Impact of statin usage patterns on outcomes after percutaneous coronary in-tervention in acute myocardial infarction：Korea Working Group on Myocar-dial Infarction registry （KorMI） study

Background The benefit of statin use after acute ST-segment elevation myocardial infarction （STEMI） has been well established, however, the influence of the timing of statin administration has not been elucidated. The objective of this study focused on early clinical outcomes after percutaneous coronary intervention （PCI）. Methods This analysis of the Korea Working Group on Myocardial Infarction registry （KorMI） study included 3,584 STEMI patients （mean age, 63 ±13 years;male, 2,684, 74.9%） undergoing PCI from January 2008 to June 2009. Rates of major adverse cardiac events （MACE：all-cause death, recurrent MI, and target lesion revascularization） were compared among patients grouped according to statin therapy timing：I, both during and after hospitalization （n=2,653, 74%）;II, only during hospita-lization （n=309, 8.6%）;III, only after discharge （n=157, 4.4%）;and IV, no statin therapy （n=465, 13%）. Mean follow-up duration was 234 ± 113 days. Results Multivariate factors of statin use during hospitalization included prior statin use, multiple diseased vessels, final thrombolysis in myocardial infarction flow grade III, and low-density lipoprotein cholesterol level. At 6-month follow-up, groups Ⅲ and Ⅳ had the highest MACE rates （2.3%, 3.9%, 5.1%, and 4.9%for groups I-IV, respectively, P=0.004）. After adjusting for confounders, groups Ⅱ-Ⅳ had a higher MACE risk than group Ⅰ [hazard ratio （HR）：3.20, 95%confidence interval （95%CI）：1.31-7.86, P=0.011;HR：3.84, 95%CI：1.47-10.02, P=0.006;and HR：3.17, 95%CI：1.59-6.40, P=0.001;respectively]. Conclusions This study, based on the national registry database, shows early and continuous statin therapy improvs early outcomes of STEMI patients after PCI in real-world clinical prac-tice.     

Relation of coronary collateral circulation with epicardial fat volume in patients with stable coronary artery disease

Objective

To investigated the relationship between epicardial fat volume (EFV) and coronary collateral circulation (CCC) in patients with stable coronary artery disease (CAD).

Methods

The study population consisted of 152 consecutive patients with CAD who underwent coronary angiography and were found to have at least 95% significiant lesion in at least one major coronary artery. EFV was assessed utilizing 64-multislice computed tomography. The patients were classifield into impaired CCC group (Group 1, Rentrop grades 0−1, n = 58), or adequate CCC (Group 2, Rentrop grades 2−3, n = 94).

Results

The EFV values were significantly higher in paitients with adequate CCC than in those with impaired CCC. In multivariate logistic regression analysis, EFV (OR = 1.059; 95% CI: 1.035−1.085; P = 0.001); and presence of angina were independent predictors of adequate CCC. In receiver-operating characteristic curve analysis, the EFV value > 106.5 mL yielded an area under the curve value of 0.84, with the test sensitivity of 49.3%, and with 98.3% specifity.

Conclusions

High EFV, and the presence of angina independently predict adequate CCC in patients with stable coronary artery disease. This association offers new diagnostic opportinities to assess collateral flow by conventional ultrasound techniques.     

Clopidogrel resistance response in patients with coronary artery disease and metabolic syndrome: the role of hyperglycemia and obesity

Background Despite the proven benefits of clopidogrel combined aspirin therapy for coronary artery disease (CAD), CAD patients with metabolic syndrome (MS) still tend to have coronary thrombotic events. We aimed to investigate the influence of metabolic risk factors on the efficacy of clopidogrel treatment in patients with CAD undergoing percutaneous coronary intervention (PCI). Methods Cohorts of 168 MS and 168 non-MS subjects with CAD identified by coronary angiography (CAG) were enrolled in our study. MS was defined by modified Adult Treatment Panel III criteria. All subjects had taken 100 mg aspirin and 75 mg clopidogrel daily for more than 1 month, and administered loading doses of 600 mg clopidogrel and 300 mg aspirin before PCI. Blood samples were taken 24 h after the loading doses of clopidogrel and aspirin. Platelet aggregation was measured using light transmittance aggregometry (LTA) and thrombelastography (TEG). Clopidogrel resistance was defined as more than 50% adenosine diphosphate (ADP) induced platelet aggregation as measured by TEG. Results Platelet aggregation inhibition rate by ADP was significantly lower in patients with MS as measured both by TEG (55% ± 31% vs. 68% ± 32%; P < 0.001) and LTA (29% ± 23% vs. 42% ± 29%; P < 0.001). In the multivariate analysis, elderly [OR (95% CI): 1.483 (1.047–6.248); P = 0.002], obesity [OR (95% CI): 3.608 (1.241–10.488); P = 0.018], high fasting plasma glucose level [OR (95% CI): 2.717 (1.176–6.277); P = 0.019] and hyperuricemia [OR (95% CI): 2.583 (1.095–6.094); P = 0.030] were all statistically risk factors for clopidogrel resistance. CAD patients with diabetes and obesity were more likely to have clopidogrel resistance than the CAD patients without diabetes and obesity [75% (61/81) vs. 43% (67/156); P < 0.001]. Conclusions CAD patients with MS appeared to have poorer antiplatelet response to clopidogrel compared to those without MS. Obesity, diabetes and hyperuricemia were all significantly associated with clopidogrel resistance.     

