Circulation Journal
Online ISSN : 1347-4820
Print ISSN : 1346-9843
ISSN-L : 1346-9843
Volume 86, Issue 5
Displaying 1-31 of 31 articles from this issue
Message From the Editor-in-Chief
Focus on issue: Ischemic Heart Disease
Reviews
  • Masahiro Natsuaki, Takeshi Kimura
    Article type: REVIEW
    2022 Volume 86 Issue 5 Pages 741-747
    Published: April 25, 2022
    Released on J-STAGE: April 25, 2022
    Advance online publication: September 23, 2021
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    Optimal antiplatelet therapy after percutaneous coronary intervention (PCI) has been changed in parallel with the improvements of coronary stent and antiplatelet therapy. Over the past 25 years, dual antiplatelet therapy (DAPT) with aspirin plus P2Y12inhibitor has been the standard of care used after coronary stent implantation. First-generation drug-eluting stent (DES) appeared to increase the risk of late stent thrombosis, and duration of DAPT was prolonged to 12 months. DAPT duration up to 12 months was the dominant strategy after DES implantation in the subsequent >10 years, although there was no dedicated randomized controlled trial supporting this recommendation. The current recommendation of DAPT duration is getting shorter due to the development of new-generation DES, use of a P2Y12inhibitor as a monotherapy, and the increasing prevalence of high-bleeding risk patients. Furthermore, an aspirin-free strategy is now emerging as one of the novel strategies of antiplatelet therapy after PCI. This review gives an overview of the history of antiplatelet therapy and provides current and future perspectives on antiplatelet therapy after PCI.

Original Articles
Coronary Intervention
  • Masahiro Natsuaki, Takeshi Morimoto, Hiroki Shiomi, Ko Yamamoto, Kyohe ...
    Article type: ORIGINAL ARTICLE
    Subject area: Coronary Intervention
    2022 Volume 86 Issue 5 Pages 748-759
    Published: April 25, 2022
    Released on J-STAGE: April 25, 2022
    Advance online publication: September 16, 2021
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    Supplementary material

    Background: Optimal intensity is unclear for P2Y12receptor blocker therapy after percutaneous coronary intervention (PCI) in real-world clinical practice.

    Methods and Results: From the CREDO-Kyoto Registry, the current study population consisted of 25,419 patients (Cohort-2: n=12,161 and Cohort-3: n=13,258) who underwent their first PCI. P2Y12receptor blocker therapies were reduced dose of ticlopidine (200 mg/day), and global dose of clopidogrel (75 mg/day) in 87.7% and 94.8% of patients in Cohort-2 and Cohort-3, respectively. Cumulative 3-year incidence of GUSTO moderate/severe bleeding was significantly higher in Cohort-3 than in Cohort-2 (12.1% and 9.0%, P<0.0001). After adjusting 17 demographic factors and 9 management factors potentially related to the bleeding events other than the type of P2Y12receptor blocker, the higher bleeding risk in Cohort-3 relative to Cohort-2 remained significant (hazard ratio (HR): 1.52 95% confidence interval (CI) 1.37–1.68, P<0.0001). Cohort-3 compared with Cohort-2 was not associated with lower adjusted risk for myocardial infarction/ischemic stroke (HR: 0.96, 95% CI: 0.87–1.06, P=0.44).

    Conclusions: In this historical comparative study, Cohort-3 compared with Cohort-2 was associated with excess bleeding risk, which might be at least partly explained by the difference in P2Y12receptor blockers.

  • Kensuke Takagi, Teruo Noguchi
    Article type: EDITORIAL
    2022 Volume 86 Issue 5 Pages 760-762
    Published: April 25, 2022
    Released on J-STAGE: April 25, 2022
    Advance online publication: October 21, 2021
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  • Raisuke Iijima, Kazushige Kadota, Koichi Nakao, Yoshihisa Nakagawa, Ju ...
    Article type: ORIGINAL ARTICLE
    Subject area: Coronary Intervention
    2022 Volume 86 Issue 5 Pages 763-771
    Published: April 25, 2022
    Released on J-STAGE: April 25, 2022
    Advance online publication: December 08, 2021
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    Supplementary material

    Background: The balance between thrombotic and bleeding risk is of great concern in high bleeding risk (HBR) patients. This study evaluated the relationship between perioperative antiplatelet reactivity and thrombotic and bleeding events in patients at HBR undergoing percutaneous coronary intervention (PCI).

