Twenty-year trends in clinical outcome of randomized controlled trial for coronary intervention: systematic review and meta-regression analysis of 46 randomized controlled trials

Aim

The technology of percutaneous coronary intervention (PCI) has been developed after the advent of coronary stent. However, the impact of the technological development on clinical outcomes is still unclear, whereas a remarkable improvement of clinical outcomes after PCI has not been observed in the trials comparing to medical therapy or coronary bypass graft. The current analysis aims to investigate trends in clinical outcomes after PCI after the emargence of coronary stent, using the randomized controlled trials (RCTs) comparing coronary stents.

Methods and results

We performed a systematic review of RCTs investigating coronary stents in non-specific population (excluding the trials particularly enrolling diabetic or myocardial infarction etc.) conducted between 1996 and 2015 (publication between 1997 and 2019) with independent clinical event adjudication. The random-effect meta-regression analysis including 90 arms with 94,831 patients in 46 RCTs was performed investigating the 20-year trends in clinical outcomes such as death, cardiac death, myocardial infarction, target lesion revascularization (TLR) and stent thrombosis at one and five years after the index procedure. The sensitivity analysis was performed by limiting to 20 all comer trials. In the meta-regression analysis, we did not observe significant change in the incidences of cardiac death and myocardial infarction after PCI over 20 years (P values for cardiac death: 0.666 at one year, 0.256 at five years and P values for myocardial infarction: 0.121 at one year, 0.376 at five years; R2 for cardiac death: <0.01 at one year and five years and R2 for myocardial infarction: <0.01 at one year and five years), whereas the incidences of clinically indicated TLR (P value <0.001, R2 = 0.40 at one year, P value = 0.002, R2 = 0.22 at five years) and stent thrombosis were decreased steeply in the first decade and slightly in the second decade (P value = 0.040, R2 = 0.09 at one year; P value = 0.017, R2 = 0.17 at five year). The sencitivity analysis limiting all-comer population revealed the consistent results.

Conclusion

The development of PCI had an impact on the 20-year trends in TLR and ST, despite there were no trends in the cardiac death and myocardial infarction.

Trends in the incidence of the outcomes

Funding Acknowledgement

Type of funding source: None

P1643An exploratory analysis for the optimal monitoring interval of N-terminal pro-B-type natriuretic peptide in patients with stable heart failure

Background

N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a potential biomarker for monitoring the status of heart failure. However, the optimal monitoring interval is unknown. This study aims to investigate minimal informative monitoring interval of NT-proBNP in patients with stable chronic heart failure.

Methods

In this retrospective open cohort study, adult patients followed up at a tertiary hospital for chronic heart failure with NT-proBNP measurements were included if they had been previously admitted due to acute heart failure and were free from readmission over 6 months after discharge. We analyzed NT-proBNP measured between 6 months after discharge and the timepoint of an alteration of medication regimen or readmission due to worsening of heart failure. To distinguish actual progression of the disease from biological variability and measurement error, the signal-to-noise ratio method was applied with a random-effects model. Stratified analysis was performed according to underlying risks.

Results

In this analysis, 368 patients were included with NT-proBNP measured between July 2009 and December 2017. The patients had 6.0 times of NT-proBNP measurements in median (interquartile range [IQR] 4.0–10.0) during the follow-up period (median 12.0 months [IQR 6.0–27.0]). In the estimates of the random-effects model, signal (i.e. actual progression of the disease) exceeded noise (i.e. biological variability and measurement error) at 8.1 months (95% confidence interval [CI]: 5.7–10.1) after the index measurement. In a subgroup analysis according to the AHEAD risk score, the minimal informative monitoring interval was shortened as the risk score increased (0–1 point: 12.3 months [95% CI: 10.3–14.5]; 2–3 points: 8.0 months [95% CI: 6.8–9.7]; 4–5 points: 3.3 months [95% CI: 3.0–3.8]; Figure).

Informative intervals stratified by risk

Conclusion

In patients with stable chronic heart failure, the overall minimal informative monitoring interval of NT-proBNP measurement was 8.1 months, which varies by underlying risk. The optimal monitoring interval could be lengthened especially for patients at lower risk.

Participation of elderly patients in registration trials for oncology drug applications in Japan

BACKGROUND

The objective of this study was to evaluate the age-based enrollment of cancer patients into registration trials of new drug applications or expanding the indications for use.

MATERIALS AND METHODS

The data from 234 registration trials in Japan and overseas of 43 drugs, which were reviewed by the Pharmaceuticals and Medical Devices Agency and approved by the Ministry of Health, Labour and Welfare in Japan between 1999 and 2008, were retrospectively analyzed according to the age distribution of enrolled patients. The age distribution of the Japanese cancer population was derived from Cancer Statistics in Japan 2003 and Annual Report on Health, Labour and Welfare 2003-2004.

