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Impaired glucose homeostasis leads to numerous complications, with coronary artery disease (CAD) being a major contributor to healthcare costs worldwide. Because continuous glucose monitoring (CGM) captures multidimensional features of glucose regulation beyond average glycemia, we evaluated whether CGM-derived indices better predict coronary plaque vulnerability than conventional measures. We examined associations between CGM-derived indices and coronary plaque vulnerability assessed by virtual histology-intravascular ultrasound, focusing on the necrotic core (%NC) in humans. We analyzed 14 CGM-derived indices, including average daily risk ratio (ADRR) and autocorrelation-based metrics (AC_Mean and AC_Var), alongside commonly used measures, such as fasting blood glucose (FBG), hemoglobin A1c (HbA1c), and 120 min plasma glucose during oral glucose tolerance testing (PG120). Factor analysis was used to identify latent components underlying glucose dynamics and to relate these components to %NC. Findings were validated across independent datasets from Japan (n=64), the United States (n=53), and China (n=100). CGM-derived indices, particularly ADRR and AC_Var, demonstrated stronger predictive capability for %NC than FBG, HbA1c, and PG120. Factor analysis identified three independent components of glucose dynamics: mean, variance, and autocorrelation, each showing an independent association with %NC. ADRR reflected both mean and variance components, whereas AC_Var primarily captured the autocorrelation component. In contrast, FBG, HbA1c, and PG120 primarily reflected the mean component alone and were, therefore, insufficient for %NC prediction. CGM-derived indices reflecting the three components of glucose dynamics can serve as more effective screening tools for CAD risk assessment, complementing or possibly replacing traditional diabetes diagnostic methods. This study was supported by the Japan Society for the Promotion of Science (JSPS) KAKENHI (JP21H04759), CREST, the Japan Science and Technology Agency (JST) (JPMJCR2123), The Uehara Memorial Foundation, and The Takeda Science Foundation.

ObjectiveTo assess the distribution of pressure and shear-related forces acting on atherosclerotic plaques and their association with lesion characteristics using coronary CT angiography (cCTA)-based computational fluid dynamics (CFD) model of epicardial coronary arteries.MethodsPatient-specific models of epicardial coronary arteries were reconstructed from cCTA in 80 patients (12 women, 63.8±9.0 years). The pressure and wall shear stress (WSS) in left anterior descending coronary arteries were assessed using CFD. High-risk plaques were defined as the presence of at least one of the following adverse plaque characteristics: low-density plaque, positive remodelling, napkin-ring sign and spotty calcification.ResultsAt resting condition, 39.5% of stenotic segments (% diameter stenosis 52.3±14.4%) were exposed to high WSS (>40 dyne/cm2). When the stenotic lesion was subdivided into three segments, the distribution of WSS was different from that of pressure change and its magnitude was highest at minimal lumen area (p<0.001). High pressure gradient, proximal location, small lumen and short length were independent determinants of WSS (all p<0.05). The plaques exposed to the highest WSS tertile had a significantly greater proportion of high-risk plaques. The addition of WSS to % diameter stenosis significantly improved the measures of discrimination and reclassification of high-risk plaques (area under the curves from 0.540 to 0.718, p=0.031; net reclassification index 0.827, p<0.001).ConclusionsThe cCTA-based CFD method can improve the identification of high-risk plaques and the risk stratification for coronary artery disease patients by providing non-invasive measurements of WSS affecting coronary plaques.

Optical frequency domain imaging (OFDI) is a high-resolution intracoronary imaging modality with fast automated longitudinal pullback. We aimed to evaluate the ability of performing OFDI from the superficial femoral artery (SFA) to the below-knee (BK) artery. This clinical trial was a multi-center, single-arm, open-label study. The primary endpoint was to obtain a clear image of the intra-vascular lumen from the SFA to the BK artery, specifically  > 270° visualization of the blood vessel lumen with  > 16/21 cross sections. The proportion of the clear image (≥ 85%) was regarded as confirmatory of the ability of OFDI to visualize the vessel lumen. Overall, 20 patients were enrolled. The proportion of the primary endpoint was 90% (18/20), and the pre-specified criterion was successfully attained. The proportion of the clear image assessed by the operator was 100% (20/20), and an additional statistical analysis for the proportion of the visualization,  > 270°, of the blood vessel lumen revealed a significantly higher cut-off value than that for the pre-specified criterion, 85% ( p  = 0.0315). There were three adverse events not related to OFDI. OFDI achieved acceptable visualization of the vessel lumen without any adverse event related to it. After regulatory approval based on the present study, OFDI will be available as a new option of endovascular imaging for peripheral artery diseases in daily practice Trial registration: This study was registered in the Japanese Registry of Clinical Trials (jRCT 2052190025, https://jrct.niph.go.jp/latest-detail/jRCT2052190025 ).

