Demographics, practice patterns and long-term outcomes of patients with non–ST-segment elevation acute coronary syndrome in the past two decades: the CREDO-Kyoto Cohort-2 and Cohort-3

OBJECTIVES: To evaluate patient characteristics and long-term outcomes in patients with non-ST-segment elevation acute coronary syndrome (NSTEACS) in the past two decades. DESIGN: Multicenter retrospective study. SETTING: The Coronary REvascularization Demonstrating Outcome Study in Kyoto (CREDO-Kyoto) percutaneous coronary intervention (PCI)/coronary artery bypass grafting (CABG) Registry Cohort-2 (2005-2007) and Cohort-3 (2011-2013). PARTICIPANTS: 3254 patients with NSTEACS who underwent first coronary revascularisation. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was all-cause death. The secondary outcomes were cardiovascular death, cardiac death, sudden cardiac death, non-cardiovascular death, non-cardiac death, myocardial infarction, definite stent thrombosis, stroke, hospitalisation for heart failure, major bleeding, any coronary revascularisation and target vessel revascularisation. RESULTS: Patients in Cohort-3 were older and more often had heart failure at admission than those in Cohort-2. The prevalence of PCI, emergency procedure and guideline-directed medical therapy was higher in Cohort-3 than in Cohort-2. In patients who received PCI, the prevalence of transradial approach, drug-eluting stent use and intravascular ultrasound use was higher in Cohort-3 than in Cohort-2. There was no change in 3-year adjusted mortality risk from Cohort-2 to Cohort-3 (HR 1.00, 95% CI 0.83 to 1.22, p=0.97). Patients in Cohort-3 compared with those in Cohort-2 were associated with lower adjusted risks for stroke (HR 0.65, 95% CI 0.46 to 0.92, p=0.02) and any coronary revascularisation (HR 0.76, 95%CI 0.66 to 0.87, p<0.001), but with higher risk for major bleeding (HR 1.25, 95% CI 1.06 to 1.47, p=0.008). The unadjusted risk for definite stent thrombosis was lower in Cohort-3 than in Cohort 2 (HR 0.29, 95% CI 0.11 to 0.67, p=0.003). CONCLUSIONS: In the past two decades, we did not find improvement for mortality in patients with NSTEACS. We observed a reduction in the risks for definite stent thrombosis, stroke and any coronary revascularisation, but an increase in the risk for major bleeding

重症三枝冠動脈病変患者における経皮的冠動脈形成術と冠動脈バイパス手術治療後の3年予後の比較 CREDO-Kyoto PCI/CABG Registry からの観察

京都大学0048新制・論文博士博士(医学)乙第12789号論医博第2069号新制||医||1000(附属図書館)30808(主査)教授 佐藤 俊哉, 教授 森田 智視, 教授 今中 雄一学位規則第4条第2項該当Doctor of Medical ScienceKyoto UniversityDA

Pathological analyses of very long-term sirolimus-eluting stent implantation in human coronary artery

A 73-year-old man underwent sirolimus-eluting stent (SES) implantation for chest pain on exertion with left anterior descending coronary artery (LAD) and left circumflex coronary artery (LCX). The patient died due to non-obstructive mesenteric ischemia after 57 months of SES implantation. An autopsy demonstrated that the lesions of stented site at LAD and LCX were histopathologicaly similar images. In short, only mild neointimal formation with enough patent lumen was observed in all stented sites with no evidence of restenosis. In addition, complete coverage of endothelial cells in the surface of neointima was visible. Furthermore, necrotic core formation with a lot of circumferential cholesterol clefts was evident around the struts. In spite of these findings, observations of neointimal rupture and stent thrombosis were not found in this very late period autopsy study. In this histopathological examination, although neointimal coverage with enough lumen was observed, accumulation of extracellular lipid and cholesterol crystal was shaping necrotizing core, in short neoatherosclerosis. In the future, biocompatible drug-eluting stents which do not induce inflammation to the arterial wall post stenting should be appropriately addressed by the future development of improved coronary stents

Immediate Tooth Autotransplantation with Root Canal Filling and Partially Demineralized Dentin/Cementum Matrix into Congenital Missing Tooth Region

This clinical report describes immediate tooth auto-transplantation with an autograft of partially demineralized dentin/cementum matrix (pDDM), based on an orthodontic treatment plan for a 16-year-old male patient with a congenital missing tooth (#45). First, vital teeth (#14, #24) were extracted, and root canal filling (#14) was immediately performed with the support of a fixation device. Simultaneously, the tooth (#24) was crushed in an electric mill for 1 min, and the crushed granules were partially demineralized in 2% HNO3 solution for 20 min as the graft material. Next, the donor tooth was transplanted into the created socket (#45), and stabilized using an enamel bonding agent. The wet pDDM was loaded into the location of the congenital missing tooth, and the flap was repositioned. The bonding agent for stabilization was removed at 28 days, and also small contact points between the transplanted tooth and the upper premolar (#14) were added using photopolymerizable composite resin. X-ray photos were taken sequentially, and there were no postoperative complications. The radiographic images showed that the periodontal ligament space and alveolar ridge line could be observed at 18 months. The pDDM was harmonized with the mandible, and the remodeled bone-like shadow was observed in the graft region. We concluded that immediate tooth transplantation with root canal fillings and autogenous pDDM may be a valuable alternative to dental implanting or bridge formation for patients with a congenital missing tooth, followed by orthodontic treatment

Comparative Study of a Proton Pump Inhibitor with a Histamine H2 Receptor Antagonist in Japanese Patients with Functional Dyspepsia

The present study sought to compare the effectiveness of a proton pump inhibitor （PPI） with that of a histamine H2 receptor antagonist （H2RA） for treating functional dyspepsia （FD） in a real-world setting. A multicenter, open-label, randomized trial was conducted. FD patients were randomly assigned to receive either 20mg, q.d., omeprazole （OPZ; a PPI） or 150mg, b.i.d., ranitidine hydrochloride （RAN; an H2RA） for 4 weeks. Any change in the total Gastrointestinal Symptom Rating Scale （GSRS） score （delta） at week 4 was the primary outcome measure. Secondary outcome measures were reductions in scores for individual items on the GSRS at week 4. As a subanalysis, patients were stratified according to Helicobacter pylori serology and the analyses were repeated. The mean （±SD） deltas in total GSRS score for the OPZ and RAN groups were 0.8±0.7 and 0.6±0.6, respectively （P＝0.098）; however, the delta in reflux score between the OPZ and RAN groups differed significantly （1.1±0.7 vs. 0.5±0.5, respectively; P＝0.001）. There were no significant differences between the two groups in any other scores for individual items on the GSRS. The results of the subanalysis were like those of the main analysis. The PPI and H2RA produced a comparable improvement in symptoms of FD in our patient cohort, thus we propose no advantage would be gained in using a PPI rather than an H2RA