Five Prognostic Factors for Readmission in Patients Over 75 Years Old with Worsening Heart Failure

Heart failure （HF） is a common disease in elderly patients, particularly in those presenting as readmission for worsening HF. While recent studies have revealed mortality-associated factors in this population, little is known about prognostic factors associated with worsening HF. To investigate this clinical evidence gap in patients aged over 75 years, we retrospectively investigated 165 patients hospitalized for HF at Showa University Hospital, of whom 65 （39.4％） were readmitted for worsening HF. We extracted the candidate variables based on univariate analysis, and then elucidated the independent prognostic factors by multivariate analysis. Compared with non-readmitted patients, readmitted patients with worsening HF had lower left ventricular ejection fraction （LVEF） （39％ vs. 50％, P＝0.002） and body mass index （BMI） （19.9kg/m2 vs. 21.4kg/m2, P＝0.007）, higher levels of B-type natriuretic peptide （BNP） （478pg/ml vs. 198pg/ml, P＜0.001）, and heart rate （HR） （71.0 beats/min vs. 67.0 beats/min, P＝0.021） upon discharge during the primary admission. Multivariate logistic analysis identified LVEF ＜40％, BMI ＜21kg/m2, BNP ≥500pg/ml, Charlson score ≥3, and HR ≥70 beats/min upon initial discharge as independent prognostic factors. Based on these factors, readmission for worsening HF was more frequent in those with our proposed risk score of ≥3.0 than in those with a risk score ＜3.0 （P＜0.001）, and we suggested five prognostic factors for HF patients over 75 years old. Our proposed risk score combines these factors and might predict readmission for worsening HF in the elderly population

Abnormal Vasomotor Function of Porcine Coronary Arteries Distal to Sirolimus-Eluting Stents

ObjectivesThis study sought to determine vasomotor functional responses of conduit coronary artery distal to bare-metal stents (BMS), polymer-only stents (POLY), and sirolimus-eluting stents (SES) in a clinically relevant animal model.BackgroundDrug-eluting stents (DES) reduce in-stent restenosis, and also affect neointima formation and vascular remodeling in downstream coronary segments. Whether distal artery vasomotor function is also influenced by DES has not been determined.MethodsPigs (n = 12) received coronary stent implants, and hearts were harvested at 1 month. Arterial segments ≥15 mm distal to stents were excised and studied in an organ-chamber apparatus. Endothelium-dependent and endothelium-independent relaxation and contraction to classical agonists were measured.ResultsThe SES showed increased lumen area and reduced neointima; abnormal vasomotor function of conduit arteries distal to SES also was observed. Contraction to endothelin-1 was significantly enhanced for SES compared with both BMS and POLY. Endothelium-dependent relaxation to a maximal dose of substance P was attenuated for SES compared with both BMS and POLY (46 ± 6% vs. 71 ± 3% and 78 ± 3%, respectively, p < 0.001). Endothelium-independent relaxation to sodium nitroprusside was potentiated for SES, compared with BMS and POLY (100 ± 5% vs. 69 ± 7% and 77 ± 5%, respectively, p = 0.02).ConclusionsStent-based local delivery of sirolimus profoundly inhibited neointima formation but caused vasomotor dysfunction in distal conduit vessel segments. These observations suggest that distal coronary vasospasm may be more readily evoked in the presence of DES and contribute to pathophysiological sequela

Predictive importance of left ventricular myocardial stiffness for the prognosis of patients with congestive heart failure

SummaryObjectivesThis study was designed to determine the prognostic importance of left ventricular (LV) myocardial stiffness, a hemodynamic index which is closely related to B-type natriuretic peptide (BNP) concentration in patients with congestive heart failure (CHF).BackgroundWhile elevated BNP, an abnormality of cardiac neurohormones, is known to be an independent marker of death or re-admission, it remains to be clarified whether there is also a strong predictor directly related to cardiac dysfunction.MethodsLV performance variables and stress–strain analyses including diastolic myocardial stiffness constant (Km) were obtained from 37 patients with initial CHF by the combined simultaneous measurement of echocardiographic and hemodynamic data. Survivors were monitored for a mean of 23 months, with the main endpoint being combined death or first re-admission for CHF.ResultsTen patients (27%) were primary endpoint cases. Both Km and plasma BNP levels were higher in the event than in the event-free group. By Cox proportional hazards analysis, Km≥4.0 was identified as the only variable with significant and independently incremental predictive power to affect the primary endpoint (adjusted hazard ratio=7.354, 95% confidence interval 1.379–39.232, p=0.02).ConclusionsIn patients with CHF, increased myocardial stiffness may have greater prognostic significance compared to other conventional predictors. Increased myocardial stiffness may be considered to be an important prognostic factor independent of the loading conditions

