Major bleeding after percutaneous coronary intervention (PCI) is associated with increased mortality. Therefore, assessing major bleeding risk before the procedure is essential. According to the European Society of Cardiology guidelines, early switching to oral anticoagulant (OAC) monotherapy should be considered in high-bleeding-risk patients requiring OAC therapy and not having a high ischemic risk. However, no standardized assessment tools for predicting bleeding risk have been established in those patients. Moreover, since OAC utilization is included as a criterion for bleeding risk criteria in the Academic Research Consortium for high bleeding risk (ARC-HBR), many patients with atrial fibrillation (AF) are stratified as high-bleeding risk. This suggests that the ARC-HBR may not provide sufficient risk stratification in AF patients undergoing PCI. The Direct Oral Anticoagulant (DOAC) score was recently developed to predict bleeding events in patients with AF. However, its clinical implications in patients with AF undergoing PCI remain unclear. This study aims to evaluate the predictive value of the DOAC score for major bleeding risk in patients with AF undergoing PCI. The present study was a retrospective analysis of data from the SAKURA PCI2 Antithrombotic Registry, a multicenter prospective observational study. A total of 140 patients with AF underwent PCI between June, 2020 and September, 2022 were analyzed in the present study. Based on previous reports, patients with AF were stratified into a very high-risk (VHR) group (DOAC score ≥10) or a non-very high-risk (non-VHR) group (DOAC score <10). The primary outcome was defined as major bleeding within one year. The secondary outcome was defined as all-cause mortality within one year. A total of 140 patients were analyzed. The mean age was 75.4 ± 9.6 years old, and the prevalence of high-bleeding risk as defined by the ARC-HBR was 94.2%. Among the study participants, 53(37.9%) were assigned to a VHR group and 87(62.1%) to a non-VHR group. Patients with VHR had higher rates of one-year major bleeding than those with non-VHR (10.2% vs. 1.2%, log-rank p= 0.02). All-cause mortality within one year tended to be higher in patients with VHR than those with non-VHR (11.3% vs. 3.5%, log-rank p= 0.07). In the Receiver Operating Characteristic curve analysis for predicting major bleeding, the DOAC score had the largest area under the curve compared to the ARC-HBR and HAS-BLED score (0.779 vs. 0.662 vs. 0.535, p = 0.016). Patients with AF classified as VHR were associated with one-year major bleeding. The DOAC score may be useful information for assessing major bleeding risk in patients with AF undergoing PCI and for guiding the optimal timing of switching to OAC monotherapy in clinical practice.Kaplan-Meyer curves for bleeding

The immunonutritional status, as assessed by the hemoglobin, albumin, lymphocyte, and platelet (HALP) score, has been linked to poor prognosis in various cancer patients. However, the clinical implications of the HALP score remain unclear in cancer patients undergoing percutaneous coronary intervention (PCI). This study aimed to clarify the association between the HALP score and clinical prognosis in cancer patients undergoing PCI. We retrospectively analyzed 709 patients who underwent PCI from June 2020 to July 2022 in the SAKURA PCI2 Antithrombotic Registry, a prospective multicenter registry. Cancer patients were stratified into high or low HALP score groups based on an optimal cut-off value of 51.3. The primary outcome was defined as two-year all-cause mortality. Of the study participants, 99 patients (14.0%) had a cancer history. Cancer patients had significantly lower HALP scores than noncancer patients (57.0 [34.2-83.3] vs. 72.1 [45.5-108.0], p<0.01). Cancer patients with a low HALP score had higher mortality than those with a high HALP score and noncancer patients (35.4% vs. 9.7%. vs. 7.6%, p< 0.01). Compared to noncancer patients, Cancer patients with a low HALP score had a 3.11-fold increased risk of mortality (adjusted HR 3.11, 95%CI 1.67-5.78, p<0.01), whereas those with a high HALP score had a similar risk (adjusted HR 1.44, 95%CI 0.56-3.69, p=0.45). In the cancer patient cohort, a decrease in the HALP score was associated with mortality (adjusted HR 1.02, 95%CI 1.00-1.04, p=0.03). A low HALP score in cancer patients was associated with an increased risk of two-year mortality. Therefore, the HALP score may provide valuable information for risk stratification in cancer patients undergoing PCI.Outcome

