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  • 1
    Online Resource
    Online Resource
    Prognostic Impact of Coronary Flow Reserve in Patients With Reduced Left Ventricular Ejection Fraction
    Ovid Technologies (Wolters Kluwer Health) ; 2022
    In:  Journal of the American Heart Association Vol. 11, No. 15 ( 2022-08-02)
    Details
    In: Journal of the American Heart Association, Ovid Technologies (Wolters Kluwer Health), Vol. 11, No. 15 ( 2022-08-02)
    Abstract: Intracoronary physiologic indexes such as coronary flow reserve (CFR) and left ventricular ejection fraction (LVEF) have been regarded as prognostic indicators in patients with coronary artery disease. The current study evaluated the association between intracoronary physiologic indexes and LVEF and their differential prognostic implications in patients with coronary artery disease. Methods and Results A total of 1889 patients with 2492 vessels with available CFR and LVEF were selected from an international multicenter prospective registry. Baseline physiologic indexes were measured by thermodilution or Doppler methods and LVEF was recorded at the index procedure. The primary outcome was target vessel failure, which was a composite of cardiac death, target vessel myocardial infarction, or clinically driven target vessel revascularization over 5 years of follow‐up. Patients with reduced LVEF 〈 50% (162 patients [8.6%], 202 vessels [8.1%] ) showed a similar degree of epicardial coronary artery disease but lower CFR values than those with preserved LVEF (2.4±1.2 versus 2.7±1.2, P 〈 0.001), mainly driven by the increased resting coronary flow. Conversely, hyperemic coronary flow, fractional flow reserve, and the degree of microvascular dysfunction were similar between the 2 groups. Reduced CFR (≤2.0) was seen in 613 patients (32.5%) with 771 vessels (30.9%). Reduced CFR was an independent predictor for target vessel failure (hazard ratio, 2.081 [95% CI, 1.385–3.126], P 〈 0.001), regardless of LVEF. Conclusions CFR was lower in patients with reduced LVEF because of increased resting coronary flow. Patients with reduced CFR showed a significantly higher risk of target vessel failure than did those with preserved CFR, regardless of LVEF. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04485234.
    Type of Medium: Online Resource
    ISSN: 2047-9980
    URL: Article
    DOI: 10.1161/JAHA.122.025841
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2022
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  • 2
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    Clinical Relevance of Ischemia with Nonobstructive Coronary Arteries According to Coronary Microvascular Dysfunction
    Ovid Technologies (Wolters Kluwer Health) ; 2022
    In:  Journal of the American Heart Association Vol. 11, No. 9 ( 2022-05-03)
    Details
    In: Journal of the American Heart Association, Ovid Technologies (Wolters Kluwer Health), Vol. 11, No. 9 ( 2022-05-03)
    Abstract: In the absence of obstructive coronary stenoses, abnormality of noninvasive stress tests (NIT) in patients with chronic coronary syndromes may indicate myocardial ischemia of nonobstructive coronary arteries (INOCA). The differential prognosis of INOCA according to the presence of coronary microvascular dysfunction (CMD) and incremental prognostic value of CMD with intracoronary physiologic assessment on top of NIT information remains unknown. Methods and Results From the international multicenter registry of intracoronary physiologic assessment (ILIAS [Inclusive Invasive Physiological Assessment in Angina Syndromes] registry, N=2322), stable patients with NIT and nonobstructive coronary stenoses with fractional flow reserve 〉 0.80 were selected. INOCA was diagnosed when patients showed positive NIT results. CMD was defined as coronary flow reserve ≤2.5. According to the presence of INOCA and CMD, patients were classified into 4 groups: group 1 (no INOCA nor CMD, n=116); group 2 (only CMD, n=90); group 3 (only INOCA, n=41); and group 4 (both INOCA and CMD, n=40). The primary outcome was major adverse cardiovascular events, a composite