Applications of multislice coronary computed tomographic angiography to percutaneous coronary intervention: How did we ever do without It?

By providing data previously available only by intravascular ultrasound, 64‐slice multidetector computed tomographic angiography (CTA) will impact percutaneous coronary intervention (PCI) in multiple areas: (1) pre‐PCI patient selection; (2) identification of significant lesions; (3) in‐stent restenosis; (4) procedure planning: stent sizing, choice of intervention, and equipment, chronic total occlusions, 3D‐CTA in the catheterization laboratory; (5) plaque evaluation and identification of high‐risk lesions; (6) postcatheterization decisions, and (7) structural heart disease. The likely outcome is transformation of the catheterization laboratory into a streamlined interventional suite, utilizing on‐line CTA data in an interactive format. © 2008 Wiley‐Liss, Inc.     

Coronary computed tomography angiography in patients with stable coronary artery disease

The treatment of coronary artery disease (CAD), which is defined by stable anatomical atherosclerotic and functional alterations of epicardial vessels or microcirculation, focuses on managing intermittent angina symptoms and preventing major adverse cardiovascular events with optimal medical therapy. When patients with known CAD present with angina and no acute coronary syndrome, they have historically been evaluated with a variety of noninvasive stress tests that utilize electrocardiography, radionuclide scintigraphy, echocardiography, or magnetic resonance imaging for determining the presence and extent of inducible myocardial ischemia. Patient event-free survival, however, is largely driven by the coronary atherosclerotic disease burden, which is not directly assessed by functional testing. Direct evaluation of coronary atherosclerotic disease by coronary computed tomography angiography (coronary CTA) has emerged as the first line noninvasive imaging modality as it improves diagnostic accuracy and positively influences clinical management. Compared to functional assessment of CAD, coronary CTA-guided management results in improved patient outcomes by facilitating prevention of myocardial infarction. Other strengths of coronary CTA include detailed atherosclerotic plaque characterization and the ability to assess functional significance of specific lesions, which may further improve risk assessment and prognosis and lead to more appropriate referrals for additional testing, such as invasive coronary angiography.     

Multislice computed tomography in an asymptomatic high-risk population

Approximately 50% of all acute coronary syndromes occur in previously asymptomatic patients. This study evaluated the value of multislice computed tomography for early detection of significant coronary artery disease (CAD) in high-risk asymptomatic subjects. One hundred sixty-eight asymptomatic subjects with >or=1 major risk factor (hypertension, diabetes, hypercholesterolemia, family history, or smoking) and an inconclusive or unfeasible noninvasive stress test result (stress electrocardiography, echocardiography, or nuclear scintigraphy) were evaluated in an outpatient setting. After clinical examination and laboratory risk analysis, all patients underwent multislice computed tomographic (MSCT) coronary angiography within 1 week. In all subjects, conventional coronary angiography was also carried out. Multislice computed tomography displayed single-vessel CAD in 16% of patients, 2-vessel CAD in 7%, and 3-vessel CAD in 4%. Selective coronary angiography confirmed the results of multislice computed tomography in 99% of all patients. Sensitivity and specificity of MSCT coronary angiography were 100% and 98%, respectively, with a positive predictive value of 95% and a negative predictive value of 100%. In conclusion, MSCT coronary angiography is an excellent noninvasive technique for early identification of significant CAD in high-risk asymptomatic patients with inconclusive or unfeasible noninvasive stress test results.     

64排螺旋CT冠状动脉成像在无保护左主干冠脉病变PCI中的应用价值

目的 探讨64排螺旋CT冠状动脉成像（CTA）在冠状动脉无保护左主干病变（UPLM）介入治疗中的应用价值.方法 随机选取25例2012年1月至2014年1月在粤北人民医院心血管内科临床诊断为冠心病,并进行经导管冠脉造影（CAG）,确诊为UPLM的患者.其中12例患者术前进行了CTA检查;13例患者术前未进行CTA检查,而直接进行CAG及PCI.结果 12例介入诊疗前进行CTA检查的患者,CTA检查阳性预测值为100％,介入治疗均成功,手术成功率100％,术中未出现低血压及慢血流等并发症情况,PCI平均操作时间（30±5）min.13例术前未进行CTA检查的患者,有11例选择行PCI并成功,PCI成功率100％.但其中有6例患者在CAG及PCI术中出现低血压（46％）,2例患者术中出现冠脉慢血流（15％）,整体并发症发生率为61％,与CTA组比较差异有统计学意义（P＜0.01）;PCI平均操作时间（50±9）min,较CTA组明显增加（P＜0.01）.另外2例患者术前未行CTA检查,行CAG后放弃PCI治疗,择期行CABG（15％）.结论 冠心病患者术前行CTA检查,有助于提前发现UPLM,从而提高UPLM患者介入手术成功率,减少术中并发症.     