Background Murray law-based quantitative flow ratio (μQFR) is a novel computational method that enables accurate estimation of fractional flow reserve (FFR) using a single angiographic projection. However, its diagnostic value in patients with severe aortic stenosis (AS) remains unclear. Method We included 25 consecutive patients who underwent transcatheter aortic valve replacement (TAVR) for severe AS with intermediate or greater (30–90%) coronary artery disease (CAD). Pre- and post-TAVR μQFR, QFR, instantaneous flow reserve (iFR), and post-TAVR invasive FFR values were measured. We evaluated the diagnostic performance of pre-TAVR μQFR, QFR, and iFR using post-TAVR FFR ≤ 0.80 as a reference standard of ischemia. Result Pre-TAVR μQFR was significantly correlated with post-TAVR FFR ( r  = 0.73, p  < 0.0001). The area under the curve of pre-TAVR μQFR on post-TAVR FFR ≤ 0.8 was 0.91 (95% confidence interval [CI] 0.77–0.98), comparable to that of pre-TAVR iFR (0.86 [95% CI 0.71–0.98], p  = 0.97). The accuracy, sensitivity, specificity, and positive and negative predictive values of pre-TAVR μQFR on post-TAVR FFR ≤ 0.8 were 84.2% (95% CI 68.7–93.4), 61.6% (95% CI 31.6–86.1), 96.0% (95% CI 79.6–99.9), 88.9% (95% CI 52.9–98.3), and 82.8% (95% CI 70.6–90.6), respectively. For pre-TAVR iFR, these values were 76.5% (95% CI 58.8–89.3), 90.9% (95% CI 58.7–99.8), 69.6% (95% CI 47.1–86.8), 58.8% (95% CI 42.8–73.1), and 94.1% (95% CI 70.8–99.1), respectively. Conclusion μQFR could be useful for the physiological evaluation of patients with severe AS with concomitant CAD.

•The ATLAS-OCT (ST-elevation Acute myocardial infarcTion and cLinicAl outcomeS treated by Optical Coherence Tomography-guided percutaneous coronary intervention) trial aims to investigate the feasibility of optical coherence tomography (OCT) guidance during primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI).•This study will include 600 consecutive patients with STEMI undergoing primary PCI.•The primary endpoint is the rate of successful OCT imaging during primary PCI.•The study will clarify the feasibility of OCT-guided primary PCI for patients with STEMI.•The study may identify a suitable patient group for OCT-guided primary PCI. Even after successful revascularization with primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI), subsequent adverse events still occur. Previous studies have suggested potential benefits of intravascular imaging, including optical coherence tomography (OCT). However, the feasibility of OCT-guided primary PCI has not been systematically examined in these patients. The ATLAS-OCT (ST-elevation Acute myocardial infarcTion and cLinicAl outcomeS treated by Optical Coherence Tomography-guided percutaneous coronary intervention) trial was designed to investigate the feasibility of OCT guidance during primary PCI for STEMI in experienced centers with expertise on OCT-guided PCI as a prospective, multicenter registry of consecutive patients with STEMI who underwent a primary PCI. The sites’ inclusion criteria are as follows: (1) acute care hospitals providing 24/7 emergency care for STEMI, and (2) institutions where OCT-guided PCI is the first choice for primary PCI in STEMI. All patients with STEMI who underwent primary PCI at participating sites will be consecutively enrolled, irrespective of OCT use during PCI. The primary end point will be the rate of successful OCT imaging during the primary PCI. As an ancillary imaging modality to angiography, OCT provides morphologic information during PCI for the assessment of plaque phenotypes, vessel sizing, and PCI optimization. Major adverse cardiac events, defined as a composite of all-cause death, myocardial infarction, and target vessel revascularization at 1 year, will also be recorded. The ATLAS-OCT study will clarify the feasibility of OCT-guided primary PCI for patients with STEMI and further identify a suitable patient group for OCT-guided primary PCI.

