Single-vessel Disease Patients Research Articles

TCT-261 Comparison of Clinical Outcomes Between First- and Second-Generation Drug-Eluting Stents in Single-Vessel Disease Patients: Up to 10-Year Follow-up Results

TCT-261 Comparison of Clinical Outcomes Between First- and Second-Generation Drug-Eluting Stents in Single-Vessel Disease Patients: Up to 10-Year Follow-up Results

Comparison of the Gut Microbiome between Single-Vessel Disease and Multivessel Disease in Chronic Coronary Syndrome Patients

Background: Chronic coronary syndrome (CCS) has a high mortality rate worldwide, especially in developing countries. The degree of vessel stenosis and the number of stenotic vessels impact the mortality rate in coronary artery disease (CAD) patients. Additionally, multivessel disease (MVD) significantly influences clinical outcomes more than single-vessel disease (SVD). Objective: To examine if gut microbial communities could be used as biomarkers to discriminate patients with varying numbers of coronary stenotic vessels. Materials and Methods: Patients between 35 and 70 years old hospitalized at Chulabhorn Hospital were recruited between February 25 and July 15, 2023. Participants were divided into three groups, CCS patients with SVD, CCS patients with MVD, and healthy participants. On the day of the assessment, blood was drawn from each patient. The day before an appointment, the feces of every patient were collected. The present study was cross-sectional. Results: Forty-nine patients were included, and were divided into 11 SVD patients, 19 MVD patients, and 19 healthy participants. The patients were 38.78% female, with a mean age of 59.38±7.66 years, and 48.98% had hypertension. Based on sequencing of the V3-V4 regions of the 16S rRNA gene, it was revealed that the relative abundance of the Prevotella and Veillonella genera was significantly higher in MVD than in SVD patients. In the present study, MVD patients had differences in the diversity and composition of the gut microbiome compared to SVD patients and healthy participants. Conclusion: The development of SVD and MVD is correlated with changes in the gut microbiome, which may create a diagnostic marker of CAD to distinguish MVD patients from SVD patients and may be useful for further therapy and prevention.

Impact of chronic total occlusion in a non-infarct-related coronary artery on myocardial injury assessed by cardiac magnetic resonance imaging and prognosis in ST-elevation myocardial infarction

BackgroundMechanisms underlying increased mortality in patients with chronic total occlusion (CTO) of a non-infarct-related artery (non-IRA) are unknown. Cardiac magnetic resonance (CMR) is uniquely suited to provide important mechanistic and pathophysiological information on myocardial damage and reperfusion injury. Aim of this study was to investigate the association of a CTO in a non-IRA with myocardial damage assessed by CMR in patients with ST-elevation myocardial infarction (STEMI). MethodsSTEMI patients (n = 791) were stratified according to the presence of single-vessel disease (SVD), multivessel disease (MVD) without a CTO and MVD with a concomitant CTO in a non-IRA. CMR parameters of myocardial injury and clinical outcome after 12 months (major adverse cardiac events [MACE]: death, re-infarction, readmission for heart failure) were compared between groups. ResultsA CTO in a non-IRA was present in 74 patients (9%), whereas 372 (47%) had MVD without a CTO and 345 (44%) had SVD. Patients with a CTO in a non-IRA had significantly larger infarcts, a lower myocardial salvage index and lower left ventricular ejection fraction as compared to patients with SVD or MVD without a CTO. MACE rates were significantly higher in patients with MVD and concomitant non-IRA CTO (9.7%) versus MVD patients without CTO (6.5%) and SVD patients (4.1%) (p = 0.015). MVD with non-IRA CTO was a significant independent predictor of clinical outcome [hazard ratio 2.06, 95% confidence interval 1.11–3.82, p = 0.021]. ConclusionIn patients with acute reperfused STEMI, the presence of a CTO in a non–IRA was associated with larger myocardial damage and increased MACE rates.