of all‐cause death, target vessel myocardial infarction, or clinically driven target vessel revascularization at 5 years. Among 287 patients with nonobstructive coronary stenoses (fractional flow reserve=0.91±0.06), 81 patients (38.2%) were diagnosed with INOCA based on positive NIT. By intracoronary physiologic assessment, 130 patients (45.3%) had CMD. Regardless of the presence of INOCA, patients with CMD showed a significantly lower coronary flow reserve and higher hyperemic microvascular resistance compared with patients without CMD ( P 〈 0.001 for all). The cumulative incidence of major adverse cardiovascular events at 5 years were 7.4%, 21.3%, 7.7%, and 34.4% in groups 1 to 4. By documenting CMD (groups 2 and 4), intracoronary physiologic assessment identified patients at a significantly higher risk of major adverse cardiovascular events at 5 years compared with group 1 (group 2: adjusted hazard ratio [HR adjusted ], 2.88; 95% CI, 1.52–7.19; P =0.024; group 4: HR adjusted , 4.00; 95% CI, 1.41–11.35; P =0.009). Conclusions In stable patients with nonobstructive coronary stenoses, a diagnosis of INOCA based only on abnormal NIT did not identify patients with higher risk of long‐term cardiovascular events. Incorporating intracoronary physiologic assessment to NIT information in patients with nonobstructive disease allowed identification of patient subgroups with up to 4‐fold difference in long‐term cardiovascular events. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04485234.
    Type of Medium: Online Resource
    ISSN: 2047-9980
    URL: Article
    DOI: 10.1161/JAHA.121.025171
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2022
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  • 3
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    Impaired Coronary Autoregulation Is Associated With Long-term Fatal Events in Patients With Stable Coronary Artery Disease
    Ovid Technologies (Wolters Kluwer Health) ; 2013
    In:  Circulation: Cardiovascular Interventions Vol. 6, No. 4 ( 2013-08), p. 329-335
    Details
    In: Circulation: Cardiovascular Interventions, Ovid Technologies (Wolters Kluwer Health), Vol. 6, No. 4 ( 2013-08), p. 329-335
    Abstract: Abnormalities in the coronary microcirculation are increasingly recognized as an elementary component of ischemic heart disease, which can be accurately assessed by coronary flow velocity reserve in reference vessels (refCFVR). We studied the prognostic value of refCFVR for long-term mortality in patients with stable coronary artery disease. Methods and Results— We included patients with stable coronary artery disease who underwent intracoronary physiological evaluation of ≥1 coronary lesion of intermediate severity between April 1997 and September 2006. RefCFVR was assessed if a coronary artery with 〈 30% irregularities was present. RefCFVR 〉 2.7 was considered normal. Patients underwent revascularization of all ischemia-causing lesions. Long-term follow-up was performed to document the occurrence of (cardiac) mortality. RefCFVR was determined in 178 patients. Kaplan–Meier estimates of 12-year all-cause mortality were 16.7% when refCFVR 〉 2.7 and 39.6% when refCFVR ≤2.7 ( P 〈 0.001), whereas Kaplan–Meier estimates for cardiac mortality were 7.7% when refCFVR 〉 2.7 and 31.6% when refCFVR ≤2.7 ( P 〈 0.001). After multivariable adjustment, refCFVR ≤2.7 was associated with a 2.24-fold increase in all-cause mortality hazard (hazard ratio, 2.24; 95% confidence interval, 1.13–4.44; P =0.020) and a 3.32-fold increase in cardiac mortality hazard (hazard ratio, 3.32; 95% confidence interval, 1.27–8.67; P =0.014). Impairment of refCFVR originated from significantly higher baseline flow velocity in the presence of significantly lower reference vessel baseline microvascular resistance ( P 〈 0.001), indicating impaired coronary autoregulation as its cause. Conclusions— In patients with stable coronary artery disease, impaired refCFVR, resulting from increased baseline flow velocity indicating impaired coronary autoregulation, is associated with a significant increase in fatal events at long-term follow-up.