Correlation between serum free fatty acids levels and Gensini score in elderly patients with coronary heart disease

Objectives To investigate the relationship between serum fxee fatty acids （FFAs） levels and the severity of coronary artery lesions in elderly patients with coronary heart disease （CAD）. Methods A total of 172 elderly patients who underwent coronary angiography were divided into CAD group （n = 128） and non-CAD group （n = 44） according to the results of coronary angiography. Serum FFAs and lipid levels were measured and the Gensini score were calculated. Results No matter the differences between age, gender and the usage of stat- ins or not, there was no statistical significance in FFAs levels （P 〉 0.05）. In terms of the Gensini score, it was higher in patients aged 70-79 years than in patients 60-69 years old [15.00 （5.00, 34.00） vs. 10.00 （2.00, 24.00）, P 〈 0.05], higher in men than women [14.00 （4.00, 34.00） vs. 7.00 （2.50, 19.75）, P 〈 0.05], and higher in patients on statins [13.50 （4.25, 33.50）vs. 6.50 （2.00, 18.00）, P 〈 0.05]. The serum FFAs lev- els [449.50 （299.00, 624.75） mEq/L vs. 388.00 （258.50, 495.25） mEq/L, P 〈 0.05J and Gensini score [17.50 （8.00, 41.75） vs. 1.00 （0, 5.00）, P 〈 0.05] were higher in the CAD group than in the non-CAD group. In the CAD group, there was no statistical significance in FFAs levels among patients with different numbers of diseased coronary vessels （P 〉 0.05）. Furthermore, the FFAs levels were positively correlated with the Gensini score （r = 0.394, P = 0.005）. Regression analysis showed that the FFAs levels were related to the Gensini score independently after adjusting for the other risk factors. Conclusions The serum FFAs levels were associated with the Gensini score in elderly patients with CAD. It might indicate FFAs as a biomarker predicting the severity of coronary artery lesions.     

Polymorphisms of the methylenetetrahydrofolate reductase, vascular endothelial growth factor, endothelial nitric oxide synthase, monocyte chemoattractant protein-1 and apolipoprotein E genes are not associated with carotid intima-media thickness

BACKGROUND:

Single nucleotide polymorphisms in the 5,10-methylenetetrahydrofolate reductase (MTHFR), vascular endothelial growth factor (VEGF), endothelial nitric oxide synthase (eNOS), monocyte chemoattractant protein-1 (MCP-1) and apolipoprotein E (ApoE) genes appear to be a genetic risk factor for atherosclerosis. Common carotid intima-media thickness (cIMT) provides information on the severity of atherosclerosis.

OBJECTIVE:

To investigate the relationship between cIMT and gene polymorphisms associated with atherosclerosis in Turkish patients with coronary artery disease (CAD).

METHODS:

Sixty-two patients with angiographically diagnosed stable CAD were divided into two groups according to their cIMT values (group 1: n=35, cIMT of 1 mm or greater; group 2: n=27, cIMT of less than 1 mm). MTHFR 677 C/T, VEGF–460 C/T, eNOS 894 G/T, MCP-1–2518 A/G and ApoE (E2, E3 and E4) gene polymorphisms (where A is adenine, C is cytosine, G is guanine and T is thymine) were analyzed by polymerase chain reaction and restriction fragment length polymorphism. Evaluations of cardiovascular risk factors and coronary atherosclerotic lesions were performed in all patients. Serum homocysteine and high-sensitivity C-reactive protein were measured and compared between the two groups.