The sdLDL Reduces MRC1 Expression Level and Secretion of Histamin e in Differentiated M2-macrophages from Patients with Coronary Artery Stenosis.

The macrophage polarization is proposed to be involved in initial events and remodeling of atherosclerosis plaques. Mannose receptor, C type 1 (MRC1) is a trans-membrane glycoprotein participating in phagocytosis and, is highly expressed in the M2 macrophages. The aim of this study was to investigate the effects of sdLDL (small dense LDL) on the MRC1 gene expression level and secretion of histamine in the differentiated M2 macrophages from monocytes of patients with coronary artery stenosis and healthy subjects. The monocytes were isolated from healthy subjects (< 5% stenosis) and patients (> 70% stenosis, SVD (Single Vessel Disease), 2VD (Two-Vessel Disease) and 3VD (Three-Vessel Disease)) by RosetteSep kit and, were differentiated into M2 macrophages by macrophage colonystimulating factor (M-CSF). The sdLDL particles were obtained by PEG-combined precipitation method. The MRC1 gene expression and histamine levels were measured by RT-qPCR and ELISA techniques, respectively. The MRC1 gene expression level was significantly increased in M2 macrophages of healthy subjects (P=0.05) while it reduced in SVD (P=0.05), 2VD (P=0.01) and 3VD (P=0.9) patients after treatment with sdLDL. The histamine value secreted from M2 macrophages (7-day) was higher (>3-fold, P=0.02) in patients as compared to healthy controls. The results showed that the sdLDL particles reduce the MRC1 gene expression levels in the differentiated M2 macrophages from patients with coronary artery disease. Furthermore, they had high inflammatory capacity for the secretion of histamine.

Cangrelor reduces the risk of ischemic complications in patients with single-vessel and multi-vessel disease undergoing percutaneous coronary intervention: Insights from the CHAMPION PHOENIX trial

To examine the safety and efficacy of cangrelor in patients with single-vessel disease (SVD) and multi-vessel disease (MVD). Cangrelor, an intravenous, rapidly acting P2Y12 inhibitor, is superior to clopidogrel in reducing ischemic events among patients receiving percutaneous coronary intervention (PCI). We studied a modified intention to treat population of patients with SVD and MVD from the CHAMPION PHOENIX trial. The primary efficacy outcome was the composite of death, myocardial infarction (MI), ischemia-driven revascularization (IDR), and stent thrombosis (ST) at 48hours. The key safety outcome was non-coronary artery bypass grafting GUSTO severe bleeding at 48hours. Among 10,921 patients, 5,220 (48%) had SVD and 5,701 (52%) had MVD. MVD patients were older and more often had diabetes, hyperlipidemia, hypertension, prior stroke, and prior MI. After adjustment, MVD patients had similar rates of 48-hour death/MI/IDR/ST (6.3% vs 4.2%, adjusted odds ratio [OR] 1.6 [95% CI 0.42-6.06]) and GUSTO severe bleeding (0.1% vs 0.2%, P=.67) compared with SVD patients. Consistent with overall trial findings, cangrelor use reduced ischemic complications in patients with both SVD (3.9% vs 4.5%; OR 0.86, 95% CI 0.65-1.12) and MVD (5.5% vs 7.2%; OR 0.74, 95% CI 0.6-0.92, P-interaction=.43). GUSTO severe bleeding outcomes were not significantly increased with cangrelor or clopidogrel in either SVD or MVD patients. In the CHAMPION PHOENIX trial, MVD and SVD patients had similar ischemic outcomes at 48hours and 30days. Cangrelor consistently reduced ischemic complications in both SVD and MVD patients without a significant increase in GUSTO severe bleeding. CLINICAL PERSPECTIVES.

Impact of multi-vessel versus single-vessel disease on outcomes after percutaneous coronary interventions for chronic total occlusions.

