Circulation Journal最新文献

Background: Patients with atrial fibrillation (AF) often present with symptoms similar to acute coronary syndrome (ACS), including chest pain and elevated levels of high-sensitivity cardiac troponin (hs-cTn). The 0/1-hour algorithm using hs-cTn is a rapid diagnostic tool endorsed by the European Society of Cardiology to rule out myocardial infarction (MI). However, because its effectiveness in patients with AF remains unclear, in this study we assessed the diagnostic accuracy of the 0/1-hour algorithm in patients with and without AF presenting with chest pain in the emergency department.

Methods and results: We conducted a secondary analysis of the DROP-ACS cohort, including 1,333 patients from Japan and Taiwan, with AF in 10.3% of cases. We examined the algorithm's negative predictive value (NPV), sensitivity, positive predictive value (PPV), and specificity for ruling MI in or out. Patients with AF were more frequently placed in the observe group (54% vs. 34.9%, P<0.05) and less often in the rule-out group (24.1% vs. 44.6%, P<0.05). The NPV and sensitivity for ruling out MI were 100%, while the PPV and specificity were lower in patients with AF (60% and 89.7%, respectively).

Conclusions: The 0/1-hour algorithm effectively ruled out MI in patients with AF, with high safety and accuracy. However, patients with AF are more likely to be stratified into the observe group, requiring further examination for final diagnosis.

Background: With the aging of the population, the number of patients with chronic heart failure (CHF) and comorbidities is increasing in Japan. Among the comorbidities, cardiorenal anemia syndrome (CRAS) is particularly important, but the age-specific prevalence and prognosis of CRAS remain unclear.

Methods and results: The KUNIUMI registry chronic cohort is a prospective observational study of CHF (Stages B-D) in Awaji Island. In this study, we analyzed 1,646 patients registered in the KUNIUMI registry and categorized them into 4 groups: Group 1 included patients without cardiac failure (Stage B); Group 2 consisted of patients with cardiac failure but without renal failure or anemia; Group 3 comprised patients with both cardiac failure and renal failure but without anemia; and Group 4 (CRAS) included patients with cardiac failure, renal failure, and anemia. The primary endpoint was composite of all-cause-death and heart failure hospitalization. The proportion of patients with CRAS increased with age. Furthermore, Group 4 showed a significantly worse prognosis than other groups (log-rank P<0.01). On Cox proportional hazard regression analysis, compared with patients without cardiac failure, renal failure, or anemia, the age- and sex-adjusted hazard ratio for the primary endpoint in those with CRAS was 8.94 (95% confidence interval: 5.36-14.92).

Conclusions: The prevalence of CRAS in CHF increases with age, and the prognosis associated with CRAS is generally worse compared with other comorbidities.

Background: The effect of paced-QRS (p-QRS) duration on long-term outcomes is unclear, so we assessed the association between p-QRS duration and cardiac events.

Methods and results: We enrolled 187 patients (103 males, mean age: 77±12 years) who underwent pacemaker implantation between 2018 and 2021. During the median follow-up period of 972 days (761-1,292 days), 18 patients experienced cardiac events (1 cardiac death, 17 heart failure hospitalizations). The p-QRS duration was longer in the cardiac event group than in the noncardiac event group (162±17 vs. 148±17 ms, P=0.005). Receiver operating characteristic curve analysis identified 149 ms as the optimal cutoff value for predicting cardiac events (area under the curve, 0.72). Kaplan-Meier analysis showed better outcomes for mid-range p-QRS duration (≤149 ms, n=89) compared with long p-QRS duration (>149 ms, n=98) (P=0.005). Multivariate Cox hazard analysis indicated a good outcome with mid-range p-QRS duration (hazard ratio: 0.28, 95% confidence interval: 0.06-0.88, P=0.029).

Conclusions: A p-QRS duration of ≤149 ms was associated with a reduction in cardiac events. Therefore, it may serve as a target index of success in right ventricular pacing.

Background: Endovascular therapy (EVT) with a drug-coated balloon (DCB) is an established treatment for patients with atherosclerotic lesions in the femoropopliteal (FP) artery, including complex lesions. Currently, 3 types of DCBs are available, but the most effective DCB for FP chronic total occlusive (CTO) lesions is unknown.

Methods and results: In this retrospective, single-center study, we enrolled 539 consecutive patients (562 FP lesions) treated with EVT between January 2018 and December 2022. Of these patients, 161 with FP CTO lesions who underwent EVT with DCBs were included. Propensity-score matching was performed to compare the clinical outcomes of the high-dose (HD) and low-dose (LD) DCB groups, resulting in the analysis of 56 matched pairs. Primary patency and freedom from target lesion revascularization were significantly higher with HD-DCB than with LD-DCB (89.9% vs. 70.8%, respectively P=0.03; and 93.6% vs. 79.7%, respectively, P=0.046). Multivariate analysis showed that a larger minimum lumen area and the use of HD-DCB (vs. LD-DCB) were favorable predictors of primary patency at 1 year, while a small vessel diameter (≤4.5 mm) was an unfavorable predictor.

