Circulation Journal最新文献

Background: This study compared changes in percentage atheroma volume (PAV) using an end-diastolic (ED) intravascular ultrasound (IVUS) segmentation approach vs. the conventional 1-mm interval analysis in serial IVUS data from the PACMAN-AMI trial.

Methods and results: IVUS data from the PACMAN-AMI study were analyzed by 2 core laboratories: one with 1-mm segmentation and the other with an ED-based approach. The same arterial segments were assessed at baseline and at the 52-week follow-up in patients receiving alirocumab or placebo. Changes in segment length, lumen, vessel, total atheroma volume (TAV), and PAV between baseline and follow-up were compared between methods. Biomarkers associated with atherosclerotic progression were measured and correlated with TAV and PAV changes. In all, 387 segments were analyzed. Agreement between conventional and ED volumetric analysis was excellent (intraclass coefficient >0.891, P<0.001). TAV and PAV were larger in both groups in the ED analysis than with the conventional approach; however, changes between treatment arms were similar for the conventional and ED analyses (TAV: 14.34 vs. 14.64 mm³, respectively [P=0.823]; PAV: 1.29% vs. 1.25%, respectively [P=0.911]). Biomarker correlations with TAV and PAV changes did not differ between approaches.

Conclusions: ED- and 1-mm-based analyses demonstrated comparable treatment effects of alirocumab on plaque regression in PACMAN-AMI. These findings support the use of the less time-consuming 1-mm segmentation method in serial IVUS studies.

Background: Lipoprotein(a) [Lp(a)] is a recognized risk factor for atherosclerotic cardiovascular disease (ASCVD), but the shape and potential nonlinearity of its association remain uncertain. We assessed the linear and nonlinear associations between Lp(a) levels and ASCVD risk using observational and Mendelian randomization (MR) approaches.

Methods and results: We analyzed 351,858 UK Biobank participants (2006-2023), stratified into Lp(a) percentiles: <70th, 70th-<80th, 80th-<90th, and ≥90th. Outcomes included ASCVD events from hospital, primary care, self-report, and death registry data. Cox models estimated the hazard ratios (HRs). MR analyses used a polygenic risk score from 10 Lp(a)-associated single-nucleotide polymorphisms, with nonlinearity tested by doubly ranked MR. Higher Lp(a) levels were associated with increased ASCVD risk. Compared with the <70th percentile, adjusted HRs (95% confidence interval) were 1.11 (1.07-1.16), 1.18 (1.14-1.22), and 1.25 (1.21-1.30) for the 70th-<80th, 80th-<90th, and ≥90th groups. Kaplan-Meier curves diverged early by group. Spline models suggested nonlinearity with an inflection near 130 nmol/L (P=0.007). MR showed a 2% higher ASCVD risk per 10 nmol/L genetically predicted Lp(a) (P<2×10^-16). Nonlinear MR suggested steeper gradients at higher levels, though not statistically significant (P=0.087).

Conclusions: Elevated Lp(a) concentrations were causally associated with ASCVD risk, showing a predominantly graded relationship with possible nonlinearity at very high levels, supporting routine Lp(a) measurement and the development of Lp(a)-lowering therapies.

Background: This study evaluated early and mid-term clinical outcomes of surgical correction for anomalous aortic origin of a coronary artery (AAOCA) and expansion of surgical indications beyond current guidelines, particularly for asymptomatic patients with anomalous aortic origin of the right coronary artery (AAORCA).

Methods and results: Between December 2004 and July 2023, 34 patients underwent surgery for AAOCA. Surgical indications included evidence of myocardial ischemia and high-risk anatomy. AAOCA was assessed pre- and postoperatively using imaging and functional studies. Early and mid-term outcomes were evaluated retrospectively. AAORCA was the predominant type (n=32; 94.1%), and 32 of 34 patients (94.1%) underwent unroofing. Five (14.7%) asymptomatic AAORCA patients had a history of Kawasaki disease. There were no surgical mortalities or coronary artery-related complications. Of 12 patients with symptoms or signs likely related to the coronary artery in the early postoperative period, 2 had persistent symptoms until the last follow-up. During follow-up, 2 patients had suspicious mild coronary stenosis on computed tomography, and 1 had decreased stress perfusion on a myocardial perfusion scan. Among patients with preoperative abnormalities, 92.3% exhibited postoperative functional improvement.

Conclusions: Surgical treatment of AAOCA, primarily through unroofing, is safe and effective, with favorable early and mid-term outcomes. Our findings support consideration of surgery for asymptomatic AAORCA patients with high-risk anatomy due to the potential risk of sudden cardiac events and the substantial benefits of the procedure.