Successful chronic total occlusion (CTO) revascularization has been associated with prognostic benefits. Whether the extent of coronary artery disease interferes with these benefits has not been investigated yet. We sought to compare the survival after percutaneous coronary intervention (PCI) for CTO between patients with multi- (MVD) and single-vessel disease (SVD). A total of 2002 consecutive patients undergoing CTO PCI between 01/2005 and 12/2013 were identified and stratified according to the presence/absence of MVD. The primary endpoint was all-cause mortality. Median follow-up was 2.6 (interquartile range 1.1-3.1) years. A total of 1634 (81.6%) patients had MVD. Procedural success rates were 81.5 and 89.7% in the MVD and SVD groups (p < 0.001). All-cause mortality during entire follow-up was higher in MVD as compared to SVD patients (13.5 versus 5.7%, p < 0.001), and differences were attenuated after multivariable adjustment for baseline characteristics [adjusted hazard ratio (HR) 1.51, 95% CI 0.98-2.33, p = 0.06]. The effect of successful CTO PCI on all-cause mortality was consistent among patients with MVD [11.0 versus 24.5%; adjusted HR 0.60, 95% CI 0.45-0.80, p < 0.001] and SVD [5.2 versus 10.5%; adjusted HR 0.74, 95% CI 0.24-2.26, p = 0.59, P int = 0.65]. However, due to the greater baseline risk in the former group, the absolute survival benefit after successful CTO PCI was higher. Successful recanalization of a CTO is a strong independent predictor for reduced long-term mortality. Due a higher baseline risk, the absolute benefit in patients with MVD is substantially larger than in patients with SVD.

Acute myocardial infarction and lesion location in the left circumflex artery: importance of coronary artery dominance.

Due to the limitations of 12-lead ECG, occlusions of the left circumflex artery (LCX) are more likely to present as non-ST-elevation acute coronary syndrome (NSTEACS) compared with other coronary arteries. We aimed to study mortality in patients with LCX lesions and to assess the importance of coronary artery dominance on triage of these patients. From the Eastern Danish Heart Registry, 3,632 NSTEACS and 3,907 ST-elevation myocardial infarction (STEMI) consecutive, single-vessel disease patients were included. LCX was the culprit in 25% of NSTEACS and 14% of STEMIs (p<0.001). LCX lesions presented predominantly as STEMI in left dominant coronary arteries compared with NSTEACS (46% vs. 30%, p<0.001). Higher 30-day mortality was found in LCX-STEMI compared with LCX-NSTEACS (HR 7.9, 95% CI: 3.2-19.7, p<0.001) with no difference in long-term mortality (HR 0.9, 95% CI: 0.7-1.2, p=0.5). LCX-NSTEACS were not associated with higher mortality compared with other NSTEACS lesions. The 12-lead ECG seems sufficient for triage of patients with LCX lesions as a majority of patients with a large LCX due to a dominant left coronary artery present as STEMI. Patients with LCX-NSTEACS do not have higher mortality compared with patients with LCX-STEMI or NSTEACS with lesions in other coronary territories.

The association of serum parathyroid hormone and severity of coronary artery diseases

The serum level of parathyroid hormone (PTH) has been shown to be a predictor of cardiovascular mortality. Data on the association between PTH level and degree of atherosclerosis severity are lacking. The objective of this study was to determine the relationship of serum PTH level and number of stenotic coronary arteries. The present article is a descriptive cross-sectional study on 476 patients who had undergone coronary angiography according to documented indications and had coronary lesion more than 50% in at least one main vessel during 2010-2012. The outcome was evaluated by comparison between PTH levels and the number of stenotic coronary arteries. Demographic data of the patients, severity, and number of stenotic vessels were evaluated. Of the 476 patients included, 183 (38.4%) had PTH more than 40 pg/ml. There was a significant association between PTH level and severity and number of coronary lesion: 80% of three-vessel disease patients had PTH more than 40 pg/ml but only 7% of single-vessel disease patients had PTH more than 40 pg/ml (P<0.001). The mean levels of PTH serum in single-vessel, two-vessel, and three-vessel disease were 24.8, 35.8, and 49.8 pg/ml, respectively (P<0.001). Individuals with the higher PTH level had longer history of hypertension and lower left ventricular ejection fraction (P<0.01 and P<0.002, respectively). In this relatively small prospective study, serum PTH level is associated with the number of stenotic coronary arteries. There is a correlation between high PTH level with hypertension and low ejection fraction. A prospective study that evaluates the additional value added (by ROC analysis) by PTH to already known cardiac risk factors is recommended.

