[Show abstract][Hide abstract] ABSTRACT: As first responders to an increasing number of natural and manmade disasters, active-duty firefighters are at increased risk for physical and psychiatric impairment as reflected by high rates of posttraumatic stress disorder (PTSD). Because little is known about related factor with PTSD according to job stress level among firefighters, we assessed utility of the Minnesota Multiphasic Personality Inventory (MMPI) using 5-year medical surveillance.
Data were analyzed from 185 male firefighters without psychiatric disease history and who at assessments in 2006 and 2011 completed all questionnaires on personal behaviors (including exercise, drinking and smoking habits) and job history (including job duration and department). MMPI, Events Scale-Revised-Korean version (IES-R-K) and Korean Occupational Stress Scale-Short Form (KOSS-SF) were used to screen for personality trait, PTSD symptom presence and job stress level, respectively. IES-R-K subgroups were compared using two-sample t- and χ2 tests, and factors influencing IES-R-K according to KOSS-SF were determined using uni- and multivariate logistic regression.
Mean age and job duration were higher in PTSD-positive than negative groups. In multivariate analysis, increased PTSD risk was associated with: job duration (Odds ratio (OR) = 1.064, 95 % CI 1.012-1.118) for firefighters overall; masculinity-femininity (OR = 5.304, 95 % CI 1.191-23.624) and job duration (OR = 1.126, 95 % CI 1.003-1.265) for lower job stress level; and social introversion (OR = 3.727, 95 % CI 1.096-12.673) for higher job stress level.
MMPI relates with PTSD according to job stress level among experienced firefighters. Masculinity-femininity and social introversion were the strongest related factor for PTSD symptom development in low and high job stress levels, respectively.
[Show abstract][Hide abstract] ABSTRACT: Background-We aimed to compare the long-Term clinical outcomes between fractional flow reserve (FFR)-guided and routine drug-eluting stent (DES) implantation in patients with an intermediate coronary stenosis. Methods and Results-A total of 229 patients with an angiographically intermediate coronary stenosis were randomly assigned to FFR-guided or Routine-DES implantation group. For FFR-guided group (n=114), treatment strategy was determined according to the target vessel FFR (FFR<0.75: DES implantation [FFR-DES group]; FFR≥0.75: deferral of stenting [FFR-Defer group]). Routine-DES group underwent DES implantation without FFR measurement (n=115). The primary end point was the incidence of major adverse cardiac events, a composite of cardiac death, myocardial infarction, and target lesion revascularization. Of lesions assigned to FFR-guided strategy, only one quarter had functional significance (FFR<0.75). At 2-year follow-up, the cumulative incidence of major adverse cardiac events was 7.9±2.5% in the FFR-guided group and 8.8±2.7% in Routine-DES group (P=0.80). At 5-year follow-up, the cumulative incidence of major adverse cardiac events was 11.6±3.0% and 14.2±3.3% for the FFR-guided group and the Routine-DES group (P=0.55). There was no difference in major adverse cardiac events rates between the 2 groups ≤5-year follow-up (hazard ratio, 1.25; 95% confidence interval, 0.60-2.60). Conclusions-In lesions with angiographically intermediate stenosis, FFR guidance provides a tailored approach, which is at least as good as an angiography-guided routine-DES implantation strategy and avoids unnecessary DES-stenting in a considerable part of the patients. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00592228.