RESULTS

In the Japanese cancer population, the estimated median age of cancer patients is 70 years, and 66% of cancer patients are aged 65 years or more. The estimated median age of cancer patients in all registration trials conducted in Japan was 59 years, whereas it was 55 years in the registration trials conducted overseas. The proportion of patients aged 65 years or more enrolled in registration trials conducted in Japan was 35%; this number was 28% in registration trials conducted overseas.

CONCLUSION

Elderly patients are underrepresented in oncology registration trials in Japan.

Limited balloon expansion through the struts of the Palmaz-Schatz and NIR stents compared with the Multi-Link stent

After placing a stent in the main vessel of a bifurcation lesion, it is sometimes necessary to perform further balloon inflation in order to treat an ostial lesion in a side branch. The stent struts may prevent full balloon expansion at the ostium of a side branch, resulting in residual ostial stenosis. The degree of completeness of balloon inflation may vary significantly depending on the stent design and structure. A model of a bifurcation lesion with an angle of 45 degrees was created from acrylic resin. The diameters of the main vessel and the side branch were both 3.5 mm. Deployment of the Palmaz-Schatz stent (n=5), NIR stent (n=5) or Multi-Link stent (n=5) was performed in the main vessel with a 3.5-mm balloon catheter inflated to 12 atm. A 3.5-mm balloon catheter was then inflated to 12 atm through the stent struts of the main vessel and into the ostium of the side branch. The degree of completeness of balloon inflation (% balloon expansion) was calculated as (smallest diameter of balloon catheter/reference diameter of balloon catheter) x 100%. The minimal lumen diameter (MLD) and cross-sectional area (CSA) at the ostium of the side branch created with the stent struts were also measured. Limited balloon expansion through the struts was observed with the Palmaz-Schatz stent and the NIR stent, but almost full balloon expansion was observed with the Multi-Link stent (% balloon expansion: Palmaz-Schatz stent 80%, NIR stent 60%, Multi-Link stent 94%, p<0.01). The MLD and CSA of the dilated struts, representing the ostium of the side branch, of the Palmaz-Schatz stent (2.2+/-0.1 mm, 4.5+/-0.3 mm2) and the NIR stent (1.8+/-0.1 mm, 3.1+/-0.3 mm2) were significantly smaller compared with those of the Multi-Link stent (3.0+/-0.2 mm, 8.4+/-0.6 mm2) (p<0.01). The struts of the Palmaz-Schatz stent and the NIR stent deployed in the main vessel of a bifurcation prevent full expansion of a balloon catheter inflated at the side branch ostium. In contrast, almost full balloon expansion through the struts of the Multi-Link stent is achieved.

Descending aorta wall volume and coronary artery disease: a comparative study using enhanced computed tomography of the chest and coronary angiography

The study examined the association between aortic wall volume (AWV) detected by enhanced computed tomography and coronary artery atherosclerosis observed on angiography. In 180 cases, AWV was measured as the total wall volume of a 7-cm portion of the descending thoracic aorta distal from the tracheal bifurcation. Coronary artery atherosclerosis was angiographically quantified by both Gensini score, in terms of the severity of coronary artery stenosis, and Extent score, in terms of the severity of coronary artery involvement. Mean AWV values between the patients with significant coronary artery stenosis and those without significant stenosis were 9.83+/-4.04 cm3 and 8.09+/-2.39 cm3, respectively (p<0.001). AWV was a significantly independent variable for significant coronary artery disease (p=0.0097) and an Extent score > or = 60 (p=0.0092). Calcification of AWV, however, was not associated with coronary atherosclerosis. The quantification of aortic atherosclerosis was useful for diagnosing coronary artery disease.

Tissue characterization of atherosclerotic plaques by intravascular ultrasound radiofrequency signal analysis: an in vitro study of human coronary arteries

BACKGROUND

Conventional gray-scale images of intravascular ultrasound (IVUS) cannot accurately differentiate histologic subtypes of sonolucent coronary plaques with or without a lipid core.

METHODS

We analyzed radiofrequency signals obtained in vitro from 24 regions of interest (ROI) of noncalcified (sonolucent) plaques in 10 atherosclerotic coronary artery specimens pressure-fixed by formalin. Radiofrequency signals were sampled with a 30-MHz IVUS catheter and digitized at 500 MHz in 8-bit resolution. The ROIs were histologically categorized into 12 plaques with a lipid core and 12 plaques without it. Integrated backscatter and statistical parameters of the radiofrequency envelope (mean/SD ratio [MSR], skewness, and kurtosis) within the ROI were calculated offline, and their ability to detect a lipid core was compared with visual analysis of the IVUS video images. In the group with lipid cores, percent area of a lipid core in each ROI was measured in a digitized histologic image by a computerized planimeter.