Impact of electronegative low-density lipoprotein on angiographic coronary atherosclerotic burden

ObjectiveLow density lipoproteins (LDL) with an electronegative charge [LDL(−)] may cause endothelial injury. We assessed the association between serum LDL(−) levels and coronary artery disease (CAD) severity. MethodsWe prospectively enrolled patients with CAD angiographic evidence [stable angina (SA) or non-ST-elevation-acute coronary syndrome (NSTE-ACS)], or with normal coronary arteries (NCA). Baseline LDL(−) serum levels were measured in all patients. Angiographic CAD extent was assessed by using the Bogaty extent index, while CAD severity by evaluating the presence of multi-vessel disease. ResultsForty-seven patients (age 61 ± 9 years, male sex 60%) were enrolled (17 SA, 15 NSTE-ACS and 15 NCA patients). LDL(−) levels were significantly higher in SA [21% (18–34) p = 0.0001] and NSTE-ACS [22% (18–28), p = 0.0001] as compared to NCA [6% (5–8)], without significant differences between SA and NSTE-ACS (p = 0.92). Multi-vessel disease patients had higher LDL(−) levels as compared to single-vessel disease patients (p = 0.002) but similar total LDL levels (p = 0.66). LDL(−) significantly correlated with extent index (r = 0.38, p = 0.03), while total LDL did not (p = 0.24). ConclusionLDL(−) serum levels are associated with CAD angiographic severity and extent. This exploratory analysis should prime further larger studies in order to assess LDL(−) proatherogenic role.

Prognostic impact of a chronic total occlusion in a non-infarct-related artery in patients with ST-segment elevation myocardial infarction: 3-year results from the HORIZONS-AMI trial

We sought to investigate the impact of multivessel disease (MVD) with and without a chronic total occlusion (CTO) in a non-infarct-related artery (IRA) on mortality in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). In the HORIZONS-AMI trial, of 3283 patients undergoing primary PCI, 1524 patients (46.4%) had single-vessel disease (SVD), 1477 (45.0%) had MVD without a CTO, and 283 (8.6%) had MVD with a CTO in a non-IRA. Compared with SVD patients and MVD patients without a CTO, patients with a non-IRA CTO were significantly less likely to achieve post-procedural TIMI 3 flow (P = 0.0003), more often had absent myocardial blush (P = 0.0002), and less frequently achieved complete ST-segment resolution (P = 0.0001). By multivariable analysis, MVD with CTO in a non-IRA was an independent predictor of both 0- to 30-day mortality [hazard ratio (HR) 2.88, 95% confidence interval (CI) 1.41-5.88, P = 0.004] and 30-day to 3-year mortality (HR 1.98, 95% CI 1.19-3.29, P= 0.009), while MVD without a CTO was a significant predictor for 0- to 30-day mortality (HR 2.20, 95% CI 1.00-3.06, P = 0.049) but not late mortality. In patients with STEMI undergoing primary PCI in the HORIZONS-AMI trial, MVD with or without a CTO in a non-IRA was an independent predictor of early mortality. The presence of a CTO in a non-IRA was also an independent predictor of increased late mortality to 3 years.