    Type of Medium: Online Resource
    ISSN: 1941-7640 , 1941-7632
    URL: Article
    DOI: 10.1161/CIRCINTERVENTIONS.113.000378
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2013
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  • 4
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    Physiological Basis and Long-Term Clinical Outcome of Discordance Between Fractional Flow Reserve and Coronary Flow Velocity Reserve in Coronary Stenoses of Intermediate Severity
    Ovid Technologies (Wolters Kluwer Health) ; 2014
    In:  Circulation: Cardiovascular Interventions Vol. 7, No. 3 ( 2014-06), p. 301-311
    Details
    In: Circulation: Cardiovascular Interventions, Ovid Technologies (Wolters Kluwer Health), Vol. 7, No. 3 ( 2014-06), p. 301-311
    Abstract: Discordance between fractional flow reserve (FFR) and coronary flow velocity reserve (CFVR) may reflect important coronary pathophysiology but usually remains unnoticed in clinical practice. We evaluated the physiological basis and clinical outcome associated with FFR/CFVR discordance. Methods and Results— We studied 157 intermediate coronary stenoses in 157 patients, evaluated by FFR and CFVR between April 1997 and September 2006 in which revascularization was deferred. Long-term follow-up was performed to document the occurrence of major adverse cardiac events: cardiac death, myocardial infarction, or target vessel revascularization. Discordance between FFR and CFVR occurred in 31% and 37% of stenoses at the 0.75, and 0.80 FFR cut-off value, respectively, and was characterized by microvascular resistances during basal and hyperemic conditions. Follow-up duration amounted to 11.7 years (Q1–Q3, 9.9–13.3 years). Compared with concordant normal results of FFR and CFVR, a normal FFR with an abnormal CFVR was associated with significantly increased major adverse cardiac events rate throughout 10 years of follow-up, regardless of the FFR cut-off applied. In contrast, an abnormal FFR with a normal CFVR was associated with equivalent clinical outcome compared with concordant normal results: ≤3 years when FFR 〈 0.75 was depicted abnormal and throughout 10 years of follow-up when FFR ≤0.80 was depicted abnormal. Conclusions— Discordance of CFVR with FFR originates from the involvement of the coronary microvasculature. Importantly, the risk for major adverse cardiac events associated with FFR/CFVR discordance is mainly attributable to stenoses where CFVR is abnormal. This emphasizes the requirement of intracoronary flow assessment in addition to coronary pressure for optimal risk stratification in stable coronary artery disease.
    Type of Medium: Online Resource
    ISSN: 1941-7640 , 1941-7632
    URL: Article
    DOI: 10.1161/CIRCINTERVENTIONS.113.001049
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2014
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  • 5
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    Abstract 2000: Incomplete ST-Segment Deviation Resolution after Primary Percutaneous Coronary Intervention in Patients with Multivessel Disease is Mainly Due to the Presence of a Non-Infarct-Related Chronic Total Occlusion
    Ovid Technologies (Wolters Kluwer Health) ; 2008
    In:  Circulation Vol. 118, No. suppl_18 ( 2008-10-28)
    Details
    In: Circulation, Ovid Technologies (Wolters Kluwer Health), Vol. 118, No. suppl_18 ( 2008-10-28)
    Abstract: Background Incomplete ST-segment deviation resolution (STR) after epicardial flow restoration may represent microvascular dysfunction and predicts an unfavorable outcome in patients with ST-segment elevation myocardial infarction (STEMI). From recently published data concerning STEMI patients that underwent primary percutaneous coronary intervention (PCI), increased mortality in patients with multivessel disease (MVD) was attributed to the presence of a chronic total occlusion (CTO) in a non-infarct-related artery (IRA). We evaluated whether the presence of MVD with or without a CTO in a non-IRA significantly contributes to incomplete STR in a large cohort of patients undergoing primary PCI for STEMI. Methods In this single-center study, 2127 STEMI patients underwent primary PCI between 2000 and 2006. The IRA and presence of MVD was determined during diagnostic angiography preceding primary PCI. MVD was assessed if ≥ 1 non-IRA showed ≥ 1 coronary stenosis of ≥ 70% and a CTO was defined as a 100% luminal narrowing in a non-IRA. STR was defined as the relative difference (in %) of the summed ST deviation between the pre-PCI and the immediately post-PCI 12-lead ECG. A post-PCI STR of ≥ 70% was considered complete. Results During emergency coronary angiography, singlevessel disease (SVD) was observed in 1474 (69.3 %) patients, MVD without a CTO in 433 (20.4 %) patients, and MVD with a CTO in a non-IRA in 220 (10.3 %) patients. MVD patients less frequently showed complete STR compared to patients with SVD (OR 1.2 95% CI, 1.0 – 1.5 p = 0.046). However, the occurrence of complete STR in SVD patients and MVD patients without a CTO was comparable (OR 1.1, 95% CI, 0.9 – 1.4 p = 0.43). In MVD patients with a CTO, STR was significantly less often complete compared to patients with SVD or with MVD without a CTO (OR 1.6 95% CI, 1.1 – 2.6 p = 0.01). Conclusion STEMI patients with MVD undergoing primary PCI showed complete STR less often compared to SVD patients. This effect is mainly due to a subgroup of MVD patients with a CTO in a non-IRA and not due to mere MVD.