RESULTS

Sensitivity and specificity of MSR, skewness, and kurtosis for lipid core detection were substantially greater than visual video image analysis (83.3% and 91.7%, 100% and 91.7%, 100% and 91.7% vs 53.3% and 71.7%). Furthermore, the parameters of integrated backscatter, MSR, skewness, and kurtosis were significantly correlated to percent of core area (r = -0.64, -0.73, 0.78, and 0.63, respectively; P<.05).

CONCLUSIONS

Compared with IVUS video images, the parameters of radiofrequency signal analysis may be used to aid in more accurate detection and quantitative evaluation of a lipid core, which is one of the major factors of a vulnerable coronary plaque.

Activation of coagulation in C57BL/6 mice given verotoxin 2 (VT2) and the effect of co-administration of LPS with VT2

To obtain better insight into the pathogenesis of verotoxin-producing Escherichia coli-associated diseases, in this study, we explored the effect of verotoxin 2 (VT2) on coagulation in an animal model. After being given VT2 (50 ng/kg, lethal dose), C57BL/6 mice showed progressively increasing expression of TF mRNA in the kidney and brain and elevated plasma levels of thrombin-antithrombin III complex (TAT), normotest, fibrinogen, and PAI-1 paralleling the disease course over 24 hours; platelet counts were decreased at 48 hours with hemorrhage in the kidney and brain. Co-administration of lipopolysaccharide (LPS, 0.5 mg/kg) with VT2 (50 ng/kg) exhibited more prominant and/or prolonged increase in not only expression of TF and PAI-1 mRNAs in the kidney and brain but also plasma levels of TAT, fibrinogen, and PAI-1 and was associated with more remarkable hemorrhage in the tissues. Although VT2 (5 ng/kg) was not a lethal dose, co-administration of LPS (0.5 mg/kg) with VT2 (5 ng/kg) enhanced the susceptibility to VT2, resulting in more prolonged elevation of TAT levels during the first 24 hours than that in the LPS group and a second elevation at 72 hours, followed by death. Plasma IL-1beta level reached a maximum at 24 hours after VT2 (50 ng/kg) injection prior to the increase in TAT levels, whereas the increase in TNFalpha level immediately after injection was associated with the increase in PAI-1 mRNA. These observations indicate that the activation of coagulation by VT2 may occur through a mechanism different from that used by LPS, since plasma TAT levels rose in the mice immediately after LPS injection and returned to normal over 36 hours.

Cost analysis between stent and conventional balloon angioplasty

The present study evaluated the cost of coronary stenting compared with conventional balloon angioplasty in Japan. Procedural cost was estimated as the sum of the procedural fee and the cost of devices such as angioplasty balloon and stent. The data such as the number of balloon catheters and stents used, and the rate of crossovers that was shown by the Stent Restenosis Study (STRESS) were applied to calculate the costs of stenting and conventional balloon angioplasty. For the estimation of hospital room and nursing costs, the length of the in-hospital stay was estimated at 7 days. The costs of procedures such as laboratory and radiological tests were determined based on routine coronary intervention at Chiba University Hospital. The rates of target lesion revascularization in the STRESS trial (conventional balloon angioplasty: 21%, stenting: 15%) were used to calculate the cost during follow up. The in-hospital costs of conventional balloon angioplasty and stenting were estimated to be Yens 982,300 and Yens 1,416,893, respectively. The overall costs, including follow-up cost, of conventional balloon angioplasty and stenting were estimated to be Yens 1,188,583 and Yens 1,564,238, respectively. The in-hospital cost of stenting is higher compared with conventional balloon angioplasty because of greater balloon use and direct stent cost. Lower target lesion revascularization reduces the cost difference between conventional balloon angioplasty and stenting, but the higher initial cost of stenting is not fully offset.

Feasibility of in vivo intravascular ultrasound tissue characterization in the detection of early vascular transplant rejection

BACKGROUND

Unprocessed ultrasound radiofrequency (RF) signal analysis has been shown to distinguish different tissue structures more reliably than gray-scale interpretation of conventional ultrasound images.

METHODS AND RESULTS

The objective of this study was to test the feasibility of in vivo intravascular ultrasound (IVUS) RF signal analysis in an animal model of allograft rejection. Six cynomolgus monkeys underwent transplantation of 3-cm aortic allograft segments distal to the renal arteries from immunologically mismatched donors. IVUS imaging with a 30-MHz system was performed 84 to 105 days after the operation. RF signals were acquired from cross sections of the recipient and the allograft aortas in real time with a digitizer at 500 MHz with 8-bit resolution. Sixty-five cross sections and 68 regions of interest (31 in host aorta and 37 in allograft) were analyzed in the adventitial layer with a total number of 8568 vectors processed. For each region of interest, a weighted-average attenuation was calculated on the basis of the attenuation and length for each individual vector. Histological examination was performed at every cross section imaged by IVUS. When the gray-scale images of conventional IVUS scored by an independent observer were compared, no distinction between adventitia of the native aorta and allograft was possible. Analysis of the average RF backscatter power also showed no significant difference (70.32+/-3.55 versus 70.72+/-3.38 dB). However, the average attenuation of allografts was significantly lower than that of the host aortas (2.64+/-1.38 versus 4.02+/-1.16 dB/mm, P<0.001). Histology demonstrated a marked adventitial inflammatory response in all allografts, with no inflammation observed in the host aortas.

