Hiroyoshi Mori

Chronic kidney disease (CKD) is a well-established risk factor in acute myocardial infarction (AMI); however, the clinical relevance of admission estimated glomerular filtration rate (eGFR)-based categories remains unclear. We analyzed 10,870 patients from a prospective multicenter AMI registry in Japan. Patients were stratified into stages 1 (≥ 90), 2 (60–89), 3a (45–59), 3b (30–44), 4 (15–29), and 5 (< 15 mL/min/1.73 m²) based on the admission eGFR. The primary endpoint was 30-day major adverse cardiovascular events (MACE), defined as cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke. Bleeding was defined as BARC type 3 or 5. More advanced admission eGFR stages were associated with a higher risk of adverse events. After multivariable adjustment, stages 4 and 5 were associated with a significantly higher risk of MACE compared with the reference group of stages 1 and 2 (stage 4: HR 2.12, 95% CI 1.03–4.33; stage 5: HR 4.14, 95% CI 1.54–11.09), whereas stages 3a and 3b were not significantly associated with MACE. In patients with AMI, clinical outcomes varied across admission eGFR categories, with more advanced renal dysfunction, particularly stages 4 and 5, associated with a higher risk of short-term MACE. Detailed categorization of admission eGFR may provide additional prognostic information for early risk assessment.

BACKGROUND: There were no previous studies comparing aspirin with clopidogrel on top of oral anticoagulation (OAC) within 1 year after percutaneous coronary intervention when dual therapy with OAC and clopidogrel was recommended. METHODS: We conducted a subgroup analysis stratified by OAC in the 1-year follow-up of the STOPDAPT-3 trial (Short and Optimal Duration of Dual Antiplatelet Therapy-3), which randomly compared 1-month dual antiplatelet therapy followed by aspirin monotherapy (aspirin group) with 1-month prasugrel monotherapy followed by clopidogrel monotherapy (clopidogrel group). This subgroup analysis compared aspirin with clopidogrel in patients with or without OAC by the 30-day landmark analysis. The coprimary end points were the cardiovascular (a composite of cardiovascular death, myocardial infarction, definite stent thrombosis, or ischemic stroke), and bleeding end points (Bleeding Academic Research Consortium 3 or 5). RESULTS: In the 30-day landmark analysis (N=5809), there were 788 patients (13.6%) with OAC at discharge. Regardless of OAC, the incidence rates beyond 30 days up to 1 year were similar between the aspirin and clopidogrel groups for cardiovascular end point (OAC: 3.7% versus 3.9%, hazard ratio, 0.92 [95% CI, 0.44–1.93]; no OAC: 3.7% versus 3.6%; hazard ratio, 1.03 [95% CI, 0.77–1.38]; P interaction=0.78) and for bleeding end point (OAC: 3.5% versus 4.2%, hazard ratio, 0.82 [95% CI, 0.39–1.73]; no OAC 1.5% versus 1.4%, hazard ratio, 1.07 [95% CI, 0.66–1.72]; P interaction=0.57). CONCLUSIONS: Aspirin compared with clopidogrel was associated with similar cardiovascular and bleeding outcomes beyond 30 days and up to 1 year after percutaneous coronary intervention regardless of OAC at discharge. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04609111.

