Prediction of cardiovascular events by inflammatory markers in patients undergoing carotid stenting

Capillaroscopy: a useful tool in the early diagnosis of connective tissue disease and nonscleroderma spectrum disorders

BACKGROUND

Detection of early capillaroscopic alterations in the preclinical phase may prove useful in patients with non-scleroderma connective tissue disease (CTD). We aimed to verify whether certain capillaroscopic alterations, alone or in combination, might be predictive of CTD.

METHODS

We retrospectively collected data on patients with Raynaud's phenomenon who underwent capillaroscopy conducted by highly expert examiners with a degree in vascular medicine at our institutions. Included subjects were divided in two groups: those developing rheumatic disease during follow-up, and those without subsequent diagnosis of CTD. Notably, we excluded subjects who presented with an evident scleroderma pattern or rheumatic disease during their initial examination.

RESULTS

We included a total of 76 patients, 60 who developed CTD during follow-up, which spanned in this group 23±7 months, and 16 who did not develop CTD during follow-up, which spanned 23±9 months. The following features were significantly associated with Raynaud's phenomenon: 1) angiotectonic disorder (p<0.001), 2) nonhomogeneous loop morphology (p<0.001), 3) avascular areas (p<0.001), 4) pseudo-avascular areas (p<0.001), and, albeit to a lesser degree, 5) ectasias (p=0.050). Notably, the initial capillaroscopic pattern did not undergo any changes in subsequent tests.

CONCLUSIONS

Although certain pathological characteristics of the capillaroscopic pattern are nonspecific and not diagnostic if considered individually, they can be significantly suggestive for latent CTD when found in combination. At the very least, they warrant an in-depth diagnostic analysis and a lengthy follow-up.

Editorial comment: sandwich carotid stenting: too much of a good thing?

This editorial comment refers to the article "Detection of in-stent protrusion (ISP) by intravascular ultrasound during carotid stenting: usefulness of stent-in-stent placement for ISP" by Okazaki T et al Eur Radiol., July 2018.

Decreased PPAR-γ expression after internal carotid artery stenting is associated with vascular lesions induced by smooth muscle cell proliferation and systemic inflammation in a minipig model

Vascular restenosis after stenting is known to be largely mediated by proliferation of vascular smooth muscle cells. Recently, peroxisome proliferator-activated receptor gamma (PPAR-γ) has been implicated as a regulator of cellular inflammatory responses, and the PPAR-γ agonist rosiglitazone (ROSI) has been shown to attenuate atherosclerosis formation. However, whether ROSI can inhibit neointimal formation by regulating the inflammatory response and inhibiting vascular smooth muscle hyperplasia after stenting-induced injury remains to be clarified. Accordingly, in this study, 10 minipigs were randomly divided into two groups: the stenting group (n = 5) and the ROSI group (n = 5). Morphometric analysis was conducted for the stented arteries. The protein expressions of PPAR-γ and smooth muscle 22-alpha (SM22α) were analyzed by immunohistochemistry and western blotting, and the serum interferon-γ and interleukin-10 levels were measured by enzyme-linked immunosorbent assay. Three months after implantation, morphometric analysis revealed that administration of ROSI (0.5 mg/kg/d, continuous administration for 90 days) resulted in significant reductions of luminal stenosis, the neointimal area, and neointimal thickness, as compared to the stenting groups. The expression of PPAR-γ and the PPAR-γ/SM22α ratio in the ROSI group were higher than in the stenting group. Furthermore, the serum interferon-γ and interleukin-10 levels were found to be increased and to reach peak levels at 4 h and 7 days after stenting, respectively, after which both declined. However, ROSI treatment resulted in decreased interferon-γ and increased interleukin-10 levels after stenting. In both groups, the cytokine levels returned to the baseline levels on day 56 after stenting. Taken together, these results suggest that ROSI can reduce neointimal formation after stenting by inhibiting the local and systemic inflammatory responses as well as vascular smooth muscle hyperplasia.

Incidence and risk factors of embolized particles in carotid artery stenting and association with clinical outcome

BACKGROUND

One of the mechanisms for periprocedural neurologic events in carotid artery stenting (CAS) is catheter manipulation within the aorta and supraaortic arteries causing plaque embolization. Therefore, the present analysis sought to determine risk factors for embolic particle dimensions and their relationship with adverse clinical events after CAS.

METHODS

Between 1999 and 2015 embolic protection devices (EPD) of a total of 944 CAS procedures were evaluated regarding the occurrence and size of captured particles.

RESULTS

Particles were found in 819 of 944 (87%) EPDs. Larger particles were detected in procedures using open cell stents (150±282μm vs. 107±177μm; p=0.005) and longer stents (≥40mm) (165±315μm vs. 122±215μm; p=0.026). With increasing learning curve, particle size was continually reduced (168±282μm in the first third of the cohort vs. 127±309μm in the second third vs. 108±114μm in the last third; p=0.009). Longer stents and use of Acculink stent were found to be independent predictors for particle diameter. In patients who died or sustained a stroke during long-term follow-up (median 5.5years [IQR 2.6-7.9]) significantly larger particles were captured during CAS compared to those patients with an uneventful follow-up (160±330μm vs. 121±195μm; p=0.047).