No-reflow phenomenon is a critical factor affecting the acute-phase treatment outcomes of acute myocardial infarction (AMI). Despite being an independent predictor of mortality following percutaneous coronary intervention (PCI), predicting slow flow/no-reflow phenomenon during PCI remains challenging. Mechanical stimulation of vulnerable plaques can cause fragmentation of plaque components, such as thrombi, lipids, and inflammatory cells, which may embolize peripheral arteries and lead to slow flow/no-reflow phenomenon. Cholesterol crystals are known to be released into the bloodstream from ruptured vulnerable plaques and are increasingly recognized as markers of plaque rupture. A novel technique, the filter paper rinse method, has recently been reported as a means to detect cholesterol crystals in coronary artery blood samples. However, no studies have evaluated the relationship between the detection rate of cholesterol crystals in blood samples aspirated from culprit lesions in AMI and the frequency of slow flow/no-reflow phenomenon. To investigate the association between the detection rate of cholesterol crystals in culprit lesions of AMI and the frequency of slow flow/no-reflow phenomenon. This study analyzed 90 consecutive AMI patients admitted to the Cardiac Care Unit (CCU) of our hospital. Blood samples aspirated from culprit lesions were examined for the presence of cholesterol crystals using the filter paper rinse method. Cholesterol crystals were detected in 35 cases. Patients with detected cholesterol crystals were older and had a significantly higher incidence of slow flow/no-reflow phenomenon compared to those without cholesterol crystals (p = 0.014, p = 0.043, respectively). Additionally, positive remodeling on intravascular ultrasound (IVUS) and the presence of thrombi in blood samples were more frequently observed in the cholesterol crystal-positive group (p < 0.001, p < 0.001, respectively). Univariate analysis identified positive remodeling on IVUS, the presence of thrombi in blood samples, and the presence of cholesterol crystals as predictors of slow flow/no-reflow phenomenon (p = 0.032, p = 0.018, p < 0.001, respectively). Multivariate analysis revealed that among these factors, only the presence of cholesterol crystals was an independent predictor of slow flow/no-reflow (p = 0.006). The detection of cholesterol crystals using the filter paper rinse method may serve as a valuable tool for assessing the characteristics of culprit lesions in AMI, which conventional methods cannot evaluate. Furthermore, the presence of cholesterol crystals in blood samples aspirated from culprit lesions may play a crucial role in guiding treatment strategies for acute myocardial infarction.Cholesterol crystal from a blood sample

Abstract Background/Introduction Coronary microvascular dysfunction (CMD) is a condition in which the distal microvasculature is compromised, resulting in inadequate blood flow to the subsequent arteries and myocardial ischemia. Index of microvascular resistance (IMR), which can quantify CMD, is becoming the standard for the diagnosis of CMD. Patients with CMD have a 4 to 5 times greater risk of cardiovascular death and myocardial infarction than patients without heart disease and similar cardiovascular risk. Early diagnosis of CMD may reduce cardiovascular risk and improve quality of life with therapeutic intervention. Pericoronary adipose tissue mean attenuation (PCATMA) is an indirect measure of adipocyte size and lipid content around coronary artery, reflecting inflammation status. Previous studies have shown that both PCATMA and CMD are associated with the functional severity of coronary artery disease, but no study has yet examined the relationship between PCATMA and CMD. Purpose We conducted a study comparing PCATMA in patients with and without CMD. Methods Between September 2022 and October 2023, 25 patients without significant stenosis (<50% stenosis) who underwent IMR measurement on invasive coronary angiography and coronary CT angiography (CCTA) were included. CMD was diagnosed when the IMR exceeded 25 as measured by a pressure wire inserted into the left anterior descending artery after invasive coronary angiography had excluded significant stenosis. PCATMA was measured on CCTA using the average of the values of right coronary artery, left anterior descending artery, and left circumflex artery. Multivariable logistic regression analysis with stepwise forward selection was used to assess predictors for patients with abnormal IMR. The following variables were included for adjustment: PCATMA, age, sex, diabetes, dyslipidemia, hypertension. Results The mean age of 25 patients in this study was 63 years, 48.0% were female, 29.2% had diabetes, 62.5% had dyslipidemia and 66.7% had hypertension. PCATMA was significantly higher in patients with abnormal IMR (IMR>25) (-79.6 [IQR: -82.1, -74.6] HU vs -86.3 [IQR: -89.8, -78.9] HU, p = 0.043). Multivariate logistic regression analysis demonstrated that PCATMA remained an independent predictor of patients with abnormal IMR (OR 1.27 [95% CI: 1.05–1.65], p = 0.039). Optimal cut-off value of PCATMA for predicting patients with abnormal IMR by Youden index was -82.1 HU (AUC = 0.75 [95% CI: 0.55-0.95]). Conclusions In patients without significant coronary artery stenosis, PCATMA on CCTA may be used to predict the patients with CMD, noninvasively.