No preview · Article · Dec 2015 · Circulation Cardiovascular Interventions
[Show abstract][Hide abstract] ABSTRACT: Background: After acute myocardial infarction (AMI), the replicated phenomenon of obesity paradox, i.e., obesity appearing to be associated with increased survival, has not been evaluated in stabilized (i.e., without clinical events within 1 month post AMI) Asian patients with diabetes mellitus (DM). Methods: Among 1192 patients in the DIabetic Acute Myocardial InfarctiON Disease (DIAMOND) Korean multicenter registry between April 2010 and June 2012, 2-year cardiac and all-cause death were compared according to obesity (body mass index ≥25 kg/m2) in 1125 stabilized DM patients. Results: Compared with non-obese DM patients (62 % of AMI patients), obese DM patients had: higher incidence of dyslipidemia (31 vs. 24 %, P < 0.01); lower incidence of chronic kidney disease (26 vs. 33 %) (P < 0.01); higher left ventricular ejection fraction after AMI (53 ± 11 vs. 50 ± 12 %, P < 0.001); and lower 2-year cardiac and all-cause death occurrence (0.7 vs. 3.6 % and 1.9 vs. 5.2 %, both P < 0.01) and cumulative incidence in Kaplan-Meier analysis (P < 0.005, respectively). Likewise, both univariate and multivariate Cox hazard regression analyses adjusted for the respective confounders showed that obesity was associated with decreased risk of both cardiac [HR, 0.18 (95 % CI 0.06-0.60), P = 0.005; and 0.24 (0.07-0.78), P = 0.018, respectively] and all-cause death [0.34 (0.16-0.73), P = 0.005; and 0.44 (0.20-0.95), P = 0.038]. Conclusions: In a Korean population of stabilized DM patients after AMI, non-obese patients appear to have higher cardiac and all-cause mortality compared with obese patients after adjusting for confounding factors.
Preview · Article · Dec 2015 · Cardiovascular Diabetology
[Show abstract][Hide abstract] ABSTRACT: Fractional flow reserve (FFR) is an index for identifying functionally significant stenotic lesions. A FFR value of ≤0.75 is considered clinically significant and indicative of physiological ischemia. Focal lesions with 30-80 % stenosis by angiography with lesion lengths of less than 20 mm were selected from left anterior descending arteries of 74 patients. The analysis for the total lesion was processed first, and then each lesion was divided into three segments to assess the each segment. Data on plaque geometry and composition of two FFR groups, FFR ≤ 0.75 and FFR > 0.75, were compared by total and segmental analysis. Lesions with FFR ≤ 0.75 had more fibrofatty tissue (13.5 ± 7.4 vs. 10.2 ± 6.5 %, p = 0.05) and less dense calcium (7.2 ± 5.3 vs. 11.9 ± 7.5 %, p = 0.01) compared to lesions with FFR > 0.75. The content of necrotic core in mid segments was higher compared to proximal and distal segments (22.9 ± 10.6, 20.2 ± 10.9, 17.1 ± 11.2 %, respectively, p = 0.032) in lesions with FFR > 0.75 but the difference was less obvious in lesions with FFR ≤ 0.75 (17.9 ± 9.9, 18.7 ± 9.9, 15.8 ± 9.0 %, respectively, p = 0.533). Coronary lesions with FFR > 0.75 have larger content of dense calcium and slightly less fibrofatty tissue compared to lesions with FFR ≤ 0.75. While segmental plaque compositions for each segment show noticeable variations in lesions with FFR > 0.75 such as high concentrations of necrotic core in mid segment, these differences in each segment become obscure in FFR ≤ 0.75 and are evenly distributed across the lesion.
No preview · Article · Oct 2015 · The international journal of cardiovascular imaging
[Show abstract][Hide abstract] ABSTRACT: Background:
The index of microcirculatory resistance (IMR) is a quantitative and specific index for coronary microcirculation. However, the distribution and determinants of IMR have not been fully investigated in patients with ischemic heart disease (IHD).
Methods and results:
Consecutive patients who underwent elective measurement of both fractional flow reserve (FFR) and IMR were enrolled from 8 centers in 5 countries. Patients with acute myocardial infarction were excluded. To adjust for the influence of collateral flow, IMR values were corrected with Yong's formula (IMRcorr). High IMR was defined as greater than the 75th percentile in each of the major coronary arteries. FFR≤0.80 was defined as an ischemic value. 1096 patients with 1452 coronary arteries were analyzed (mean age 61.1, male 71.2%). Mean FFR was 0.84 and median IMRcorr was 16.6 U (Q1, Q3 12.4 U, 23.0 U). There was no correlation between IMRcorr and FFR values (r=0.01, P=0.62), and the categorical agreement of FFR and IMRcorr was low (kappa value=-0.04, P=0.10). There was no correlation between IMRcorr and angiographic % diameter stenosis (r=-0.03, P=0.25). Determinants of high IMR were previous myocardial infarction (odds ratio [OR] 2.16, 95% confidence interval [CI] 1.24-3.74, P=0.01), right coronary artery (OR 2.09, 95% CI 1.54-2.84, P<0.01), female (OR 1.67, 95% CI 1.18-2.38, P<0.01), and obesity (OR 1.80, 95% CI 1.31-2.49, P<0.01). Determinants of FFR ≤0.80 were left anterior descending coronary artery (OR 4.31, 95% CI 2.92-6.36, P<0.01), angiographic diameter stenosis ≥50% (OR 5.16, 95% CI 3.66-7.28, P<0.01), male (OR 2.15, 95% CI 1.38-3.35, P<0.01), and age (per 10 years, OR 1.21, 95% CI 1.01-1.46, P=0.04).
