Comparison of drug-eluting balloon with repeat drug-eluting stent for recurrent drug-eluting stent in-stent restenosis Objective Approximately, 10–20% of patients with drug eluting stent (DES) in-stent restenosis (ISR) will develop recurrent ISR; yet, the optimal management of recurrent DES-ISR is unknown. We sought to compare the outcomes of recurrent DES-ISR treated with drug eluting balloons (DEB) to those with repeated implantation of new-generation DES. Methods A total of 172 patients with recurrent DES-ISR were enrolled and stratified into two cohorts: the repeated DES implantation (Re-DES) group and the DEB group. The primary endpoint was the 1-year incidence of major adverse cardiovascular events (MACE). Results Ninety-three patients treated with DEB and 79 patients with Re-DES implantation were analyzed. Both groups had comparable baseline characteristics. Lesser residual stenosis was achieved in the Re-DES group (11.3 ± 3.2% vs. 22.4 ± 4.3%; P = 0.00) than in the DEB group. However, the incidence of MACE and target lesion revascularization (TLR) were less in the DEB group (17.2% vs. 32.9%; P = 0.02 and 15.1% vs. 27.8%; P = 0.04, respectively). For the ≥3 metal-layered DES-ISR subgroup, DEB drastically reduced the incidences of MACE and TLR compared with Re-DES (20.0% vs. 57.9%; P = 0.02 and 16.0% vs. 47.4%; P = 0.04, respectively). Survival analysis demonstrated that MACE-free survival was significantly higher in the DEB group compared with the Re-DES group, whether the metal layers were ≥3 or 2. Multivariate analysis revealed that the risk factors of MACE were diabetes mellitus, ≥3 metal-layered DES ISR, and repeat DES deployment. Conclusions For recurrent DES-ISR, DEB may improve clinical outcomes compared with Re-DES implantation, especially for ≥3 metal-layered DES-ISR. Received 26 December 2018 Accepted 20 July 2019 Correspondence to Guozhong Wang, MD, Cardiology Department, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, 2 Anzhen Road, Chaoyang District, Beijing 100029, ROC, Tel: +86 10 64456747; fax: +86 10 64456313; e-mail: wgz1974@hotmail.com This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Predictive value of the combination of age, creatinine, and ejection fraction score and diabetes in patients with ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention Background: This study investigated whether the age, creatinine, and ejection fraction (ACEF) score [age (years) /ejection fraction (%) +1 (if creatinine>176μmol/L)] could predict 1-year outcomes following ST-segment elevation myocardial infarction after percutaneous coronary intervention, and whether accuracy could be improved by establishing novel ACEF-derived risk models. Methods: A total of 1146 patients were included. The study endpoint was 1-year major adverse cardio-cerebrovascular events, including all-cause death, nonfatal myocardial infarction, unplanned revascularization, and nonfatal stroke. Accuracy was defined with area under the curve by receiver-operating characteristic curve analysis. Results: The incidence of 1-year major adverse cardio-cerebrovascular event increased with the rising age, creatinine, and ejection fraction score tertiles (4.8%, 8.4%, and 15.2%, P < 0.001 for all). Higher ACEF score was significantly associated with an increased risk of the endpoint in overall (odds ratio = 3.75, 95% confidence interval, 2.44–5.77, P < 0.001) and in subgroups (all P < 0.05). The accuracy of the ACEF score was equivalent to the other complex risk scores. The combination of ACEF, and diabetes (ACEF-diabetes score) yielded a superior discriminatory ability than the original ACEF score (increase in C-statistic from 0.67 to 0.71, P = 0.048; continuous net reclassification improvement = 51.9%, 95% confidence interval, 33.4–70.5%, P < 0.001; integrated discrimination improvement = 0.020, 95% confidence interval, 0.011–0.030, P < 0.001). Conclusions: The simplified ACEF score performed well in predicting 1-year outcomes in ST-segment elevation myocardial infarction patients undergoing percutaneous coronary intervention. The novel ACEF-diabetes score provided a better predictive value and thus may help stratify high-risk patients and potentially facilitate decision making. Received 9 June 2019 Accepted 29 July 2019 Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website, www.coronary-artery.com. Correspondence to Hongwei