Conclusions: For FP CTO lesions, EVT performed with HD-DCB is superior to that with LD-DCB.

Background: Global coronary flow reserve (G-CFR) impairment represents coronary microvascular dysfunction (CMD) and correlates with poor prognosis. Hyperemic coronary flow is reduced in conventional CMD, but normal or mildly reduced with elevated resting flow in endogenous-type CMD (E-CMD). This retrospective study assessed the prognostic value of post-percutaneous coronary intervention (PCI) CMD, focusing on E-CMD.

Methods and results: We included 320 chronic coronary syndrome (CCS) patients undergoing PCI and post-PCI phase contrast cine-cardiac magnetic resonance imaging (CMR). Major adverse cardiac and cerebrovascular events (MACCE) were evaluated, considering the presence of post-PCI CMD and E-CMD based on G-CFR and resting myocardial flow assessed by coronary sinus flow using CMR. CMD was defined as G-CFR <2.0 and classified as E-CMD or non-E-CMD. Post-PCI CMD was observed in 43.4% of patients, 63.3% exhibiting E-CMD. During a median 2.5-year follow-up, MACCE occurred in 26 (8.1%) patients, more often in those with CMD (11.5% vs. 5.5%; P=0.063). MACCE incidence was higher in E-CMD than non-E-CMD and non-CMD (14.8% vs. 5.9% and 5.5%, respectively; P=0.027). Kaplan-Meier analysis revealed worse prognosis in E-CMD (P=0.025). Cox proportional hazards modeling revealed that E-CMD independently predicted MACCE (hazard ratio 3.24; 95% confidence interval 1.47-7.14; P=0.004).

Conclusions: Post-PCI CMD, particularly E-CMD, was significantly associated with worse outcomes in CCS patients. Post-PCI CMD evaluation could guide therapeutic strategies for CCS patients.

Background: The clinical outcomes of percutaneous coronary intervention (PCI) using drug-coated balloons (DCB) for de novo coronary artery lesions with eruptive calcified nodules remain unclear.

Methods and results: This retrospective study analyzed the long-term outcomes of 308 consecutive patients (389 lesions) treated with PCI using DCB under optical coherence tomography guidance for de novo coronary artery lesions between September 2018 and November 2020. Patients were classified into 2 groups: those with an eruptive calcified nodule in the culprit lesion (CN group) and those without (non-CN group). The primary endpoint was major adverse cardiovascular events (MACE), including clinically driven target lesion revascularization (TLR), myocardial infarction (MI), and cardiac death. The median follow-up period was 2.6 years (interquartile range 1.9-3.4 years). The CN group had significantly higher rates of MACE (hazard ratio [HR] 9.2; 95% confidence interval [CI] 4.1-20.2; P<0.0001), TLR (HR 5.0; 95% CI 1.7-15.1; P<0.01), MI (HR 30.5; 95% CI 5.0-184.8; P<0.001), and cardiac death (HR 25.1; 95% CI 8.7-72.6; P<0.0001) than the non-CN group. Results were similar even after adjusting for potential confounding factors using propensity score matching.

Conclusions: This study demonstrated that patients with eruptive calcified nodules who underwent PCI with DCB for de novo coronary artery lesions had worse long-term clinical outcomes than patients without such nodules.

Background: The optimal duration of dual antiplatelet therapy (DAPT) in patients with chronic kidney disease undergoing percutaneous coronary intervention (PCI), especially with third-generation drug-eluting stents (DES), remains unknown.

Methods and results: We conducted a prespecified post hoc analysis of the HOST-IDEA trial, randomizing patients undergoing PCI with third-generation DES to 3- to 6-month or 12-month DAPT. In all, 1,997 patients were grouped by their estimated glomerular filtration rate (eGFR): high (>90 mL/min/1.73 m²), intermediate (60-90 mL/min/1.73 m²), and low (<60 mL/min/1.73 m²). The primary outcome was net adverse clinical events (NACE), a composite of cardiac death, target vessel myocardial infarction, clinically driven target lesion revascularization, stent thrombosis, or major bleeding (Bleeding Academic Research Consortium Type 3 or 5) at 12 months. Secondary outcomes were target lesion failure (TLF) and major bleeding. The low eGFR group had the highest rates of NACE, TLF, and major bleeding compared with the other 2 groups (P<0.001). Rates of NACE were similar in the 3- to 6-month and 12-month DAPT in the high (2.9% vs. 3.2%; P=0.84), intermediate (2.1% vs. 2.8%, P=0.51), and low (8.9% vs. 9.1%; hazard ratio 0.99; P=0.97; P_interaction=0.88) eGFR groups. TLF and major bleeding events showed similar trends.

Conclusions: In patients undergoing PCI with third-generation DES, 3- to 6-month DAPT was comparable to 12-month DAPT for clinical outcomes regardless of renal function.