Multi-slice computed tomography coronary angiography: anatomic vs functional assessment in clinical practice.

Non-invasive imaging plays an increasingly important role in the diagnosis and risk stratification of coronary artery disease (CAD). Several techniques such as stress echocardiography and myocardial perfusion imaging have become available to assess cardiac function and myocardial perfusion. With the arrival of multi-slice computed tomography coronary angiography (CTA), non-invasive imaging of coronary anatomy has also become possible. Studies concerning the diagnostic accuracy have demonstrated a good agreement with conventional coronary angiography resulting in a sensitivity and specificity of approximately 86% and 96%, respectively. The high negative predictive value of 97% renders it particularly useful to rule out the presence of CAD in patients with an intermediate pretest likelihood. Moreover, comparative studies have demonstrated that anatomic imaging with CTA may provide information complementary to the traditionally used techniques for functional assessment. From these studies can be derived that only approximately 50% of significant stenoses on CTA are functionally relevant; a large proportion of significant (>50%) lesions on CTA does not result in perfusion abnormalities. Alternatively, many patients with a normal perfusion CTA show considerable atherosclerosis on CTA. Therefore, the combined use of these techniques may enhance the assessment of the presence and extent of CAD. In the future diagnostic algorithms, combining non-invasive anatomic and functional imaging need to be evaluated in large patient populations to establish their efficacy, safety, and cost effectiveness. Importantly, these investigations should result in the development of comprehensive guidelines on the use of CTA in clinical practice as well.     

Association between colorectal adenoma and coronary atherosclerosis detected by CT coronary angiography in Korean men; a cross-sectional study

Background: Colorectal adenoma and coronary artery disease (CAD) appear to share common risk factors, such as male gender, diabetes mellitus, smoking, and obesity. We investigated the relationship between colorectal adenoma and coronary atherosclerosis, as a risk factor for colorectal adenoma. Methods: A cross‐sectional study was conducted on Korean men who presented for a health check‐up. The subjects were 488 men (217 colorectal adenoma and 271 normal colonoscopic findings) who underwent colonoscopy and coronary computed tomography angiography (CTA) on the same day as a screening examination. Advanced colonic lesion was defined as a presence of adenoma with villous component, high‐grade dysplasia, and/or with size of ≥1 cm. CTA findings were classified as normal, mild (low‐grade atherosclerosis or <50% stenosis), and significant CAD (≥50% stenosis). Abnormal CTA findings included mild and significant CAD. Results: Patients with abnormal CTA findings were more likely to have colorectal adenoma compared with those with normal CTA findings (P < 0.005). Furthermore, presence of advanced adenoma was significantly associated with significant CAD (P < 0.01). On multivariate analyses, abnormal CTA findings (OR = 1.66, 95% CI: 1.14–2.41, P < 0.01) and significant CAD (OR = 1.96, 95% CI: 1.15–3.35, P < 0.05) were found to be independent risk factors for colorectal adenoma after adjusting for age, current smoking, and metabolic syndrome. Conclusions: In this study, in the population who underwent CTA and colonoscopy for health check‐up, prevalence of colorectal adenoma was greater in subjects with low‐grade coronary atherosclerosis or significant CAD. The presence of advanced adenoma was significantly associated with significant CAD.     

