COLIN trial: Value of colchicine in the treatment of patients with acute myocardial infarction and inflammatory response

Mesenchymal stromal cells for improvement of cardiac function following acute myocardial infarction: a matter of timing

Acute myocardial infarction (AMI) is the leading cause of cardiovascular death and remains the most common cause of heart failure. Reopening of the occluded artery, i.e., reperfusion, is the only way to save the myocardium. However, the expected benefits of reducing infarct size are disappointing due to the reperfusion paradox, which also induces specific cell death. These ischemia-reperfusion (I/R) lesions can account for up to 50% of final infarct size, a major determinant for both mortality and the risk of heart failure (morbidity). In this review, we provide a detailed description of the cell death and inflammation mechanisms as features of I/R injury and cardioprotective strategies such as ischemic postconditioning as well as their underlying mechanisms. Due to their biological properties, the use of mesenchymal stromal/stem cells (MSCs) has been considered a potential therapeutic approach in AMI. Despite promising results and evidence of safety in preclinical studies using MSCs, the effects reported in clinical trials are not conclusive and even inconsistent. These discrepancies were attributed to many parameters such as donor age, in vitro culture, and storage time as well as injection time window after AMI, which alter MSC therapeutic properties. In the context of AMI, future directions will be to generate MSCs with enhanced properties to limit cell death in myocardial tissue and thereby reduce infarct size and improve the healing phase to increase postinfarct myocardial performance.

Meta-Analysis of Randomized Trials: Efficacy and Safety of Colchicine for Secondary Prevention of Cardiovascular Disease

Background

Colchicine has shown potential cardioprotective effects owing to its broad anti-inflammatory properties. We performed a meta-analysis to assess its safety and efficacy in secondary prevention in patients with established coronary artery disease (CAD).

Methods

We searched Ovid Healthstar, MEDLINE, and Embase (inception to May 2022) for randomized controlled trials (RCTs) evaluating the cardiovascular effects of colchicine compared with placebo or usual care in patients with CAD. Study-level data on efficacy and safety outcomes were pooled using the Peto method. The primary outcome was the composite of cardiovascular (CV) death, myocardial infarction (MI), or stroke.

Results

A total of 8 RCTs were included with a follow-up duration of ≥1 month, comprising a total of 12,151 patients. Compared with placebo or usual care, colchicine was associated with a significant risk reduction in the primary outcome (odds ratio (OR) 0.70, 95% CI 0.60 to 0.83, P < 0.0001; I2 = 52%). Risks of MI (OR 0.75, 95% CI 0.62 to 0.91, P = 0.003; I2 = 33%), stroke (OR 0.47, 95% CI 0.30 to 0.74, P = 0.001; I2 = 0%), and unplanned coronary revascularization (OR 0.67, 95% CI 0.55 to 0.82, P = 0.0001; I2 = 58%) were all reduced in the colchicine group. Rates of CV and all-cause mortality did not differ between the two groups, but there was an increase in noncardiac deaths with colchicine (OR 1.54, 95% CI 1.10 to 2.15, P = 0.01; I2 = 51%). The occurrence of all other adverse events was similar between the two groups, including GI reactions (OR 1.06, 95% CI 0.94 to 1.20, P = 0.35; I2 = 42%) and infections (OR 1.04, 95% CI 0.84 to 1.28, P = 0.74; I2 = 53%).

Conclusions

Colchicine therapy may reduce the risk of future cardiovascular events in patients with established CAD; however, there remains a concern about non-CV mortality. Further trials are underway that will shed light on non-CV mortality and colchicine NCT03048825, and NCT02898610.

Low-Dose Colchicine for the Prevention of Cardiovascular Events After Acute Coronary Syndrome

Colchicine, an established anti-inflammatory drug, is examined for its potential in mitigating adverse cardiovascular events following acute coronary syndrome (ACS). ACS, primarily triggered by plaque rupture and subsequent thrombosis, is a critical cardiovascular condition. Colchicine's mechanism of action involves inhibiting microtubule activity, leading to immobilization of white blood cells and reducing inflammation. Clinical data from studies, including low-dose colchicine for secondary prevention of cardiovascular disease two and colchicine cardiovascular outcomes trial, support its efficacy in reducing major cardiovascular events post-ACS, though some studies report varying results. Colchicine can cause transient gastrointestinal side effects and is prescribed with caution in patients with certain medical conditions. The recent FDA approval of a low dose of colchicine reiterates its benefit in reducing cardiovascular risk. The cost-effectiveness of colchicine products (0.5 and 0.6 mg doses) are compared, suggesting the generic 0.6 mg dose of colchicine to be an alternative to branded forms of the drug.

A systematic literature review of randomised controlled trials evaluating colchicine for cardiovascular prevention: There is an elephant in the room

OBJECTIVES

To review randomised controlled trials (RCT) investigating colchicine (COL) for cardiovascular (CV) prevention in patients at high to very high CV risk aiming to extract data that could be useful in rheumatology practice.

METHODS

A systematic search of multiple databases according to the PICO framework was performed from inception to April 3, 2023. Three researchers independently screened abstracts/titles and reviewed full texts reviewed. Data extraction was performed using a pilot-tested data extraction form.

RESULTS

A total of 14,096 references were retrieved by the search and 30 articles, describing 28 RCTs, were included in the review (Total number of patients 16,795, of which 8,463 randomised to COL; dose 0.5-2 mg/day, treatment duration 1day-29 months). Only one of the 28 RCTs provided clear information on whether patients with rheumatic diseases (more specifically gout) were enrolled in the study cohorts and previous use of COL was an exclusion criterion only in 14 (50 %) RCTs. Previous therapy with glucocorticoids and/or non-steroidal anti-inflammatory drugs and/or immune suppressive therapies was an exclusion criterion only in 9 (32 %) RCTs.

CONCLUSION

Our results highlight the need to redefine the eligibility criteria as well as the reporting of results in future RCTs in order to minimise bias or previous exposure to COL and also obtain data that could be useful in rheumatology practice.

Efficacy and safety of inhibiting the NLRP3/IL-1β/IL-6 pathway in patients with ST-elevation myocardial infarction: A meta-analysis

BACKGROUND

The NLRP3/IL-1β/IL-6 pathway plays a key role in mediating inflammatory responses after ST-elevation myocardial infarction (STEMI). However, the clinical benefits of inhibiting this pathway in STEMI are uncertain. We aimed to evaluate the efficacy and safety of inhibiting the NLRP3/IL-1β/IL-6 pathway in STEMI patients.

METHODS

This study followed PRISMA guidelines. PubMed, Embase, CENTRAL and ClinicalTrials.gov databases were searched for randomized controlled trials (RCTs) of inhibiting the NLRP3/IL-1β/IL-6 pathway in STEMI patients within 7 days of symptom onset. The efficacy outcomes included all-cause death, cardiovascular death, recurrent MI, new-onset or worsening heart failure (HF) and stroke. The safety outcomes were serious infection, gastrointestinal adverse events and injection site reactions.

RESULTS

Of 316 screened records, nine trials with 1211 patients were included in the meta-analysis. Colchicine reduced the risk of recurrent MI (RR 0.28, 95% CI 0.10-0.74; I2  = 0.0%). Anakinra was associated with reduced risk of new-onset or worsening HF (RR 0.32, 95% CI 0.13-0.77; I2  = 0.0%) and decreased C-reactive protein levels (SMD -1.34, 95% CI -2.04 to -0.65; I2  = 0.0%). Colchicine and anakinra increased the risk of gastrointestinal adverse events (RR 4.43, 95% CI 2.75-7.13; I2  = 38.1%) and injection site reactions (RR 4.52, 95% CI 1.32-15.49; I2  = 0.8%), respectively. None of the three medications affected the risks of all-cause death, cardiovascular death, stroke and serious infection.

CONCLUSIONS

There is still no large-scale RCT evidence on the efficacy and safety of inhibiting the NLRP3/IL-1β/IL-6 pathway for the treatment of STEMI. Preliminary results from the available RCTs suggest colchicine and anakinra may respectively reduce the risks of recurrent MI and new-onset or worsening HF. The available RCTs in this meta-analysis lack power to determine any differences on mortality.

Inflammation in Coronary Atherosclerosis: Insights into Pathogenesis and Therapeutic Potential of Anti-Inflammatory Drugs

Atherosclerosis is a lipid-driven immune-inflammatory disease that affects the arteries, leading to multifocal plaque development. The inflammatory process involves the activation of immune cells and various inflammatory pathways. Anti-inflammatory drugs have been shown to be effective in reducing cardiovascular events in individuals with coronary disease. However, their use is still limited due to concerns about long-term follow-up, cost-effectiveness, adverse effects, and the identification of the ideal patient profile to obtain maximum benefits. This review aims to improve the understanding of inflammation in coronary atherosclerosis and explore potential therapeutic interventions, encompassing both traditional and non-traditional anti-inflammatory approaches. By addressing these concepts, we seek to contribute to the advancement of knowledge about this type of treatment for coronary artery disease.

Early long-term low-dosage colchicine and major adverse cardiovascular events in patients with acute myocardial infarction: a systematic review and meta-analysis

Background

Current evidence on the efficacy and safety of colchicine after acute myocardial infarction (AMI) remains controversial. This study aims to clarify early low-dose long-term colchicine's exact efficacy and safety in AMI patients via more studies.