RESULTS:

Serum high-sensitivity C-reactive protein (P=0.04) and homocysteine (P=0.006) levels were higher in group 1 than in group 2. The ratio of multivessel CAD and previous myocardial infarction was significantly higher in group 1 than in group 2 (P=0.014). In the study population, no significant difference in cIMT was observed according to the polymorphisms studied. Only hyperhomocysteinemia (OR 1.17 [95% CI 1.01 to 1.35], P=0.033) and previous myocardial infarction (OR 3.76 [95% CI 1.10 to 12.81], P=0.034) maintained a significant correlation with cIMT on multiple logistic regression analysis.

CONCLUSION:

cIMT is increased in patients with hyperhomocysteinemia, inflammation and extended CAD. MTHFR 677 C/T, VEGF–460 C/T, eNOS 894 G/T, MCP-1–2518 A/G and ApoE single nucleotide polymorphisms were not associated with increased cIMT.     

Differences in the predictive value of red cell distribution width for the mortality of patients with heart failure due to various heart diseases

Background Increased red blood cell distribution width (RDW) is associated with adverse outcomes in patients with heart failure (HF). The objective of this study was to compare the differences in the predictive value of RDW in patients with HF due to different causes. Methods We retrospectively investigated 1,021 HF patients from October 2009 to December 2011 at Fuwai Hospital (Beijing, China). HF in these patients was caused by three diseases; coronary heart disease (CHD), dilated cardiomyopathy (DCM) and valvular heart disease (VHD). Patients were followed-up for 21 ± 9 months. Results The RDW, mortality and survival duration were significantly different among the three groups. Kaplan–Meier analysis showed that the cumulative survival decreased significantly with increased RDW in patients with HF caused by CHD and DCM, but not in those with HF patients caused by VHD. In a multivariable model, RDW was identified as an independent predictor for the mortality of HF patients with CHD (P < 0.001, HR 1.315, 95% CI 1.122–1.543). The group with higher N-terminal pro-brain natriuretic peptide (NT-proBNP) and higher RDW than median had the lowest cumulative survival in patients with HF due to CHD, but not in patients with HF due to DCM. Conclusions RDW is a prognostic indicator for patients with HF caused by CHD and DCM; thus, RDW adds important information to NT-proBNP in CHD caused HF patients.     

RETRACTED: Association between erectile dysfunction and coronary artery disease and it's severity

Background/aims

To investigate the prevalence of erectile dysfunction (ED) in patients with coronary artery disease (CAD), its relationship between the severity of ED and the extent of coronary vessel involvement and to register the mean time interval between them.

Methods

240 patients with CAD divided into three age-matched groups: Group 1 (n = 60), ACS with one-vessel disease (1VD); group 2 (n = 60), ACS with 2,3VD; group 3 (n = 60), CSA. Control group (C, n = 60) was composed of patients with suspected CAD who were found to have entirely normal coronary arteries by angiography. ED as any value <26 according to the Gensini''s scores and according to the International Index of Erectile Function (IIEF).

Results

ED prevalence was 76%. ED prevalence was lower in G1 vs. G3 (22 vs.65%). G2 ED rate [55%, P < 0.0001] IIEF = 24 (17–29) & Gensini''s scores-21 (12.5–32) were significantly different from G1 and similar to G3, ED in ACS differs according to the extent of CAD. G3 patients who had ED symptoms prior to CAD symptoms and time interval between ED and CAD symptom onset in CCS according to number of vessels. Onset of sexual dysfunction occurred before CAD onset with a mean time interval of 24 m [12–36].

Conclusion

Early diagnosis of ED, cardiovascular assessment and aggressive treatment of cardiovascular risk factors might have contributed to prevent the acute events of this patient. Patients should be systematically screened for ED as a part of periodic examination programs. This would lead to early detection of modifiable vascular risk factors, or already existing vascular disease and to prevent ED and vascular disease progression through pharmacological and life style modifications.     