    Type of Medium: Online Resource
    ISSN: 0009-7322 , 1524-4539
    URL: Article
    DOI: 10.1161/circ.118.suppl_18.S_654-a
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2008
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  • 6
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    Abstract 4491: One-Year Clinical Outcome of a Real World Experience in Patients Treated with a Genous ™ EPC Capturing Stent
    Ovid Technologies (Wolters Kluwer Health) ; 2008
    In:  Circulation Vol. 118, No. suppl_18 ( 2008-10-28)
    Details
    In: Circulation, Ovid Technologies (Wolters Kluwer Health), Vol. 118, No. suppl_18 ( 2008-10-28)
    Abstract: Background Clinical trials of drug-eluting stenting (DES) have demonstrated a marked reduction in the incidence of restenosis compared to bare metal stents. However, concerns have risen regarding the long-term safety of DES. The Endothelial Progenitor Cell (EPC)-capturing stent is coated with an antibody (CD34+) that binds circulating EPCs which differentiate into a functional endothelial layer. This accelerated healing may reduce in-stent restenosis by reducing neointimal hyperplasia and smooth muscle cell proliferation and, in addition, may prevent stent thrombosis(ST). In this single center study, we report the 1-year clinical outcome in patients treated with an EPC-capturing stent. Methods Between September 2005 and March 2007, 257 patients were treated with an EPC-capturing stent for coronary artery stenosis and 236 patients had completed 1-year follow-up. Dual anti-platelet therapy was prescribed for at least 1 month. Results Mean age of the population was 65 years, 72% were male, and 14% were diabetic patients. Three patients had a contra-indication for treatment with a DES, receiving only 2 weeks of clopidogrel post-PCI. A total of 282 lesions were treated of which 252 lesions were treated with an EPC-capturing stent. Of the lesions treated with an EPC-capturing stent, 64% were type B2 or C lesions according to ACC/AHA classification, 16% were CTO and 23% were bifurcated lesions, reflecting daily practice. Mean stent length was 25.13±12.02 mm and mean stent diameter was 3.27±0.36 mm. At 1-year clinical follow-up, 3.0% of the patients died of which 0.8% died from a cardiac cause, and 2.5% of all patients suffered a myocardial infarction. Target vessel revascularization was 9.7% and definite ST was 1.2% (occurring within 24 hours, at 7, and 18 days respectively). At 1-year clinical follow-up the cumulative MACE rate was 11.4%. Conclusion In this single center study, PCI of predominantly complex lesions with a Genous ™ EPC-capturing stent shows excellent 1-year clinical outcomes. Furthermore, using this stent avoids the need for long-term dual anti-platelet therapy.