Li, MD, PhD, Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, No. 95, Yongan Road, Xicheng District, Beijing 100050, China, Tel: + 86 13801396679; e-mail: lhw19656@sina.com This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Association between new circulating proinflammatory and anti-inflammatory adipocytokines with coronary artery disease Background The aim of this study was to evaluate the diagnostic and risk predictive value of emerging proinflammatory and anti-inflammatory adipocytokines on coronary artery disease (CAD). Patients and methods The study involved 259 inpatients suspected acute coronary syndrome who underwent coronary angiography. Demographic, clinical characteristics, and coronary artery stenosis rated by Gensini score were collected by cardiovascular doctors. The levels of serum inflammatory adipocytokines were evaluated by ELISA. The correlations of the cytokines with clinical parameters were assessed. Receiver operating characteristic curves were constructed for the diagnosis of CAD. Results The 259 inpatients were assigned to the CAD (n = 180) and control groups (n = 79). Compared with the control group, the CAD group displayed significantly higher serum levels of retinol-binding protein-4 (RBP4), pentraxin 3 (PTX3), galectin-3 (GAL-3), and plasminogen activator inhibitor (PAI-1), and significantly lower levels of netrin-1 (NTN1), interleukin-37 (IL-37), and adiponectin (ADP) (all P < 0.05). PAI-1 was significantly upregulated, and IL-37 and ADP were significantly downregulated in the three-vessels CAD subgroup compared to the one- and two-vessels CAD subgroups (P < 0.05). The RBP4, PTX3, GAL-3, PAI-1, and IL-37 inflammatory cytokines were significantly positively correlated with Gensini score, and ADP was negatively correlated (all P < 0.001). IL-37 was a more accurate anti-inflammatory biomarker than NTN1 and ADP. Combining cytokines significantly increased the sensitivity and specificity. Conclusion The inflammatory adipocytokines GAL-3, RBP4, PTX3, NTN1, and IL-37 were more effective than the classical biomarkers PAI-1 and ADP in the diagnosis and risk assessment of CAD patients. Received 4 January 2019 Accepted 1 July 2019 Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website, www.coronary-artery.com. Correspondence to Lixian Sun, MD, Department of Cardiology, The Affiliated Hospital of Chengde Medical University, Chengde, Heibei 067000, China, Tel: +860314 227 9016; fax: +86 0314 227 4895; e-mail: lixiansun01@126.com This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Relationship between C-reactive protein-to-albumin ratio and the extent of coronary artery disease in patients with non-ST-elevated myocardial infarction Background This study aimed to investigate the predictive value of the newly defined C-reactive protein (CRP)-to-albumin ratio (CAR) in determining the extent and severity of coronary artery disease (CAD) in comparison with the other inflammatory markers such as neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR), in patients with non-ST-elevated myocardial infarction (NSTEMI). Patients and methods This study is retrospectively designed and includes 205 patients with NSTEMI with a mean age of 56.6±11.4 years. The study cohort was subdivided into two groups according to Synergy Between Percutaneous Coronary Intervention with Taxus and cardiac surgery score (SS) as low (<23) and intermediate-high (≥23). Complete blood counts, serum CRP, and serum albumin were obtained at admission. The CAR, NLR, and PLR values of all patients were calculated. Then, we evaluated the relationship of CAR, NLR, and PLR with the CAD extent and severity. Results CAR and NLR were moderately correlated with SS (r=0.517, P<0.001; r=0.222, P=0.001, respectively), whereas PLR showed weak correlation with SS (r=0.191, P=0.006). According to multivariate analysis models, CAR, NLR, and left ventricular ejection fraction were found to be independent predictors of CAD severity (P<0.05). The area under the curve (AUC) for CAR (AUC: 0.829; 95% confidence interval: 0.770–0.878) was significantly greater than the AUC of NLR (AUC: 0.657; 95% confidence interval: 0.588–0.722), with P value of 0.002. A CAR more than 17 predicted an intermediate-high SS with 86% sensitivity and 76% specificity. Conclusion Novel inflammatory marker CAR can be used as a reliable marker in prediction of CAD severity in patients with NSTEMI. Correspondence to Muhsin Kalyoncuoglu, MD, Cardiology Department, Haseki Training and Research Hospital, University of Health Sciences, 34107 Istanbul, Turkey Tel: +90 537 598 1051; fax: +90 212 589 6229; e-mail: mkalyoncuoglu80@gmail.com Received May 4, 2019 Received in revised form May 18, 2019 Accepted May 29, 2019 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

