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

Effect of Heart Failure on Long‐Term Clinical Outcomes After Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients With Severe Coronary Artery Disease

[Background] Heart failure might be an important determinant in choosing coronary revascularization modalities. There was no previous study evaluating the effect of heart failure on long‐term clinical outcomes after percutaneous coronary intervention (PCI) relative to coronary artery bypass grafting (CABG). [Methods and Results] Among 14 867 consecutive patients undergoing first coronary revascularization with PCI or isolated CABG between January 2011 and December 2013 in the CREDO‐Kyoto PCI/CABG registry Cohort‐3, we identified the current study population of 3380 patients with three‐vessel or left main coronary artery disease, and compared clinical outcomes between PCI and CABG stratified by the subgroup based on the status of heart failure. There were 827 patients with heart failure (PCI: N=511, and CABG: N=316), and 2553 patients without heart failure (PCI: N=1619, and CABG: N=934). In patients with heart failure, the PCI group compared with the CABG group more often had advanced age, severe frailty, acute and severe heart failure, and elevated inflammatory markers. During a median 5.9 years of follow‐up, there was a significant interaction between heart failure and the mortality risk of PCI relative to CABG (interaction P=0.009), with excess mortality risk of PCI relative to CABG in patients with heart failure (HR, 1.75; 95% CI, 1.28–2.42; P<0.001) and no excess mortality risk in patients without heart failure (HR, 1.04; 95% CI, 0.80–1.34; P=0.77). [Conclusions] There was a significant interaction between heart failure and the mortality risk of PCI relative to CABG with excess risk in patients with heart failure and neutral risk in patients without heart failure

Percutaneous coronary intervention using new-generation drug-eluting stents versus coronary arterial bypass grafting in stable patients with multi-vessel coronary artery disease: From the CREDO-Kyoto PCI/CABG registry Cohort-3

AIMS: There is a scarcity of studies comparing percutaneous coronary intervention (PCI) using new-generation drug-eluting stents (DES) with coronary artery bypass grafting (CABG) in patients with multi-vessel coronary artery disease. METHODS AND RESULTS: The CREDO-Kyoto PCI/CABG registry Cohort-3 enrolled 14927 consecutive patients who underwent first coronary revascularization with PCI or isolated CABG between January 2011 and December 2013. The current study population consisted of 2464 patients who underwent multi-vessel coronary revascularization including revascularization of left anterior descending coronary artery (LAD) either with PCI using new-generation DES (N = 1565), or with CABG (N = 899). Patients in the PCI group were older and more often had severe frailty, but had less complex coronary anatomy, and less complete revascularization than those in the CABG group. Cumulative 5-year incidence of a composite of all-cause death, myocardial infarction or stroke was not significantly different between the 2 groups (25.0% versus 21.5%, P = 0.15). However, after adjusting confounders, the excess risk of PCI relative to CABG turned to be significant for the composite endpoint (HR 1.27, 95%CI 1.04-1.55, P = 0.02). PCI as compared with CABG was associated with comparable adjusted risk for all-cause death (HR 1.22, 95%CI 0.96-1.55, P = 0.11), and stroke (HR 1.17, 95%CI 0.79-1.73, P = 0.44), but with excess adjusted risk for myocardial infarction (HR 1.58, 95%CI 1.05-2.39, P = 0.03), and any coronary revascularization (HR 2.66, 95%CI 2.06-3.43, P<0.0001). CONCLUSIONS: In this observational study, PCI with new-generation DES as compared with CABG was associated with excess long-term risk for major cardiovascular events in patients who underwent multi-vessel coronary revascularization including LAD

A Simple, Fast, and Safe Mediator for Congestion Management

Congestion is a severe problem in cities. A large population with little information about each other's preferences hardly reaches equilibrium and causes unexpected congestion. Controlling such congestion requires us to collect information dispersed in the market and to coordinate actions among agents. We aim to design a mediator that a) induces a game with high social welfare in equilibrium, b) computes an equilibrium efficiently, c) works without common prior, and d) performs well even when only some of the agents in the market use the mediator. We propose a mediator based on a version of best response dynamics (BRD). We prove that, in a simple setting with two resources, “good behavior” (reporting truthfully and following the recommendation) forms an (approximate) ex-post Nash equilibrium in the mediated game; in the equilibrium, the welfare is close to the first-best when preferences diverge enough. Furthermore, under a certain behavioral assumption, those who are not using the mediator can always enjoy non-negative payoff gain by joining it even without the full participation of others. Additionally, our experimental results suggest that such results remain valid for more general settings