Vascular endothelial function plays an important role in the pathophysiology of acute coronary syndrome (ACS). Plaque erosion (PE) and plaque rupture (PR) are the two major mechanisms of ACS; however, how the vascular endothelial function differs between these etiologies is not well understood. Flow-mediated dilation (FMD) is a method used to evaluate the endothelial function. We aimed to assess endothelial function using FMD in patients with PE and PR. ACS patients (N = 160) who underwent primary percutaneous coronary intervention (PCI) with optical frequency domain imaging (OFDI) and FMD assessment were retrospectively enrolled. Culprit plaques were categorized as PE or PR based on OFDI. Based on the median value of FMD (4.1%) in our data, patients were classified into high-FMD (> 4.1%) and low-FMD (≤ 4.1%) groups. Based on the plaque type and FMD values, the patients were divided into PR-HighFMD (N = 48), PR-LowFMD (N = 47), PE-HighFMD (N = 33), and PE-LowFMD (N = 32) groups, and then the clinical characteristics were compared. Major adverse cardiac events (MACE) were defined as cardiovascular death, nonfatal myocardial infarction, stroke, ischemia-driven revascularization, hospitalization for angina or heart failure. FMD was similarly impaired in the PE and PR groups (4.2% vs. 4.1%, P = 0.85). Most clinical characteristics did not differ between the groups. The PR-High_FMD group showed the highest MACE-free survival, followed by the PE-Low_FMD (HR = 2.62, CI = 0.58–11.7, P = 0.21), PE-High_FMD (HR = 3.18, CI = 0.76–13.3, P = 0.11), and PR-Low_FMD (HR = 5.44, CI = 1.55–19.1, P = 0.008) groups. FMD is likely to have a prognostic impact on patients with ACS, which might vary depending on the culprit lesion.

Newer-generation drug-eluting stents (DES) that combine ultrathin struts and nanocoating (biodegradable polymer sirolimus-eluting stents, BP-SES) could improve vascular healing in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) over previous DES. However, its time course has not been elucidated.Patients with STEMI caused by plaque rupture who underwent primary PCI at our institution using BP-SES between June 2018 and August 2020 were eligible. Vascular responses were assessed by frequency-domain optical coherence tomography (OCT), which was serially performed before the final angiography (post-PCI), after 2 weeks (2W-OCT) and 1 year (1Y-OCT).A total of 24 patients with STEMI were finally assessed. The percentage of uncovered struts declined significantly at 1 year (post-PCI 61.7 ± 20.0%; 1Y-OCT 3.3 ± 3.3%; P < 0.0001). The percentage of malapposed struts also decreased significantly (% malapposed struts: post-PCI; 4.1 ± 3.6%: 1Y-OCT; 1.0 ± 2.3%, P< 0.0001). On the other hand, a total of 9 patients (37.5%) had at least 1 portion (> 3 mm length) of persistent malapposition (16.7%), late acquired malapposition (4.2%), or coronary evagination (16.7%) at 1 year. The site of late acquired malapposition was mostly at the culprit site, while the sites of persistent malapposition and evagination were not. None of the lesions showed signs of stent thrombosis.In conclusion, BP-SES implanted into culprit plaque ruptures in patients with STEMI showed fast vascular healing in the chronic phase, while subclinical malappositions and evaginations were not rare and showed dynamic changes.

Background: In patients presenting with acute coronary syndromes (ACS), impaired coronary blood flow (CBF) after percutaneous coronary interventions (PCI) is linked to mortality. We developed a novel angiography‐based approach for blood flow quantification using automatic contrast bolus tracking. Therefore, this study aimed to investigate the clinical impact of angiography‐based blood flow quantification on major adverse cardiovascular events (MACE) after PCI in patients with ACS. Methods: Prospective, multicenter, nested case–control study of patients presenting ACS. A propensity score was used to match patients with and without MACE at 1 year of follow‐up. MACE was defined as cardiovascular death, myocardial infarction, hospitalization for heart failure, or ischemia‐driven revascularization. CBF was measured automatically from angiograms after PCI. Results: One hundred sixty‐two patients were included. The mean age was 68.3±13.0 years, 83% were male, and 33% had diabetes. Overall, 66% of patients presented with ST‐segment–elevation myocardial infarction. CBF after PCI was lower after ST‐segment–elevation myocardial infarction compared with other clinical presentations (74.1±47.0 mL/min ST‐segment–elevation myocardial infarction, 89.1±45.8 mL/min, non‐ST‐segment–elevation myocardial infarction, 95.7±48.8 mL/min, unstable angina, P =0.046). Patients with low post‐PCI CBF (P =0.001). Conclusions: After PCI, automatic quantification of CBF using angiography was associated with MACE in patients with ACS. Risk stratification using post‐PCI CBF‐derived angiography may enable tailored management strategies for individuals with ACS.