    Methods and Results: In this post hoc analysis of the PENDULUM (Platelet rEactivity in patieNts with DrUg eLUting stent and balancing risk of bleeding and ischeMic event) registry, patients undergoing PCI were categorized as HBR or non-HBR, and stratified as having high platelet reactivity (HPR; P2Y12reaction unit [PRU] >208) or non-HPR (PRU ≤208). Cumulative incidences of cardiovascular and cerebrovascular events (Journal of the American College of Cardiology expert definitions) and bleeding events (Bleeding Academic Research Consortium criteria) were assessed 12 months after index PCI. The incidence of ischemic and bleeding events was ~3-fold higher in HBR vs. non-HBR patients. Thrombotic/ischemic events were significantly more common in the HPR subgroup in HBR patients (hazard ratio [HR]: 1.59; 95% confidence interval [CI]: 1.11–2.28; P=0.012), but there was no difference in non-HBR patients. After adjustment for covariates, HPR in HBR patients remained an independent factor for thrombotic and ischemic events (HR: 1.69; 95% CI: 1.13–2.54; P=0.011), but not for bleeding events (HR: 1.56; 95% CI: 0.78–3.11; P=0.210).

    Conclusions: Maintaining adequate PRU levels during PCI is an important factor in improving clinical outcomes, especially for HBR patients.

  • Seiji Hokimoto, Kenichi Tsujita, Hisao Ogawa
    Article type: EDITORIAL
    2022 Volume 86 Issue 5 Pages 772-774
    Published: April 25, 2022
    Released on J-STAGE: April 25, 2022
    Advance online publication: January 20, 2022
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  • Yuya Taguchi, Katsuya Miura, Yuki Shima, Koya Okabe, Akihiro Ikuta, Ko ...
    Article type: ORIGINAL ARTICLE
    Subject area: Coronary Intervention
    2022 Volume 86 Issue 5 Pages 775-783
    Published: April 25, 2022
    Released on J-STAGE: April 25, 2022
    Advance online publication: January 28, 2022
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    Supplementary material

    Background: Gastrointestinal bleeding (GIB) and intracranial bleeding (ICB) are frequently observed as major bleeding events after percutaneous coronary intervention (PCI); however, there are few reports on these predictors and their association with the Academic Research Consortium for High Bleeding Risk (ARC-HBR).

    Methods and Results: The study included 3,453 patients who underwent PCI with second-generation drug-eluting stents between 2010 and 2013. Mean follow up was 2,663±596 days. The cumulative incidences of GIB and ICB were significantly higher in the HBR group than in the non-HBR group (6.3% vs. 1.9%, P<0.001, 5.5% vs. 2.3%, P<0.001). Older age, oral anticoagulant (OAC), and severe chronic kidney disease were independent predictors of GIB (hazard ratios [HR], 1.64; 95% confidence intervals [CI], 1.11–2.41; P=0.012; HR, 1.94; 95% CI, 1.23–3.05; P=0.004; HR, 1.80; 95% CI, 1.02–3.19, P=0.043 respectively), and low body weight, OAC, and left main coronary artery stenting were independent predictors of ICB by multivariate logistic regression analysis (HR, 1.83; 95% CI, 1.20–2.80; P=0.005; HR, 2.04; 95% CI, 1.31–3.19; P=0.002; HR, 1.79; 95% CI, 1.18–2.70; P=0.006 respectively).

    Conclusions: ARC-HBR was consistently associated with GIB and ICB within a 7-year period. GIB and ICB had three predictors each. Of these, only OAC administration was common, and the other two were different.

  • Kohei Moribayashi, Yunosuke Matsuura, Koichi Kaikita
    Article type: EDITORIAL
    2022 Volume 86 Issue 5 Pages 784-786
    Published: April 25, 2022
    Released on J-STAGE: April 25, 2022
    Advance online publication: March 12, 2022
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  • Keita Shibata, Kohei Wakabayashi, Tomoyuki Ishinaga, Mitsuyuki Morimur ...
    Article type: ORIGINAL ARTICLE
    Subject area: Coronary Intervention
    2022 Volume 86 Issue 5 Pages 787-796
    Published: April 25, 2022
    Released on J-STAGE: April 25, 2022
    Advance online publication: February 10, 2022
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    Supplementary material

    Background: The long-term safety and utility of intravascular ultrasound (IVUS)-guided zero-contrast percutaneous coronary intervention (PCI) in patients with chronic kidney disease (CKD) are unknown.

    Methods and Results: A total of 698 consecutive patients treated with PCI (1,061 procedures) in our center were studied. Patients with acute coronary syndrome, who are on maintenance hemodialysis, and who had a planned rotational atherectomy were excluded. Finally, they were divided into 2 groups: zero-contrast PCI (n=55, 78 procedures) and conventional PCI (n=462, 670 procedures). After propensity score matching, 50 patients were matched for each group to evaluate long-term outcomes. Primary endpoints were major adverse cardiovascular events (MACE), including all-cause death, non-fatal myocardial infarction (MI), and clinically driven target lesion revascularization. All patients in the zero-contrast PCI group had stage 3–5 CKD with an estimated glomerular filtration rate of 38.3±14.8 mL/min/1.73 m2. Zero-contrast PCI was successful in all 78 procedures without renal events such as acute kidney injury or emergent hemodialysis and procedural complications such as coronary perforation or periprocedural MI. During a follow-up period of 32 months, 7 patients died (1 cardiac, 6 non-cardiovascular), and 4 patients were introduced to renal replacement therapy. The incidence of MACE was similar between the zero-contrast and conventional PCI groups (log-rank, P=0.95).

    Conclusions: IVUS-guided zero-contrast PCI might be safe and feasible in patients with CKD with satisfactory acute and long-term renal and cardiovascular outcomes.

  • Masataka Nakano, Nobuhiko Ogata
    Article type: EDITORIAL
    2022 Volume 86 Issue 5 Pages 797-798
    Published: April 25, 2022
    Released on J-STAGE: April 25, 2022
    Advance online publication: March 31, 2022
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  • Tomotsugu Seki, Hironobu Tokumasu, Hiroyuki Tanaka, Harumi Katoh, Koji ...
    Article type: ORIGINAL ARTICLE
    Subject area: Coronary Intervention
    2022 Volume 86 Issue 5 Pages 799-807
    Published: April 25, 2022
    Released on J-STAGE: April 25, 2022
    Advance online publication: October 06, 2021
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    Background: The appropriateness of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) lesions has rarely been investigated.

    Methods and Results: The Japanese CTO-PCI Expert Registry enrolled consecutive patients undergoing CTO-PCI carried out by highly experienced Japanese CTO specialists who performed more than 50 CTO-PCIs per year and 300 CTO-PCIs in total. This study included patients undergoing CTO-PCI between January 2014 and December 2019. The appropriateness, trends, and differences among the procedures performed by the operators using the 2017 appropriate use criteria were analyzed. Furthermore, we performed a logistic regression analysis to assess whether the appropriateness was associated with in-hospital major adverse cardiovascular and cerebrovascular events (MACCE). Of the 5,062 patients who underwent CTO-PCI, 4,309 (85.1%) patients who did not undergo the non-invasive stress test were classified as having no myocardial ischemia. Of the total cases, 3,150 (62.2%) were rated as “may be appropriate,” and 642 (12.7%) as “rarely appropriate” CTO-PCI cases. The sensitivity analyses showed that the number (%) of “may be appropriate” ranged from 4,125 (57.8%) to 4,744 (66.4%) and the number of “rarely appropriate” ranged from 843 (11.8%) to 970 (13.6%) among best and worst scenarios.

    Conclusions: In a large Japanese CTO-PCI registry, approximately 13% of CTO-PCI procedures were classified as “rarely appropriate”. Substantial efforts would be required to decrease the number of “rarely appropriate” CTO-PCI procedures.