Performance Diagnóstica da FFR por Angiotomografia de Coronárias através de Software Baseado em Inteligência Artificial

BackgroundThe non-invasive quantification of the fractional flow reserve (FFRCT) using a more recent version of an artificial intelligence-based software and latest generation CT scanner (384 slices) may show high performance to detect coronary ischemia.ObjectivesTo evaluate the diagnostic performance of FFRCT for the detection of significant coronary artery disease (CAD) in contrast to invasive FFR (iFFR) using previous generation CT scanners (128 and 256- detector rows).MethodsRetrospective study with patients referred to coronary artery CT angiography (CTA) and catheterization (iFFR) procedures. Siemens Somatom Definition Flash (256-detector rows) and AS+ (128-detector rows) CT scanners were used to acquire the images. The FFRCT and the minimal lumen area (MLA) were evaluated using a dedicated software (cFFR version 3.0.0, Siemens Healthineers, Forchheim, Germany). Obstructive CAD was defined as CTA lumen reduction ≥ 50%, and flow-limiting stenosis as iFFR ≤0.8. All reported P values are two-tailed, and when <0.05, they were considered statistically significant.ResultsNinety-three consecutive patients (152 vessels) were included. There was good agreement between FFRCT and iFFR, with minimal FFRCT overestimation (bias: -0.02; limits of agreement:0.14-0.09). Different CT scanners did not modify the association between FFRCT and FFRi (p for interaction=0.73). The performance of FFRCT was significantly superior compared to the visual classification of coronary stenosis (AUC 0.93vs.0.61, p<0.001) and to MLA (AUC 0.93vs.0.75, p<0.001), reducing the number of false-positive cases. The optimal cut-off point for FFRCT using a Youden index was 0.85 (87% Sensitivity, 86% Specificity, 73% PPV, 94% NPV), with a reduction of false-positives.ConclusionMachine learning-based FFRCT using previous generation CT scanners (128 and 256-detector rows) shows good diagnostic performance for the detection of CAD, and can be used to reduce the number of invasive procedures.     

Diagnostic value of the 16-detector row multislice spiral computed tomography for the detection of coronary artery stenosis in comparison to invasive coronary angiography

OBJECTIVES: The aim of this study was to determine the diagnostic accuracy of 16-slice multislice spiral computed tomography (MSCT) of the coronaries and to provide data in a real clinical setting. Previous 16-slice MSCT studies presented data excluding patients with calcification, vessels of < 1.5 or 2 mm, and segments with impaired image quality. By including these data for 16-slice MSCT, a direct comparison with new data from 64-slice MSCT is possible. METHODS AND RESULTS: Sixty two patients with suspected or known coronary artery disease (CAD) were prospectively enrolled and underwent computed tomography angiography (CTA) and invasive coronary angiography (ICA). All vessels were evaluated for the presence of a significant coronary artery stenosis (>50%) using the American Heart Association (AHA) 15-segment model. From the evaluation of 917 segments, sensitivity, specificity, and positive and negative predictive value (NPV) (positive predictive value [PPV] and NPV) for the presence of relevant coronary stenosis were 73, 98, and 71 and 98% per segment and 94, 90, and 91 and 93% per patient, respectively. The influence of age, gender, body surface area (BSA), heart rate (HR), stents, and Ca(2+)-score value was analyzed. High Ca(2+)-score values were the only statistically significant predictor for impaired diagnostic accuracy. CONCLUSIONS: In summary, CTA with evaluation of all vessel segments in a broad spectrum of patients allowed accurate and fast noninvasive coronary artery evaluation, including evaluation of stented segments. These data are very similar to those published recently for 64-slice scanners.     

Coronary anomalies by cardiac computed tomographic angiography

BACKGROUND: Early identification of an anomalous coronary anatomy is quite relevant because of the increased incidence of sudden cardiac death or related symptoms of myocardial ischemia in the patients. Invasive coronary angiography (ICA) is not only invasive, but expensive, and cannot always adequately provide the required information about the abnormal coronary anatomy. Cardiac computed tomographic angiography (CTA) is a robust noninvasive imaging modality that has several clinical applications and is now being used increasingly in practices across the nation. It not only provides high-resolution anatomical information of the coronary artery tree but also helps define other aspects of the cardiovascular anatomy, be it normal or abnormal. HYPOTHESIS: This study sought to determine the clinical role played by CTA in the evaluation of different types of coronary arterial anomalies by reviewing CTA studies since 1997. METHODS: We reviewed 6,089 case studies of contrast CTA conducted at our institution. There were 53 coronary anomalies in 39 patients (0.64%). RESULTS: Computed tomographic angiography correctly identified the course of coronary arteries in all cases. CONCLUSION: The results of this study support the use of CTA as a safe and effective noninvasive imaging modality for defining coronary arterial anomalies in an appropriate clinical setting, providing detailed three-dimensional anatomic information that may be difficult to obtain with invasive angiography.     