IMR showed no correlation with FFR and angiographic lesion severity, and the predictors of high IMR value were different from those for ischemic FFR value. Therefore, integration of IMR into FFR measurement may provide additional insights regarding the relative contribution of macro- and microvascular disease in patients with ischemic heart disease.
Clinical trial registration:
URL: http://www.clinicaltrials.gov. Unique identifier: NCT02186093.
No preview · Article · Oct 2015 · Circulation Cardiovascular Interventions
[Show abstract][Hide abstract] ABSTRACT: Objectives:
The purpose of this study was to characterize the hemodynamic force acting on plaque and to investigate its relationship with lesion geometry.
Coronary plaque rupture occurs when plaque stress exceeds plaque strength.
Computational fluid dynamics was applied to 114 lesions (81 patients) from coronary computed tomography angiography. The axial plaque stress (APS) was computed by extracting the axial component of hemodynamic stress acting on stenotic lesions, and the axial lesion asymmetry was assessed by the luminal radius change over length (radius gradient [RG]). Lesions were divided into upstream-dominant (upstream RG > downstream RG) and downstream-dominant lesions (upstream RG < downstream RG) according to the RG.
Thirty-three lesions (28.9%) showed net retrograde axial plaque force. Upstream APS linearly increased as lesion severity increased, whereas downstream APS exhibited a concave function for lesion severity. There was a negative correlation (r = -0.274, p = 0.003) between APS and lesion length. The pressure gradient, computed tomography-derived fractional flow reserve (FFRCT), and wall shear stress were consistently higher in upstream segments, regardless of the lesion asymmetry. However, APS was higher in the upstream segment of upstream-dominant lesions (11,371.96 ± 5,575.14 dyne/cm(2) vs. 6,878.14 ± 4,319.51 dyne/cm(2), p < 0.001), and in the downstream segment of downstream-dominant lesions (7,681.12 ± 4,556.99 dyne/cm(2) vs. 11,990.55 ± 5,556.64 dyne/cm(2), p < 0.001). Although there were no differences in FFRCT, % diameter stenosis, and wall shear stress pattern, the distribution of APS was different between upstream- and downstream-dominant lesions.
APS uniquely characterizes the stenotic segment and has a strong relationship with lesion geometry. Clinical application of these hemodynamic and geometric indices may be helpful to assess the future risk of plaque rupture and to determine treatment strategy for patients with coronary artery disease. (Evaluation of FFR, WSS, and TPF Using CCTA; NCT01857687).
[Show abstract][Hide abstract] ABSTRACT: Long-term clinical outcomes of real-world use of fractional flow reserve (FFR), including the decisions against FFR, have not been fully evaluated in the era of drug-eluting stent (DES) implantation.
A total of 1294 patients who underwent FFR measurement for de novo coronary lesions were included. FFR measured lesions (n = 1628) were divided into FFR-defer or FFR-stent lesions according to the treatment strategy selected after FFR measurement. Clinical outcomes were assessed by patient-related major adverse cardiac event (a composite of all-cause death, myocardial infarction, and any revascularization) and target-lesion related event (target-lesion related myocardial infarction and revascularization).
Mean FFR was 0.80 ± 0.12, and FFR was ≤0.8 in 728 lesions (44.7%). Five-year cumulative all-death rate was 6.3%, myocardial infarction rate was 1.5%, and rate of any revascularization was 12.5%. Among 797 deferred lesions, 105 lesions had FFR ≤0.8 and those lesions had a higher risk of 5-year target-lesion related events than the lesions with FFR >0.8 (21.2% vs 6.6%, respectively; P=.03). By multivariate analyses, the determinant for the 1-year target-lesion related events was the presence of diabetes (hazard ratio, 3.74; 95% confidence interval, 1.45-9.67; P=.01), while the determinant for delayed events at 1-5 years was FFR ≤0.8 (hazard ratio, 4.50; 95% confidence interval, 1.65-12.28; P=.01). Angiographic lesion severity was not an independent predictor for clinical events during follow-up among deferred lesions.