Intravascular imaging for acute coronary syndrome is recommended in the guidelines; however, the actual rate of patients with ST-segment elevation myocardial infarction (STEMI) who successfully undergo optical coherence tomography (OCT)-guided primary percutaneous coronary intervention (PCI) is unclear. This study aimed to determine the feasibility of OCT-guided primary PCI and identify the patient population that would benefit most from OCT guidance in STEMI. The ATLAS-OCT trial was a prospective, single-arm, all-comers study conducted at 16 institutions. The primary endpoint was the feasibility of OCT guidance for primary PCI, defined as successful image acquisition (vessel’s circumferential or > 270° visualization along > 70% of the lesion’s length, as evaluated by an independent core laboratory). A total of 632 patients (mean age: 68.4 years; 80.2% male) were enrolled in the study. OCT-guided PCI was performed in 503 patients, whereas OCT guidance was avoided in 129 patients for patient’s condition. Successful image acquisition was achieved in all but seven patients who underwent OCT. The primary endpoint was achieved in 78.5% (496/632) of patients. No procedural complications were associated with OCT. Patients with left main disease (adjusted odds ratio, 4.1; 95% confidence interval, 1.2–14.7; p  = 0.024), estimated glomerular filtration rate (mL/min/1.73 m 2 ) < 30 (3.7; 1.6–8.3; p  = 0.002), and Killip IV (2.5; 1.3–4.6; p  = 0.003) were significantly avoided for OCT guidance. OCT guidance was feasible in four-fifths of all-comers with STEMI. Further studies are warranted to evaluate the efficacy of OCT-guided PCI in selected patient populations based on the findings of this trial (UMIN000048590). Graphical abstract

Background The prognosis of aortic stenosis (AS) with cardiogenic shock remains poor, and optimal initial treatment remains unclear. Emergent balloon aortic valvuloplasty (BAV) is a treatment option for salvage and recent studies have reported that early release of valve obstruction by emergent BAV could improve prognosis. This study aimed to assess the efficacy and safety of emergent BAV for severe AS with cardiogenic shock. Methods Among 8,230 patients hospitalized for heart failure, 7924 patients with heart failure unrelated to severe AS were excluded. Among the remaining 306 patients, 256 patients who developed cardiogenic shock due to other causes except severe AS were further excluded. Finally, a total of 41 patients with severe AS in cardiogenic shock were enrolled and divided into the emergent (underwent BAV within 6 h of admission, n  = 9) and non-emergent (underwent BAV more than 6 h after admission, n  = 16) groups, after excluding 16 patients who did not undergo BAV. The primary endpoints were the 30-day mortality rate and procedural complications. The secondary endpoints were days to withdrawal from the mechanical support device, days to initial rehabilitation, and clinical frailty scale (CFS) score at discharge. Results In the emergent group, the time from admission to BAV was 3.0 ± 1.4 h, whereas BAV was performed 4.5 days (median) after admission in the non-emergent group. The 30-day mortality rate was not significantly different between the emergent and non-emergent groups (0% vs. 25%, p  = 0.260); furthermore, there was no statistically significant difference regarding the incidence of procedural complications (0% in the emergent vs. 12.5% in the non-emergent group, p  = 0.520). The days to withdrawal from mechanical support device and to start rehabilitation were earlier in emergent group (2.9 ± 1.2 days vs. 7.8 ± 4.6 days; p  = 0.008, 4.2 ± 1.9 days vs. 10.8 ± 6.5 days; p  = 0.004). The CFS score at discharge in the emergent group was maintained compared to before admission (from 3.8 ± 1.0 to 3.9 ± 1.1; p  = 0.347), whereas worsened in the non-emergent group (from 3.8 ± 0.9 to 4.6 ± 1.2; p  = 0.032). Conclusions Emergent BAV for cardiogenic shock is feasible, and earlier BAV may support faster recovery and help prevent deterioration of frailty.

•Limited data exist on the comparison of clinical outcomes after first- and second-generation drug-eluting stent (DES) thrombosis.•At 1 year, patients with second-generation DES thrombosis (G2-ST) showed a similar mortality to those with first-generation DES thrombosis (G1-ST; 23.0% vs 22.9%, p = 0.76), highlighting that ST remains a life-threatening complication in the second-generation DES era.•Cumulative 1-year incidence of target lesion revascularization was significantly lower in the G2-ST than in the G1-ST (9.7% vs 17.1%, p = 0.01). Limited data exist on the comparison of clinical outcomes after first- and second-generation drug-eluting stent (DES) thrombosis. From the Retrospective Multicenter Registry of Stent Thrombosis (ST) After First- and Second-Generation DES Implantation registry, this study evaluated 655 ST patients (first-generation DES thrombosis [G1-ST], n = 342; second-generation DES thrombosis [G2-ST], n = 313). After propensity score matching, the final study population consisted of 159 matched patients. The primary end point was the cumulative 1-year incidence of mortality. The mortality after G2-ST at 1 year was similar to that after G1-ST (23.0% vs 22.9%, p = 0.76). Also, the G2-ST group showed a significantly lower rate of target lesion revascularization than the G1-ST group (9.7% vs 17.1%, p = 0.01). Risk factors of 1-year mortality included cardiogenic shock or arrest at the time of ST, multivessel ST, left ventricular ejection fraction ≤40%, advanced age, and final thrombolysis in myocardial infarction flow grade ≤2. In conclusion, patients with G2-ST showed a similar 1-year mortality to those with G1-ST, highlighting that ST remains a life-threatening complication in the second-generation DES era.