Abstract Background Hepatorenal function is a prognostic predictor for heart failure, cardiac surgery, and transcatheter intervention for structural heart disease. However, the clinical implications of hepatorenal function assessed by the Model for End-stage Liver Disease eXcluding International normalized ratio (MELD-XI) score is still unclear in patients undergoing percutaneous coronary intervention (PCI). Purpose This study aimed to clarify the association between clinical prognosis and the MELD-XI score. Methods We analyzed 993 patients who underwent PCI from June 2020 to July 2022 in the SAKURA PCI2 registry, a prospective multicenter registry. Patients were stratified into high (>10) or low (≤10) MELD-XI scores. Primary outcome was defined as 2-year major adverse cardio or cerebrovascular event (MACCE), including all-cause death, ischemic stroke, and non-fatal myocardial infarction. Secondary outcome was defined as major bleeding according to the Bleeding Academic Research Consortium 3 or 5. Results Of study participating patients, 253 patients (25.5%) were stratified into a high MELD-XI score group and had a higher prevalence of the high bleeding risk than patients with a low MELD-XI score (92.5% vs. 53.7%, p<0.01). Patients with a high MELD-XI score were associated with MACCE (13.1% vs. 2.7%, p<0.01; adjusted HR 3.78, 95%CI 1.78-8.03, p<0.01) and major bleeding (4.0% vs. 1.3%, p<0.01: unadjusted HR 3.32, 95%CI 1.35-8.18, p=0.01). Moreover, these associations remained consistent in patients with chronic and acute coronary syndrome (MACCE, p for interaction=0.89; major bleeding; p for interaction=0.64). Conclusion A high MELD-XI score was associated with an increased risk of MACCE and major bleeding within two years. Therefore, the MELD-XI score could provide information for risk stratification in patients undergoing PCI.Outcomes