Four‐year clinical outcome of sirolimus‐ and paclitaxel‐eluting stents compared to bare‐metal stents for the percutaneous treatment of stable coronary artery disease

Background : There are limited data on the long‐term safety and efficacy profile of coronary stent implantation in patients with stable coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI). Objective : We aimed to assess the 4‐year clinical outcome in patients who received a bare‐metal stent (BMS), sirolimus‐eluting stent (SES), or a paclitaxel‐eluting stent (PES) for the percutaneous treatment of stable angina in our center during 2000–2005. Methods : In the study period, a total of 2,449 consecutive patients (BMS = 1,005; SES = 373; and PES = 1071) underwent a PCI as part of three historical PCI‐cohorts for stable angina and were routinely followed for the occurrence of major adverse cardiac events (MACE). Results : At 4 years follow‐up, 264 BMS patients (26.8%) had a MACE, compared to 75 SES patients (20.9%) and 199 PES patients (23.9%). Multivariate analysis showed that SES and PES were superior to BMS with respect to MACE [hazard ratio (HR) = 0.62, 95% confidence interval (CI): 0.47–0.81; HR = 0.67, 95% CI: 0.55–0.82, respectively]. The occurrence of MACE was significantly lower in the SES and PES population, primarily due to less target‐vessel revascularization (TVR) procedures (HR = 0.53, 95% CI: 0.37–0.75; HR = 0.71, 95% CI: 0.62–0.81, respectively). The occurrence of early, late, and very late stent thrombosis was equally rare with each stent type. There were no significant differences between SES and PES on death, myocardial infarction, TVR, and MACE. Conclusion : These findings suggest that SES and PES result in decreased TVR procedures and MACE compared to BMS at 4 years follow‐up. SES or PES implantation should be the preferred choice over BMS for patients with stable CAD undergoing PCI. © 2010 Wiley‐Liss, Inc.     

Fractional flow reserve‐CT assessment of coronary stenosis

Coronary computed tomography angiography (CCTA) has been an established noninvasive method for detection of coronary artery disease (CAD). Although CCTA has had a high sensitivity and negative predictive value for CAD detection, specificity for obstructive CAD has been relatively low, partly due to coronary calcium, imaging artifacts, and other factors leading to an overestimation of stenosis severity. A relatively new noninvasive method of calculation of fractional flow reserve (FFR) using CCTA (FFR_CT) data has been developed. This noninvasive method yields similar results to invasive FFR measurement, improving specificity for noninvasively detecting lesion‐specific ischemia thus helping guide revascularization.     

Multivessel percutaneous coronary intervention without contrast agents

Contrast‐induced nephropathy (CIN) following coronary angiography is associated with significant morbidity and mortality. Contrast media volume is the key risk factor for CIN in patients with chronic kidney disease undergoing coronary angiography and interventions. Very often, coronary interventions are avoided in such high‐risk patients because of possible significant adverse clinical outcomes. We present a case demonstrating use of intravascular ultrasound (IVUS) to guide multivessel percutaneous coronary intervention (PCI) performed without any contrast administration in a patient with extreme risk for CIN. With the availability of advanced imaging of the coronary arteries such as high definition IVUS, contrast free PCI is a feasible approach and is associated with significant advantages of reducing or eliminating the development of CIN following PCI. This case report highlights the key practical aspects of performing contrast‐free PCI and the challenges associated with such approach. © 2015 Wiley Periodicals, Inc.     

Diagnostic accuracy of 64-slice computed tomography for detecting angiographically significant coronary artery stenosis in an unselected consecutive patient population: comparison with conventional invasive angiography.