  • Taku Inohara, Shun Kohsaka
    Article type: EDITORIAL
    2022 Volume 86 Issue 5 Pages 808-810
    Published: April 25, 2022
    Released on J-STAGE: April 25, 2022
    Advance online publication: November 18, 2021
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  • Taku Fukushima, Taishi Yonetsu, Norio Aoyama, Akira Tashiro, Takayuki ...
    Article type: ORIGINAL ARTICLE
    Subject area: Coronary Intervention
    2022 Volume 86 Issue 5 Pages 811-818
    Published: April 25, 2022
    Released on J-STAGE: April 25, 2022
    Advance online publication: November 18, 2021
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    Background: This study aimed to investigate the effect of periodontal disease (PD) on the outcomes of patients with coronary artery disease (CAD) treated with percutaneous coronary intervention (PCI).

    Methods and Results: The study included 77 consecutive non-smoking patients with de novo coronary lesions treated with a drug-eluting stent (DES). Periodontal measurements, including the community periodontal index (CPI), were performed by independent periodontists. A CPI score of ≥3 was used to define PD. The occurrence of major adverse cardiac events (MACEs), which were defined as a composite of cardiovascular death, non-fatal myocardial infarction, target lesion revascularization, or non-target lesion revascularization, was compared between patients with and without PD. Of the 77 patients, 49 (63.6%) exhibited a CPI score of 3 or 4 and were assigned to the PD group. The remaining 28 patients (36.4%) were assigned to the non-PD group. Baseline clinical characteristics and angiographic findings were comparable between the 2 groups. MACEs occurred in 13 (26.5%) of the PD patients and 2 (7.1%) of the non-PD patients. Kaplan-Meier analysis showed a significantly lower MACE-free survival rate in the PD group than for the non-PD group (P=0.034).

    Conclusions: PD at baseline was associated with an increased risk of MACEs in CAD patients who were treated with a DES for de novo coronary lesions.

  • Futoshi Yamanaka, Kenichi Tsujita, Shigeru Saito
    Article type: EDITORIAL
    2022 Volume 86 Issue 5 Pages 819-820
    Published: April 25, 2022
    Released on J-STAGE: April 25, 2022
    Advance online publication: December 25, 2021
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  • Hao-ming He, Chen He, Zhe-bin You, Si-cheng Zhang, Xue-qin Lin, Man-qi ...
    Article type: ORIGINAL ARTICLE
    Subject area: Coronary Intervention
    2022 Volume 86 Issue 5 Pages 821-830
    Published: April 25, 2022
    Released on J-STAGE: April 25, 2022
    Advance online publication: December 21, 2021
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    Supplementary material

    Background:Pre-procedure liver dysfunction was associated with acute kidney injury after percutaneous coronary intervention (PCI). The aim of this study is to assess and compare the predictive value of different liver function scoring systems for contrast-associated acute kidney injury (CA-AKI) in patients undergoing elective PCI.

    Methods and Results:A total of 5,569 patients were retrospectively enrolled. The model for end-stage liver disease (MELD) including albumin (MELD-Albumin) score (AUC=0.661) had the strongest predictive value in comparison to the MELD score (AUC=0.627), the MELD excluding the international normalized ratio (MELD-XI) score (AUC=0.560), and the MELD including sodium (MELD-Na) score (AUC=0.652). In the fully adjusted logistic regression model, the MELD-Albumin score and the MELD-Na score were independently associated with CA-AKI regardless of whether they were treated as continuous or categorical variables; however, this was not the case for the MELD score and the MELD-XI score. Furthermore, the addition of the MELD-Albumin score significantly improved the reclassification beyond the fully adjusted logistic regression model. The study further explored the association between different versions of the MELD score and CA-AKI using restricted cubic splines and found a linear relationship between the MELD-Albumin score and the risk of CA-AKI.

    Conclusions:The MELD-Albumin score had the highest predictive value for CA-AKI in patients undergoing elective PCI. The addition of the MELD-Albumin score to the existing risk prediction model significantly improved the reclassification for CA-AKI.