Impact of multivessel coronary artery disease on early ischemic injury, late clinical outcome, and remodeling in patients with acute myocardial infarction treated by primary coronary angioplasty

The mechanism through which multivessel coronary artery disease (MVD) adversely affects the outcome of patients with ST-elevation myocardial infarction (STEMI) is poorly characterized. We assessed whether the impact of MVD on outcome of STEMI patients is because of ischemic damage after primary percutaneous coronary intervention (PPCI) or to late ischemic events. From August 2005 to 2007, 288 STEMI patients treated by (bare metal) stent-PPCI were prospectively enrolled. The ischemic injury early after PPCI (evaluated by multiparametric approach) and the incidence of late adverse cardiovascular events were compared between the two groups. Compared with single vessel coronary artery disease, MVD patients (n=134) were older, with higher prevalence of diabetes, prior MI, anterior MI and higher collateral score. Myocardial perfusion as assessed by myocardial blush and SigmaST-segment resolution was similar in the two groups as well as the infarct size and microvascular obstruction as assessed by Troponin I and by the delayed enhancement of cardiac magnetic resonance. At clinical (98% complete) and echocardiogaphic (94% complete) follow-up (median 32 months) MVD patients showed a higher incidence of re-MI (6.1 vs. 1.3%), and urgent revascularization (8.3 vs. 2.7%) and worse left ventricular remodeling than single vessel disease patients. At propensity adjusted analysis MVD was an independent predictor of re-MI (odds ratio: 5.7) and ventricular remodeling (odds ratio: 2.2). The impact of MVD on clinical outcome and remodeling of STEMI patients is not because of the extent of ischemic damage observed after PPCI, but to recurrent ischemic events during follow-up.

Role of Genetic Polymorphism of Angiotensin-Converting Enzyme, Plasminogen Activator Inhibitor-1 and Endothelial Nitric Oxide Synthase in the Prognosis of Coronary Artery Disease

BackgroundThis study was to investigate the effects of multiple genetic polymorphisms and conventional risk factors in the prognosis of coronary artery disease (CAD).MethodsOne hundred and fifty five patients with CAD were prospectively recruited, they were subgrouped as single vessel disease (SVD) and multiple vessel disease (MVD). All patients were detected I/D polymorphism of angiotensin-converting enzyme (ACE) gene, 4G/5G polymorphism of plasminogen activator inhibitor-1 (PAI-1) gene, and G894→T mutation of endothelial nitric oxide synthase (eNOS) gene. The patients were followed up for 10-65 months, mean 35 months. End points were major adverse cardiovascular events (MACE), including angina, myocardial infarction, and cardiac sudden death.ResultsDuring the follow-up period, MACE developed in 81 patients, 73 patients with angina, seven with myocardial infarction, and one with cardiac sudden death. CAD patients with MVD were more probable of developing MACE during follow-up. Distribution of PAI-1 gene polymorphism was significantly different between SVD and MVD patients, p < 0.001. The frequency of DD genotype of ACE and 4G/4G genotype of PAI-1 in patients with MACE were significantly higher than those in patients without MACE, p < 0.001 and p = 0.002, respectively. Incidence of diabetes mellitus was significantly higher in patients with MACE than in patients without MACE, P = 0.03. Cox regression analysis showed that diabetes mellitus (HR 2.36, 95% CI 1.33-4.46, p = 0.003), 4G/4G polymorphism of PAI-1 gene (HR 3.45, 95% CI 1.71-6.56, p = 0.009), and D/D polymorphism of ACE gene (HR 2.99, 95% CI 1.84-5.76, p = 0.005), were independent predictors of the MACE.ConclusionsOur results showed that the conventional risk factors and genetic polymorphisms have significant influence on prognosis of CAD patients. CAD patients with diabetes mellitus, DD genotype of ACE, and 4G/4G genotype of PAI-1 suggested poor prognosis.