    Type of Medium: Online Resource
    ISSN: 0009-7322 , 1524-4539
    URL: Article
    DOI: 10.1161/circ.118.suppl_18.S_899-b
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2008
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  • 7
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    Timing of Mortality After Severe Bleeding and Recurrent Myocardial Infarction in Patients With ST-Segment–Elevation Myocardial Infarction
    Ovid Technologies (Wolters Kluwer Health) ; 2013
    In:  Circulation: Cardiovascular Interventions Vol. 6, No. 4 ( 2013-08), p. 391-398
    Details
    In: Circulation: Cardiovascular Interventions, Ovid Technologies (Wolters Kluwer Health), Vol. 6, No. 4 ( 2013-08), p. 391-398
    Abstract: The prognosis of initial survivors of ST-segment–elevation myocardial infarction (STEMI) is affected by both recurrent myocardial infarction (MI) and severe bleeding. The aim of the current study was to investigate how mortality is affected in time after bleeding and recurrent MI. Methods and Results— From January 1, 2003, to July 31, 2008, a total of 2002 patients were treated with primary percutaneous coronary intervention for ST-segment–elevation MI and followed up for the occurrence of recurrent MI and Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Arteries (GUSTO) severe bleeding. Primary outcome was all-cause mortality within 4 years of follow-up. In a time-dependent, covariate-adjusted Cox regression model, both bleeding and recurrent MI were associated with an increase in mortality shortly after the adverse event: hazard ratio, 14.37 (95% confidence interval [CI], 7.69–26.84) for the first day after recurrent MI and 5.42 (95% CI, 2.88–10.22) for the first day after bleeding. Thereafter the risk of subsequent mortality gradually decreased but remained elevated long after a recurrent MI (hazard ratio, 4.95 [95% CI, 3.27–7.48] between 1 day and 1 year after recurrent MI and hazard ratio, 2.56 [95% CI, 1.56–4.21] beyond 1 year after recurrent MI), but decreased to nonsignificant level beyond 1 month after the bleeding (hazard ratio, 0.56 [95% CI, 0.27–1.14] ). Conclusions— The occurrence of both recurrent MI and bleeding in the first year after ST-segment–elevation MI is associated with subsequent mortality. The risk implication of recurrent MI, however, was greater and more sustained over time than that of severe bleeding.
    Type of Medium: Online Resource
    ISSN: 1941-7640 , 1941-7632
    URL: Article
    DOI: 10.1161/CIRCINTERVENTIONS.113.000425
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2013
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  • 8
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    Plasma glucose and not hemoglobin or renal function predicts mortality in patients with STEMI complicated with cardiogenic shock
    Ovid Technologies (Wolters Kluwer Health) ; 2010
    In:  Journal of Cardiovascular Medicine Vol. 11, No. 11 ( 2010-11), p. 827-831
    Details
    In: Journal of Cardiovascular Medicine, Ovid Technologies (Wolters Kluwer Health), Vol. 11, No. 11 ( 2010-11), p. 827-831
    Type of Medium: Online Resource
    ISSN: 1558-2027
    URL: Article
    DOI: 10.2459/JCM.0b013e32833cdc6d
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2010
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  • 9
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    Presence of Older Thrombus Is an Independent Predictor of Long-Term Mortality in Patients With ST-Elevation Myocardial Infarction Treated With Thrombus Aspiration During Primary Percutaneous Coronary Intervention
    Ovid Technologies (Wolters Kluwer Health) ; 2008
    In:  Circulation Vol. 118, No. 18 ( 2008-10-28), p. 1810-1816
    Details
    In: Circulation, Ovid Technologies (Wolters Kluwer Health), Vol. 118, No. 18 ( 2008-10-28), p. 1810-1816
    Abstract: Background— Routine thrombus aspiration is frequently used during primary percutaneous coronary intervention in patients with ST-elevation myocardial infarction to prevent distal embolization. Recently, evidence of clinical benefit was published. In 50% of the ST-elevation myocardial infarction patients with an onset of symptoms 〈 12 hours before, thrombi were shown to be 〉 1 day old. This observation illustrates that plaque rupture and coronary occlusion are significantly separated in time. In the present study, we correlate the presence of fresh versus older thrombus with long-term mortality. Methods and Results— Thrombus aspiration was performed in 1315 patients treated with primary percutaneous coronary intervention with 3 devices (Rescue, Export, and Proxis). Aspirated material was fixed in formalin and processed for histopathology. If possible, thrombus age was classified as either fresh only ( 〈 1 day) or older ( 〉 1 day). We identified fresh thrombus in 552 patients and older thrombus in 372 patients. The cumulative Kaplan-Meier estimate of all-cause mortality at 4 years was significantly higher in patients with older thrombus (16.0%) compared with patients with fresh thrombus (7.4%), with a hazard ratio of 1.82 (95% confidence interval, 1.17 to 2.85; P =0.008). Multivariate analysis identified the presence of older thrombus, in addition to other established predictors, as an independent predictor (hazard ratio, 1.83; 95% confidence interval, 1.14 to 2.93; P =0.01) of long-term mortality. Conclusion— Our study demonstrates that the presence of older thrombus, in addition to other established predictors, is an independent predictor of long-term mortality in patients with ST-elevation myocardial infarction treated with thrombus aspiration during primary percutaneous coronary intervention.