‘One for all’ configuration: single left coronary artery with origin of the right coronary artery from the septal branch No abstract available

Isolated septal branch lesion as the only diagnostic clue for spontaneous coronary artery dissection No abstract available

Long-term outcomes after percutaneous coronary intervention relative to bypass surgery in diabetic patients with multivessel coronary artery disease according to clinical presentation Background For diabetic patients with multivessel coronary artery disease (MVD), limited data exist on the long-term outcomes of percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) according to clinical presentation [stable coronary artery disease (SCAD) or non-ST-elevation acute coronary syndrome (NSTE-ACS)]. Patients and methods From a Korean multicenter registry, we analyzed 1135 diabetic patients with MVD treated with PCI (n=660) or CABG (n=475). After propensity score matching, 8-year major adverse cardiovascular and cerebrovascular events [MACCE; composite of all-cause death, myocardial infarction (MI), or stroke] were compared between PCI and CABG according to clinical presentation. Results After matching, MACCE was not different between PCI and CABG for SCAD patients [15.6 vs. 17.2%, hazard ratio (HR)=0.94, 95% confidence interval (CI)=0.55–1.63, P=0.837], whereas it was higher in PCI than in CABG for NSTE-ACS patients (31.1 vs. 22.4%, HR=1.63, 95% CI=1.03–2.59, P=0.036), mainly driven by the higher MI occurrence (HR=2.18, 95% CI=1.04–4.59, P=0.035). A significant interaction between revascularization strategy and clinical presentation was observed for MACCE (P-interaction=0.022). However, when PCI was further classified according to revascularization completeness, the treatment gap between PCI and CABG with respect to MI in NSTE-ACS patients was improved by complete-revascularization PCI. Conclusion Among diabetic patients with MVD, the long-term outcomes of PCI versus CABG differed according to clinical presentation. CABG may be more beneficial for NSTE-ACS patients with MVD in reducing MACCE and MI, whereas PCI was as effective as CABG for SCAD patients with MVD. Therefore, clinical presentation must be considered when choosing revascularization strategies in these patients. * Yong-Joon Lee and Sung-Jin Hong contributed equally to the writing of this article. Correspondence to Byeong-Keuk Kim, MD, PhD, Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, 250 Seongsanno, Seodaemun-gu, Seoul 03722, South Korea Tel: +82 222 288 460; fax: +82 222 277 732; e-mail: kimbk@yuhs.ac Received May 7, 2019 Received in revised form May 9, 2019 Accepted May 11, 2019 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Coronary artery tortuosity: a narrative review Coronary artery tortuosity (CAT) is a prevalent angiographic finding commonly associated with aging, hypertension, atherosclerosis and other conditions. Preliminary evidence suggests that degradation of elastin, a key component of extracellular matrix in the vascular wall, may be responsible for the development of CAT. The clinical significance of CAT should be considered in several aspects. First, coronary flow alteration associated with CAT may result in myocardial ischemia owing to reduced perfusion pressure distal to the tortuous segment. Second, increased and oscillatory shear stress in the tortuous vessel may promote atherosclerotic plaque formation and acute coronary syndrome. Third, as one of the criteria for coronary lesion complexity, the presence of severe tortuosity proximal to the culprit lesion may pose a challenge to wiring and stent or balloon delivery, thereby increasing the risk of periprocedural complications. Last, the presence of CAT may serve as a diagnostic clue of concurrent vasculopathy such as fibromuscular dysplasia or spontaneous coronary artery dissection. In general, CAT represents a benign entity that does not require specific treatment or intervention. Further research is warranted to elucidate the pathogenesis and prognostic effect of coronary tortuosity. Correspondence to Gerald Chi, MD, Department of Medicine, Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 930 Commonwealth Avenue #3, Boston, MA 02215, USA Tel: +1 617 975 9952; fax: +1 617 975 9955; e-mail: geraldcchi@gmail.