Background: In Japan, intravascular lithotripsy (IVL) is indicated during percutaneous coronary intervention (PCI) for calcified lesions when the calcium score assessed by intravascular ultrasound (IVUS) or optical coherence tomography (OCT) is ≥3. This study evaluated the effectiveness of IVL in achieving optimal stent expansion in lesions with an OCT calcium score ≥3, regardless of the IVUS calcium score.

Methods and results: We retrospectively compared 26 consecutive PCIs in 23 patients who underwent IVL with pre-PCI OCT or optical frequency domain imaging and simultaneous pre- and post-PCI IVUS with 102 patients who underwent PCI without atherectomy but similar imaging protocols. Of all 128 PCIs, 84 with an OCT calcium score ≥3 and a simultaneous IVUS calcium score ≤2 were analyzed. Stent expansion was measured by IVUS. Among the 84 PCIs included in the analysis, 17 were performed using IVL and 67 were performed without atherectomy or IVL (non-IVL group). Stent expansion at the site of maximum superficial calcium was greater in the IVL than non-IVL group (90.9% vs. 84.6%, respectively; P=0.028). The non-IVL group was independently associated with reduced stent expansion at the site of maximum superficial calcium, even after adjusting for IVUS calcium score components (B=-0.817; P<0.001).

Conclusions: Even in calcified lesions with an IVUS calcium score ≤2, IVL was independently associated with favorable stent expansion when the OCT calcium score was ≥3.

Background: The quantitative flow ratio (QFR), an angiography-based index for the assessment of coronary functional stenosis, correlates well with fractional flow reserve (FFR). In this study we explored the clinical significance of the difference between these values, calculated by subtracting FFR from QFR (delta QFR-FFR), in patients undergoing FFR-guided elective percutaneous coronary intervention (PCI).

Methods and results: This retrospective analysis included patients with chronic coronary syndrome who underwent FFR-guided PCI and comprehensive coronary functional assessments, including QFR. Patients were divided into tertiles based on pre-PCI delta QFR-FFR. We compared clinical and physiological characteristics and major adverse cardiovascular events (MACE; a composite of cardiac death, myocardial infarction, stroke, and heart failure requiring admission) among the 3 groups, and evaluated delta QFR-FFR as a predictor of MACE. Among 301 patients, lower delta QFR-FFR was associated with a lower QFR pullback pressure gradient, a higher index of microcirculatory resistance, lower microvascular resistance reserve, and reduced post-PCI coronary flow reserve, whereas post-PCI FFR was similar across tertiles. MACE occurred more frequently in patients with delta QFR-FFR less than -0.060 (log-rank P=0.006). Cox regression analysis identified lower delta QFR-FFR as an independent predictor of MACE.

Conclusions: Pre-PCI delta QFR-FFR correlates with microvascular dysfunction and diffuse disease patterns. A lower delta QFR-FFR predicted an increased risk of MACE after FFR-guided revascularization, highlighting its potential clinical significance as a risk stratification tool.

Background: In the presence of a potent P2Y₁₂inhibitor such as prasugrel, the additional clinical antithrombotic benefit of aspirin is unclear. The feasibility of prasugrel monotherapy without aspirin after percutaneous coronary intervention (PCI) has been demonstrated in chronic coronary syndrome, but is yet to be assessed in patients with non-ST elevation acute coronary syndrome (NSTE-ACS) and low anatomical complexity.

Methods and results: ASET-Japan is a single-arm study investigating the safety of prasugrel 12-month monotherapy with a locally approved dose (loading 20 mg; maintenance 3.75 mg), started immediately after successful PCI using platinum-chromium everolimus-eluting SYNERGY stents. The primary ischemic endpoint is a composite of cardiac death, spontaneous target vessel myocardial infarction, or definite stent thrombosis; the primary bleeding endpoint is Bleeding Academic Research Consortium (BARC) Type 3 and 5 bleeding. ASET-Japan recruited 101 NSTE-ACS patients from 11 Japanese sites. The mean (±SD) age was 69.1±12.3 years and 36.6% had a PRECISE-DAPT score >25. The mean anatomical SYNTAX score was 7.9±4.7. At 1 year, the primary ischemic endpoint occurred in 1 patient (1.0%; cardiac death). Two BARC Type 3a bleeding events occurred (2.0%): 1 due to a gastric ulcer and 1 to a descending colon malignancy.

Conclusions: Low-dose (3.75 mg/day) prasugrel monotherapy started immediately after SYNERGY stent deployment was feasible and safe in selected NSTE-ACS patients.