Is ratio of ApoB/apoA-1 the best predictor for the severity of coronary artery lesions in Chinese diabetics with stable angina pectoris? An assessment based on Gensini scores

Background There is a paucity of data about the best lipid ratio predicting the severity of coronary artery disease (CAD) in patients with diabetes mellitus. We determined the relationship between five conventional lipid ratios and the extent of coronary artery lesions in Chinese Type 2 diabetics with stable angina pectoris (SAP). Methods A prospective cohort study within 373 Type 2 diabetic patients diagnosed with stable CAD by coronary angiography was performed. All patients were classified into three groups according to the tertiles of Gensini scores (GS, low group < 8 points n = 143; intermediate group 8–28 points, n = 109; high group > 28 points, n = 121). Association between the ratios of apolipoprotein (apo) B and apoA-1, total cholesterol and high density lipoprotein cholesterol (TC/HDL-C), triglycerides and HDL-C (TG/HDL-C), low density lipoprotein cholesterol and HDL-C (LDL-C/HDL-C), Non-HDL-C/HDL-C and GS were evaluated using the receivers operating characteristic (ROC) curves and multivariate logistic regression models. Results The ratio of apoB/apoA-1, TC/HDL-C, LDL-C/HDL-C, and Non-HDL-C/HDL-C were correlated with Gensini scores. Area under the ROC curves for predicting high Gensini scores in the ratios of apoB/apoA-1, TC/HDL-C, LDL-C/HDL-C and Non-HDL-C/HDL-C were 0.62, 0.60, 0.59 and 0.60, respectively (P < 0.005 for all). According to multivariate logistic regression analysis after adjusted with demographic characteristic and other lipid parameters, the ratio of apoB/apoA-1 is qualified as an independent discriminator for the severity of CAD. However, after further adjusting different baseline variables, such as left ventricular ejective fraction, hemoglobin A1c, leukocytes count and serum creatinine, none of the above lipid ratios remained. Conclusion Compared with other lipid parameters, the ratio of apoB/apoA-1 appears to be more significantly correlated with the extent of coronary artery lesions in Chinese diabetics, but it was not an independent predictor in these settings.     

Is frailty associated with short-term outcomes for elderly patients with acute coronary syndrome?

Background Frailty is a new prognostic factor in cardiovascular medicine due to the aging and increasingly complex nature of elderly patients. It is useful and meaningful to prospectively analyze the manner in which frailty predicts short-term outcomes for elderly patients with acute coronary syndrome (ACS). Methods Patients aged ? 65 years, with diagnosis of ACS from cardiology department and geriatrics department were included from single-center. Clinical data including geriatrics syndromes were collected using Comprehensive Geriatrics Assessment. Frailty was defined according to the Clinical Frailty Scale and the impact of the co-morbidities on risk was quantified by the coronary artery disease (CAD)—specific index. Patients were followed up by clinical visit or telephone consultation and the median follow-up time is 120 days. Following-up items included all-cause mortality, unscheduled return visit, in-hospital and recurrent major adverse cardiovascular events. Multivariable regression survival analysis was performed using Cox regression. Results Of the 352 patients, 152 (43.18%) were considered frail according to the study instrument (5?7 on the scale), and 93 (26.42%) were considered moderately or severely frail (6?7 on the scale). Geriatrics syndromes including incontinence, fall history, visual impairment, hearing impairment, constipation, chronic pain, sleeping disorder, dental problems, anxiety or depression, and delirium were more frequently in frail patients than in non-frail patients (P = 0.000, 0.031, 0.009, 0.014, 0.000, 0.003, 0.022, 0.000, 0.074, and 0.432, respectively). Adjusted for sex, age, severity of coronary artery diseases (left main coronary artery lesion or not) and co-morbidities (CAD specific index) by Cox survival analysis, frailty was found to be strongly and independently associated with risk for the primary composite outcomes: all-cause mortality [Hazard Ratio (HR) = 5.393; 95% CI: 1.477?19.692, P = 0.011] and unscheduled return visit (HR = 2.832; 95% CI: 1.140?7.037, P = 0.025). Conclusions Comprehensive Geriatrics Assessment and Clinical Frail Scale were useful in evaluation of elderly patients with ACS. Frailty was strongly and independently associated with short-term outcomes for elderly patients with ACS.     

Surgical treatment of intrahepatic cholangiocarcinoma: outcomes and predictive factors

Background

Intrahepatic cholangiocarcinoma (ICC) remains a rare tumour, although its incidence is increasing. Surgical resection is the mainstay of treatment. Published data regarding prognostic factors and optimal patient selection for resection are scant. We sought to determine the clinicopathologic characteristics of resectable ICC and outcomes following surgical treatment.

Methods

We reviewed prospectively collected clinical data including patient, pathologic and operative details. Survival and recurrence outcomes were analysed using Cox hazard models and the Kaplan–Meier method.