Background Prognosis of chronic thromboembolic pulmonary hypertension (CTEPH) has improved after the availability of balloon pulmonary angioplasty (BPA) and approved drugs. However, the clinical effects of cancer, which is one of the associated medical conditions of CTEPH, remain unclear. We aimed to investigate prognosis in patients with CTEPH and comorbid cancer. Methods Between January 2011 and December 2022, data of 264 consecutive patients with CTEPH who were treated with pulmonary endarterectomy, BPA, or medical therapy were retrospectively analyzed. The patients were allocated, based on the comorbidity of cancer as of December 2022, into the cancer ( n  = 47) and non-cancer ( n  = 217) groups. In the cancer group, active and non-active cancers were identified in 30 (64%) and 17 (36%) patients, respectively. Results The baseline characteristics, hemodynamics, and treatments were similar between the groups. More than half of the cancer were diagnosed within two years before or after CTEPH diagnosis. Twenty-seven patients died during the study period. Among them, 13 (48%) and 7 (26%) died of cancer and right heart failure, respectively. The 5-year survival rate was lower in the cancer group than in the non-cancer group (67.8% vs. 94.5%, p  < 0.001). In the active cancer group, the 5-year survival rate was also lower than that in the non-active cancer and non-cancer groups (52.0% vs. 99.5%, p  < 0.001 and 52.0% vs. 92.3%, p  < 0.001, respectively). Multivariate Cox hazard analysis revealed that hemodialysis ( p  < 0.001) and cancer ( p  < 0.001) were independently associated with poor survival. Conclusion Patients with CTEPH rarely die of right heart failure, even if hemodynamically severe at diagnosis in the modern management era. However, patients with CTEPH frequently have comorbid cancer, which may be a strong prognostic factor.

Background Nocturnal desaturation is occasionally observed in patients with chronic thromboembolic pulmonary hypertension (CTEPH) despite the absence of parenchymal lung disease; however, the underlying mechanism remains unclear. This study aimed to clarify the clinical features of nocturnal desaturation in patients with CTEPH. Methods Data of 163 patients with CTEPH who underwent balloon pulmonary angioplasty (BPA) between March 2011 and December 2022 were retrospectively analyzed. We evaluated their hemodynamics using right heart catheterization, arterial blood gas examination, respiratory function tests, nocturnal oximetry, and cardiopulmonary exercise testing, which were routinely performed at baseline and after BPA. Results A higher ratio of dead space to tidal volume (VD/VT) ( p  < 0.001) and higher alveolar-arterial oxygen difference (A-aDO2) ( p  = 0.026) at baseline were associated with greater nocturnal desaturation in the multivariable linear analysis. After BPA, nearly normal hemodynamics was achieved (mean pulmonary arterial pressure: 37.5 ± 10.0 to 20.2 ± 4.9 mmHg, p  < 0.01). Nocturnal desaturation also improved from − 13.3 ± 5.8% at baseline to -10.3 ± 5.4% after BPA ( p  < 0.01). Improvement in VD/VT correlated well with improvement in nocturnal desaturation after BPA ( p  < 0.001, R 2 linear = 0.18). Conclusions Nocturnal desaturation often coexists with CTEPH. VD/VT, a marker of physiologic dead-space fraction, A-aDO2, a marker of ventilation-perfusion mismatch, and lung diffusing capacity were strongly associated. Nocturnal desaturation improved slightly after BPA, which was associated with a decrease in the physiological dead- space fraction. Our study emphasizes the importance of including nocturnal oximetry in routine evaluations and continuation of nocturnal oxygen therapy, if necessary, in patients with CTEPH. Summary at a glance Nocturnal desaturation often coexisted with chronic thromboembolic pulmonary hypertension despite the absence of parenchymal lung disease. The ratio of dead space to tidal volume (a marker of the physiologic dead-space) and alveolar-arterial oxygen difference (a marker of ventilation-perfusion mismatch and lung diffusing capacity) were strongly associated with nocturnal desaturation. Nocturnal desaturation improved slightly after balloon pulmonary angioplasty, which was associated with a decrease in the physiological dead-space fraction.