Single or multivessel percutaneous coronary intervention in ST‐elevation myocardial infarction patients

To evaluate clinical results of percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI) in patients with multivessel disease (MVD), in relation to single or multivessel (MV)-PCI and to patients with single vessel disease (SVD). Patients treated with PCI in the setting of <24 hr STEMI in the years 2004-2007 were considered. Seven hundred forty-five primary PCI, 346 (46%) in patients with SVD and 399 (54%) in patients with MVD were performed. Among MVD patients, 156 (39%) had infarct related artery (IRA)-only treatment and 243 had MV-PCI: 147 (37%) in a single session, 48 (12%) within 24 hr, and 48 (12%) predischarge. Revascularization was complete in 46% of MVD patients. At a median follow-up of 597 days, mortality was 6.3% in SVD and 12% in MVD (P = 0.007), new revascularization 2.9% and 9%, respectively (P < 0.001). Thirty-day mortality was 2.4% in SVD and 6.7% in MVD (P = 0.006). After exclusion of patients with cardiogenic shock or pulmonary oedema, more frequent in the MV-PCI in single session group (P = 0.006), 30-day mortality was SVD 1.3%, IRA-only 6.3%, MV-PCI 2.8% (P = 0.023), without differences if in a single (3.3%) or in staged session (2.2%). By multivariate analysis, female sex, anterior STEMI, cardiogenic shock, MVD, and procedural failure were independent predictors of 30-day mortality. STEMI patients with MVD have a worse prognosis than those with SVD. MV-PCI in patients without hemodynamic compromise yields good short-term results, even if performed very early, with a 30-day mortality in between that of SVD patients and that of MVD patients with IRA-only treatment.

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

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.

Promoter Polymorphism of Interleukin-18 in Angiographically Proven Coronary Artery Disease

Interleukin 18 (IL-18) is a pro-atherogenic cytokine associated with the occurrence of various cardiac complications. The IL-18 gene has a functional -137 G/C polymorphism (rs187238) in the promoter region. Using the ligase detection reaction-polymerase chain reaction, we genotyped a cohort of patients in Chinese Han population in Xiangfan region. Case patients of coronary artery disease and control patients were identified by coronary angiography. The plasma IL-18 concentrations were measured by ELISA. A significant increase of G allele or GG-genotype was observed in 241 case patients compared to 145 control individuals (frequency of G allele = 0.90 vs 0.83, p=0.004; frequency of GG-genotype = 0.81 vs 0.68, p = 0.005). In case patients, G allele carriers in multi-vessel disease patients had a higher occurrence rate when compared to single-vessel disease patients, but no significant difference was detected (frequency of G allele = 0.92 vs 0.88, p=0.107; frequency of GG-genotype = 0.84 vs 0.75, p = 0.089). IL-18 protein concentration of the -137GG genotype was much higher than concentration of the CG and CC genotype (case patients: 229.1+/-131.5 vs 122.7+/-73.6 pg/ml, P < 0.001; control patients: 65.9+/-31.6 vs 42.4+/-19.5 pg/ml, P < 0.001). To conclude, IL-18 promoter -137G/C polymorphism influences IL-18 levels and the occurrence of coronary artery disease, suggesting that IL-18 is causally involved in the development of atherosclerosis.

Direct comparison between pharmacological stress with adenosine triphosphate disodium and exercise stress myocardial perfusion imagings