Results

We identified 31 surgically treated patients. Their 3-year overall survival rate (OS) was 40.1%; median follow-up was 16.2 months (range: 0.2–86.9 months). R0 resection was associated with significantly improved OS compared with R1/R2 resection (3-year OS was 68.6% in R0 vs. 24.0% in R1/R2; P = 0.042). The postoperative complication rate was 58.1%. Two patients died of postoperative liver failure within 30 days. Preoperative hypoalbuminaemia was significantly associated with worse survival.

Conclusions

Surgical therapy for ICC is associated with longterm survival in the subset of nutritionally replete patients in whom an R0 resection can be achieved. Surgical mortality is significant in patients undergoing extended resection. The margin involvement rate is high and surgeons should consider the infiltrative nature of the disease in operative planning.     

Robotic versus laparoscopic resection of liver tumours

Background

There are scant data in the literature regarding the role of robotic liver surgery. The aim of the present study was to develop techniques for robotic liver tumour resection and to draw a comparison with laparoscopic resection.

Methods

Over a 1-year period, nine patients underwent robotic resection of peripherally located malignant lesions measuring <5 cm. These patients were compared prospectively with 23 patients who underwent laparoscopic resection of similar tumours at the same institution. Statistical analyses were performed using Student''s t-test, χ²-test and Kaplan–Meier survival. All data are expressed as mean ± SEM.

Results

The groups were similar with regards to age, gender and tumour type (P = NS). Tumour size was similar in both groups (robotic −3.2 ± 1.3 cm vs. laparoscopic −2.9 ± 1.3 cm, P = 0.6). Skin-to-skin operative time was 259 ± 28 min in the robotic vs. 234 ± 17 min in the laparoscopic group (P = 0.4). There was no difference between the two groups regarding estimated blood loss (EBL) and resection margin status. Conversion to an open operation was only necessary in one patient in the robotic group. Complications were observed in one patient in the robotic and four patients in the laparoscopic groups. The patients were followed up for a mean of 14 months and disease-free survival (DFS) was equivalent in both groups (P = 0.6).

Conclusion

The results of this initial study suggest that, for selected liver lesions, a robotic approach provides similar peri-operative outcomes compared with laparoscopic liver resection (LLR).     

Low density lipoprotein cholesterol level inversely correlated with coronary flow velocity reserve in patients with Type 2 Diabetes

Objectives To evaluate the association of coronary artery endothelial function and plasma levels of low density lipoprotein cholesterol (LDL-C) and high density lipoprotein cholesterol (HDL-C) in patients with Type 2 Diabetes Mellitus (DM). Methods We investigated 90 participants from our institution between October 2007 to March 2010: non-DM (n = 60) and DM (n = 30). As an indicator of coronary endothelial dysfunction, we used non-invasive Doppler echocardiography to quantify coronary flow velocity reserve (CFVR) in the distal part of the left descending artery after rest and after intravenous adenosine administration. Results Plasma level of LDL-C was significantly higher in patients with DM than in non-DM (3.21±0.64 vs. 2.86±0.72 mmo/L, P < 0.05), but HDL-C level did not differ between the groups (1.01 ± 0.17 vs. 1.05 ± 0.19 mmo/L). Furthermore, the CFVR value was lower in DM patients than non-diabetics (2.45 ± 0.62 vs. 2.98 ± 0.68, P < 0.001). Plasma levels of LDL-C were negatively correlated with CFVR in all subjects (r = -0.35, P < 0.001; 95% confidence interval (CI): -0.52 - -0.15) and in the non-DM (r = -0.29, P < 0.05; 95% CI:-0.51 - -0.05), with an even stronger negative correlation in the DM group (r = -0.42, P < 0.05; 95% CI:-0.68 - -0.06). Age (β = 0.019, s = 0.007, sβ = -0435, 95% CI: -0.033 - -0.055, P = 0.008), LDL-C (β = -0.217, s = 0.105,sβ= -0.282, 95% CI: -0.428 - -0.005, P = 0.045) remained independently correlated with CFVR in the DM group. However, we found no correlation between HDL-C level and CFVR in any group. Conclusions Diabetes may contribute to coronary artery disease (CAD) by inducing dysfunction of the coronary artery endothelium. Increased LDL-C level may adversely impair coronary endothelial function in DM. HDL-C may lose its endothelial-protective effects, in part as a result of pathological conditions, especially under abnormal glucose metabolism.     

