (30.3% vs. 22.1%, P=0.004 by log-rank test). However, after adjustment for clinical characteristics, presenting AF was not an independent predictor of all-cause mortality (hazard ratio, 1.15; 95% CI, 0.67–1.88; P=0.588). Conclusions: AF is a common complication of AMI and associated with a more complicated clinical course. However, AF is not an independent predictor of both in-hospital and long-term mortalities in the PCI era