BACKGROUND: Multislice computed tomography (MSCT) is a promising noninvasive method of detecting coronary artery disease (CAD). However, most data have been obtained in selected series of patients. The purpose of the present study was to investigate the accuracy of 64-slice MSCT (64 MSCT) in daily practice, without any patient selection. METHODS AND RESULTS: Using 64-slice MSCT coronary angiography (CTA), 69 consecutive patients, 39 (57%) of whom had previously undergone stent implantation, were evaluated. The mean heart rate during scan was 72 beats/min, scan time 13.6 s and the amount of contrast media 72 mL. The mean time span between invasive coronary angiography (ICAG) and CTA was 6 days. Significant stenosis was defined as a diameter reduction of > 50%. Of 966 segments, 884 (92%) were assessable. Compared with ICAG, the sensitivity of CTA to diagnose significant stenosis was 90%, specificity 94%, positive predictive value (PPV) 89% and negative predictive value (NPV) 95%. With regard to 58 stented lesions, the sensitivity, specificity, PPV and NPV were 93%, 96%, 87% and 98%, respectively. On the patient-based analysis, the sensitivity, specificity, PPV and NPV of CTA to detect CAD were 98%, 86%, 98% and 86%, respectively. Eighty-two (8%) segments were not assessable because of irregular rhythm, calcification or tachycardia. CONCLUSION: Sixty-four-MSCT has a high accuracy for the detection of significant CAD in an unselected patient population and therefore can be considered as a valuable noninvasive technique.     

Outcomes of cardiac catheterization and percutaneous coronary intervention for in‐hospital ventricular tachycardia or fibrillation cardiac arrest

Objective: This study examined outcomes of patients with sudden cardiac death attributable to primary ventricular tachycardia (VT) or ventricular fibrillation (VF) that underwent cardiac catheterization with or without percutaneous coronary intervention (PCI). Background: The decision to perform cardiac catheterization and PCI in resuscitated patients with sudden cardiac death remains controversial. Prior data suggest a potential benefit from percutaneous revascularization. Methods: All patients with an in‐hospital pulseless VT or VF cardiac arrest from August 2002 to February 2008 who underwent cardiac catheterization were included. Retrospective chart review was performed to obtain clinical, neurologic, and angiographic data. Primary endpoints were all‐cause mortality and neurologic outcome. Results: Two thousand and thirty‐four patients had in‐hospital cardiac arrest, of these 116 had pulseless VT or VF and were resuscitated and 93 (80%) underwent coronary angiography. The median time to follow‐up was 1.3 years (IQR: 0.5–2.9 years). Obstructive coronary artery disease (CAD) was observed in 74 (79%) individuals, of whom 37 underwent PCI. Thirty‐five patients with obstructive CAD (47%) died compared to 41% with nonobstructive CAD. In unadjusted and multivariable adjusted analysis PCI was not associated with lower mortality (adjusted hazard ratio: 1.54, 95% CI, 0.79–3.02, P = 0.20). No significant differences were noted in neurologic status at discharge (P = 0.49). Conclusion: In this study, an aggressive revascularization strategy with PCI did not confer a survival advantage nor was it associated with improved neurologic outcomes. There was no suggestion of harm with PCI and further studies are necessary to identify potential subgroups that may benefit from revascularization. © 2011 Wiley Periodicals, Inc.     

In‐hospital and long‐term outcomes of percutaneous balloon aortic valvuloplasty with concomitant percutaneous coronary intervention in patients with severe aortic stenosis

Background

Severe aortic stenosis (AS) often coexists with significant coronary artery disease.

Objective

To evaluate procedural complications and long‐term outcomes of patients with severe AS undergoing balloon aortic valvuloplasty (BAV) and percutaneous coronary intervention (PCI).

Methods

A total of 97 patients with severe AS underwent 104 BAVs as palliative procedure, bridge to definitive treatment, or before urgent non‐cardiac surgery. Patients were followed‐up for at least 12 months.

Results

Of the 97 patients, 34 (35.0%) underwent standalone BAV, 45 (46.4%) underwent BAV with coronary angiography, and 18 (18.6%) BAV with PCI. There were no differences in baseline characteristics and indications for BAV among the groups (P > 0.05). No higher risk of complications after BAV performed with concomitant coronary angiography/PCI was observed. Transcatheter aortic valve implantation was performed after BAV in 13 (13.4%) patients and surgical aortic valve replacement in three (3.1%) patients. In spite of no difference in in‐hospital mortality (5.6% vs. 8.9%; P = 0.76), patients with BAV and concomitant PCI had lower long‐term mortality than patients with BAV and concomitant coronary angiography (28.5% vs. 51.0%; P = 0.03). In multivariable Cox analysis adjusted for age, sex, and body mass index, the Society of Thoracic Surgeons Predicted Risk of Mortality score was identified as the only independent predictor of long‐term mortality for all patients (HR: 1.09, 95%CI: 1.04‐1.15, P = 0.0006).