Relationship between red blood cell distribution width and intermediate-term mortality in elderly patients after percutaneous coronary intervention

Background Large-scale clinical research on the relationship between red blood cell distribution width (RDW) and intermediate-term prognosis in elderly patients with coronary artery disease (CAD) is lacking. Thus, this study investigated the effects of RDW on the intermediate-term mortality of elderly patients who underwent elective percutaneous coronary intervention (PCI). Methods Data from 1891 patients ≥ 65 years old underwent elective PCI from July 2009 to September 2011 were collected. Based on preoperative median RDW (12.3%), the patients were divided into two groups. The low RDW group (RDW < 12.3%) had 899 cases; the high RDW group (RDW ≥ 12.3%) had 992 cases. The all-cause mortality rates of the two groups were compared. Results Patients in the high RDW group were more likely to be female and accompanied with diabetes, had lower hemoglobin level. The mean follow-up period was 527 days. During follow-up, 61 patients died (3.2%). The postoperative mortality of the high RDW group was significantly higher than that of the low RDW group (4.3% vs. 2.0%, P = 0.004). After adjusting other factors, multivariate Cox regression analysis revealed that preoperative high RDW was significantly associated with postoperative all-cause mortality (hazard ratio: 2.301, 95% confidence interval: 1.106–4.785, P = 0.026). Conclusions Increased RDW was an independent predictor of the increased intermediate-term all-cause mortality in elderly CAD patients after elective PCI.     

Impact of Age on Transcatheter Aortic Valve Implantation Outcomes: Comparison Between Patients Aged ≤80 Years versus Patients >80 Years

Objective To investigate the procedural outcomes and the long-term survival of patients undergoing transcatheter aortic valve implantation (TAVI) and compare study results of patients ≤ 80 years and patients > 80 years old. Methods A total of 240 patients treated with TAVI were divided into two groups according to age ≤ 80 years (n = 105; 43.8%) and > 80 years (n = 135; 56.2%). The baseline characteristics and the procedural outcomes were compared between these two groups of patients. Results With the exception of peripheral artery disease and hypercholesterolemia, which were more frequently observed in the older age group, baseline characteristics were comparable between groups. Complication rates did not differ significantly between patients ≤ 80 years and patients > 80 years. There were no differences in 30-day mortality rates between patients aged ≤ 80 years and patients > 80 years old (9.5% vs. 7.4%, respectively; P = 0.557). After a median follow-up of 28 months (interquartile range: 16–42 months), 50 (47.6%) patients aged ≤ 80 years died compared to 57 (42%) deaths in the group of patients > 80 years old (P = 0.404). Conclusion The results of the present single center study showed that age didn't significantly impact the outcomes of TAVI.     

Prevalence and clinical profile of metabolic obesity and phenotypic obesity in Asian Indians

Background

We estimated the prevalence of metabolically obese nonobese (MONO), metabolically obese obese (MOO), and metabolically healthy obese (MHO) individuals and correlated this with the prevalence of coronary artery disease (CAD) compared to metabolically healthy nonobese (MHNO) in urban South Indians.

Method

Study subjects (n = 2350) were recruited from the Chennai Urban Rural Epidemiology Study. Generalized obesity was defined as a body mass index (BMI) ≥25 kg/m², based on the World Health Organization Asia Pacific guidelines. Metabolic syndrome (MS) was diagnosed based on the South Asian Modified-National Cholesterol Education Programme criteria. Coronary artery disease was defined by known myocardial infarction or Q waves on resting electrocardiogram.

Results

Metabolically obese nonobese was defined as nonobese subjects (BMI < 25 kg/m²) with MS, MOO as obesity (BMI ≥ 25 kg/m²) with MS, MHO as obese subjects (BMI ≥ 25 kg/m²) with no MS, and MHNO as no obesity or MS. Metabolically obese nonobese was identified in 355 (15.1%), MOO in 348 (14.8%), MHO in 312 (13.3%), and MHNO in 1335 (56.8%) subjects. The prevalence of CAD among the MONO, MOO, MHO, and MHNO was 5.5%, 4.2%, 1.4%, and 2.6%. However, when age standardization was done, there was no statistically significant increase in the risk of CAD among MONO [odds ratio (OR) = 1.300, 95% confidence interval (CI) 0.706–2.394, p = .339], MOO (OR = 1.651, 95% CI 0.852–3.199, p = .137), and MHO (OR = 0.524, 95% CI 0.250–2.130, p = .564) groups compared to MHNO, perhaps due to small numbers.