The Controlling Nutritional Status (CONUT) score is well known as a marker of nutritional status. Previous studies have reported that CONUT score could predict a prognosis of acute or chronic heart failure, and infective endocarditis. Takotsubo syndrome (TTS) is said to have a relatively good prognosis, but some patients have a bad turning point in hospital stay. Lower systolic blood pressure on admission, history of diabetes mellitus, and β-blocker use before admission have been reported as predictors of in-hospital cardiac complications. However, the prognostic utility of CONUT score in TTS is unclear. The aim of study was to evaluate duration of hospital stay and short-term clinical events with CONUT score in TTS. Seventy-nine TTS patients who were admitted to 3 medical centers in Japan between January 2011 and October 2019 were enrolled. The average age was 71.8±11.5 years old, and the prevalence of female sex was 81%. The CONUT score was calculated based on the serum albumin, total lymphocyte and total cholesterol on admission. We retrospectively investigated the association between the short-term clinical events and CONUT score. The duration of hospital stay was defined as the primely outcome, and all cause death and congestive heart failure in hospital stay as the secondary outcome. The average CONUT score was 3.7±3.0. A positive correlation was found between the CONUT score and the duration of hospital stay (r=0.56, p<0.01). Twenty (25.3%) patients suffered from clinical events (all cause death and congestive heart failure in hospital). Those patients with clinical events had significantly higher the CONUT score than those without (all cause death, 7.2±2.6 vs. 3.5±2.9, p<0.01, congestive heart failure, 5.3±3.4 vs. 3.3±2.8, p=0.02, composite clinical events, 5.8±3.2 vs. 3.0±2.6, p<0.01). ROC curve analysis revealed that the optimal cut-off value of the CONUT score for the prediction of composite clinical events was 4.0 (AUC: 0.75, sensitivity: 80%, Specificity: 64%). The patients with CONUT score of 4 or more (high COUNT score) were more prevalent in patients who experienced composite clinical events than in those who didn't (80% vs. 35.6%, p<0.01). The patients with a high CONUT score had a longer hospital stay and higher occurrence of composite clinical events than those with CONUT score less than 4 (respectively, 27.2±19.1 days vs. 13.8±8.3 days, p<0.01, 25.3% vs. 9.5%, p<0.01). The CONUT score in TTS patients was strongly associated with the duration of hospital stay and clinical events in hospital. The CONUT score is a simple indicator that can be calculated with only three factors. Therefore, the CONUT score on admission may be useful for a predictor of short-term clinical events in TTS patients. Type of funding source: None

Abstract Background Aortic calcification is associated with atherosclerotic risk factors and an increased risk of death and cardiovascular disease. However, the relationships aortic calcification and aortic plaque instability are not yet elucidated. Recently, some reports showed non-obstructive aortic angioscopy seemed to visualize atherosclerotic changes of aortic wall more clearly compared with computed tomography (CT). The purpose of this study was to evaluate whether aortic calcification is associated with aortic vulnerable plaques in patients with cardiovascular disease. Methods We investigated 60 consecutive patients with confirmed or suspected coronary artery disease who underwent both aortic angioscopy and CT. The AC volume (ACV) was measured using the volume-rendering method by extracting the area >130 HU within the whole aorta. ACV index (ACVI) was defined as ACV divided by the body surface area. We evaluated the number of ruptured plaque (RP), ulceration and fissure by aortic angioscopy in the whole aorta. We excluded 4 hemodialysis patients. All patients were divided into the median value of ACVI. Results The mean age of patients was 68±10. The median of ACVI was 10.7 ml/m2 [3.9–22.7]. High ACVI patients had significantly greater number of RP, ulceration and atheromatous plaques detected by aortic angioscopy compared with those of low ACVI (2.2±2.7 vs 0.8±1.1, p=0.033, 1.6±1.2 vs 0.9±1.0, p=0.041, 4.0±3.1 vs 1.9±1.8, p=0.009, respectively). Furthermore, the patients without aortic calcification did not have RP at all. In a multivariate model, the number of the atheromatous plaques was independently associated with high ACVI (odds ratio 1.57, 95% confidence interval 1.07–2.69, p=0.018) Conclusions Aortic calcification detected by CT was related to aortic vulnerable plaques in patients with cardiovascular disease.