Methods

We searched PubMed, Web of Science, Embase, and Cochrane Library databases for randomized controlled trials assessing the efficacy of colchicine on major adverse cardiovascular events (MACE) in recent AMI patients from inception to January 29, 2023, without any restriction. Additionally, we conducted subgroup analyses to assess the impact of early (≤3 days) long-term (≥1 year) low-dosage (0.5 mg/d) colchicine. Summary estimates were computed using Mantel-Haenszel and reported as risk ratios (RRs) or standard mean differences (SMDs), mean differences (MDs) with 95% confidence intervals (CIs). Sensitivity analyses were performed to explore the potential sources of heterogeneity. Review Manager software was used for the meta-analysis.

Results

Eight studies identified from 564 screened records were analyzed, with 5,872 patients after AMI. The length of follow-up varied from five days to 22.7 months, and 0.5-1.0 mg colchicine was administered daily. In summary, compared to the control group, colchicine reduced the occurrence of MACE (RR, 0.56; 95% CI, 0.48-0.67) with 2.99-fold gastrointestinal adverse events in patients with recent AMI. Moreover, the relation referred to a gradual decrease in the occurrence of MACE with a longer follow-up duration (≥1 year) and lower dosage (0.5 mg/d) without leading more gastrointestinal adverse events. Colchicine decreased the follow-up levels of C-reactive protein (CRP) (MD -0.66, 95% CI, -0.98- -0.35) and neutrophils (SMD -0.22, 95% CI, -0.39- -0.55) when the follow-up period was 30 days.

Conclusion

Early long-term low-dose colchicine decreases the risk of MACE via anti-inflammation without leading more gastrointestinal adverse events in patients with AMI.

Colchicine efficacy comparison at varying time points in the peri-operative period for coronary artery disease: a systematic review and meta-analysis of randomized controlled trials

Objectives

Over the years, it has been found that colchicine offers substantial benefits in secondary prevention in patients with coronary artery disease (CAD). We studied the effects of colchicine timing because there are no guidelines about when to provide it during the perioperative period for patients with CAD.

Methods

Up to January 1, 2023, seven electronic literature databases were screened (including three English databases and four Chinese databases). Randomized controlled trials included only treatment with colchicine in the perioperative period of CAD. The Cochrane Evaluation Tool was used to judge the risk of bias in research. Statistical analysis was performed by Stata 16.0 software.

Results

We evaluated twelve studies that found colchicine to be effective in decreasing the occurrence of major adverse cardiac events (MACEs) (p < 0.00001), but it also raised the rate of adverse events (p = 0.001). Subgroup analysis showed the same benefit in lowering the incidence of MACE with continuous administration of a total daily dose of 0.5 mg postoperatively while minimizing drug-related side effects in the patients (p = 0.03). When it comes to preventing surgical stroke occurrences, postoperative administration is more effective (p = 0.006). While the effect of simultaneous preoperative and postoperative administration was marginally greater than other periods in reducing postoperative hs-CRP levels (p = 0.02).

Conclusion

Colchicine, a traditional anti-inflammatory drug, also reduces the risk of MACE by reducing inflammation after PCI. Administration at different periods had no significant effect on decreasing the occurrence of MACE, but when administered postoperatively, we advise continuous administration with a total daily dose of 0.5 mg to obtain the same benefit while minimizing the drug's side effects. Postoperative administration is the better measure to prevent postoperative stroke events. Due to the effective anti-inflammatory effect of colchicine, we recommend its use as early as possible in the perioperative period and its continued use at low doses in the postoperative period.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=316751, identifier CRD42022316751.

Efficacy and Safety of Different Dosing Regimens of Colchicine in Patients With Coronary Artery Disease: A Network Meta-analysis of 15 Randomized Controlled Trials

ABSTRACT

Several meta-analyses have investigated the effects of different doses of colchicine in treating coronary artery disease, but all dosing regimens were never compared in a single study. We aimed to compare the efficacy and safety of 3 dosing regimens of colchicine in patients with coronary artery disease. PubMed, EMBASE, the Cochrane Library, and SCOPUS were searched for randomized controlled trials involving different colchicine doses. Major adverse cardiac events (MACE), all-cause and cardiovascular mortality, recurrent myocardial infarction (MI), stroke, gastrointestinal adverse events (AEs), discontinuation, and hospitalization were evaluated using risk ratio (RR) with 95% confidence interval (CI). A total of 15 randomized controlled trial involving 13,539 patients were included. Pooled results calculated with STATA 14.0 showed that low-dose colchicine significantly reduced MACE (RR, 0.51; 95% CI, 0.32-0.83), recurrent MI (RR, 0.56; 95% CI, 0.35-0.89), stroke (RR, 0.48; 95% CI, 0.23-1.00), and hospitalization (RR, 0.44; 95% CI, 0.22-0.85), whereas high and loading doses significantly increased gastrointestinal AEs (RR, 2.84; 95% CI, 1.26-6.24) and discontinuation (RR, 2.73; 95% CI, 1.07-6.93), respectively. Sensitivity analyses confirmed that 3 dosing regimens did not reduce all-cause and cardiovascular mortality but significantly increased the gastrointestinal AEs, and high dose significantly increased AEs-related discontinuation; loading dose resulted in more discontinuation than low dose. Although differences between 3 dosing regimens of colchicine are not significant, low dose is more effective in reducing MACE, recurrent MI, stroke, and hospitalization than the control, whereas high and loading doses increase gastrointestinal AEs and discontinuation, respectively.

Anti-inflammatory Therapeutics and Coronary Artery Disease

It has been demonstrated that atherosclerotic disease progression is contingent upon chronic inflammation. The sequence of events leading up to plaque formation, instability, and eventual plaque rupture hinges upon the interaction of proinflammatory cytokines and fat deposition within the coronary vasculature. Over the past decade, a large body of evidence has demonstrated the efficacy of specific anti-inflammatory therapeutics in halting the progression of coronary artery disease. Despite this, these therapeutics have yet to be included in guideline-directed medical therapy regimens. This review will focus on several anti-inflammatories, which have been studied in the context of cardiovascular disease-colchicine, canakinumab, VIA-2291, and methotrexate, and will highlight the potential benefits majority hold in hindering atherosclerosis and cardiovascular disease progression. This holds especially true for individuals already on optimal medical therapy who continue to be at high risk for adverse cardiovascular events.

Rationale and design of COLchicine On-admission to Reduce inflammation in Acute Coronary Syndrome (COLOR-ACS) study

AIMS

The aim of the colchicine on-admission to reduce inflammation in acute coronary syndrome (COLOR-ACS) study is to evaluate the effects of the addition of short-term, low-dose colchicine to high-dose atorvastatin in limiting levels of inflammatory markers, such as high-sensitivity C-reactive protein (hs-CRP), in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS).

METHODS

The COLOR-ACS study is a multicenter, randomized, open-label, two-arm trial. Statin-naive patients with NSTE-ACS, scheduled for an early invasive strategy, are randomized on admission to receive standard treatment of atorvastatin 80 mg or standard treatment plus colchicine (1 mg loading dose followed by 0.5 mg/day until discharge). The main exclusion criteria are prior statin and/or colchicine treatment, current treatment with potent inhibitors of CYP3A4, P-glycoprotein or immunosuppressive drugs, known active malignancy, severe kidney, cardiac, liver disease. There is clinical and biochemical follow-up at 30 days after discharge and telephone interview at 6 months. The primary end point is the change in hs-CRP from admission to discharge. Secondary end points include: incidence of acute kidney injury; MB fraction of creatine kinase peak value; glomerular filtration rate change from baseline to 30 days; persistence of hs-CRP ≥2 mg/dl at 30 days; adverse clinical events within 30 days; tolerance to colchicine.

CONCLUSION

The COLOR-ACS study will provide evidence on the efficacy of early short-term treatment with colchicine in addition to high-dose atorvastatin compared to atorvastatin alone in ACS patients. The potential anti-inflammatory action of colchicine plus atorvastatin is expected to limit hs-CRP increase with resultant clinical benefits.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT05250596.

The Role of Inflammation in Cardiovascular Disease

Atherosclerosis is a chronic inflammatory disease, in which the immune system has a prominent role in its development and progression. Inflammation-induced endothelial dysfunction results in an increased permeability to lipoproteins and their subendothelial accumulation, leukocyte recruitment, and platelets activation. Recruited monocytes differentiate into macrophages which develop pro- or anti-inflammatory properties according to their microenvironment. Atheroma progression or healing is determined by the balance between these functional phenotypes. Macrophages and smooth muscle cells secrete inflammatory cytokines including interleukins IL-1β, IL-12, and IL-6. Within the arterial wall, low-density lipoprotein cholesterol undergoes an oxidation. Additionally, triglyceride-rich lipoproteins and remnant lipoproteins exert pro-inflammatory effects. Macrophages catabolize the oxidized lipoproteins and coalesce into a lipid-rich necrotic core, encapsulated by a collagen fibrous cap, leading to the formation of fibro-atheroma. In the conditions of chronic inflammation, macrophages exert a catabolic effect on the fibrous cap, resulting in a thin-cap fibro-atheroma which makes the plaque vulnerable. However, their morphology may change over time, shifting from high-risk lesions to more stable calcified plaques. In addition to conventional cardiovascular risk factors, an exposure to acute and chronic psychological stress may increase the risk of cardiovascular disease through inflammation mediated by an increased sympathetic output which results in the release of inflammatory cytokines. Inflammation is also the link between ageing and cardiovascular disease through increased clones of leukocytes in peripheral blood. Anti-inflammatory interventions specifically blocking the cytokine pathways reduce the risk of myocardial infarction and stroke, although they increase the risk of infections.