The deferral of stenting according to FFR was associated with favorable long-term outcomes. Presence of diabetes and low FFR (≤0.8) increased the risk of clinical events in deferred lesions.
No preview · Article · Sep 2015 · The Journal of invasive cardiology
[Show abstract][Hide abstract] ABSTRACT: The prognostic value of poststent fractional flow reserve (FFR) has not been clearly defined in patients with drug-eluting stent (DES) implantation. This study sought to evaluate the association between FFR and clinical outcomes after DES implantation with intravascular ultrasound (IVUS) assistance.
A total of 115 lesions (107 patients) with FFR measurement after IVUS-assisted DES implantation were enrolled. Poststent angiographic and IVUS parameters were compared with FFR values. Clinical outcomes were assessed by target vessel failure (TVF), defined as a composite of target vessel revascularization, death, or non-fatal myocardial infarction attributed to the target vessel.
Mean poststent FFR was 0.92 ± 0.04. Minimal stent area by IVUS had a positive correlation with poststent FFR (r = 0.36; P<.01). Poststent FFR ≥0.89 was a physiologic cut-off value for 1-year TVF-free survival. The best cut-off value of minimal stent area to define poststent FFR ≥0.89 was >5.4 mm² (sensitivity, 63.2%; specificity, 90.0%). At 3-year follow-up, lesions with poststent FFR ≥0.89 had a better TVF-free survival rate than those with poststent FFR <0.89 (89.3% vs 61.1%, P =.03).
Poststent FFR can be a useful predictor for long-term clinical outcomes after DES implantation and relevant to IVUS minimal stent area.
No preview · Article · Aug 2015 · The Journal of invasive cardiology
[Show abstract][Hide abstract] ABSTRACT: Efficacy of combined intravascular ultrasound (IVUS) parameters in functional significance prediction and discrepancy between IVUS and fractional flow reserve (FFR) have not been well defined. This study therefore aimed to: 1) evaluate the diagnostic accuracy of combined IVUS parameters, namely minimal lumen area (MLA) and percent plaque burden (%PB), in functional significance prediction of coronary artery stenosis; and 2) define factors that affect the relation between FFR value and IVUS parameters.
At 11 international centres, IVUS and FFR measurements were concurrently performed in 945 major epicardial coronary artery lesions (886 patients). Functional significance was defined as FFR ≤0.8. MLA and FFR correlated weakly (r=0.289, p<0.001). Diagnostic accuracy of MLA ≤4.0 mm2, %PB >70% and their combination were 50%, 47% and 51%, respectively, with similar area under the curve (AUC) of 0.561, 0.511 and 0.516, respectively. The best cut-off values (BCV) were MLA ≤3.0 mm2 and %PB >75%, with accuracy of 60% for MLA, 50% for %PB and 56% for their combination, and AUC of 0.618, 0.511 and 0.533, respectively. MLA BCV ≤3.0 mm2 had higher predictive power than %PB BCV >75% or their combination. Independent predictors of functional significance were male gender (odds ratio 1.76 [95% confidence interval: 1.19-2.62]), left ventricular ejection fraction (LVEF, 0.98 [0.96-0.99]), LAD lesion (2.52 [1.73-3.67]), reference vessel diameter (0.60 [0.41-0.86]), lesion length (1.04 [1.02-1.06]) and MLA (0.79 [0.69-0.92]). False negative lesion incidence was 24.4% in association with race (for Asians, 0.391 [0.219-0.698]), LAD lesion (2.677 [1.709-4.191]) and LVEF (0.977 [0.957-0.997]). False positive lesion incidence was 17.0% in association with non-LAD lesion (2.444 [1.620-3.686]).
Combined IVUS parameters did not improve the accuracy of functional significance prediction. Discrepancy between IVUS and FFR, which was not rare, should be taken into account in clinical decision making.
No preview · Article · Jun 2015 · EuroIntervention: journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology