Background and Aims: The DanGer shock trial showed a survival benefit of Impella in highly selected patients with ST-elevation myocardial infarction-related cardiogenic shock (STEMI-CS). In real-world settings, however, Impella is often used in broader populations not meeting trial criteria. This study aimed to assess the distribution and outcomes of DanGer shock-eligible and -ineligible acute myocardial infarction-related cardiogenic shock (AMI-CS) patients in a nationwide Japanese registry. Methods: A total of 3975 AMI-CS patients treated with Impella between 2020 and 2023 were identified from the J-PVAD registry. Patients were stratified into five groups: eligible STEMI-CS, non-eligible STEMI-CS, out-of-hospital cardiac arrest (OHCA), mechanical complications (MCs), and non-STEMI-CS (NSTEMI-CS). Eligible STEMI-CS was defined as STEMI-CS fulfilling all of the following: lactate ≥ 2.5 mmol/L, systolic blood pressure <100 mmHg or catecholamine use, left ventricular ejection fraction <45%, and shock onset to first Impella support ≤24 h. Thirty-day mortality, associated risk factors, and complications were examined across the five groups. Results: Eligible STEMI-CS accounted for 35.6% of all AMI-CS cases, with a 30-day mortality of 37.6%. Non-eligible STEMI-CS patients had lower mortality (27.6%), but it increased significantly with advanced age, renal dysfunction, veno-arterial extracorporeal membrane oxygenation use, ventricular arrhythmia, or sepsis. Thirty-day mortality was 51.3% in OHCA (63.4% without return of spontaneous circulation), 39.8% in MC, and 33.3% in NSTEMI-CS groups. Conclusions: In this nationwide registry, one-third of AMI-CS patients treated with Impella met DanGer shock criteria. Outcomes in non-eligible subgroups were heterogeneous, highlighting the importance of individualized risk assessment in guiding Impella use in real-world practice.

Background: Nonobstructive general angioscopy (NOGA) can identify vulnerable plaques in the aortic lumen that serve as potential risk factors for cardiovascular events such as embolism. However, the association between computed tomography (CT) images and vulnerable plaques detected on NOGA remains unknown. Methods and Results: We investigated 101 patients (67±11 years; women, 13.8%) who underwent NOGA and contrast‐enhanced CT before or after 90 days in our hospital. On CT images, the aortic wall thickness, aortic wall area (AWA), and AWA in the vascular area were measured at the thickest point from the 6th to the 12th thoracic vertebral levels. Furthermore, the association between these measurements and the presence or absence of NOGA‐derived aortic plaque ruptures (PRs) at the same vertebral level was assessed. NOGA detected aortic PRs in the aortic lumens at 145 (22.1%) of the 656 vertebral levels. The presence of PRs was significantly associated with greater aortic wall thickness (3.3±1.7 mm versus 2.1±1.2 mm), AWA (1.33±0.68 cm ² versus 0.89±0.49 cm ² ), and AWA in the vascular area (23.2%±9.3% versus 17.2%±7.6%) ( P <0.001 for all) on the CT scans compared with the absence of PRs. The frequency of PRs significantly increased as the aortic wall thickness increased. Notably, a few NOGA‐derived PRs were detected on CT in near‐normal intima. Conclusions: The presence of NOGA‐derived PRs was strongly associated with increased aortic wall thickness, AWA, and AWA in the vascular area, measured using CT. NOGA can detect PRs in the intima that appear almost normal on CT scans.

We have a great interest in the article in Journal of Atherosclerosis and Thrombosis by Suzuki et al. titled Complex Aortic Arch Atherosclerosis in Acute Ischemic Stroke Patients with Non-Valvular Atrial Fibrillation. The authors demonstrated that 38.7% transesophageal echocardiography-derived complex aortic arch plaques (CAPs) among 106 patients with acute ischemic strokes with atrial fibrillation (AF), suggesting that patients with acute ischemic stroke and AF often had CAPs. The atheromatous lesions at the aortic arch are one of the causes of ischemic strokes. The cause of acute ischemic strokes in patients with AF could not only be cardiogenic embolisms due to AF but also aortogenic embolisms due to CAPs. The possibility of concomitant CAPs should be considered for stroke patients with AF. Non-obstructive general angioscopy has the possibility to detect aortic plaques in the aortic arch more accurately than TEE and might help to diagnose atheromatous plaques and embolic materials in the aortic arch. Further studies are needed to elucidate the causes of ischemic strokes and are expected to improve the outcomes for acute ischemic strokes in patients with AF.

The optimal duration of dual antiplatelet therapy for acute myocardial infarction is controversial because the bleeding risk outweighs the thromboembolic risk. We hypothesized that an in-stent thrombus (IS-thrombus) detected by coronary angioscopy (CAS) after stent implantation would be associated with high bleeding risk. This study included 208 patients who underwent CAS at 2 weeks after stent implantation for an acute myocardial infarction. The study was approved by the ethics committee at the Nihon University Itabashi Hospital (reference number RK-200714-10). In 84 patients, in whom no IS-thrombus was identified in the culprit vessel using CAS, the major bleeding event rate was significantly higher than that in patients with IS-thrombi (n = 124). However, no difference was detected in major adverse cardiovascular events (MACE; stroke, hospitalization for a non-fatal myocardial infarction/unstable angina, target lesion revascularization, and cardiovascular death). After adjustments by the propensity score based on patient characteristics, the absence of IS-thrombi remained an independent predictor of major bleeding events (hazard ratio 4.73, 95% confidence interval 2.04-11.00, p < 0.001). The absence of CAS-detected IS-thrombi in the subacute phase was independently associated with future major bleeding events, but not with MACE. These findings may help optimize the duration of dual antiplatelet therapy.