Colchicine and coronary heart disease risks: A meta-analysis of randomized controlled clinical trials

Background

Several trials have considered the safety and clinical benefits of colchicine as a treatment option for secondary prevention in patients with coronary atherosclerotic heart disease (CAD), but its safety and clinical benefits remain controversial. The purpose of this study was to explore the clinical benefits of colchicine, focusing on certain subgroups of patients.

Methods

Randomized controlled trials (RCTs) of colchicine in subjects with acute or chronic CAD compared with controls were included to assess all-cause mortality, non-cardiovascular mortality, gastrointestinal adverse effects, diarrhea, MACE, cardiovascular mortality, MI, stroke, and revascularization. We analyzed the association of cardiovascular, mortality, and gastrointestinal risk with colchicine in all subjects. We also focused on the cardiovascular risk of colchicine in subgroups with different drug doses, different treatment durations, age, gender, and associated comorbidities.

Results

This meta-analysis included 15 clinical RCTs, including 13,539 subjects. Colchicine reduced the risk of MACE (RR: 0.65; 95% CI: 0.38–0.77, p for heterogeneity < 0.01; I2 = 70%; p < 0.01), stroke (RR: 0.48; 95% CI: 0.30–0.76; p heterogeneity = 0.52; I2 = 0%; p < 0.01), MI by 40% (RR: 0.60; 95% CI: 0.43–0.83; p for heterogeneity = 0.01; I2 = 59%; p < 0.01) and risk of revascularization (RR: 0.68; 95% CI: 0.56–0.83; p for heterogeneity = 0.17; I2 = 40%; p < 0.01), but had no significant effect on risk of cardiovascular death and risk of all-cause mortality. In addition, colchicine increased the risk of gastrointestinal side effects and diarrhea. In a subgroup analysis, low-dose colchicine and treatment duration > 1 month reduced the risk of MACE, MI, stroke, and revascularization. Also, the cardiovascular benefits of colchicine were observed in subjects up to 65 years of age. The results showed that hypertension and diabetes did not have a specific effect on colchicine and MACE risk.

Conclusion

Colchicine has a positive effect in reducing the incidence of MACE, MI, stroke, and revascularization, but can increase the risk of gastrointestinal and diarrhea events. Low-dose colchicine significantly reduces the risk of MACE more than high-dose colchicine, and the benefits of long-term treatment are higher than those of short-term treatment. Long-term low-dose colchicine treatment may significantly reduce the risk of cardiovascular events. Furthermore, colchicine significantly reduced the risk of cardiovascular events in patients up to 65 years of age, but it did not appear to reduce cardiovascular risk in patients over 65 years of age or in preoperative PCI patients.

Systematic review registration

[https://www.crd.york.ac.uk/prospero/], identifier [CDR42022332170].

Efficacy of Colchicine in the Treatment of Patients With Coronary Artery Disease: A Mini-Review

PURPOSE

This review of colchicine, an effective anti-inflammatory agent, examines whether the reduction in ischemic events produced by colchicine translates to a reduction in mortality, the optimal duration of treatment, and the patient populations that benefits the most from colchicine treatment.

METHODS

We performed a comprehensive PubMed database search using the key words colchicine and coronary heart disease on August 23, 2021. We also screened the included reference list of manuscripts.

FINDINGS

Colchicine's role in the secondary prevention of coronary artery disease has been the focus of recent large-scale randomized controlled trials in chronic coronary syndrome (ie, the Low-Dose Colchicine and Low-Dose Colchicine 2 trials), acute myocardial infarction (the Colchicine Cardiovascular Outcomes Trial and Colchicine in Patients With Acute Coronary Syndrome trial), and after percutaneous coronary intervention (the Colchicine-Percutaneous Coronary Intervention trial).

IMPLICATIONS

Current evidence suggests that low-dose colchicine (0.5 mg once a day) reduces the risk of cardiovascular events among patients with acute myocardial infarction or chronic coronary syndrome. Colchicine has the potential to become a new standard therapy for the prevention of coronary artery disease-related atherothrombotic events because it is effective and cost-efficient and has a well-tolerated safety profile. (Clin Ther. 2022;XX:XXX-XXX) © 2022 Elsevier HS Journals, Inc.

Effect of colchicine on inflammatory markers in patients with coronary artery disease: A meta-analysis of clinical trials

Whether colchicine reduces the levels of high-sensitivity C-reactive protein (hs-CRP) and interleukin-6 (IL-6) remains uncertain. Therefore, this systematic review and meta-analysis were conducted to evaluate the overall effect of colchicine treatment on hs-CRP and IL-6 levels in patients with coronary artery disease (CAD). PubMed/Medline, Embase, and the Cochrane Central Register of Controlled Trials were searched for studies published before October 2021. Clinical trials in patients with CAD with reports of hs-CRP and IL-6 level changes before and after colchicine intervention were included. In total, 11 trials on hs-CRP and two trials on IL-6 were included in this meta-analysis. Compared with that in the control group, colchicine treatment was significantly associated with decreased hs-CRP levels (weighted mean differences [WMDs], -0.81 mg/L; 95% confidence interval [CI], -1.34 to -0.28 mg/L; P = 0.003) in patients with CAD. Besides, the levels of IL-6 were significantly reduced in colchicine users compared to that of placebo (WMD, -1.28 pg/mL; 95% CI, -2.35 to -0.21 pg/mL; P = 0.02). In a subgroup analysis, colchicine led to a significant reduction in hs-CRP levels in studies with duration of intervention >7 days (WMD, -0.65 mg/L; 95% CI, -1.08 to -0.21 mg/L; P = 0.004) and studies with baseline hs-CRP levels ≥3.0 mg/L (WMD, -0.99 mg/L; 95% CI, -1.92 to -0.06 mg/L; P = 0.04). Colchicine intervention was associated with a reduction in hs-CRP and IL-6 levels in patients with CAD. Future investigations are required to verify the effect of colchicine on inflammatory markers and clarify the potential mechanisms of the cross talk between colchicine, inflammation, and cardiovascular outcomes.

Efficacy and Safety of Colchicine in Prevention of Secondary Cardiovascular Outcomes Among Patients With Coronary Vessel Disease: A Meta-Analysis

Coronary vessel disease (CVD) is a class of diseases that impacts the blood vessels and heart and is one of the leading causes of disability and death. CVD includes cerebrovascular disease and coronary heart disease, both illnesses of the vessels transporting the oxygenated blood to the brain or heart. Colchicine is an inexpensive and old drug with strong anti-inflammatory effects. Numerous randomized control trials (RCTs) have demonstrated the effectiveness of low-dose colchicine for the prevention of severe cardiovascular events without showing any signs of serious adverse effects within the regime of treatment. In the current meta-analysis, we aim to assess the efficacy and safety of colchicine for secondary cardiovascular outcome prevention among patients with clinically proven CVD. The current meta-analysis was carried out using the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. PUBMED, Cochrane, and EMBASE databases were used to search for RCTs comparing colchicine and placebos for the prevention of secondary cardiovascular outcomes. The primary efficacy endpoint was mortality due to cardiovascular disease, stroke, urgent coronary revascularization, and myocardial infarction. Secondary efficacy outcomes included death due to all-cause mortality. Seven RCTs were reviewed, with a pooled sample size of 12114, out of which 6099 were randomized to the colchicine group, and 6015 were randomized to the control group. The decrease in cardiovascular events, including myocardial infarction, stroke, urgent coronary revascularization, and cardiac-related death, was significantly lower in patients randomized to colchicine (p-value<0.05). The incidence of safety outcomes did not vary significantly different between groups (p>0.05). In patients with CVD, compared to standard medical therapy, colchicine significantly decreases the risk of cardiovascular events such as cardiovascular-related death, myocardial infarction, stroke, and urgent coronary revascularizations.

The Role of Colchicine in Atherosclerosis: From Bench to Bedside

Inflammation is a key feature of atherosclerosis. The inflammatory process is involved in all stages of disease progression, from the early formation of plaque to its instability and disruption, leading to clinical events. This strongly suggests that the use of anti-inflammatory agents might improve both atherosclerosis progression and cardiovascular outcomes. Colchicine, an alkaloid derived from the flower Colchicum autumnale, has been used for years in the treatment of inflammatory pathologies, including Gout, Mediterranean Fever, and Pericarditis. Colchicine is known to act over microtubules, inducing depolymerization, and over the NLRP3 inflammasome, which might explain its known anti-inflammatory properties. Recent evidence has shown the therapeutic potential of colchicine in the management of atherosclerosis and its complications, with limited adverse effects. In this review, we summarize the current knowledge regarding colchicine mechanisms of action and pharmacokinetics, as well as the available evidence on the use of colchicine for the treatment of coronary artery disease, covering basic, translational, and clinical studies.