CONCLUSIONS

In the vast majority of CAS procedures particles could be retrieved from the EPDs used. Procedural characteristics such as stent type and stent length were associated with larger particles.

Risk analysis of carotid stent from a population-based database in Taiwan

Because stroke is the third leading disease that causes mortality in the world, the prevention of stroke from advanced carotid stenosis is an important issue. The carotid stent (CAS) is a less invasive to treat advanced carotid stenosis, but for high-risk patients it may cause some events after the procedure that reduces the benefit of stroke prevention. Because patients and their families have less information about risk of events after CAS and are easy concerned, this study calculates the individual probability of major adverse cardiovascular events including any stroke, myocardial infarction, or death after procedure.The analyzed dataset was composed of patients undergoing CAS from the longitudinal National Health Insurance claim database in Taiwan. The validation dataset was composed of patients undergoing CAS from the Tri-Service General Hospital. We excluded patients under 18 years of age. The prediction model was constructed with a multivariable Cox proportional hazard regression and performed with forward stepwise selection. The nomogram construction was based on the multivariable Cox model.The risk factors were determined as follows: age with a hazard ratio (HR) of 1.027 (95% confidence interval [CI]: 1.002-1.053) for every 1 year older, congestive heart failure with a HR of 2.196 (95% CI: 1.368-3.524), malignant disease with a HR of 1.724 (95% CI: 1.009-2.944), diabetes mellitus with a HR of 1.722 (95% CI: 1.109-2.674), and symptomatic status with a HR of 1.604 (95% CI: 1.027-2.507). The model showed good discrimination with a P < 0.001 (concordance index, 0.681; bootstrap corrected, 0.661) in the derivation data. The concordance index of external validation was 0.66 (P = 0.048), which indicates acceptable performance.We developed a nomogram with a visual scale method and prognostic information, and it is easy to use in clinical practice. The integer-base method may support communication between clinicians and patients before CAS to reduce the anxiety about making a treatment decision. However, insofar as older patients with multiple comorbidities are at high risk, the option of an alternative treatment strategy with medical therapy should be suggested. In the future, prospective tests should be performed to validate whether this model helps patients to prevent events.

Interleukin-6 C-572G gene polymorphism and coronary artery disease in Asian: a meta-analysis of 2511 subjects

The interleukin-6 (IL-6) C-572G gene polymorphism has been suggested to be associated with the increased coronary artery disease (CAD) risk, but the study results are still debatable. To explore the association between IL-6 C-572G gene polymorphism and CAD in the Asian population, the current meta-analysis involving 2511 subjects from 7 separate studies was conducted. The combined odds ratio (ORs) for the association between IL-6 C-572G gene polymorphism and CAD and their corresponding 95% confidence intervals (95% CIs) were assessed by random or fixed effect model. A significant association between IL-6 C-572G gene polymorphism and CAD was found in the Asian population under an allelic (OR: 1.50, 95% CI: 1.30-1.71, P<0.00001), recessive (OR: 2.221, 95% CI: 1.444-3.417, P=1.0×10(-10)) dominant (OR: 1.313, 95% CI: 1.188-1.451, P=1.0×10(-10)), homozygous (OR: 2.454, 95% CI: 1.606-3.751, P=1.0×10(-10)), heterozygous (OR: 3.01, 95% CI:1.99-4.55, P<0.00001) and additive genetic models (OR: 1.372, 95% CI: 1.231-1.528, P=1.0×10(-10)). In the Asian population, the IL-6 C-572G gene polymorphism was indicated to be correlated with CAD susceptibility. The carriers of -572G allele might be predisposed to CAD risk.

Serum Levels of IL-1 β , IL-6, TGF- β , and MMP-9 in Patients Undergoing Carotid Artery Stenting and Regulation of MMP-9 in a New In Vitro Model of THP-1 Cells Activated by Stenting

Inflammation plays an important role in the pathophysiological process after carotid artery stenting (CAS). Monocyte is a significant source of inflammatory cytokines in vascular remodeling. Telmisartan could reduce inflammation. In our study, we first found that, after CAS, the serum IL-1β, IL-6, TGF-β, and MMP-9 levels were significantly increased, but only MMP-9 level was elevated no less than 3 months. Second, we established a new in vitro model, where THP-1 monocytes were treated with the supernatants of human umbilical vein endothelial cells (HUVECs) that were scratched by pipette tips, which mimics monocytes activated by mechanical injury of stenting. The treatment enhanced THP-1 cell adhesion, migration and invasion ability, and the phosphorylation of ERK1/2 and Elk-1 and MMP-9 expression were significantly increased. THP-1 cells pretreated with PD98095 (ERK1/2 inhibitor) attenuated the phosphorylation of ERK1/2 and Elk-1 and upregulation of MMP-9, while pretreatment with telmisartan merely decreased the phosphorylation of Elk-1 and MMP-9 expression. These results suggested that IL-1β, IL-6, TGF-β, and MMP-9 participate in the pathophysiological process after CAS. Our new in vitro model mimics monocytes activated by stenting. MMP-9 expression could be regulated through ERK1/2/Elk-1 pathway, and the protective effects of telmisartan after stenting are partly attributed to its MMP-9 inhibition effects via suppression of Elk-1.