Abstract Background Wall shear stress (WSS) has been considered as a major determinant of aortic atherosclerosis. Recently, non-obstructive general angioscopy (NOGA) was developed to be able to visualize a variety of its atherosclerotic pathology, including in vivo ruptured plaque (RP) in the aorta. We, therefore, investigated the relationship between NOGA derived RP in the aortic arch and the stereographic distribution of WSS by using computational fluid dynamics modeling (CFD) on three-dimensional CT angiography (3D-CT). Methods We investigated 30 consecutive patients who underwent 3D-CT before and NOGA during coronary angiography. WSS in the aortic arch was measured with an application of CFD based on finite element method by using uniform inlet and outlet flow conditions. Aortic RP was detected by NOGA. Results The maximum and mean values of WSS were 67.2±29.2 Pa and 2.4±0.6 Pa. A total of 18 RPs was detected by NOGA. The patients with a distinct RP showed a significantly higher maximum WSS in the whole aortic arch, and the greater and lesser curvature of the aortic arch than those without it (73.3±29.0 Pa vs 50.4±15.2 Pa, p=0.035, 95.0±27.5 Pa vs 42.8±25.2 Pa, p=0.003, 70.8±29.3 Pa vs 46.1±11.9 Pa, p=0.013, respectively), whereas there was no significant difference in the mean WSS between those with and without it. In a multivariate analysis, the maximum value of WSS was an independent predictor of RP in the aortic arch (odds ratio 1.05, 95% confidence interval 1.01–1.13, p=0.019). Representative picture of WSS and NOGA Conclusions Aortic RP detected by NOGA was strongly associated with the higher maximum WSS in the aortic arch derived by CFD using 3D-CT. Maximum WSS may explain the underlying mechanism of not only aortic atherosclerosis, but also aortic RP.

Background and Purpose: It has been documented that neovascularization in atherosclerotic plaques is associated with plaque vulnerability. This study was to examine tissue characteristics of plaque with micro-channels detected by optical coherence tomography (OCT). The tissue was assessed by use of a commercially available color-coded intravascular ultrasound (IVUS), iMap software. Method: A total of 61 coronary plaques was classified into two groups: plaques with micro-channels (Pm, n=37) and without (Po, n=24). Micro-channel was defined as a tiny tubule with a diameter of 50 to 300 micrometers detected over 3 or more frames in OCT. Plaques over a length of 5mm were also analyzed by IVUS at the corresponded portion of the OCT imaging. The i-Map software identified four types of tissue component such asfibrotic, lipidic, necrotic, and calcified areas. Result: There was no significant difference in plaque and vessel volume between the two groups. However, % content of fibrotic area was significantly smalle...

Background: Various reports have been documented for comparison between paxclitaxel-eluting stent (PES) and everolimus-eluting stent (EES) in terms of the degree or charactetristics of neointima coverage or late thrombosis. However, the comparison studies between PES and EES have not been performed on the same stent platform.Method: A total of 38 consecutive patients (male: 29 patients, 67.7±10.0 years old) who underwent PES or EES implantation between November 2011 and Jun 2012 were imaged by coronary angioscopy (PES:Taxus Element™, 22 lesions vs. EES:Promus Element™ 26 lesions) at the baseline and the follow-up period. The follow-up duration was 8.4±1.4 months. Coverage grade of neointima as well as yellow grade of intima (residual plaque or neointima) were semi-quantitatively determined by angioscopy with a grade of 0 to 3. (Coverage grade: none=0, fully covered=3, Yellow grade: whitest=0, yellowest=3).Results: Prevalence of yellow residual plaques (yellow grade ≥ 1) and its yellow grade of residual plaque under the stents were similar between 2 groups at baseline (EES group: 42.9% vs. PES group: 31.6%, p=0.46, 0.8±0.2 vs. 0.4±0.2, p=0.24). The coverage grade of neointima were similar (1.5±0.2 vs. 1.7±0.1, p=0.94) at follow-up. Prevalence of yellow intima (yellow grade ≥1) plaques and the yellow grade of intima were similar between 2 groups at follow-up (59.1% vs. 50%, p=0.53, 0.8±0.2 vs. 0.8±0.2, p=0.84). Incidence of thombus formation was higher in PES group than EES group (4.6% vs. 53.7%, p<0.01). The thrombi were observed frequently over the yellow intima in PES group. Incidence of target lesion revascularization was similar between 2 groups (0% vs. 7.7%, p=0.50).Conclusion: The comparison study on the basis of the same stent platfrom revealed that everolimus and paclitaxel provided similar grade of coverage and yellowness of intima. However, paclitaxel showed higher incidence of thrombus formation than everolimus. This study suggested that paclitaxel might cause higher thrombogenicity than everolimus.