Targeting Microtubules for the Treatment of Heart Disease

Heart disease remains the leading cause of morbidity and mortality worldwide. With the advancement of modern technology, the role(s) of microtubules in the pathogenesis of heart disease has become increasingly apparent, though currently there are limited treatments targeting microtubule-relevant mechanisms. Here, we review the functions of microtubules in the cardiovascular system and their specific adaptive and pathological phenotypes in cardiac disorders. We further explore the use of microtubule-targeting drugs and highlight promising druggable therapeutic targets for the future treatment of heart diseases.

Colchicine for Secondary Prevention of Coronary Artery Disease: A Meta-Analysis of Randomised Controlled Trials

BACKGROUND

Colchicine has become prominent as an anti-inflammatory therapy for secondary cardiovascular prevention in patients with coronary artery disease (CAD). This meta-analysis was performed to evaluate the efficacy and safety of colchicine in patients with CAD.

METHODS

Randomised controlled trials (RCTs) that compare major adverse cardiovascular events (MACEs) between patients with CAD randomised to colchicine versus placebo (or no colchicine) were included. Random effect risk ratios (RRs) were calculated for clinical outcomes.

RESULTS

A total of 12,071 patients in seven RCTs were included in the meta-analysis. Compared with placebo or no colchicine, colchicine was associated with a significantly lower incidence of MACEs (RR 0.64, 95% CI 0.51-0.80, p<0.01). The reduction in MACEs in the colchicine group was driven by statistically significant reductions in the incidence of myocardial ischaemia (RR 0.74, 95% CI 0.58-0.95, p=0.02), coronary revascularisation (RR 0.61, 95% CI 0.42-0.89, p=0.01), and stroke (RR 0.48, 95% CI 0.28-0.83, p=0.01). However, there was no statistically significant difference for cardiovascular death (RR 0.82, 95% CI 0.55-1.22, p=0.33). All-cause and non-cardiovascular mortality, gastrointestinal events, infection, and cancer were not significantly different between the colchicine and control groups.

CONCLUSIONS

Colchicine is a reasonably efficacious and safe drug that could be successfully utilised for the secondary prevention of CAD.

Colchicine for Patients With Coronary Artery Disease: A Systematic Review and Meta-analysis

ABSTRACT

Several randomized controlled trials have studied the role of colchicine, a potent anti-inflammatory drug, to prevent adverse cardiovascular events in patients with coronary artery disease (CAD). In this meta-analysis, we aimed to determine the role of colchicine in patients with CAD in clinical outcomes and mortality. We searched PubMed, PubMed Central, Scopus, and Embase for randomized controlled trials/experimental studies evaluating the role of colchicine in patients with CAD. After assessing the eligibility for inclusion, risk-of-bias assessment, and data extraction from the included studies, a narrative synthesis was conducted. Of 17 studies included for the qualitative analysis, 11 studies reported that inflammatory markers such as C-reactive protein and cytokines were reduced in the colchicine group, suggesting an anti-inflammatory role of colchicine in CAD. Quantitative analysis with pooling of data from 9 studies using a fixed-effect model showed 28% lower odds of acute myocardial infarction [odds ratio (OR) 0.72, 95% CI 0.59-0.86; n = 11,712], 52% lower occurrence of stroke (OR 0.48, 95% CI 0.30-0.76), and 37% reduction in odds of coronary revascularization procedure in the colchicine group (OR 0.63, 95% CI 0.52-0.76; n= 11,258). However, the odds of gastrointestinal adverse events were 50% higher in the colchicine group (OR 1.50, 95% CI 1.01-2.23; n = 12,214). In conclusion, colchicine is associated with a lower risk of acute myocardial infarction, stroke, and coronary revascularization. However, there is some increased risk of gastrointestinal adverse events with the use of colchicine.

Colchicine may become a new cornerstone therapy for coronary artery disease: a meta-analysis of randomized controlled trials

PURPOSE

Colchicine is an ancient anti-inflammatory drug. In recent years, an increasing number of studies have shown that colchicine improves the prognosis of patients with coronary artery disease (CAD), while other studies have reported the opposite. The aim of this study was to evaluate the relative efficacy and safety of colchicine in treating CAD.

METHODS

PubMed, EMBASE, the Cochrane Library, and ClinicalTrials.gov were searched from inception to 20 October 2020 for randomized controlled trials (RCTs) comparing colchicine and placebo in patients with CAD. The primary outcomes were the primary composite outcomes of cardiovascular death, myocardial infarction (MI), ischemic stroke, or ischemia-driven coronary revascularization after colchicine administration. The secondary outcomes were cardiovascular death, death from any cause, noncardiac death, MI, ischemic stroke, coronary revascularization, gastrointestinal (GI) symptoms, and the different effects of colchicine in acute and chronic CAD. We assessed the pooled odds ratio (OR) of all-cause and cardiovascular mortality for CAD in fixed-effects models, the pooled risk ratio (RR) of the primary composite outcomes, MI, ischemic stroke, and ischemia-driven coronary revascularization in fixed-effects models and the pooled RR of GI symptoms in random-effects models. The Cochrane risk of bias tool was used to assess the risk of bias in the included RCTs.

FINDINGS

Eleven of the 894 identified studies (n = 12,899 patients) were included (6501 subjects in the colchicine group; 6389 subjects in the control group). The colchicine group had significantly lower pooled RRs of the primary composite outcomes (0.73, 95% confidence interval (CI) 0.64-0.84, P < 0.0001), MI (0.77, 95% CI 0.64-0.92, P = 0.004), ischemic stroke (0.47, 95% CI 0.30-0.76, P = 0.002), and ischemia-driven coronary revascularization (0.77, 95% CI 0.66-0.89, P = 0.0007), while the pooled RR of adverse GI events (2.15 95% CI 1.40-3.31, P = 0.0005) was significantly higher. Colchicine had a lower pooled RR of ischemic stroke (0.28, 95% CI 0.12-0.65, P = 0.003) for patients with acute compared with chronic CAD.

IMPLICATIONS

Colchicine treatment significantly decreased the risk of primary cardiovascular composite outcomes, MI, ischemic stroke, and ischemia-driven coronary revascularization in CAD patients but increased adverse GI events. There was no significant difference in all-cause mortality, cardiovascular mortality, and non-cardiovascular death between the colchicine and control groups. Colchicine performs better in acute CAD patients with ischemic stroke than chronic CAD patients. Colchicine might be a new treatment for patients with CAD.

Efficacy and safety of colchicine in patients with coronary artery disease: A systematic review and meta-analysis of randomized controlled trials

AIMS

Inflammation plays a central role in the pathogenesis and clinical manifestations of atherosclerosis. Randomized controlled trials have investigated the potential benefit of colchicine in reducing cardiovascular (CV) events in patients with coronary artery disease (CAD) but produced conflicting results. The aim of this meta-analysis was to evaluate the efficacy and safety of colchicine in patients with CAD.

METHODS

We systematically searched selected electronic databases from inception until 10 December 2020. Primary clinical endpoints were: major adverse cardiac events; all-cause mortality; CV mortality; recurrent myocardial infarction; stroke; hospitalization; and adverse medication effects. Secondary endpoints were short-term effect of colchicine on inflammatory markers.

RESULTS

Twelve randomized controlled trials with a total of 13 073 patients with CAD (colchicine n = 6351 and placebo n = 6722) were included in the meta-analysis. At mean follow-up of 22.5 months, the colchicine group had lower risk of major adverse cardiac events (6.20 vs. 8.87%; P < .001), recurrent myocardial infarction (3.41 vs. 4.41%; P = .005), stroke (0.40 vs. 0.90%; P = .002) and hospitalization due to CV events (0.90 vs. 2.87%; P = .02) compared to the control group. The 2 patient groups had similar risk for all-cause mortality (2.08 vs. 1.88%; P = .82) and CV mortality (0.71 vs. 1.01%; P = .38). Colchicine significantly reduced high-sensitivity C-reactive protein (-4.25, P = .001) compared to controls but did not significantly affect interleukin (IL)-β1 and IL-18 levels.

CONCLUSION

Colchicine reduced CV events and inflammatory markers, high-sensitivity C-reactive protein and IL-6, in patients with coronary disease compared to controls. Its impact on cardiovascular and all-cause mortality requires further investigation.

Inflammatory Burden and Immunomodulative Therapeutics of Cardiovascular Diseases

Phenotyping cardiovascular illness and recognising heterogeneities within are pivotal in the contemporary era. Besides traditional risk factors, accumulated evidence suggested that a high inflammatory burden has emerged as a key characteristic modulating both the pathogenesis and progression of cardiovascular diseases, inclusive of atherosclerosis and myocardial infarction. To mechanistically elucidate the correlation, signalling pathways downstream to Toll-like receptors, nucleotide oligomerisation domain-like receptors, interleukins, tumour necrosis factor, and corresponding cytokines were raised as central mechanisms exerting the effect of inflammation. Other remarkable adjuvant factors include oxidative stress and secondary ferroptosis. These molecular discoveries have propelled pharmaceutical advancements. Statin was suggested to confer cardiovascular benefits not only by lowering cholesterol levels but also by attenuating inflammation. Colchicine was repurposed as an immunomodulator co-administered with coronary intervention. Novel interleukin-1β and −6 antagonists exhibited promising cardiac benefits in the recent trials as well. Moreover, manipulation of gut microbiota and associated metabolites was addressed to antagonise inflammation-related cardiovascular pathophysiology. The gut-cardio-renal axis was therein established to explain the mutual interrelationship. As for future perspectives, artificial intelligence in conjunction with machine learning could better elucidate the sequencing of the microbiome and data mining. Comprehensively understanding the interplay between the gut microbiome and its cardiovascular impact will help identify future therapeutic targets, affording holistic care for patients with cardiovascular diseases.