Significance of Trans Fatty Acids and Omega-3 Fatty Acids in Japanese Men with Coronary Heart Disease

Trans fatty acids (TFA) are found naturally in ruminant foods (R-TFA) by biohydrogenation in ruminant animals or industrially produced oils (IP-TFA) by partial hydrogenation of vegetable or fish oils. The intake of TFA mainly IP-TFA is associated with an elevated risk of coronary heart disease (CHD), while some prospective cohort studies showed that R-TFA were associated with a lower risk for sudden cardiac death (SCD). Our case-control study showed that trans-C18:2 isomers (IP-TFA) were significantly higher, and palmitelaidic acid (R-TFA) levels were lower in patients with acute coronary syndrome (ACS) compared with healthy men. Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) have different effects on cardiometabolic risk factors. Delta-5 desaturase (D5D) is a key enzyme in the conversion of linoleic acid and alpha-linoleneic acid to arachidonic acid (AA) and EPA, respectively. Previous studies reported that low D5D estimated from the ratio of AA to dihomo-gamma linolenic acid predicts the incident cardiovascular disease. In our cross-sectional study with 436 men with ACS, various atherogenic lipid markers such as small dense LDL cholesterol and malondialdehyde-modified LDL were significantly inversely associated with D5D activity. We found that the EPA/AA may be a superior risk marker than DHA/AA in terms of correlation with atherogenic lipid profiles

Percutaneous coronary intervention for a healed erosion with excimer laser coronary angioplasty and drug-coated balloon angioplasty: a case report

BackgroundHealed plaque, characterized by distinct layers of organizing thrombus and collagen, is the hallmark of tissue self-repair. However, the efficacy of excimer laser coronary angioplasty (ELCA) followed by drug-coated balloon (DCB) angioplasty in patients with healed plaques is not fully understood.Case summaryA 42-year-old woman with a history of anxiety disorder was admitted to our institution with worsening chest pain and subsequently diagnosed with anterior non-ST-elevation myocardial infarction. Coronary angiography revealed severe stenosis in the proximal left anterior descending artery (LAD) despite Thrombolysis in Myocardial Infarction (TIMI) grade 3. Optical coherence tomography (OCT) showed healed plaques with partial macrophage accumulation and no fresh thrombus. Plaque disruption and thin-cap fibrous atheroma were not identified in the culprit lesions. Intravascular ultrasound (IVUS) confirmed high-intensity marginal irregular masses at the culprit site, suggesting that the thrombus was formed by plaque erosion rather than lipid plaque or necrotic tissue. With lesion modification using ELCA prior to DCB angioplasty, OCT examination of the LAD after ELCA showed a significant reduction in plaque burden and preserved lumen size. Post-percutaneous coronary intervention angiography revealed no stenosis with TIMI grade 3. A follow-up coronary computed tomography scan showed no angiographic restenosis, and the patient remained symptom-free.ConclusionsHere we describe a case in which OCT and IVUS evaluation suggested organizing thrombus due to erosion healing, and a favorable outcome was achieved with the combination of ELCA and DCB. The combination use of ELCA and DCB might be a potential strategy for acute coronary syndrome patients with organizing thrombus

Impact of hemodialysis on local vessel healing and thrombus formation after drug-eluting stent implantation