Conclusion

Metabolic obesity may have different clinical implications than phenotypic obesity.     

Prognostic value of coronary artery calcium score in patients with stable an-gina pectoris after percutaneous coronary intervention

Objectives To evaluate the prognostic value of the coronary artery calcium （CAC） score in patients with stable angina pectoris （SAP） who underwent percutaneous coronary intervention （PCI）. Methods A total of 334 consecutive patients with SAP who underwent first PCI following multi-slice computer tomography （MSCT） were enrolled from our institution between January 2007 and June 2012. The CAC score was calculated according to the standard Agatston calcium scoring algorithm. Complex PCI was defined as use of high pressure bal-loon, kissing balloon and/or rotablator. Procedure-related complications included dissection, occlusion, perforation, no/slow flow and emer-gency coronary artery bypass grafting. Main adverse cardiac events （MACE） were defined as a combined end point of death, non-fatal myo-cardial infarction, target lesion revascularization and rehospitalization for cardiac ischemic events. Results Patients with a CAC score〉300 （n=145） had significantly higher PCI complexity （13.1%vs. 5.8%, P=0.017） and rate of procedure-related complications （17.2%vs. 7.4%, P=0.005） than patients with a CAC score≤300 （n=189）. After a median follow-up of 22.5 months （4-72 months）, patients with a CAC score≤300 differ greatly than those patients with CAC score＆gt;300 in cumulative non-events survival rates （88.9 vs. 79.0%, Log rank 4.577, P=0.032）. After adjusted for other factors, the risk of MACE was significantly higher [hazard ratio （HR）：4.3, 95%confidence inter-val （95%CI）：2.4-8.2, P=0.038] in patients with a CAC score〉300 compared to patients with a lower CAC score. Conclusions The CAC score is an independent predictor for MACE in SAP patients who underwent PCI and indicates complexity of PCI and proce-dure-related complications.     

Patients ≥75 years with acute coronary syndrome but without critical epicardial coronary disease: prevalence, characteristics, and outcome

Objective Absence of significant epicardial coronary artery disease (CAD) in patients with acute onset of chest pain and elevation of myocardial necrosis markers is occasionally observed. The aim of this study was to analyse the clinical characteristics and outcome of such patients with advanced age. Methods We retrospectively analysed 4,311 patients with acute onset of chest pain plus necrosis marker elevation. Two hundred and seventy two patients without CAD on angiogram (6.3%) were identified. Out of them, 50 (1.2%) patients ≥ 75 years (Group I) were compared with (1) 222 acute coronary syndrome (ACS) patients without CAD on angiogram < 75 years (Group II), and (2) 610 consecutive patients ≥ 75 years with Non-ST-elevation Myocardial Infarction (NSTEMI) undergoing percutaneous coronary intervention (Group III). Results Group I compared to Group III patients made up for more females (64.0% vs. 49.2%; P < 0.0001), and had more severe anginal symptoms on presentation [Canadian Cardiovascular Society (CCS) class I/II, 26.0% vs. 49.8%; P = 0.02]. Group I patients also had lower troponin levels (0.62 ± 0.8 ng/mL vs. 27 ± 74 ng/mL; P < 0.02), lower leukocyte count (9.4 ± 3.13 × 10⁹ vs. 12 ± 5.1 × 10⁹; P = 0.001) and better preserved left ventricular function (56.7% ± 14.3% vs. 45% ± 11%; P < 0.0001). Event-free survival (cardiac death, myocardial infarction, recurrent angina, and re-hospitalisation) was more frequent in Group I and II patients compared to Group III patients (64.9%, 66.7%, and 41.6%, respectively; P < 0.0001). Conclusions ACS in patients ≥ 75 years without CAD is very infrequent, associated with a (1) similar outcome compared to ACS patients < 75 years without CAD, and (2) significant better outcome compared to NSTEMI patients ≥ 75 years.     