    Type of Medium: Online Resource
    ISSN: 0009-7322 , 1524-4539
    URL: Article
    DOI: 10.1161/CIRCULATIONAHA.108.780734
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2008
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  • 10
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    Abstract 5582: Impact of a Concurrent Chronic Total Occlusion on Long-term Mortality in Hospital Survivors after ST Elevation Myocardial Infarction
    Ovid Technologies (Wolters Kluwer Health) ; 2008
    In:  Circulation Vol. 118, No. suppl_18 ( 2008-10-28)
    Details
    In: Circulation, Ovid Technologies (Wolters Kluwer Health), Vol. 118, No. suppl_18 ( 2008-10-28)
    Abstract: Background: Patients with multivessel disease (MVD) constitute a patient group with a high risk of mortality after STEMI. Recently, it was reported that the higher mortality in patients with MVD is determined by the presence of a chronic total occlusion (CTO) in a noninfarct-related artery. Due to the higher risk profile, the in-hospital mortality rate accounted for this unfavorable outcome, moreover, multivariate analysis did not correct for residual left ventricular ejection fraction (LVEF). Therefore, we studied the effect of a concurrent CTO on long-term mortality, excluding deaths in the first 30 days and correcting for LVEF. Methods: Between 1997 and 2005, we admitted 3309 patients with STEMI treated with primary PCI. We categorized patients as having single vessel disease (SVD), MVD without CTO and CTO based on the angiogram before PCI. LVEF was assessed with echocardiography by global assessment of ejection fraction within 30 days after primary PCI and classified as ≤40% or 〉 40%. Stepwise Cox regression was used for multivariate analysis. Results: LVEF data were available for 1538 patients, of which 1485 (97%) survived the first 30 days after STEMI. SVD was present in 1013 patients (68%), MVD without CTO in 325 patients (22%) and a concurrent CTO in 147 patients (10%). Median duration of follow-up was 3.5 years (IQR 2.1–5.2 years). A total of 104 patients (7.0%) died; 61 (6.0%) in the SVD group, 25 (7.7%) in the MVD group and 18 (12%) in the CTO group (p=0.02). Median time to death was 2.1 years. After correction for the presence of MVD without CTO and differences in baseline variables (age 〉 60 years, residual LVEF ≤40%, diabetes, hypercholesterolemia, smoking, previous MI and shock) the presence of a CTO in a noninfarct-related artery is an independent risk factor for death (Hazard ratio (HR) 1.7, 95% CI 1.0 –2.8, p=0.04). Other independent risk factors are age 〉 60 years (HR 3.0, 95% CI 2.0 – 4.7, p 〈 0.01) and residual LVEF ≤40% (HR 2.3, 95%CI 1.5–3.4, p 〈 0.01) Conclusion: After primary PCI, the presence of a CTO in a noninfarct-related vessel, and not the mere presence of MVD, is a strong and independent risk factor for long-term mortality even when adjusted for residual LVEF ≤40% and excluding deaths in the first 30 days.
    Type of Medium: Online Resource
    ISSN: 0009-7322 , 1524-4539
    URL: Article
    DOI: 10.1161/circ.118.suppl_18.S_967-b
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2008
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