Imaging
  • Sadako Motoyama, Yasuomi Nagahara, Masayoshi Sarai, Hideki Kawai, Keii ...
    Article type: ORIGINAL ARTICLE
    Subject area: Imaging
    2022 Volume 86 Issue 5 Pages 831-842
    Published: April 25, 2022
    Released on J-STAGE: April 25, 2022
    Advance online publication: November 13, 2021
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    Supplementary material

    Background: Omega-3 fatty acids have been proposed to be useful in the prevention of cardiac events. High-risk plaque (HRP) and plaque progression on serial coronary computed tomography angiography (CTA) have been suggested to be the predecessor of acute coronary syndrome (ACS). The purpose of this study was to investigate whether addition of omega-3 fatty acids to statin therapy for secondary prevention would lead to change in plaque characteristics detected by using serial CTA.

    Methods and Results: This study enrolled 210 patients with ACS: no eicosapentaenoic acid (EPA)/ docosahexaenoic acid (DHA; EPA/DHA), low-dose EPA+DHA, high-dose EPA+DHA, and high-dose EPA alone. HRP was significantly more frequent in patients with plaque progression (P=0.0001). There was a significant interaction between plaque progression and EPA dose regardless of the DHA dose; 20.3% in EPA-none (no EPA/DHA), 15.7% in EPA-low (low-dose EPA+DHA), and 5.6% in EPA-high (high-dose EPA+DHA and high-dose EPA alone). On multivariate logistic regression analysis, HRP (OR 6.44, P<0.0001), EPA-high (OR 0.13, P=0.0004), and Rosvastatin (OR 0.24, P=0.0079) were the independent predictors for plaque progression. In quantitative analyses (n=563 plaques), the interval change of low attenuation plaque (LAP) volume was significantly different based on EPA dose; LAP was significantly increased in the EPA-none group and significantly decreased in the EPA-high group.

    Conclusions: In patients with ACS, addition of high-dose EPA (EPA-high) to statin therapy, compared to statin therapy without EPA, was associated with a lower rate of plaque progression.

  • Kota Murai, Yu Kataoka, Teruo Noguchi
    Article type: EDITORIAL
    2022 Volume 86 Issue 5 Pages 843-845
    Published: April 25, 2022
    Released on J-STAGE: April 25, 2022
    Advance online publication: December 17, 2021
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  • Yanwei Yin, Chao Fang, Senqing Jiang, Jifei Wang, Yidan Wang, Junchen ...
    Article type: ORIGINAL ARTICLE
    Subject area: Imaging
    2022 Volume 86 Issue 5 Pages 846-854
    Published: April 25, 2022
    Released on J-STAGE: April 25, 2022
    Advance online publication: December 24, 2021
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    Supplementary material

    Background: Plaque erosion can occur quietly without causing clinical symptoms, followed by a healing process resulting in healed plaque. This study aimed to assess culprit and non-culprit plaque characteristics of patients with acute myocardial infarction (AMI) caused by plaque erosion with vs. without healed phenotype at the culprit plaque using optical coherence tomography (OCT).

    Methods and Results: A total of 117 AMI patients caused by plaque erosion who underwent OCT imaging of 3 coronary arteries were included. Patients were divided into 2 groups based on presence or absence of a healed phenotype at the culprit site. Culprit and non-culprit plaque characteristics were compared between the 2 groups. A healed phenotype at the culprit lesion was identified in 47.9% of AMI patients caused by plaque erosion. Patients with a healed phenotype at the culprit site were more frequently with hyperlipidemia, and had a higher prevalence of macrophage infiltration, microchannels, cholesterol crystals, and calcification at the culprit lesion. Moreover, patients with a healed phenotype at the culprit site had more non-culprit plaques and more characteristics of plaque vulnerability at the non-culprit lesion. In addition, patients with a healed phenotype at the culprit site presented with more severe luminal stenosis at both the culprit and non-culprit lesion.

    Conclusions: A healed phenotype was identified in 47.9% of AMI patients caused by plaque erosion at the culprit site. A healed phenotype within eroded culprit plaque was associated with signs of pancoronary vulnerability and advanced atherosclerosis.