CONCLUSIONS

In vivo IVUS tissue characterization can be performed during routine imaging. In this model of transplant vasculopathy, RF attenuation measurements were more sensitive than visual or quantitative gray-scale analysis.

Purification, identification, and cDNA cloning of Cha o 2, the second major allergen of Japanese cypress pollen

The second major allergen of Chamaecyparis obtusa (Japanese cypress) pollen, Cha o 2, has been purified and its cDNA cloned. Of patients with pollinosis caused by C. obtusa, 82.5% produce IgE antibodies which react with purified Cha o 2. The purified protein has a molecular mass of 46 kDa and its 12 N-terminal amino acid sequence displays a high homology with that of Cry j 2, the second major allergen of Cryptomeria japonica pollen. cDNA clones coding for Cha o 2 have been isolated using Cry j 2 cDNA as a probe. Cha o 2 cDNA clones were sequenced and found to code a putative 50-residue signal sequence and a 464-residue mature protein with a molecular weight of 50 kDa. Two possible N-linked glycosylation sites were found in the sequence. The deduced amino acid sequence of Cha o 2 shows 74.3% identity with that of Cry j 2. In its primary structure, Cha o 2 shows significant identity with those of the polygalacturonases of avocado, tomato, and maize as well as Cry j 2.

Peptide specificity, HLA class II restriction, and T-cell subsets of the T-cell clones specific to either Cry j 1 or Cry j 2, the major allergens of Japanese cedar (Cryptomeria japonica) pollen

BACKGROUND

Cry j 1 and Cry j 2 are thought to be the major allergens of Japanese cedar pollen. HLA class II types capable of presenting T-cell epitopes in both allergens and their role in induction of T-cell subsets are not well known.

METHODS

CD4+ T (Th)-cell clones (TCCs) specific to either Cry j 1 or Cry j 2 were generated. HLA class II restrictions were determined by their reactivity to the T-cell epitope in the presence of antigen presenting cells sharing matched types. Interleukin (IL)-2, interferon-gamma, IL-4, and IL-5 contents in the supernatants of TCCs were estimated using enzyme immunoassay.

RESULTS

Peripheral blood mononuclear cells (PBMC) from patients induced proliferation with 100 microgram/ml Cry j 1 or 3-10 microgram/ml rCry j 2 stimulation. T-cell epitopes in Cry j 1 were presented to Th cells by the gene products of DRA1*01/DRB1*0901, DRA1*01/DRB5*0101, DQA1* 0102/DQB1*0602, and DPA1*01/DPB1*0501; those in Cry j 2 were restricted by DRA1*01/DRB1*0901, DRA1* 01/DRB1*1501, DRA1*01/DRB4*01, DRA1*01/DRB5* 0101, DQA1*0102/DQB1*0602, DPA1*01/DPB1*0201, and DPA1*01 and *0202/DPB1*0501. Type 2-like cells were preferentially induced in Cry j 1 stimulation, while an almost equal number of type 2- and type 1-like cells was induced in rCry j 2.

CONCLUSIONS

No clear correlation existed between peptide specificity, HLA class II restriction and induction of Th-cell subsets, suggesting that the requirement of different dose of Cry j 1 or Cry j 2 to induce proliferation in PBMC may lead to distinguishable difference in induction of Th subsets between TCCs specific to Cry j 1 and Cry j 2.

The progression of thrombus in an ex-vivo shunt model evaluated by intravascular ultrasound radiofrequency analysis

We tested the ability of ultrasound radiofrequency (RF) signal analysis to characterize thrombus accumulation in a Dacron graft incorporated into the exteriorized arteriovenous shunt in 3 baboons with constant blood flow for 60 min. Thrombus formation was quantified by sequential measurements of 111Indium-labeled platelet deposition. RF signals were acquired every 15 min at 2 sites in the graft, using a 2.9 Fr intravascular ultrasound catheter-based transducer (30 MHz) and digitized at 250 MHz in 8-bit resolution. Regions of interest were placed within a 0.5-mm perimeter adjacent to the graft wall. Integrated backscatter increased significantly (p < 0.001) with increasing platelet deposition. However, mean-to-standard deviation ratio of the RF envelope showed no significant change and the distribution pattern of the RF probability function remained constant and consistent with a Rayleigh scattering process. These results provide a basis for using RF analysis to monitor the time-course of thrombus formation.