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Assessment of the relationship between C-reactive protein-to-albumin ratio and slow coronary flow in patients with stable angina pectoris Background The relationship between severity of coronary artery disease and inflammatory parameters has been previously demonstrated. However, there is a lack of data regarding the role of C-reactive protein-to-albumin ratio (CAR) in slow coronary flow (SCF) in patients with stable angina pectoris (SAP). In this study, we aimed to investigate the relationship between CAR and presence of SCF in patients with SAP. Patients and methods This study enrolled 217 patients undergoing coronary angiography for SAP. SCF was detected in 81 (37.3%) patients, and the control group included 136 patients. All clinical, demographical, and laboratory parameters were entered into a dataset and compared between SCF group and the controls. Results The mean age of the patients was 66.1±12.1 years (male: 57.1%). C-reactive protein and CAR were significantly higher in patients with SCF compared with controls (P=0.004 and <0.001, respectively). Logistic regression analysis demonstrated that high CAR level was an independent determinant of SCF (odds ratio: 1.023; 95% confidence interval: 1.013–1.034; P<0.001). Conclusion Higher CAR level may be a valuable predictor of SCF in patients with SAP who undergo coronary angiography. Inflammation may play an important role in the pathogenesis of SCF. Correspondence to Mahmut Yesin, MD, Örnek Mah, Hastane Cad, Temel Apt. No. 32 Kars 36200, Turkey Tel: +90 532 472 6596; fax: +90 474 212 2367; e-mail: mahmutyesin@yahoo.com Received November 29, 2018 Received in revised form May 9, 2019 Accepted May 11, 2019 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

The relationship between protein convertase subtilisin kexin type-9 levels and extent of coronary artery disease in patients with non-ST-elevation myocardial infarction Background Cardiovascular disease is one of the leading causes of death worldwide. According to the results of various studies, protein convertase subtilisin kexin type-9 (PCSK9) was determined as a novel risk factor for stable coronary artery disease. Few studies have investigated the relationship between PCSK9 levels and the severity of coronary artery disease in patients with acute coronary syndrome; thus, we herein aimed to investigate this relationship in patients with non-ST-elevation myocardial infarction (NSTEMI) who underwent coronary angiography. Patients and methods Herein, 168 patients with NSTEMI were prospectively enrolled, and severity of atherosclerotic lesions was determined using SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery (SYNTAX), Gensini and Jeopardy scores. Plasma PCSK9 levels, lipid parameters and C-reactive protein levels were measured after a 12-h fasting period. The relationship of PCSK9 levels and clinical and laboratory parameters of patients with their SYNTAX, Gensini and Jeopardy scores was investigated. Results Pearson correlation analysis showed a strong positive correlation between PCSK9 and the three scores (P<0.001, r>0.5 for all). In ROC analysis, a mid-high SYNTAX score of at least 25 was predicted with a sensitivity of 81% and a specificity of 63% when the PCSK9 level was higher than 52.8 ng/ml (area under a curve 0.76, P<0.001). Multivariate linear regression analysis revealed that PCSK9, low-density lipoprotein cholesterol and creatinine levels were independent predictors of a high SYNTAX score. Conclusion Taken together, high PCSK9 levels may be a risk factor for adverse events in patients with NSTEMI. Aggressive lipid-lowering therapies may benefit this group of patients. Correspondence to Yalcin Dalgic, MD, Cardiology Institute, Haseki Sultan Mahallesi, Haseki Cd. No. 27, Fatih, Istanbul University, Istanbul 34096, Turkey Tel: +90 506 618 9077; fax: +90 212 459 2069; e-mail: yalcindalgic@hotmail.com Received February 4, 2019 Received in revised form April 17, 2019 Accepted May 7, 2019 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.