A fresh look at coronary microembolization

Mechanical stress from haemodynamic perturbations or interventional manipulation of epicardial coronary atherosclerotic plaques with inflammatory destabilization can release particulate debris, thrombotic material and soluble substances into the coronary circulation. The physical material obstructs the coronary microcirculation, whereas the soluble substances induce endothelial dysfunction and facilitate vasoconstriction. Coronary microvascular obstruction and dysfunction result in patchy microinfarcts accompanied by an inflammatory reaction, both of which contribute to progressive myocardial contractile dysfunction. In clinical studies, the benefit of protection devices to retrieve atherothrombotic debris during percutaneous coronary interventions has been modest, and the treatment of microembolization has mostly relied on antiplatelet and vasodilator agents. The past 25 years have witnessed a relative proportional increase in non-ST-segment elevation myocardial infarction in the presentation of acute coronary syndromes. An associated increase in the incidence of plaque erosion rather than rupture has also been recognized as a key mechanism in the past decade. We propose that coronary microembolization is a decisive link between plaque erosion at the culprit lesion and the manifestation of non-ST-segment elevation myocardial infarction. In this Review, we characterize the features and mechanisms of coronary microembolization and discuss the clinical trials of drugs and devices for prevention and treatment.

A Meta-Analysis Evaluating the Colchicine Therapy in Patients With Coronary Artery Disease

Background: Evidence from recent studies has shown the benefits of colchicine for patients with coronary artery disease. The aim was to assess the effect of colchicine treatment on cardiovascular events, with an estimation of the risk of discontinuation and net clinical benefit.

Methods and Results: Fourteen trials with a total of 13,186 patients were selected through a systematic search. Colchicine therapy significantly reduced the relative risk of primary endpoint by about 30% [RR 0.70 (95%CI:0.56–0.88)]. Compared with placebo, colchicine significantly reduced the risk of ischemia-driven revascularization [RR 0.57 (95%CI 0.41–0.80)], ischemia-driven revascularization and resuscitation [RR 0.50 (95%CI 0.34–0.73)], myocardial infarction [RR 0.73 (95%CI 0.57–0.95)], and stroke [RR 0.49 (95%CI 0.30–0.7)]. Patients treated with colchicine in comparison with placebo have a significant increase in the risk of treatment cessation (RR 1.60 95%CI 1.06–2.42). However, in the analysis which excluded studies without placebo, the relative risk of discontinuation was smaller (RR 1.34 95%CI 0.97–1.84) and in the three largest studies, the risk of discontinuation was lower and insignificant [RR 1.26 (95%CI 0.87–1.83)]. The net clinical benefit was 17.8/1,000 patients (p < 0.001).

Conclusion: In coronary artery disease, low-dose colchicine significantly reduces the risk of the primary composite endpoint by about 30%. The drug should be considered as part of the preventive treatment in patients with good tolerance.

Protective role of nutraceuticals against myocarditis

Myocarditis is an inflammatory disease of the myocardium that mostly affects young adults. The disease is commonly caused by viral infection, medications, autoimmune disorders, and inflammatory conditions. Nearly 50% of the cases of myocarditis are due to post-viral immune response in a setting of an identifiable or non-identifiable infection. The clinical manifestation is nonspecific ranging from asymptomatic courses to sudden death in infants and young patients. This review describes the properties of phytochemicals as plant-derived active ingredients which can be used in the prevention and treatment of myocarditis and its associated risk factors. Meanwhile, it has illustrated epidemiological analyses, mechanism of action, and the metabolism of phytochemicals in animal and human clinical trials. We also mentioned the precise mechanism of action by which phytochemicals elicit their anti-viral, anti-inflammatory, antioxidant, and immunomodulatory effects and how they regulate signal transduction pathways. Nevertheless, comprehensive clinical trials are required to study the properties of phytochemicals in vivo, in vitro, and in silico for a proper management of myocarditis. Our findings indicate that phytochemicals function as potent adjunctive therapeutic drugs in myocarditis and its related complications.

Inflammation and ischemic heart disease: The next therapeutic target?

Inflammation plays an important role in several stages of the cardiovascular continuum. In recent decades a plethora of studies have provided new data highlighting the role of inflammation in atherogenesis and atherothrombosis in two-way interactions with various cardiovascular risk factors and further influencing these dynamic processes. The concept of targeting residual inflammatory risk among individuals with ischemic heart disease (IHD) is therefore gaining increasing attention. Recently, several landmark randomized controlled trials have assessed different pharmacological approaches that may mitigate this residual risk. The results of some of these studies, such as CANTOS with canakinumab and COLCOT and LoDoCo2 with colchicine, are promising and have provided data to support this concept. Moreover, though several aspects remain to be clarified, these trials have shown the potential of modulating inflammation as a new target to reduce the risk of cardiovascular events in secondary prevention patients. In the present review, we aim to present a pragmatic overview of the complex interplay between inflammation and IHD, and to critically appraise the current evidence on this issue while presenting future perspectives on this topic of pivotal contemporary interest.

Association Between Colchicine Treatment and Clinical Outcomes in Patients with Coronary Artery Disease: Systematic Review and Meta-analysis

Background: The authors examined the association between colchicine treatment and clinical outcomes in patients with coronary artery disease. Methods: They performed a meta-analysis of randomised controlled trials (RCTs) involving patients with coronary artery disease receiving addon colchicine to standard treatment compared with standard treatment. They used a mixed-effects Poisson regression model with random intervention effects to estimate the pooled incidence rate ratios (IRR) with 95% CI. Results: Ten RCTs were identified, including 12,819 participants followed up for a median of 6 months. Colchicine was associated with a lower risk of major adverse cardiovascular events (IRR 0.69; 95% CI [0.60-0.79]; number needed to treat for an additional beneficial outcome [NNTB] = 28); MI (IRR 0.77; 95% CI [0.64-0.93]; NNTB = 95) and ischaemic stroke (IRR 0.48; 95% CI [0.30-0.76]; NNTB = 155) and with a higher risk of gastrointestinal adverse events (IRR 1.69; 95% CI [1.12-2.54]; number needed to treat for an additional harmful outcome [NNTH] = 10). Colchicine did not affect all-cause death (IRR 1.09; 95% CI [0.85-1.40]), or cardiovascular death (IRR 0.75; 95% CI [0.51-1.12]), while it was associated with a higher risk of non-cardiovascular death (IRR 1.45; 95% CI [1.04-2.02]; NNTH = 396). Conclusion: The meta-analysis showed that the relative and absolute beneficial treatment effects of colchicine on cardiovascular outcomes outweigh the potential harm for non-cardiovascular mortality. Registration: PROSPERO 2021 CRD42021248874.

Safety and Efficacy of Colchicine in Patients with Stable CAD and ACS: A Systematic Review and Meta-analysis

BACKGROUND

Evidence from recent trials has shown conflicting results in terms of the utility of colchicine in patients with coronary artery disease (CAD).

METHODS

Multiple databases were queried to identify all randomized controlled trials (RCTs) comparing the merits of colchicine in patients with acute coronary syndrome (ACS) or stable CAD. The pooled relative risk ratio (RR) of major adverse cardiovascular events (MACE), its components, and gastrointestinal (GI) adverse events were computed using a random-effect model.

RESULTS

Ten RCTs comprising a total of 12,761 patients were identified. At a median follow-up of 12 months, there was a significantly lower risk of MACE [RR 0.66, 95% confidence interval (CI) 0.45-96], ACS (RR 0.66, 95% CI 0.45-0.96), ischemic stroke (RR 0.42, 95% CI 0.22-0.81), and need for revascularization (RR 0.61, 95% CI 0.42-90) in patients receiving colchicine compared with placebo. A subgroup analysis based on the clinical presentation showed that the significantly lower incidence of MACE and stroke were driven by the patients presenting with ACS. The use of colchicine in patients with stable CAD did not reduce the incidence of MACE (RR 0.55, 95% CI 0.28-1.09), ACS (RR 0.52, 95% CI 0.25-1.08), or stroke (RR 0.61, 95% CI 0.33-1.13). There was no significant difference in the relative risk of cardiac arrest, ACS, cardiovascular mortality, and all-cause mortality between the two groups in both ACS and stable CAD populations. The risk of GI adverse events was significantly higher in patients receiving colchicine (RR 2.10, 95% CI 1.12-3.95).

CONCLUSION

In patients presenting with ACS, low-dose colchicine might reduce the incidence of MACE, stroke, and the need for revascularization at long follow-up durations. Colchicine might offer no benefits in reducing the risk of ischemic events in patients with stable angina.