To clarify the significance of adenosine triphosphate disodium stress myocardial perfusion imaging (ATP-MPI), we directly compared the findings of ATP-MPI with those of exercise stress myocardial perfusion imaging (Ex-MPI). ATP-MPI, Ex-MPI, and coronary angiography (CAG) were performed within 60 days in 17 coronary artery disease patients with mean age of 62.1+/-7.9 years. CAG revealed single-vessel disease (SVD) in 10 patients and multivessel disease (MVD) in seven patients. The summed stress score (SSS) of ATP-MPI was significantly higher than that of Ex-MPI (10.0 [7.8-14.3] vs. 8.0 [4-18], P<0.05). No difference in the SSS was observed between ATP-MPI and Ex-MPI in patients with SVD (8.0 [6.0-9.0] vs. 8.0 [6.0-10.0], NS), whereas this difference was significant in patients with MVD (15.0 [14.0-22.8] vs.9 [7.3-16.3], P<0.05). There was no difference in the summed rest score between ATP-MPI and Ex-MPI. The univariate logistic analysis showed that "MVD" was the significant factor influencing to the overt discrepancy between ATP-MPI and Ex-MPI (odds ratio: 9.0, 95% confidence interval: 1.07-75.84, P=0.043). The accuracy of ATP-MPI and Ex-MPI in detecting the territory of stenotic coronary vessel or previous myocardial infarction was 98.0% and 92.1% (NS), respectively. In conclusion, ATP-MPI is useful for detecting potential ischemic areas that cannot be detected by Ex-MPI, particularly in patients with MVD.

Risk Factors for Stent Thrombosis After Implantation of Sirolimus-Eluting Stents in Diabetic and Nondiabetic Patients: The EVASTENT Matched-Cohort Registry

We sought to assess the frequency and causes of stent thrombosis in diabetic and nondiabetic patients after implantation of sirolimus-eluting stents. Safety concerns about late stent thrombosis have been raised, particularly when drug-eluting stents are used in less highly selected patients than in randomized trials. The EVASTENT study is a matched multicenter cohort registry of 1,731 patients undergoing revascularization exclusively with sirolimus stents; for each diabetic patient included (stratified as single- or multiple-vessel disease), a nondiabetic patient was subsequently included. Patients were treated with aspirin + clopidogrel for at least 3 months and were followed for 465 (range 0 to 1,062) days (1-year follow-up in 98.5%). The primary end point was a composite of stent thrombosis (according to Academic Research Consortium definitions), cardiovascular death, and nonfatal myocardial infarction (major adverse cardiac events [MACE]). During follow-up, MACE occurred in 78 patients (4.5%), cardiac death in 35 (2.1%), and stent thrombosis in 45 (2.6%): 30 definite, 23 subacute, and 22 late, including 9 at >6 months. In univariate analysis, the 1-year stent thrombosis rate was 1.8 times higher in diabetic than in nondiabetic patients (3.2% vs. 1.7%; log rank p = 0.03), with diabetic patients with multiple-vessel disease experiencing the highest rate and nondiabetic single-vessel disease patients the lowest (4.3% vs. 0.8%; p < 0.001). In multivariate analysis, in addition to the interruption of antithrombotic treatment, independent stent thrombosis predictors were previous stroke, renal failure, lower ejection fraction, calcified lesion, length stented, and insulin-requiring diabetes. The risk of sirolimus stent thrombosis is higher for multiple-vessel disease diabetic patients.

Long-Term Clinical Outcome After Fractional Flow Reserve-Guided Percutaneous Coronary Intervention in Patients With Multivessel Disease

In the present study, we analyzed the clinical outcome of patients with multivessel coronary artery disease in whom at least one vessel was treated by percutaneous coronary intervention (PCI) and at least one other vessel was deferred on the basis of fractional flow reserve (FFR) measurements during the same session. Myocardial FFR is an established tool for assessing the severity of epicardial stenoses. It has been shown that it is safe to defer an intervention in single vessel disease patients when FFR >0.75. One hundred two patients (66 +/- 10 years) with multivessel coronary artery disease were included in the study. In all patients, PCI of at least two vessels was contemplated. Yet in all of them at least one vessel was treated by PCI, whereas at least one other vessel was deferred based on an FFR >0.75. Major adverse cardiac events (MACE) were recorded during an average follow-up of 29 +/- 18 months. In 102 patients, 113 coronary arteries underwent PCI. In these arteries FFR was 0.57 +/- 0.13 and mean diameter stenosis was 68 +/- 14%. One hundred twenty-seven coronary arteries had an FFR >0.75 and PCI was deferred. In these arteries FFR was 0.86 +/- 0.06 and mean diameter stenosis was 47 +/- 12%. No death occurred during the follow-up. A MACE occurred in 9% and 13% of patients after 12 and 36 months, respectively. These MACE were related to 22 (9.2%) arteries. Among them, 8 (6.3%) MACE were related to one of the initially deferred vessels, whereas 14 (12.3%) MACE were related to one of the initially treated coronary artery. In patients with multivessel disease, PCI of hemodynamically non-significant stenoses can be safely deferred, even if initially planned on the basis of the angiogram.