[Value of intravascular ultrasound and angioscopy for diagnosis and prediction of acute coronary syndrome]

The new catheter-based imaging modalities of intravascular ultrasound(IVUS) and angioscopy(AS) can provide with morphologic information within a vessel wall or on an intimal surface of coronary artery, which cannot be clarified by conventional angiography. They could demonstrate some evidences of coronary plaque rupture after the onset of acute coronary syndrome (ACS). IVUS showed an intimal flap and an echolucent area behind it, which might represent a fibrous cap and a lipid core, respectively. Also, AS revealed an intimal tear in various grades. IVUS and AS may contribute to detect a "vulnerable coronary plaque." Both findings of an eccentric fibrofatty plaque, sometimes with an echolucent area, demonstrated by IVUS and a yellow plaque revealed by AS may be valuable for prediction of the plaque rupture preceding ACS.

[Relationship between evolution of ischemic heart disease and changes in lipid profile]

The relationship between the evolution of ischemic heart disease and changes in lipid profile was investigated in 115 of 11,875 patients underwent coronary angiography (CAG). The 115 patients had no significant stenosis on initial CAG and underwent repeat CAG for several reasons. Changes in lipid profile and other coronary risk factors were compared in 30 patients who developed ischemic cardiac events (Group E) and 85 patients who did not (Group NE). Ischemic cardiac events were defined as ischemic chest symptoms with ST-T changes or appearance of significant angiographic stenosis. At initial CAG, smoking was significantly more common in Group E (23.3% vs 4.7%, p < 0.01) and high-density lipoprotein cholesterol was significantly lower in Group E (42 +/- 11 vs 48 +/- 15 mg/dl, p < 0.05). At repeat CAG, smoking continued to be significantly more common in Group E (26.7% vs 10.6%, p < 0.05), and serum cholesterol (219 +/- 36 vs 193 +/- 34 mg/dl, p < 0.01) and low-density lipoprotein cholesterol (141 +/- 33 vs 115 +/- 29 mg/dl, p < 0.01) were also significantly higher in Group E. Multivariate analysis revealed only the increase of serum cholesterol at repeat CAG was a significant factor in the evolution of coronary artery disease (p = 0.026). Two patients from Group E died of cardiac causes within 1 year after repeat CAG but no patients in Group NE died (6.7% vs 0%, p < 0.05). Increased serum cholesterol level is related to the evolution of ischemic heart disease and cardiac death.

[Assessment of saphenous vein graft wall characteristics with intravascular ultrasound imaging]

The wall characteristics of saphenous vein grafts (SVGs) after coronary artery bypass grafting (CABG) were assessed with intravascular ultrasound (IVUS) imaging. Twenty-seven SVGs in 25 patients who had undergone CABG were studied with IVUS in vivo. Ten SVGs excised from 6 patients who had undergone reoperation were studied with IVUS in vitro. The results were compared with the histopathologic findings. IVUS images of four SVGs studied within 1 month after CABG showed a thin and single-layer structure, which was almost identical to the IVUS features of a normal, fresh SVG. In five SVGs studied between 3 months and 1 year after CABG, the wall thickness was increased, and there were hypoechoic areas. In sixteen SVGs studied more than 2 years after CABG, two patterns were noted on IVUS imaging. One pattern was a triple-layer structure of alternating hyperechoic, hypoechoic, and hyperechoic bands seen in the angiographically normal sections of the SVGs. The second pattern was a heterogeneous, echogenic monolayer found in the angiographically irregular and diseased sections of the SVGs. Comparison of the in vitro IVUS images with the histopathology of the SVGs showed a strong correlation between the triple-layer structure and fibrointimal proliferation, and between the heterogeneous monolayer and atherosclerosis. In conclusion, IVUS is useful for assessing SVGs and for long-term qualitative monitoring of vein graft disease after CABG.

T cell epitopes in Japanese cedar (Cryptomeria japonica) pollen allergens: choice of major T cell epitopes in Cry j 1 and Cry j 2 toward design of the peptide-based immunotherapeutics for the management of Japanese cedar pollinosis

Japanese cedar pollinosis is caused by exposure to Japanese cedar (Cryptomeria japonica) pollen, of which two components, Cry j 1 and Cry j 2, are believed to be the major allergens. T cell lines specific to either Cry j 1 or rCry j 2 were reactive to various portions of each panel of overlapping peptides derived from Cry j 1 or Cry j 2. Two peptides, p211-225 and p108-120, from among six major T cell epitopes identified in Cry j 1 sequence, and three peptides, p182-200, p344-355, and p66-80, from among five in Cry j 2, were chosen to design an artificial polypeptide (named Cry-consensus) based on a difference among the types of the restriction molecules capable of presenting these peptides. After construction of a DNA encoding these peptides in order, Cry-consensus was expressed in Escherichia coli. Five of six T cell epitopes, except for Cry j 2 p344-355, in Cry-consensus were recognized by the T cell clones specific to each peptide. PBMC from allergic patients induced higher proliferation under stimulation from Cry-consensus than individual peptides. Eighty-eight percent of the PBMC (15 of 17) showed proliferation under the Cry-consensus stimulation. Thus, several major T cell epitopes from Cry j 1 and Cry j 2 can be chosen in the design of peptide-based immunotherapeutics for the management of Japanese cedar pollinosis in subjects having various types of HLA class II molecules.