Associations of high sensitivity C-reactive protein levels with the prevalence of asymptomatic intracranial arterial stenosis

BACKGROUND AND PURPOSE

High sensitivity C-reactive protein (hs-CRP), an inflammatory biomarker, has been demonstrated to contribute to the process of atherosclerosis and artery stenosis. The aim of this study was to evaluate whether hs-CRP level is associated with asymptomatic intracranial artery stenosis (ICAS).

METHODS

A random sample of 5440 participants aged 40 years or older (40.1% women) were enrolled in the Asymptomatic Polyvascular Abnormalities Community study in 2010-2011. Information on the potential risk factors for ICAS was collected and the presence of ICAS was assessed by transcranial Doppler in 5309 participants. Participants were stratified into three groups according to hs-CRP levels. A multivariate logistic regression was used to examine the association between hs-CRP levels and asymptomatic ICAS.

RESULTS

The prevalence of asymptomatic ICAS was 13.2% in this cohort. The median of hs-CRP levels was positively associated with the increasing numbers of ICASs. After adjusting for possible risk factors, hs-CRP ≥ 3 mg/l remained significantly associated with asymptomatic ICAS (odds ratio 1.28, 95% confidence interval 1.02-1.61).

CONCLUSIONS

In this large community-based study, subjects with higher hs-CRP levels showed a mild increase in the prevalence of asymptomatic ICAS, independent of traditional vascular risk factors. hs-CRP is an independent predictor of asymptomatic ICAS and intracranial atherosclerotic burden.

Inflammatory markers in patients with internal carotid artery stenosis

INTRODUCTION

Available reports underline the significance of the inflammatory process in the development, progression and destabilisation of atherosclerotic plaques in the internal carotid artery (ICA). The aim of this study was to evaluate the relationship between the degree of ICA stenosis, ultrasound plaque morphology and serum concentration of selected inflammatory markers.

MATERIAL AND METHODS

Sixty-five patients with ICA stenosis > 50% (39 symptomatic) and 30 healthy volunteers were enrolled in the study. Clinical, neurological examination and laboratory evaluation (leucocyte count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), fibrinogen, tumour necrosis factor-α (TNF-α), interleukins (1β, 6 and 10), anti-cytomegalovirus IgG antibody titre) were performed. Stenosis grade ≥ 70%, ulcerations on the plaque surface and a hypoechoic (or predominantly hypoechoic) structure of the plaque, obtained by colour-coded duplex examination, were accepted as the characteristics of unstable stenoses.

RESULTS

Unstable ultrasound features of ICA stenosis were found significantly more often in symptomatic than in asymptomatic patients (71.79% vs. 30.71% for stenosis degree ≥ 70%, p = 0.001 and 61.23% vs. 38.46% for unstable plaque morphology, p = 0.01). Patients with ICA stenosis had significantly higher serum concentrations of interleukin-6, fibrinogen, ESR and higher CRP values than the individuals from the control group (p = 0.001, p = 0.009, p = 0.036, p = 0.009 respectively). Patients with unstable plaques structure had significantly higher concentrations of TNF-α, interleukin-6, fibrinogen, higher number of leukocytes, monocytes and higher CRP values than patients with stable plaques (p = 0.008, p = 0.049, p = 0.012, p = 0.0002, p = 0.006, p = 0.0003 respectively). No significant differences in above-mentioned parameters between the groups with stenosis < 70% and ≥ 70% were found.

CONCLUSIONS

There is a relationship between the activity of the selected inflammatory markers in serum and atherosclerotic unstable internal carotid artery stenosis. There is no relationship between serum concentration of inflammatory markers and degree of carotid artery stenosis.

Interactions between cardiovascular and cerebrovascular disease

OPININION STATEMENT: All patients with ischemic stroke should undergo a comprehensive assessment of cardiovascular risk. Patients with carotid artery disease, symptoms of cerebral ischemia and high cardiovascular risk profiles should be considered for noninvasive testing for coronary artery disease (CAD). Routine testing for CAD before carotid endarterctomy is not recommended. Patients with coexisting coronary and carotid artery disease should be more aggressively treated for reducing their "very high" risk of cardiovascular events. In patients candidates to carotid revascularization, a preoperative coronary angiography and coronary revascularization are not recommended. Warfarin is recommended in all patients with moderate to high risk of stroke. Novel oral anticoagulants represent an attractive alternative to warfarin. However, their place in therapy in clinical practice is not yet established. Percutaneous closure of the left atrial appendage for stroke prophylaxis may be considered in selected patients with atrial fibrillation and contraindications for oral anticoagulant therapy. Warfarin is not indicated in patients with heart failure who are in sinus rhythm. Percutaneous closure of patent foramen does not seem to be superior to medical therapy for the prevention of recurrences in patients with cryptogenic stroke.