Features of ST segment and T-wave in exercise-induced myocardial ischemia evaluated with multichannel magnetocardiography

BACKGROUND AND AIM. Magnetocardiography (MCG) is a novel, non-contact mapping technique to record cardiac magnetic field. We evaluated MCG criteria for myocardial ischemia in stress testing. METHODS. Multichannel MCG over frontal chest was performed in 44 patients with coronary artery disease (CAD) and 26 healthy controls during supine bicycle exercise test. Of the 44 patients 16 had anterior, 15 posterior, and 13 inferior ischemia documented by coronary angiography and exercise thallium scintigraphy. ST amplitude, ST slope, T-wave amplitude, and ST-T integral were measured. The optimal sites for detecting the ischemiainduced changes on MCG were sought. The orientation of the magnetic field was also determined. RESULTS. The optimal sites for the decrease of ST slope, ST amplitude, T-wave amplitude, and ST-T integral were over the abdomen. The reciprocal increase of these parameters was found over the left parasternal area. The optimal sites were approximately the same for all patient groups. In single-vessel disease patients without previous myocardial infarction (MI), ST slope increase and ST elevation performed the best (area under the receiver operating characteristic curve 92% and 90%, respectively). In post-MI patients with triple-vessel disease the decrease of T-wave amplitude and ST slope performed the best (area under curve 91%, for both). The magnetic field orientation at ST segment performed equally well as the other ST parameters. In stepwise logistic regression analysis, by use of the presence of CAD as the dependent parameter, ST slope increase and ST peak gradient orientation entered the model. CONCLUSIONS: Various ST segment and T-wave parameters detect ischemia in MCG. ST amplitude performs especially well in non-MI patients with less severe CAD. In advanced CAD late development of T-wave amplitude might be more sensitive to ischemia than ST amplitude.

Long-term outcome of angioplasty for multivessel coronary disease: importance and price of complete revascularization

Background: Complete revascularization of multivessel coronary artery disease (MVD) by coronary artery bypass surgery has been shown to improve outcome, but there is a lack of similar data for patients treated by angioplasty. Methods: Therefore, a consecutive series of 250 patients with MVD was separated into two groups, those with complete revascularization ( n=101) and those with incomplete revascularization ( n=149). Six-month ‘clinical restenosis’ rate assessed by stress myocardial perfusion scintigraphy or symptom-driven angiography and long-term 32 months outcome were compared with an equally sized group of single vessel disease (SVD) patients. Results: MVD patients with complete revascularization had a higher ‘clinical restenosis’ rate than patients with SVD (35 vs. 22%, P<0.02), although restenosis rate per treated vessel was similar (23%, 18%, P NS). If this higher early restenosis rate were accepted as ‘price’ for complete MVD angioplasty, long-term event-free survival was no longer different from that of SVD patients (86 vs. 93%, P NS). In contrast, patients with incomplete multivessel angioplasty had a significantly worse long-term outcome (22% events), especially if initially untreated, non-occluded vessels remained untreated (25% events). Conclusion: MVD angioplasty with complete revascularization has a long-term event-free survival similar to that of SVD angioplasty but at the price of a higher rate of 6-month restenosis and repeat interventions.