Colchicine in ischemic heart disease: the good, the bad and the ugly

Inflammation is the main pathophysiological process involved in atherosclerotic plaque formation, progression, instability, and healing during the evolution of coronary artery disease (CAD). The use of colchicine, a drug used for decades in non-ischemic cardiovascular (CV) diseases and/or systemic inflammatory conditions, stimulated new perspectives on its potential application in patients with CAD. Previous mechanistic and preclinical studies revealed anti-inflammatory and immunomodulatory effects of colchicine exerted through its principal mechanism of microtubule polymerization inhibition, however, other pleiotropic effects beneficial to the CV system were observed such as inhibition of platelet aggregation and suppression of endothelial proliferation. In randomized double-blinded clinical trials informing our clinical practice, low doses of colchicine were associated with the significant reduction of cardiovascular events in patients with stable CAD and chronic coronary syndrome (CCS) while in patients with a recent acute coronary syndrome (ACS), early initiation of colchicine treatment significantly reduced major adverse CV events (MACE). On the other hand, the safety profile of colchicine and its potential causal relationship to the observed increase in non-CV deaths warrants further investigation. For these reasons, postulates of precision medicine and patient-tailored approach with regards to benefits and harms of colchicine treatment should be employed at all times due to potential toxicity of colchicine as well as the currently unresolved signal of harm concerning non-CV mortality. The main goal of this review is to provide a balanced, critical, and comprehensive evaluation of currently available evidence with respect to colchicine use in the setting of CAD.

Colchicine to Prevent Sympathetic Denervation after an Acute Myocardial Infarction: The COLD-MI Trial Protocol

Inflammatory processes are deeply involved in ischemia-reperfusion injuries (IRI) and ventricular remodelling (VR) after a ST-segment elevation myocardial infarction (STEMI). They are associated with clinical adverse events (heart failure and cardiovascular death) adding damage to the myocardium after reperfusion. Moreover, acute myocardial infarction (AMI) induces a local sympathetic denervation leading to electrical instability and arrythmia. Colchicine, a well-known alkaloid with direct anti-inflammatory effects, was shown to reduce the myocardial necrosis size and limit the VR. In a recent proof of concept study, colchicine appears to prevent sympathetic denervation in a mice model of ischemia/reperfusion, but not in the necrosis or in the border zone areas. The Colchicine to Prevent Sympathetic Denervation after an AMI study (COLD-MI) is an ongoing, confirmative, prospective, monocentre, randomized, open-label trial. The COLD-MI trial aims to evaluate the intensity of sympathetic denervation after AMI and its potential modulation due to low dose colchicine. Sympathetic denervation will be noninvasively evaluated using single-photon emission computed tomography (SPECT). After a first episode of STEMI (Initial TIMI flow ≤ 1) and primary percutaneous coronary intervention (PPCI), patients will be randomized (n = 56) in a 1:1 ratio to either receive colchicine or not for 30 days. The primary end point will be the percentage of myocardial denervation measured by 123I-metaiodobenzylguanidine (123I-MIBG) SPECT at a 6-month follow-up. The main secondary end points will be basic ECG parameters (QRS duration, corrected QT) and HRV parameters from a 24 hour-recording Holter at 1- and 6-months follow-up. Results from this study will contribute to a better understanding of the cardioprotective effect of colchicine after AMI. The present study describes the rationale, design, and methods of the trial.

Effect of Colchicine on Myocardial Injury in Acute Myocardial Infarction

Supplemental Digital Content is available in the text.

Background:

Inflammation is a key factor of myocardial damage in reperfused ST-segment–elevation myocardial infarction. We hypothesized that colchicine, a potent anti-inflammatory agent, may reduce infarct size (IS) and left ventricular (LV) remodeling at the acute phase of ST-segment–elevation myocardial infarction.

Methods:

In this double-blind multicenter trial, we randomly assigned patients admitted for a first episode of ST-segment–elevation myocardial infarction referred for primary percutaneous coronary intervention to receive oral colchicine (2-mg loading dose followed by 0.5 mg twice a day) or matching placebo from admission to day 5. The primary efficacy outcome was IS determined by cardiac magnetic resonance imaging at 5 days. The relative LV end-diastolic volume change at 3 months and IS at 3 months assessed by cardiac magnetic resonance imaging were among the secondary outcomes.

Results:

We enrolled 192 patients, 101 in the colchicine group and 91 in the control group. At 5 days, the gadolinium enhancement–defined IS did not differ between the colchicine and placebo groups with a mean of 26 interquartile range (IQR) [16–44] versus 28.4 IQR [14–40] g of LV mass, respectively (P=0.87). At 3 months follow-up, there was no significant difference in LV remodeling between the colchicine and placebo groups with a +2.4% (IQR, –8.3% to 11.1%) versus –1.1% (IQR, –8.0% to 9.9%) change in LV end-diastolic volume (P=0.49). Infarct size at 3 months was also not significantly different between the colchicine and placebo groups (17 IQR [10–28] versus 18 IQR [10–27] g of LV mass, respectively; P=0.92). The incidence of gastrointestinal adverse events during the treatment period was greater with colchicine than with placebo (34% versus 11%, respectively; P=0.0002).

Conclusions:

In this randomized, placebo-controlled trial, oral administration of high-dose colchicine at the time of reperfusion and for 5 days did not reduce IS assessed by cardiac magnetic resonance imaging.

Registration:

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03156816.

Inflammation and ischemic heart disease: The next therapeutic target?

Inflammation plays an important role in several stages of the cardiovascular continuum. In recent decades a plethora of studies have provided new data highlighting the role of inflammation in atherogenesis and atherothrombosis in two-way interactions with various cardiovascular risk factors and further influencing these dynamic processes. The concept of targeting residual inflammatory risk among individuals with ischemic heart disease (IHD) is therefore gaining increasing attention. Recently, several landmark randomized controlled trials have assessed different pharmacological approaches that may mitigate this residual risk. The results of some of these studies, such as CANTOS with canakinumab and COLCOT and LoDoCo2 with colchicine, are promising and have provided data to support this concept. Moreover, though several aspects remain to be clarified, these trials have shown the potential of modulating inflammation as a new target to reduce the risk of cardiovascular events in secondary prevention patients. In the present review, we aim to present a pragmatic overview of the complex interplay between inflammation and IHD, and to critically appraise the current evidence on this issue while presenting future perspectives on this topic of pivotal contemporary interest.

Colchicine effectively attenuates inflammatory biomarker high-sensitivity C-reactive protein (hs-CRP) in patients with non-ST-segment elevation myocardial infarction: a randomised, double-blind, placebo-controlled clinical trial

Myocardial infarction without ST-segment elevation (NSTEMI) is considered an inflammatory disorder associated with a high mortality rate worldwide. High-sensitivity C-reactive protein (hs-CRP) is an important inflammatory marker for NSTEMI and related to cardiovascular events. Colchicine, as a potent anti-inflammatory drug, is frequently prescribed for the treatment of gout and pericarditis. The present study aimed to evaluate the effects of colchicine, as an anti-inflammatory drug, on hs-CRP levels in NSTEMI patients. We performed a randomised, double-blind, placebo-controlled trial involving 150 NSTEMI patients referred to Imam Reza and Ghaem Hospitals affiliated to Mashhad University of Medical Sciences. The patients were randomised to receive colchicine or placebo along with optimal medications for 30 days. The hs-CRP was measured at the admission and end of the study. Our results revealed that, in both colchicine and placebo groups, hs-CRP levels were significantly mitigated in NSTEMI patients compared to baseline (P < 0.001). However, the decreasing properties of colchicine on hs-CRP levels were remarkably stronger than placebo following the 30 days of treatment (P < 0.001). Nevertheless, neither colchicine nor placebo treatment could achieve hs-CRP levels lower than 2 mg/L. There were no significant differences between the effects of colchicine on the hs-CRP decrease in diabetic and non-diabetic, male and female, and normal and preserved LVEF NSTEMI patients. It can be concluded that colchicine may prevent the disease progression and succedent cardiovascular events in NSTEMI patients by attenuating the inflammation.

Low-Dose Colchicine in Coronary Artery Disease - Systematic Review and Meta-Analysis

Background: Recent studies have revealed the benefits of using colchicine, a drug with anti-inflammatory properties, in coronary artery disease (CAD). This study systematically reviewed the benefits and risks of low-dose colchicine in patients with CAD. Methods and Results: We searched for randomized controlled trials (RCTs) in MEDLINE, the Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science databases (March 2020). Efficacy and safety outcomes were evaluated. Estimates are expressed as risk ratios (RRs) and 95% confidence intervals (95% CIs). Heterogeneity was assessed with I² test. Confidence in the pooled evidence was appraised using the GRADE framework. Colchicine reduced the rate of major adverse cardiovascular events (RR 0.65; 95% CI 0.49-0.86; 6 RCTs; I²=50%; 11,718 patients; GRADE, moderate confidence), acute coronary syndrome (RR 0.64; 95% CI 0.46-0.90; I²=47%; 7 RCTs; 11,955 patients; GRADE, very low confidence), stroke (RR 0.49; 95% CI 0.30-0.78; I²=0%; 6 RCTs; 11,896 patients; GRADE, moderate confidence), and cardiovascular interventions (RR 0.61; 95% CI 0.42-0.89; I²=40%; 4 RCTs; 11,284 patients; GRADE, high confidence). Colchicine did not increase the risk of adverse events, except for gastrointestinal events (RR 1.54; 95% CI 1.11-2.13; I²=72%; 9 RCTs; 12,374 patients; GRADE, very low confidence). Conclusions: Low-dose colchicine in patients with CAD is associated with beneficial effects on prognosis, although an increased risk of gastrointestinal events was confirmed.