Conclusions

Concomitant PCI or coronary angiography performed with BAV may not increase the risk of major and vascular complications. Patients with BAV and concomitant PCI may have better survival than patients with BAV and concomitant coronary angiography.     

High-Risk Plaque Detected on Coronary CT Angiography Predicts Acute Coronary Syndromes Independent of Significant Stenosis in Acute Chest Pain : Results From the ROMICAT-II Trial

Background

It is not known whether high-risk plaque, as detected by coronary computed tomography angiography (CTA), permits improved early diagnosis of acute coronary syndromes (ACS) independently to the presence of significant coronary artery disease (CAD) in patients with acute chest pain.

Objectives

The primary aim of this study was to determine whether high-risk plaque features, as detected by CTA in the emergency department (ED), may improve diagnostic certainty of ACS independently and incrementally to the presence of significant CAD and clinical risk assessment in patients with acute chest pain but without objective evidence of myocardial ischemia or myocardial infarction (MI).

Methods

We included patients randomized to the coronary CTA arm of the ROMICAT-II (Rule Out Myocardial Infarction/Ischemia Using Computer-Assisted Tomography II) trial. Readers assessed coronary CTA qualitatively for the presence of nonobstructive CAD (1% to 49% stenosis), significant CAD (≥50% or ≥70% stenosis), and the presence of at least 1 of the high-risk plaque features (positive remodeling, low <30 Hounsfield units plaque, napkin-ring sign, spotty calcium). In logistic regression analysis, we determined the association of high-risk plaque with ACS (MI or unstable angina pectoris) during the index hospitalization and whether this was independent of significant CAD and clinical risk assessment.

Results

Overall, 37 of 472 patients who underwent coronary CTA with diagnostic image quality (mean age 53.9 ± 8.0 years; 52.8% men) had ACS (7.8%; MI n = 5; unstable angina pectoris n = 32). CAD was present in 262 patients (55.5%; nonobstructive CAD in 217 patients [46.0%] and significant CAD with ≥50% stenosis in 45 patients [9.5%]). High-risk plaques were more frequent in patients with ACS and remained a significant predictor of ACS (odds ratio [OR]: 8.9; 95% CI: 1.8 to 43.3; p = 0.006) after adjustment for ≥50% stenosis (OR: 38.6; 95% CI: 14.2 to 104.7; p < 0.001) and clinical risk assessment (age, sex, number of cardiovascular risk factors). Similar results were observed after adjustment for ≥70% stenosis.

Conclusions

In patients presenting to the ED with acute chest pain but negative initial electrocardiogram and troponin, presence of high-risk plaques on coronary CTA increased the likelihood of ACS independent of significant CAD and clinical risk assessment (age, sex, and number of cardiovascular risk factors). (Multicenter Study to Rule Out Myocardial Infarction by Cardiac Computed Tomography [ROMICAT-II]; NCT01084239)     

Early recognition of catheter‐induced left main coronary artery vasospasm: Implications for revascularization

Catheter‐induced left main coronary artery (LMCA) vasospasm is a rare complication of coronary angiography that confounds the decision for coronary artery bypass graft (CABG) surgery. We report two cases of catheter‐induced LMCA vasospasm. The first case was a 68‐year‐old woman who presented 6 years after CABG for presumed severe LMCA atherosclerotic disease. Coronary angiography demonstrated totally occluded CABGs and normal native coronary arteries, including a normal LMCA. The second case was a 56‐year‐old man with severe LMCA stenosis, who was scheduled for unprotected LM percutaneous coronary intervention (PCI). Repeat angiography 2 days later showed no stenosis. These cases emphasize the need for meticulous technique and a high index of suspicion of LMCA vasospasm. Intravascular ultrasound (IVUS) at the time of angiography may help to identify minimal atherosclerotic disease suggesting vasospasm. Alternatively, noninvasive testing, such as Computed Tomography (CT) angiography, may diagnose LM spasm in these patients prior to CABG surgery. © 2010 Wiley‐Liss, Inc.     

Prognostic value and the changes of plasma levels of secretory type II phospholipase A2 in patients with coronary artery disease undergoing percutaneous coronary intervention.