  • Takashi Muramatsu, Patrick W. Serruys
    Article type: EDITORIAL
    2022 Volume 86 Issue 5 Pages 855-856
    Published: April 25, 2022
    Released on J-STAGE: April 25, 2022
    Advance online publication: February 02, 2022
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  • Naoto Kawaguchi, Masao Miyagawa, Tomohisa Okada, Kyohei Onishi, Hayato ...
    Article type: ORIGINAL ARTICLE
    Subject area: Imaging
    2022 Volume 86 Issue 5 Pages 857-865
    Published: April 25, 2022
    Released on J-STAGE: April 25, 2022
    Advance online publication: February 23, 2022
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    Supplementary material

    Background: This study aimed to quantitatively evaluate myocardial perfusion single-photon emission computed tomography (SPECT) using an original analysis tool in the compartment model for detecting regional significant coronary artery disease (CAD).

    Methods and Results: This study analyzed 41 patients (median age, 76 years) with suspected or known CAD who underwent both dynamic SPECT using 99 mTc-tetrofosmin and invasive coronary angiography. The quantitative analysis was performed using a single-tissue compartment model to evaluate the diagnostic performance of the myocardial flow reserve (MFR) for regional significant CAD, excluding infarcted territories. In the regional analysis, 114 vessels were assessed, of which 31 were diagnosed as significant coronary lesions (≥70% stenosis and/or fraction flow reserve ≤0.8). The MFR of regional significant CAD was significantly lower than that of non-significant CAD (1.11 [0.97–1.31] vs. 1.74 [1.30–2.27]; P<0.001). In the receiver operating characteristic curve analysis, the MFR displayed an area under the curve (AUC) of 0.81. While analyzing each coronary artery territory, the diagnostic performance of the MFR value in the left anterior descending (LAD) artery territory was found to be significantly higher than that found in qualitative assessment (AUC: 0.84 vs. 0.61).

    Conclusions: A quantitative analysis of dynamic SPECT data facilitated detecting regional CAD. For the LAD artery, the MFR displayed a higher diagnostic performance than the qualitative assessment of conventional myocardial perfusion SPECT.

Pathophysiology
  • Yasuyoshi Takei, Hirofumi Tomiyama, Nobuhiro Tanaka, Akira Yamashina, ...
    Article type: ORIGINAL ARTICLE
    Subject area: Pathophysiology
    2022 Volume 86 Issue 5 Pages 866-873
    Published: April 25, 2022
    Released on J-STAGE: April 25, 2022
    Advance online publication: November 18, 2021
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    Supplementary material

    Background: Although acute hyperglycemia and insulin resistance (IR) are risk factors for atherosclerosis development through oxidative stress and sympathetic activation in diabetes mellitus, the association of these factors with coronary microvascular function in the early diabetic stage remains controversial.

    Methods and Results: Using transthoracic echocardiography, coronary flow velocity (CFV) and its reserve (CFVR) as parameters of coronary microvascular function were measured before and 1 h after an oral glucose tolerance test (OGTT) in 40 patients (aged 59±12 years) without diagnosed diabetes mellitus or coronary artery disease. Plasma glucose, insulin and thiobarbituric acid reactive substance (TBARS; an oxidative stress marker) were measured during the OGTT. IR was evaluated as homeostasis model assessment of IR (HOMA-R). Sympathetic activity was evaluated by using plasma catecholamines after OGTT. CFVR decreased after an OGTT (P<0.0001) mainly because of an increased baseline CFV (P<0.0001). Although the change in CFVR was not associated with the change in TBARS and catecholamines, it was independently associated with HOMA-R on the multivariate regression analysis (β=−0.40, P=0.01). Another multivariate regression analysis revealed that change in baseline CFV was independently associated with HOMA-R (β=0.35, P=0.03).

    Conclusions: IR, rather than oxidative stress and sympathetic activity, was associated with an increase in baseline CFV and a decline in CFVR during acute hyperglycemia. IR might play an important role in increased myocardial oxygen demand and coronary microvascular dysfunction.

  • Masaya Tanno, Arata Osanami
    Article type: EDITORIAL
    2022 Volume 86 Issue 5 Pages 874-876
    Published: April 25, 2022
    Released on J-STAGE: April 25, 2022
    Advance online publication: December 21, 2021
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