Long-term outcome in triple-vessel coronary artery disease in medically treated Japanese patients

The long-term outcome in 198 patients with triple-vessel disease (TVD) treated medically was investigated. The patients, who underwent coronary angiography between September 1973 and February 1984, had significant (75% or more) stenotic lesions in all three major coronary arteries. The mean follow-up period was 8.4 years. The 5- and 10-year survival rates were 80.7% and 64.2%, respectively. Cardiac death occurred in 73 patients (36.9%) and nonfatal cardiac events developed in 60 patients (30.9%) during follow-up. When cardiac death and nonfatal myocardial infarction (MI) were defined as cardiac events, the annual attrition rate was 4.7%. There was no difference in survival with regard to the presence or absence of MI, the site of infarction, or the presence of total occlusion. In the AP group, however, the survival rate decreased as the number of totally-occluded arteries increased. In the MI group, the survival rate was not altered by the number of totally-occluded arteries, but was affected by the ejection fraction (EF). The 5-year survival rate was better in patients with good left ventricular function (EF > or = 60%) than in those with impaired left ventricular function (EF < 60%), although the 10-year survival rate was similarly low in both groups. Revascularization such as PTCA or CABG might improve the long-term outcome in patients with TVD.

Comparison of regional myocardial technetium-99m-MIBI uptake between ECG-gated and ungated SPECT imaging

Technetium-99m-MIBI uptake was compared between ECG-gated and ungated SPECT images in 10 normal subjects and 10 patients with coronary artery disease to investigate the effects of wall motion on regional myocardial uptake.

METHODS

Left ventricular ejection fraction (LVEF) and wall motion were evaluated using the first-pass data acquired immediately after injection of 1110 MBq 99mTc-MIBI. A transaxial ungated image was reconstructed with cumulative data during a cardiac cycle. For transaxial gated images, data during a cardiac cycle were divided into eight frames and the first seven frames were used. The lateral/septal ratios for ungated and gated images were obtained using the counts in the ROIs drawn in the lateral and the septal walls.

RESULTS

In 10 normal subjects, the lateral/septal ratio for gated increased during end-systole. The mean of the lateral/septal ratio was significantly lower for ungated than for gated (1.025 vs. 1.077, p < 0.05). In patients with septal wall asynergy and a normokinetic lateral wall, the mean of the lateral/septal ratios was significantly lower for ungated than for gated (1.267 vs. 1.325, p < 0.01).

CONCLUSION

Ungated SPECT acquisition may underestimate regional myocardial uptake when myocardial wall motion is good, therefore, ECG-gated data should be acquired for accurate assessment of regional myocardial uptake of 99mTc-MIBI.

Redifferentiation of smooth muscle cells after coronary angioplasty determined via myosin heavy chain expression

BACKGROUND

The pathophysiology of phenotypic modulation of smooth muscle cells (SMCs) involved in restenosis after angioplasty is not well understood. Smooth muscle myosin heavy chain (SM MHC) isoforms (SM1 and SM2) are specific markers for SMC differentiation. In particular, SM2 is useful as a marker of mature SMCs. SMemb is a nonmuscle myosin heavy chain (NM MHC) whose expression is upregulated in immature or activated SMC.

METHODS AND RESULTS

To determine SMC phenotypes in neointimal tissues after percutaneous transluminal coronary angioplasty (PTCA), we performed immunohistochemistry on human coronary arteries with antibodies against alpha-SM actin, SM1, SM2, and SMemb. Tissues were obtained from six autopsied patients and from atherectomy specimens from 16 patients who had undergone PTCA. Medial SMCs were positive for alpha-actin, SM1, and SM2. Expression of SM1 and SM2 in the neointima varied with the time after intervention, whereas alpha-actin was constitutively expressed in all cases studied. Neointimal cells at 16 and 20 days after PTCA contained alpha-actin but little or no SM1 or SM2, indicating that these cells modulated their phenotype to the immature state. Neointimal SMCs recovered SM MHC expression, first SM1 and then SM2, by 6 months after PTCA. Increased expression of SMemb was found in the neointima but without apparent relationship to the time after PTCA.

CONCLUSIONS

Neointimal SMCs show features of an undifferentiated state, indicated by altered expression of SM MHC, and undergo redifferentiation in a time-dependent manner. The expression of SM MHC isoforms provides insight into the biology of healing after angioplasty and furnishes useful tools for the understanding of the roles of differentiation and phenotypic modulation of SMCs in human vascular lesions.