AIM: To evaluate the serial changes of plasma secretory type II phospholipase A(2)(sPLA(2)), C-reactive protein (CRP) and cardiac injury markers in coronary artery disease (CAD) patients undergoing percutaneous coronary intervention (PCI) and their prognostic impacts. METHODS AND RESULTS: Plasma levels of sPLA(2), CRP, creatine kinase (CK), CK-MB and troponin-T were measured in 247 consecutive CAD patients receiving PCI procedure and 100 control subjects without CAD. In CAD group, serial blood samples were taken before coronary angiography, after coronary angiography, immediately after PCI, 24-h and 48-h after PCI. The sPLA(2)and CRP levels did not change after coronary angiography. The level of sPLA(2)significantly increased immediately after PCI. Creatine kinase and cardiac injury markers did not rise immediately after PCI, but elevated significantly at 24h after intervention. After a 2-year follow up, increased sPLA(2)(>450 ng/dl) after PCI, smoking and diabetes mellitus were the independent risk factors for subsequent coronary events (odds ratios 2.1, 2.3 and 3.1, respectively) in patients with CAD. CONCLUSION: The present study showed that PCI might cause immediate elevation of circulating levels of sPLA(2)following the mechanical disruption of coronary plaque, and the elevated level of sPLA(2)had significant prognostic impact.     

Predictors of long‐term outcomes after bypass grafting versus drug‐eluting stent implantation for left main or multivessel coronary artery disease

Background : We assessed predictors of long‐term outcomes after coronary artery bypass grafting (CABG) versus those after percutaneous coronary intervention (PCI) with drug‐eluting stents (DES) in 3,230 patients with left main or multivessel coronary artery disease (CAD). Methods and Results : Data were pooled from the BEST, PRECOMBAT, and SYNTAX trials. Age, chronic kidney disease, chronic obstructive lung disease, left ventricular dysfunction, and peripheral arterial disease (PAD) were common predictors of all‐cause mortality. Diabetes mellitus, previous myocardial infarction (MI), and SYNTAX score were independent predictors of all‐cause mortality in the PCI group, but not in the CABG group. In the CABG group, age was the only risk factor for MI; left ventricular dysfunction, hypertension, and PAD were risk factors for stroke. On the other hand, in the PCI group, incomplete revascularization and previous MI were risk factors for MI; age and previous stroke for stroke. In addition, chronic kidney disease significantly correlated with a composite outcome of death, MI, or stroke in the CABG group, and incomplete revascularization and previous MI in the PCI group. Conclusions : Simple clinical variables and SYNTAX score differentially predict long‐term outcomes after CABG versus those after PCI with DES for left main or multivessel CAD. Those predictors might help to guide the choice of revascularization strategy. © 2017 Wiley Periodicals, Inc.     

Prediction of the no-reflow phenomenon during percutaneous coronary intervention using coronary computed tomography angiography

Coronary computed tomography angiography (CTA) can assess plaque characteristics and plaque size noninvasively. The purpose of this study was to investigate whether coronary CTA before percutaneous coronary intervention (PCI) can predict the no-reflow phenomenon during PCI. Seventy-eight patients [acute coronary syndrome (ACS) = 43, stable angina pectoris (SAP) = 35, male/female = 72/6, age: 65 ± 10 years] who underwent 16- or 64-slice CTA in the 4 weeks before PCI were enrolled. The low attenuation plaque size on CTA was compared between patients with (NR+) and without the no-reflow phenomenon (NR−). No-reflow phenomenon was observed in 11 patients, including 10 patients with ACS and 1 patient with SAP. Low attenuation plaque was detected in 9 (82%) NR(+) lesions and 35 (52%) NR(−) lesions. The length of low attenuation plaque was significantly longer in NR(+) than in NR(−) patients (9.0 ± 6.5 vs. 1.6 ± 2.7 mm, p < 0.0001). On step-wise regression analysis, ACS (p = 0.036, 95% CI = 0.009–0.258) and the presence of low attenuation plaque with a length >4.7 mm (p < 0.001, 95% CI = 0.447–0.778) were significant independent predictors of NR(−) no-reflow phenomenon. Low attenuation plaque with lesion length of >4.7 mm on coronary CTA and ACS were the significant predictors for the no-reflow phenomenon during PCI. Coronary CTA assessment before PCI would be useful to predict coronary events during PCI in advance.