Journal of cardiology最新文献

Background: While fractional flow reserve (FFR) is the gold standard for assessing coronary stenosis, non-hyperemic pressure ratios (NHPRs) such as the resting full-cycle ratio (RFR) are used as less invasive alternatives. However, NHPR-guided percutaneous coronary intervention (PCI) has been reported to be associated with poorer outcomes. We hypothesized that the difference between RFR and FFR (RFR-FFR) carries important clinical information.

Methods: This retrospective study included 460 patients with chronic coronary syndrome who underwent FFR-guided elective PCI following functional assessment of the left anterior descending artery (LAD) with both RFR and FFR. Patients were stratified into tertiles based on their RFR-FFR value. The primary endpoint was all-cause death.

Results: Patients in the lowest RFR-FFR tertile presented with a higher-risk clinical profile including older age, female sex, and greater comorbidity burden such as elevated N-terminal pro-B-type natriuretic peptide and lower renal function, and evidence of microvascular dysfunction such as lower coronary flow reserve and microvascular resistance reserve. During a median follow-up of 5.2 years, lower RFR-FFR patients showed higher rate of all-cause death. Multivariable analysis identified age and baseline heart rate as independent predictors of a low RFR-FFR value. Crucially, a multivariable Cox regression analysis revealed that a low RFR-FFR value was an independent predictor of all-cause death.

Conclusions: A lower RFR-FFR value is a marker of increased comorbidities and microvascular dysfunction, correlating with poorer long-term clinical outcomes. This pre-PCI novel metric holds potential utility for risk stratification and personalizing treatment strategies in patients with chronic coronary artery disease undergoing LAD PCI.

Background: Avoiding potentially inappropriate medications (PIMs) that can worsen heart failure (HF) is a clinical priority. Yet, the prevalence and determinants of PIM use in this population are not well characterized. The Japanese Registry of All Cardiac and Vascular Diseases and the Diagnosis Procedure Combination (JROAD-DPC) database is a nationwide claims-based registry that captures detailed information on hospitalizations for cardiovascular disease across Japan, providing a unique opportunity to examine prescribing patterns in real-world practice.

Methods: We analyzed JROAD-DPC data on hospitalizations for HF among patients aged ≥ 60 years between 2012 and 2020, in a study supported by the Japan Agency for Medical Research and Development. The temporal trend in the utilization of HF-exacerbating PIMs listed in the American Geriatrics Society Beers Criteria®, non-steroidal anti-inflammatory drugs (NSAIDs), cyclooxygenase-2 (COX-2) inhibitors, non-dihydropyridine calcium-channel blockers (CCBs), cilostazol, and thiazolidinediones, was assessed using Cochran-Armitage trend tests. Factors associated with PIM use were evaluated using multivariate mixed-effects Poisson regression models, with hospitals treated as random intercepts.

Results: A total of 1,232,368 HF hospitalizations were analyzed. The overall prevalence of PIM use declined over time: NSAIDs and COX-2 inhibitors decreased from 15.7 % in 2012 to 9.2 % in 2020, and non-dihydropyridine CCBs from 14.5 % to 9.7 %. Despite this decline, these medications continued to be prescribed for a substantial proportion of patients. Utilization patterns differed by patient characteristics; notably, women were more likely than men to receive NSAIDs, COX-2 inhibitors, and non-dihydropyridine CCBs.

Conclusions: Although the use of HF-exacerbating PIMs has decreased over time, NSAIDs, COX-2 inhibitors, and non-dihydropyridine CCBs remain commonly prescribed. Given their potential to worsen HF outcomes, raising clinical awareness of PIMs and addressing patient-specific prescribing patterns are essential steps toward safer pharmacological management in older adults with HF. Findings from JROAD-DPC highlight the ongoing need for strategies to further minimize PIM-related risks.

Background and aims: The DAPT (dual antiplatelet therapy) and PRECISE-DAPT (Predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy) score have been developed to predict bleeding events after PCI (percutaneous coronary intervention). However, few studies have evaluated the predictive value of the DAPT and the 4-item PRECISE-DAPT score in patients whose low-density lipoprotein cholesterol (LDL-C) was below 70 mg/dL. Therefore, we performed this study to evaluate the long-term predictive power for MACE (major adverse cardiovascular events) and bleeding events with the 2 scores in patients whose LDL-C was below 70 mg/dL after PCI.

Methods: We included 403 PCI patients whose LDL-C was below 70 mg/dL at follow-up. We compared MACE and bleeding events between high and low 4-item PRECISE-DAPT scores (high: ≥ 25, low: < 25), and between high and low DAPT scores (high: ≥ 2, low: < 2).