Colchicine in Patients With Coronary Artery Disease: A Systematic Review and Meta-Analysis of Randomized Trials

Background

Inflammation plays a pivotal role in coronary artery disease (CAD). The anti‐inflammatory drug colchicine seems to reduce ischemic events in patients with CAD. So far there is equipoise about its safety and impact on mortality.

Methods and Results

To evaluate the utility of colchicine in patients with acute and chronic CAD, we performed a systematic review and meta‐analysis. MEDLINE, EMBASE, Cochrane CENTRAL and conference abstracts were searched from January 1975 to October 2020. Randomized trials assessing colchicine compared with placebo/standard therapy in patients with CAD were included. Data were combined using random‐effects models. The reliability of the available data was tested using trial sequential analyses . Of 3108 citations, 13 randomized trials (n=13 125) were included. Colchicine versus placebo/standard therapy in patients with CAD reduced risk of myocardial infarction (odds ratio [OR] 0.64; 95% CI, 0.46–0.90; P=0.01; I² 41%) and stroke/transient ischemic attack (OR 0.50; 95% CI, 0.31–0.81; P=0.005; I² 0%). But treatment with colchicine compared with placebo/standard therapy had no influence on all‐cause and cardiovascular mortality (OR 0.96; 95% CI, 0.65–1.41; P=0.83; I² 24%; and OR 0.82; 95% CI, 0.55–1.22; P=0.45; I² 0%, respectively). Colchicine increased the risk for gastrointestinal side effects (P<0.001). According to trial sequential analyses, there is only sufficient evidence for a myocardial infarction risk reduction with colchicine.

Conclusions

Among patients with CAD, colchicine reduces the risk of myocardial infarction and stroke, but has a higher rate of gastrointestinal upset with no influence on all‐cause mortality.

Efficacy and Safety of Colchicine in Post-acute Myocardial Infarction Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: Inflammation plays a key role in atherosclerotic plaque destabilization and adverse cardiac remodeling. Recent evidence has shown a promising role of colchicine in patients with coronary artery disease. We evaluated the efficacy and safety of colchicine in post–acute myocardial infarction (MI) patients.

Methods: We searched five electronic databases from inception to January 18, 2021, for randomized controlled trials (RCTs) evaluating colchicine in post–acute MI patients. Primary outcomes were cardiovascular mortality and recurrent MI. Secondary outcomes were all-cause mortality, stroke, urgent coronary revascularization, levels of follow-up high-sensitivity C-reactive protein (hs-CRP), and drug-related adverse events. All meta-analyses used inverse-variance random-effects models.

Results: Six RCTs involving 6,005 patients were included. Colchicine did not significantly reduce cardiovascular mortality [risk ratio (RR), 0.91; 95% confidence interval (95% CI), 0.52–1.61; p = 0.64], recurrent MI (RR, 0.87; 95% CI, 0.62–1.22; p = 0.28), all-cause mortality (RR, 1.06; 95% CI, 0.61–1.85; p = 0.78), stroke (RR, 0.28; 95% CI, 0.07–1.09; p = 0.05), urgent coronary revascularization (RR, 0.46; 95% CI, 0.02–8.89; p = 0.19), or decreased levels of follow-up hs-CRP (mean difference, −1.95 mg/L; 95% CI, −12.88 to 8.98; p = 0.61) compared to the control group. There was no increase in any adverse events (RR, 0.97; 95% CI, 0.89–1.07; p = 0.34) or gastrointestinal adverse events (RR, 2.49; 95% CI, 0.48–12.99; p = 0.20). Subgroup analyses by colchicine dose (0.5 vs. 1 mg/day), time of follow-up (<1 vs. ≥1 year), and treatment duration (≤30 vs. >30 days) showed no changes in the overall findings.

Conclusion: In post–acute MI patients, colchicine does not reduce cardiovascular or all-cause mortality, recurrent MI, or other cardiovascular outcomes. Also, colchicine did not increase drug-related adverse events.

Inflammation during Percutaneous Coronary Intervention-Prognostic Value, Mechanisms and Therapeutic Targets

Periprocedural myocardial injury and myocardial infarction (MI) are not infrequent complications of percutaneous coronary intervention (PCI) and are associated with greater short- and long-term mortality. There is an abundance of preclinical and observational data demonstrating that high levels of pre-, intra- and post-procedural inflammation are associated with a higher incidence of periprocedural myonecrosis as well as future ischaemic events, heart failure hospitalisations and cardiac-related mortality. Beyond inflammation associated with the underlying coronary pathology, PCI itself elicits an acute inflammatory response. PCI-induced inflammation is driven by a combination of direct endothelial damage, liberation of intra-plaque proinflammatory debris and reperfusion injury. Therefore, anti-inflammatory medications, such as colchicine, may provide a novel means of improving PCI outcomes in both the short- and long-term. This review summarises periprocedural MI epidemiology and pathophysiology, evaluates the prognostic value of pre-, intra- and post-procedural inflammation, dissects the mechanisms involved in the acute inflammatory response to PCI and discusses the potential for periprocedural anti-inflammatory treatment.

The Use of Colchicine in Cardiovascular Diseases: A Systematic Review

The medicinal properties of colchicine have been recognized for centuries. Although previously used for gout and familial Mediterranean fever, its immune-modulating, anti-inflammatory, and antifibrotic effects are increasingly recognized as beneficial in the treatment of cardiovascular disorders. In this systematic review, we summarize the current evidence on colchicine's effectiveness in 1) pericarditis, 2) coronary artery disease, and 3) atrial fibrillation. We also discuss the safety, potential adverse effects, and common drug interactions that should be considered during use.

Effects of Colchicine on Cardiovascular Outcomes in Patients with Coronary Artery Disease: A Systematic Review and One-Stage and Two-Stage Meta-Analysis of Randomized-Controlled Trials

AIM

Colchicine has received emerging interest due to its cardiovascular benefits in patients with coronary artery disease (CAD). We conducted a one-stage meta-analysis of reconstructed individual patient data (IPD) from randomized-controlled trials to summarize the effects of colchicine on cardiovascular outcomes in patients with CAD.

METHODS

Four databases (PubMed, Embase, Cochrane, SCOPUS) were searched for articles published from inception to 30th September 2020, examining the effect of colchicine on cardiovascular outcomes in patients with CAD, yielding 10 randomized-controlled trials with a combined cohort of 12,781 patients. IPD was reconstructed from Kaplan-Meier curves published in 3 studies and analysed using the shared-frailty Cox model. Aggregate data meta-analysis of all 10 studies was performed for outcomes unsuitable for IPD reconstruction.

RESULTS

In patients receiving colchicine compared to placebo, one-stage meta-analysis demonstrated a hazard ratio of 0.70 (95% CI 0.61-0.80) for the composite outcome of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, and urgent hospitalization for angina requiring coronary revascularization. Aggregate data meta-analysis demonstrated a significant reduction in hazard rate for stroke (HR 0.45; 95% CI 0.27-0.75) and urgent revascularization (HR 0.59; 95% CI 0.38-0.91); and a relative risk reduction for myocardial infarction (RR 0.72; 95% CI of 0.52-1.00) and post-operative atrial fibrillation (RR 0.64; 95% CI 0.48-0.86).

CONCLUSION

Given the significant benefits of colchicine demonstrated on IPD, and its consistent benefits when analyzed using aggregate data meta-analysis, we propose that colchicine may be considered as an additional pharmacological adjunct to the first line therapy for patients with coronary artery disease.

Colchicine and Cardiovascular Outcomes: a Critical Appraisal of Recent Studies

Purpose of Review

Recent studies have demonstrated an important role for inflammation in the pathogenesis of atherosclerotic cardiovascular disease. Several studies have investigated the efficacy of colchicine (a widely used and safe anti-inflammatory drug) in patients with atherosclerosis. This review explains the rationale for the use of colchicine in this setting and critically appraises recent outcome trials.

Recent Findings

Two large randomised-controlled trials LoDoCo2 (included patients with chronic coronary syndromes) and COLCOT (acute coronary syndromes) have demonstrated reductions in atherosclerotic cardiovascular events, but not mortality. A smaller study (COPS) found no beneficial effect of colchicine but was probably underpowered.

Summary

Colchicine is effective at reducing cardiovascular events in chronic and acute coronary syndromes, although reductions in all-cause mortality have not been demonstrated during the period of follow-up in trials to date. Mild gastrointestinal symptoms are the most commonly reported adverse effects, although in well-designed randomised controlled trials these are relatively uncommon.

Efficacy and safety of colchicine for the prevention of major cardiovascular and cerebrovascular events in patients with coronary artery disease: a systematic review and meta-analysis on 12 869 patients

AIMS

The key role of inflammation in the pathogenesis of coronary artery disease (CAD) is an urgent call for innovative treatments. Several trials have proposed colchicine as a therapeutic option for secondary prevention in CAD patients but its utilization is hampered by fears about drug-related adverse events (DAEs) and conflicting evidences. The aim of this meta-analysis was to consolidate evidence on the efficacy and safety of colchicine for secondary prevention in patients with CAD.