Long-term outcome in double-vessel coronary artery disease in Japanese patients

The long-term (average: 10 years) outcome in 220 patients with double-vessel disease (DVD) treated medically was investigated. The patients underwent coronary angiography between September 1973 and February 1984, and significant (75% or more) stenosis was detected in each of two major coronary arteries. These patients showed relatively good 5-year and 10-year survival rates of 94.5% and 87.4%, respectively. Cardiac death occurred in 31 patients (14.1%) and nonfatal myocardial infarction (MI) developed in 16 patients (7.3%) during follow-up. When these were defined as cardiac events, the annual attrition rate was 3.1%. A comparison of the outcome with regard to the presence or absence of MI revealed worse results for the MI group, but no difference was observed between different sites of infarction. There was also no difference in outcome with regard to the presence or absence of lesions in the left anterior descending artery (LAD). In the MI group, patients with impaired left ventricular function (ejection fraction < or = 40%) had inferior survival to those with good left ventricular function. Thus, DVD associated with good left ventricular function had a relatively good outcome when treated medically, while patients with impaired left ventricular function might benefit from revascularization.

A hemoglobin-based blood substitute: transplanting a novel allosteric effect of crocodile Hb

Recombinant DNA technology has enabled the large scale production of human hemoglobin in bacteria and yeast. This has opened up a way to produce a hemoglobin-based blood substitute which could replace conventional blood transfusion in some situations. Using our understanding of the structure-function relationships and evolutionary history of hemoglobin it has been possible to improve the oxygen transport properties of the molecule and solve a number of problems associated with the use of natural hemoglobin as a cell-free blood substitute.

[Long-term recovery of regional wall motion in patients with medically treated anterior myocardial infarction: quantitative assessment of the post-infarction left ventriculograms]

The effect of medical treatment without reperfusion therapy on the long-term recovery of regional wall motion was evaluated retrospectively in 28 patients with transmural acute anterior myocardial infarction who had coronary angiography and left ventriculography at 1-6 months after the onset of the episode and were followed for a mean of 65 months. In all patients, initial coronary angiography revealed significant stenosis in only the left anterior descending artery (LAD). All patients were treated medically without reperfusion therapy (such as thrombolytic therapy, angioplasty, or bypass grafting). The regional wall motion in the LAD territory was measured by the centerline method using the right anterior oblique projection. Long-term improvement in anterior wall motion is unlikely in patients with patent LAD or underdeveloped collaterals to the LAD (38%). However, subsequent anterior wall motion frequently improved among patients with severely stenotic or occluded LAD (63%) and well-developed collaterals (73%). Therefore, the anterior wall motion of some LAD-related infarctions improves spontaneously, the extent of coronary collaterals is an important determinant of long-term improvement, and the improvement in wall motion is completed within the early period of acute anterior infarction in patients with patent LAD.

Intravascular imaging of serial changes of disease in saphenous vein grafts after coronary artery bypass grafting

To clarify the structural changes of saphenous vein grafts after coronary artery bypass grafting, intravascular ultrasound and angioscopic images were obtained from 23 grafts in vivo and 5 grafts and 3 new veins in vitro; the images were compared with histologic findings. Intravascular ultrasound demonstrated a single-layered appearance at new veins and all of the angiographically normal grafts within 6 months after surgery. A triple-layered appearance that might be related to the remarkably proliferative and degenerated intima was revealed histologically at 73.3% of the normal sites of grafts between 5 and 10 years after operation. In 83.3% of the stenoses at several years after operation, angioscopy showed yellow atheromatous plaques, often with a friable surface; a heterogeneous, lucent echo pattern was revealed on intravascular ultrasound. Thus intravascular ultrasound and angioscopy may be used to identify the morphologic changes of graft at different points after implantation more precisely than conventional angiography.

Japanese cedar pollinosis and HLA-DP5

Japanese cedar pollinosis is a type I allergic disease caused by Japanese cedar (Cryptomeria japonica) pollen. We investigated the association between the disease and HLA class II alleles by HLA-DNA typing using a PCR-SSOP method and found that the frequency of HLA-DP5 (DPA1*02022 and DPB1*0501) was significantly increased in the patients. To investigate whether the HLA-DP5 molecule is directly involved in the pathogenesis of the disease, Japanese cedar pollen antigen (CPAg)-specific T cell lines were established from 3 patients who possessed HLA-DP5 (DPA1*02022/ DPB1*0501). By using these CPAg-specific T cell lines and HLA class II-expressing L-cell transfectants, we found that disease-associated HLA-DP5 restricted T cells specific for CPAg existed in the patients. Furthermore, among 38 synthesized overlapping peptides spanning the entire length of one of the major Japanese cedar pollen allergens, Cry j 1, an immunodominant peptide which induced HLA-DP5 restricted Th2 was identified. These observations suggest that the HLA-DP5 may be involved, at least in part, in the pathogenesis, by helping the IgE antibody production against CPAg.