Results: Over a median follow-up of 106.0 months, 138 MACE and 17 bleeding events were recorded. Patients with high 4-item PRECISE-DAPT scores had significantly lower MACE-free survival compared with those with low scores (52.8 % vs. 67.0 %, p = 0.03) and markedly lower bleeding-free survival (77.8 % vs. 97.5 %, p < 0.0001). In contrast, when stratified by DAPT score, there was no significant difference in MACE-free survival between high and low groups (64.7 % vs. 66.7 %, p = 0.638), but bleeding-free survival was significantly lower in the high-score group (91.6 % vs. 99.5 %, p < 0.0001).

Conclusions: Among patients achieving LDL-C ≤ 70 mg/dL after PCI, the PRECISE-DAPT score was more effective than the DAPT score in predicting both long-term MACE and bleeding events.

Background: Worsening renal function (WRF) during acute decompensated heart failure (ADHF) therapy portends worse outcomes. We hypothesized that renal perfusion pressure (RPP), systemic mean arterial pressure minus central venous pressure (CVP), is associated with and may elucidate mechanisms of WRF. We theorized that machine learning-based RPP trajectories could impact outcomes.

Methods: Patients in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization (PAC) Effectiveness (ESCAPE) Trial randomized to PAC-guided therapy were evaluated. M-estimation, logistic regression, and receiver operating characteristic analysis were performed. Trajectories were analyzed by selecting summary measures capturing the most variance in the trajectories using factor analysis and applying clustering with the k-means methods based on these summary measures.

Results: Among 143 patients (age 56.7 ± 13.8 years, 26.6 % female), 17 patients (11.9 %) had >30 % decrease in glomerular filtration rate (GFR) during therapy. Percent change in GFR (%∆GFR) was positively associated with percent change in RPP (%∆RPP) (M-estimation coefficient 0.248; p = 0.02). %∆GFR was associated with %∆RPP, controlling for body mass index and ischemic cardiomyopathy (M-estimation coefficients 0.22, -0.007, and - 0.109; p = 0.033). RPP trajectories were associated with overall survival [OS; Kaplan-Meier (KM) p < 0.001] and survival free of transplant, left ventricular assist device, and heart failure hospitalization (HFH, KM p = 0.002). Favorable RPP trajectory was associated with improved outcomes, even with elevated creatinine (OS: KM p < 0.001, HFH: KM p < 0.001). Mediation effect of CVP at discharge was 10.4 % and 10 % for baseline creatinine.

Conclusions: RPP changes potentially explain a mechanism of WRF in patients undergoing PAC-guided therapy for ADHF. Trajectories of RPP predict survival and hospitalization outcomes and could improve nuanced risk stratification of cardiorenal syndromes in patients with ADHF.

Background: Patients with diabetes mellitus (DM) have a high risk of ischemic events after percutaneous coronary intervention (PCI). However, the relationship between high platelet reactivity (HPR) with prasugrel and clinical events in patients with DM remains unclear. This post-hoc analysis of the PENDULUM registry examined the relationships of HPR with major adverse cardiac and cerebrovascular events (MACCE) and major bleeding in patients with DM on prasugrel.

Methods: Based on P2Y12 reaction unit (PRU) levels, patients were stratified into high platelet reactivity (HPR; PRU > 208) and no-HPR (PRU ≤ 208) groups. Clinical events were assessed up to 30 months after the index PCI. A total of 3652 patients who received prasugrel at a dose of 3.75 mg once daily were enrolled: 1522 patients with DM (HPR, n = 454; no-HPR, n = 1068), and 2130 patients without DM (HPR, n = 547; no-HPR, n = 1583).

Results: Patients with DM had MACCE significantly more frequently than patients without DM (HR: 1.64; 95 % CI: 1.30-2.06; p < 0.001). Patients without DM in the HPR subgroup had MACCE more frequently, but not significantly (HR: 1.43; 95 % CI: 1.00-2.05; p = 0.053). In contrast, in patients with DM, no significant association between HPR and MACCE was found (HR: 1.25; 95 % CI: 0.90-1.75; p = 0.18). Major bleeding occurred in 4.2 % of the HPR group and 3.5 % of the no-HPR group in patients with DM, with no significant difference between the two groups (HR: 1.22; 95 % CI: 0.70-2.12; p = 0.49).

Conclusions: In patients with DM, HPR with prasugrel was not associated with MACCE or major bleeding, whereas MACCE tended to be increased in those without DM.