Impact of concomitant use of proton pump inhibitors and clopidogrel or ticagrelor on clinical outcomes in patients with acute coronary syndrome

Background There is great debate on the possible adverse interaction between proton pump inhibitors (PPIs) and clopidogrel. In addition, whether the use of PPIs affects the clinical efficacy of ticagrelor remains less known. We aimed to determine the impact of concomitant administration of PPIs and clopidogrel or ticagrelor on clinical outcomes in patients with acute coronary syndrome (ACS) after percutaneous coronary intervention (PCI). Methods We retrospectively analyzed data from a “real world”, international, multi-center registry between 2003 and 2014 (n = 15,401) and assessed the impact of concomitant administration of PPIs and clopidogrel or ticagrelor on 1-year composite primary endpoint (all-cause death, re-infarction, or severe bleeding) in patients with ACS after PCI. Results Of 9,429 patients in the final cohort, 54.8% (n = 5165) was prescribed a PPI at discharge. Patients receiving a PPI were older, more often female, and were more likely to have comorbidities. No association was observed between PPI use and the primary endpoint for patients receiving clopidogrel (adjusted HR: 1.036; 95% CI: 0.903–1.189) or ticagrelor (adjusted HR: 2.320; 95% CI: 0.875–6.151) (P_interaction = 0.2004). Similarly, use of a PPI was not associated with increased risk of all-cause death, re-infarction, or a decreased risk of severe bleeding for patients treated with either clopidogrel or ticagrelor. Conclusions In patients with ACS following PCI, concomitant use of PPIs was not associated with increased risk of adverse outcomes in patients receiving either clopidogrel or ticagrelor. Our findings indicate it is reasonable to use a PPI in combination with clopidogrel or ticagrelor, especially in patients with a higher risk of gastrointestinal bleeding.     

Use of coronary CT angiography in the diagnosis of patients with suspected coronary artery disease: findings and clinical indications

Objective To investigate the clinical applications of coronary CT angiography in patients with suspected coronary artery disease and identify factors that affect CT findings. Methods Medical records of patients suspected of coronary artery disease over a period of 12 months from a tertiary teaching hospital were retrospectively reviewed. Patient age, sex (male/female), duration of symptoms and abnormal rates of coronary CT angiography scans were analysed to investigate the relationship among these parameters. The patients by age were characterized into five groups: under 36 years, 36–45 years, 46–55 years, 56–65 years and more than 66 years, respectively; while the duration of symptoms was also classified into five groups: less than one week, one week to one month, one to three months, three to six months and more than six months. Results Of the 880 patient records reviewed, 800 met the above study criteria. Five hundred and forty nine patients demonstrated abnormal CT findings (68.6%). There was no significant difference in the percentage of abnormal CT findings based on patient sex and the duration of symptoms (P = 0.14). The abnormal rates of coronary CT angiography, however, increased significantly with increasing age (P < 0.001); with patients over 65 years of age 2.5 times more likely to have an abnormal CT scan relative to a patient under 45 years. A significant difference was found between abnormal coronary CT angiography and the duration of symptoms (P = 0.012). Conclusions Our results indicate coronary CT angiography findings are significantly related to the patient age group and duration of symptoms. Clinical referral for coronary CT angiography of patients with suspected coronary artery disease needs to be justified with regard to the judicious use of this imaging modality.     

The importance of depression and alcohol use in coronary artery bypass graft surgery patients: risk factors for delirium and poorer quality of life

Objective To investigate whether depression, anxiety and stress increase the risk for delirium and poor quality of life (QOL) after coronary artery bypass (CABG) surgery. Methods A total of 180 CABG patients (mean age of 63.5 ± 10.1 years, 82.2% males) completed baseline and postoperative self-report questionnaires to assess distress and QOL. Incident delirium was diagnosed postoperatively with a structured clinical interview and patients were monitored every day post-operatively for confusion and disturbance in consciousness. Results Delirium developed in 63 persons (35% of sample). After adjustment for covariates, delirium was significantly associated with depression [odds ratio (OR): 1.08; 95% confidence interval (CI): 1.03–1.13, P = 0.003], anxiety (OR: 1.07; 95% CI: 1.02–1.13, P = 0.01) and stress (OR: 1.05; 95% CI: 1.00–1.09, P = 0.03). Preoperative depression scores were associated with poorer QOL including bodily pain (β = -0.39, P = 0.013), vitality (β=-0.32, P = 0.020), social functioning (β = -0.51, P ≤ 0.001), emotional role function (β = -0.44, P = 0.003) and general health (β = -0.33, P = 0.038). Among the covariates, harmful levels of alcohol use was consistently associated with poorer QOL. Conclusions Depression and harmful levels of alcohol use were consistently associated with poorer QOL whereas depression, anxiety and stress were associated with delirium risk. These findings point to further research examining depression and harmful levels of alcohol use in coronary heart disease populations undergoing coronary revascularization.