METHODS AND RESULTS

A systematic search in electronic bibliographic databases of Medline, Scopus, Embase, and the Cochrane Library was performed to identify randomized controlled trials (RCTs) assessing the cardiovascular effects of colchicine in CAD patients, compared with placebo. Outcomes of interest were the occurrence of major adverse cardiovascular and cerebrovascular events (MACCE) and DAEs. Estimates were pooled using inverse-variance random-effects model. A total of 11 RCTs, including 12 869 patients, were identified as eligible. A total of 6501 patients received colchicine, while 6368 received placebo. After a median follow-up of 6 months (interquartile range, 1-16), patients receiving colchicine had a lower risk of MACCE [6% vs. 8.8%, relative risk (RR) = 0.67, 95% confidence interval (CI) 0.56-0.80, I2 = 19%], myocardial infarction (3.3% vs. 4.3%, RR = 0.76, 95% CI 0.61-0.96, I2 = 17%), coronary revascularization (2.9% vs. 4.2%, RR = 0.61, 95% CI 0.42-0.89, I2 = 40%), stroke (0.4% vs. 0.9%, RR = 0.48, 95% CI 0.30-0.77, I2 = 0%), hospitalization for cardiovascular cause (0.9% vs. 2.9%, RR = 0.32, 95% CI 0.12-0.87, I2 = 0%). Colchicine was associated with an increased risk of gastrointestinal DAEs (11% vs. 9.2%, RR = 1.67, 95% CI 1.20-2.34, I2 = 76%), myalgia (18% vs. 16%, RR = 1.16, 95% CI 1.02-1.32, I2 = 0%) and DAEs-related discontinuation (4.1% vs. 3%, RR = 1.54, 95% CI 1.02-2.32, I2 = 65%). However, gastrointestinal DAEs and discontinuation may be prevented with a lower daily dose. Colchicine did not increase the risk of cardiovascular death (0.7% vs. 1%, RR = 0.73, 95% CI 0.45-1.21, I2 = 14%), all-cause death (2% vs. 1.9%, RR = 1.01, 95% CI 0.71-1.43, I2 = 16%), or other DAEs.

CONCLUSIONS

The use of colchicine in patients with CAD is safe and efficacious for MACCE prevention.

Colchicine administration for percutaneous coronary intervention: A meta-analysis of randomized controlled trials

INTRODUCTION

The efficacy of colchicine administration in patients undergoing percutaneous coronary intervention (PCI) remains controversial. We conduct a systematic review and meta-analysis to explore the influence of colchicine administration versus placebo on treatment efficacy for PCI.

METHODS

We search PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through June 2020 for randomized controlled trials (RCTs) assessing the effect of colchicine administration versus placebo in patients with PCI. This meta-analysis is performed using the random-effect model.

RESULTS

Five RCTs involving 5526 patients are included in the meta-analysis. Overall, compared with control group for myocardial infarction patients undergoing PCI, colchicine intervention can significantly reduce major adverse cardiovascular events (OR = 0.78; 95% CI = 0.62 to 0.97; P = 0.02), but reveals no obvious impact on mortality (OR = 0.89; 95% CI = 0.60 to 1.32; P = 0.57), myocardial infarction (OR = 0.88; 95% CI = 0.67 to 1.17; P = 0.39), serious adverse events (OR = 0.71; 95% CI = 0.31 to 1.61; P = 0.41), or restenosis (OR = 1.02; 95% CI = 0.63 to 1.64; P = 0.95).

CONCLUSIONS

Colchicine treatment may be effective to reduce major adverse cardiovascular events in patients undergoing PCI.

Efficacy and safety of colchicine for secondary prevention of coronary heart disease: a systematic review and meta-analysis

To evaluate the efficacy and safety of colchicine for secondary prevention of coronary heart disease (CHD), relevant randomized controlled trials (RCTs) were identified by searching several databases from the creation date to August 31, 2020 and were reviewed. Eight eligible trials of colchicine therapy involving a total of 11, 463 patients were included (5, 776 subjects received colchicine, while 5, 687 subjects were in the respective control arms), and the outcome was reported as risk ratio (RR) and 95% confidence interval (CI), as the relative measure of association. Overall, the incidences of major adverse cardiovascular events (MACEs) (RR 0.70; 95% CI 0.61-0.80), myocardial infarction (MI) (RR 0.77; 95% CI 0.64-0.94), emergency readmission due to CHD (RR 0.70; 95% CI 0.58-0.86), and ischemic stroke (RR 0.49; 95% CI 0.30-0.79) were lower in the colchicine group than in the placebo arm. We did not find a significant reduction in the incidence of all-cause mortality (RR 1.03; 95% CI 0.80-1.32). Although the incidence of diarrhea in the colchicine treatment group was higher than that in the placebo arms (RR 2.53; 95% CI 1.17, 5.48), the symptoms disappeared rapidly after drug withdrawal, and no serious adverse reactions occurred. In summary, colchicine is an accessible, safe, and effective drug that could be successfully utilized for the secondary prevention of CHD. The tolerability and benefits should be confirmed in in-depth clinical trials.

The Role of Colchicine in Atherosclerotic Cardiovascular Disease

Colchicine, an inexpensive immunomodulatory drug used traditionally to treat gout and familial Mediterranean fever, is rapidly accumulating basic and clinical evidence for a therapeutic role in atherosclerotic cardiovascular disease. Its athero-protective properties are thought to be mainly related to its effect on tubulin polymerisation, enabling a broad range of effect on multiple atherosclerotic plaque cell types and cellular processes, including cell division, cell migration as well as pro-inflammatory cytokine and chemokine secretion. These properties indicate the potential to favourably affect all stages of atherosclerotic plaque development including formation, progression, destabilisation, and plaque rupture. This review focusses on the pharmacology of colchicine, the mechanisms by which it modulates atherosclerosis pathobiology, and summarises the current clinical evidence for its use along with the upcoming clinical trial landscape. Given the current lack of primary immunomodulatory drugs in the treatment of atherosclerosis, colchicine is a promising candidate to fill this therapeutic gap.

Colchicine Use in Acute Coronary Syndromes: An Update

Coronary artery disease is the leading cause of death worldwide, and its main pathological substrate is represented by atherosclerosis. Inflammation is a major promoter of the atherosclerotic process and is involved in both the initiation and progression of atherosclerosis, as well as in the occurrence of fatal complications. Until the present moment, Colchicine Cardiovascular Outcomes Trial is the largest trial to demonstrate a major benefit of low-dose colchicine on major adverse cardiac events in patients with recent myocardial infarction (MI), but the mechanisms behind this relation are not completely known. The purpose of this review is to emphasize the possible pathways through which colchicine improves the clinical outcomes in the acute setting of acute coronary syndromes by referring to the results of the studies published in the past 5 years. Aside from its stated systemic anti-inflammatory effect, colchicine could be a valuable addition to the therapeutic approach of acute MI by reducing the infarct size, stabilizing the coronary plaque, as well as reducing platelet aggregation. Moreover, colchicine may improve endothelial function, reduce the transcoronary release of cytokines, and prevent a rise in inflammatory markers after percutaneous coronary intervention, thus diminishing the residual inflammatory risk.

Colchicine for the treatment of cardiovascular diseases: old drug, new targets

: Well known in past centuries as a herbal remedy for osteoarticular pain and commonly used in the treatment of gout and familial Mediterranean fever, colchicine has an emerging role in the setting of cardiovascular diseases. Its unique properties not only target the key mechanisms of recurrent inflammation underlying pericardial syndromes but also inflammation within atherosclerotic plaques, atrial fibrillation recurrence and adverse ventricular remodelling leading to heart failure.The effect of colchicine in the treatment of cardiovascular diseases along with essential pharmacology will be discussed, reviewing the most important and recent clinical studies. Colchicine is a valuable, well tolerated and inexpensive drug in the setting of cardiovascular diseases.

Drug repurposing? Cardiovascular effect of colchicine on patients with coronary artery disease: A systematic review and meta-analysis

BACKGROUND

Patients with coronary artery disease (CAD) are at high risk of atherosclerotic events. The aim of this meta-analysis is to evaluate the cardiovascular protective effect of colchicine on patients with CAD.

METHODS

In this systematic review and meta-analysis, we searched PubMed and Embase for studies published until April 28, 2020. We included studies that reported the incidence of myocardial infarction (MI), restenosis after percutaneous coronary intervention (PCI), and mortality for CAD patients within colchicine and control (placebo or usual care) groups. A random-effects meta-analysis model was then applied.

RESULTS

Ten eligible trials were identified, including 6398 patients (3248 received colchicine while 3150 were controls). The risk of composite events of MI and restenosis after PCI was significantly decreased with colchicine treatment [odds ratio (OR) 0.48, 95% confidence interval (CI) 0.28-0.79]. We found a similar trend of lowered risk of MI in the colchicine group, although without statistical significance (OR 0.41, 95% CI 0.16-1.08). The risk of restenosis after PCI also decreased significantly with colchicine treatment (OR 0.46, 95% CI 0.23-0.92). There was no significant difference in all-cause mortality between the two groups (OR 0.80, 95% CI 0.56-1.15). The included patients had significantly higher risks of gastrointestinal (GI) events with colchicine treatment.

CONCLUSIONS

This meta-analysis shows that there is a decreased composite risk of MI and restenosis after PCI with the use of colchicine in patients with CAD. However, colchicine did not appear beneficial for all-cause mortality, and it led to a higher risk of GI events.