Remorse‐related suicide attempts among young mothers after COVID‐19 infection

Abstract Background In Japan, there is a tendency to view COVID‐19 infection as one's own responsibility, which may result in more feelings of guilt than in other countries. During the COVID‐19 pandemic, the curfew imposed by COVID‐19 restricted social behavior and increased anxiety and loneliness, which may have increased the risk of suicide among young women, especially mothers who were highly stressed regarding COVID‐19 infection in their children. Case Presentation This is a case report of two Japanese mothers who developed feelings of guilt following infection with COVID‐19, leading to suicide attempts. They feared stigma or denial due to the infection, which they were unable to explain to others, leading to a heightened sense of self‐blame and suicide attempts. In addition, Japanese women have a heavy burden of housework, despite their dual roles at home and at work; the pandemic's behavioral restrictions led to increased time at home and stress. These women were also more affected by the economic crisis in the early stages of the pandemic than men. Relatedly, neuropsychiatric symptoms that persisted after recovering from COVID‐19, such as depression, anxiety, fatigue, and pain, namely postacute COVID‐19 syndrome or long COVID, may have precipitated the suicidal ideation in these cases. Moreover, the complication of bipolar disorder by COVID‐19 could have led to suicide attempts caused by infection‐related neuropsychiatric symptoms and the exacerbation of the bipolar disorder by restrictions imposed during the pandemic. Conclusion Suicide prevention measures need to be taken more seriously among mothers during or after the COVID‐19 pandemic

Characteristics of suicidal emergency room patients before and during the COVID‐19 pandemic in Japan

Abstract Aim Owing to the stress caused by the behavioral restrictions and lifestyle changes during the COVID‐19 pandemic, suicide rates have increased in Japan, especially among young people. This study aimed to identify the differences in the characteristics of patients hospitalized for suicide attempts in the emergency room, requiring inpatient care before and during the pandemic over 2 years. Methods This study was a retrospective analysis. Data were collected from the electronic medical records. A descriptive survey was conducted to examine changes in the pattern of suicide attempts during the COVID‐19 outbreak. Two‐sample independent t‐tests, Chi‐square tests, and Fisher's exact test were used for data analysis. Results Two hundred one patients were included. No significant differences were found in the number of patients hospitalized for suicide attempts, average age, or sex ratio before and during the pandemic periods. Acute drug intoxication and overmedication in patients increased significantly during the pandemic. The self‐inflicted means of injury with high fatality rates were similar during the two periods. The rate of physical complications significantly increased during the pandemic, while the proportion of unemployed individuals significantly decreased. Conclusions Despite studies predicting an increase in suicides based on past statistics of young people and of women, no significant changes were observed in this survey of the Hanshin‐Awaji region, including Kobe. This may have been owing to the effect of suicide prevention measures and mental health measures implemented by the Japanese government after an increase in suicides and after past natural disasters

Selection of Tsunami Observation Points Suitable for Database-Driven Prediction

During the Great East Japan Earthquake in 2011, real-time estimate of the earthquake’s magnitude was quite low, and consequently, the first report about the tsunami also understated its severity. To solve this issue, some proposed a massive overhaul of Japan’s offshore tsunami observation networks and methods to predict tsunamis in real time. In this study, we built a database containing 3,967 scenarios of tsunamis caused by earthquakes with hypocenters along the Nankai Trough, and tested a tsunami prediction method that uses this database along with offshore tsunami observation networks. Thus, we found that an uneven distribution of observation points had a negative effect on predictive accuracy. We then used simulated annealing to select the observation points to be used at each observation site and found that the predictive accuracy improved while using a few selected observation points compared to using every point