AbstractBackgroundAlthough hemodialysis (HD) is a suggested risk factor for stent thrombosis, its contribution to local vessel healing after drug-eluting stent (DES) implantation is unclear.MethodsA total of 121 patients (152 lesions treated with DES) who underwent 8-month follow-up coronary angiography with optical coherence tomography (OCT) were enrolled, and the findings were compared between patients with and without HD. To match baseline differences, mid-term OCT findings of 42 propensity score-matched lesions (21 non-HD vs. 21 HD) were compared. Effects of HD on the efficacy of antiplatelet therapy were also evaluated by VerifyNow assay (Accumetrics, San Diego, CA, USA).ResultsPatients with HD had a significantly higher rate of thrombus formation than those without (64% vs. 33%, p=0.007), although the baseline parameters and lesion characteristics differed between the groups. Multivariate logistic regression analysis revealed that HD was associated with an increased risk of thrombus formation (odds ratio 5.991, 95% confidence interval: 1.972–18.199, p=0.002). Even after propensity-matching for patient background and balancing of angiographic and OCT variables, the risk of thrombus formation remained significantly higher in HD patients. The P2Y12-reaction unit was significantly increased after HD (Pre HD: 211±75 vs. Post HD: 262±59, p=0.01), but patients without HD showed no increase during the same elapsed time (221±88 vs. 212±96, p=0.19).ConclusionsHD is a potential risk factor for subclinical thrombus attachment after DES therapy. Systemic problems, such as residual platelet reactivity, associated with HD as well as local vessel features in HD patients might contribute to the increased incidence of thrombus attachment and subsequent onset of thrombotic event after DES implantation

Impact of Native Coronary Artery Calcification on Lesion Outcome Following Drug-Coated Balloon Angioplasty for Treatment of In-Stent Restenosis

This study aimed to clarify whether native coronary artery（CA） calcification before index percutaneous coronary intervention（PCI） has an impact on the effectiveness of drug-coated balloon（DCB） angioplasty for the treatment of in-stent restenosis（ISR）. 100consecutive patients with 166ISR lesions underwent quantitative coronary angiography（QCA） before and after index PCI and before and after DCB angioplasty for ISR. CA calcification before index PCI was assessed by angiography and results were analyzed to reveal the predictive values for target lesion revascularization（TLR） and major adverse cardiac events（MACE）. During 1.03±1.03years of follow-up, TLR occurred in 44lesions（26.5%） and MACE in 33 patients（33%）. On multivariate analysis, CA calcification before index PCI（p=0.016）, and % diameter of stenosis（%DS）≥73%（p=0.023） and minimal lumen diameter（MLD）<0.65mm（p=0.001） before DCB angioplasty were independent predictors for TLR after DCB angioplasty. MACE was also associated with CA calcification before index PCI（p=0.01）, and %DS≥73%（p=0.001） and MLD<0.65mm（p=0.01） before DCB angioplasty, but only %DS≥73% before DCB angioplasty was an independent predictor for MACE after DCB angioplasty（p=0.039）. The combination of CA calcification before index PCI and these QCA factors before DCB angioplasty was an independent and more powerful predictor for MACE than the QCA factors alone（p<0.001）. Thereafter, the combination of CA calcification and %DS≥73% before DCB angioplasty stratified the risk of MACE after DCB angioplasty（p<0.05）. CA calcification before index PCI, as well as anatomical information at ISR, have an impact on outcome after DCB angioplasty for ISR

Effect of Implantable Cardioverter-defibrillator Therapy for Ventricular Fibrillation Patients with Out-of-hospital Cardiac Arrest

Survivors of ventricular fibrillation out-of-hospital cardiac arrest（VF-OHCA）due to potentially reversible causes such as acute coronary syndrome（ACS）, vasospastic angina and electrolyte abnormalities are considered low risk for recurrent arrhythmia. Accordingly, implantable cardioverter-defibrillator therapy is not routinely recommended in such patients. We investigated the risk of mortality and the value of ICD therapy for VF-OHCA. Among 2,248 cardiopulmonary arrest patients presenting at our hospital, we retrospectively investigated 110 patients with VF-OHCA who were admitted for treatment. We divided the patients based on ICD（n＝71） or No-ICD status（n＝39）, and on reversible cause（n＝70） or irreversible cause（n＝40）. The groups were compared for baseline characteristics, mortality and ICD therapies. Patients with a reversible cause had a significantly lower rate of ICD implantation than those with an irreversible cause（P＝0.03）. Males in the ICD group presented more frequently than those in the No-ICD group, and cardiac mortality in patients with acute coronary syndrome was significantly lower with ICD therapy than without ICD（P＝0.04）. The rate of appropriate ICD therapies with a reversible cause was 28％, and the first ICD therapy was highest within 1 year post-implantation. Patients with VF-OHCA due to a reversible cause remain at high risk of recurrent ventricular arrhythmias, suggesting that ICD implantation is a reasonable approach in such cases