Long-term outcome in single-vessel coronary artery disease in Japanese patients

We assessed the long-term outcome of medical therapy in 453 patients who underwent coronary angiography in the period from September 1973 to February 1984, and who had a significant stenotic lesion (75% or more stenosis) in a single coronary artery. The mean follow-up period was 9.8 years. The 5- and 10-year survival rates were, respectively, 96.0% and 91.3% in these patients, and these survival rates were comparable to the cumulative survival rates in the age-matched healthy male controls determined on the basis of overall death. Cardiac death occurred in 35/453 patients (7.7%) with single-vessel disease (SVD), and non-fatal myocardial infarction occurred in 17 patients (3.8%) during the follow-up period. The incidence of cardiac events, which was defined as cardiac death and nonfatal myocardial infarction, was as low as 1.2% per year. The survival rates were compared in terms of the presence or absence of myocardial infarction, the type of the coronary artery with stenosis, and proximal versus distal location of the stenotic lesion in the left anterior descending artery (LAD). The survival rates were similarly high in both assessed groups, with no significant differences. Patients with SVD treated medically had a good prognosis, except for those patients with decreased left ventricular function (ejection fraction < or = 40%). These factors should be taken into consideration when selecting therapies for patients with SVD.

Purification, characterization and molecular cloning of Cha o 1, a major allergen of Chamaecyparis obtusa (Japanese cypress) pollen

Pollen of Chamaecyparis obtusa (Japanese cypress) is one of the causes of allergic pollinosis in Japan. A major allergen of the pollen designated Cha o 1, was purified by two-step ion exchange chromatography. Cha o 1 was separated into four components with molecular masses of 48.5 kDa and 52.0 kDa, each with pIs of 6.77 and 6.82. The 23-residue N-terminal sequence of Cha o 1 was determined and shown to have high identity with that of Cry j 1, a major allergen of Cryptomeria japonica pollen. cDNA coding for Cha o 1 was cloned by hybridization screening using Cry j 1 cDNA as a probe. One of the cDNA clones, pCHA-1 was sequenced and found to code for a putative 21-residue signal peptide and a 354-residue native protein with a derived molecular mass of 38.1 kDa. The deduced amino acid sequence of Cha o 1 showed 79-80% identity with those of Cry j 1. These findings were consistent with observations of a close crossreaction between the two allergens. Homology analyses revealed that Cha o 1 had 46-49% identity with Amb a 1 families and Amb a 2, the major allergens of short ragweed. Cry j 1 has pectate lyase enzyme activity, suggesting that Cha o 1 may have the same enzyme activity as Cry j 1.

Comparison of long-term efficacy of medical treatment versus coronary artery bypass grafting (CABG) in multivessel coronary artery disease

The long-term results of medical therapy and coronary artery bypass grafting (CABG) were compared in patients with multivessel disease. All patients were confirmed to have > or = 75% luminal narrowing of major coronary arteries by coronary arteriogram. When multivessel disease was stratified into double- and triple- vessel disease, the outcomes varied. In triple-vessel disease, the outcome with CABG was good, but the outcome was unfavorable in those employing medical therapy, particularly in patients with decreased left ventricular (LV) function. In patients with double-vessel disease with good LV function, the long-term results with medical therapy were just as favorable as those with CABG. However, double-vessel disease complicated by reduced LV function (ejection faction < or = 40%) had a clearly less favorable outcome when treated with medical therapy than with CABG. Thus, it is important for patients with multivessel disease to undergo revascularization if indicated, to improve their prognosis. On the other hand, the incidence of cardiac events arising from vein graft occlusions tended to increase in CABG patients after 5 years or more following surgery.

Comparison of long-term efficacy of medical treatment versus percutaneous transluminal coronary angioplasty (PTCA) in single-vessel disease

The long-term outcome of PTCA and medical therapy were compared in patients with SVD. All patients were confirmed to have > or - 75% stenosis of a major coronary artery by coronary arteriogram. The 5-year survival rates were 96.0% for medical therapy and 98.9% for successful angioplasty. Both therapies achieved an equally good long-term outcome for SVD. The incidence of nonfatal cardiac events during follow-up was higher in patients treated by PTCA than in those on medical therapy, but there was no difference between the two groups in the incidence of nonfatal MI at 5 years (2.5% vs 1.8%). The most common cardiac event in patients undergoing successful PTCA was repeat intervention associated with restenosis. In view of the long-term efficacy of PTCA, the high restenosis rate remains an important problem and it is necessary to elucidate the causes of restenosis and develop countermeasures as soon as possible.

cDNA cloning and expression of Cry j II the second major allergen of Japanese cedar pollen

We have isolated and sequenced a cDNA clone coding for Cry j II, the second major allergen of Japanese cedar (Cryptomeria japonica) pollen. A 1.7-kilobase cDNA clone contained an open reading frame coding for a 514-amino acid protein, including a putative signal peptide of 54 amino acid and three potential glycosylation sites. The deduced amino acid sequence of the Cry j II shows significant identities to those of the polygalacturonases associated with fruit-ripening in tomato (40%) and avocado (43%) and found in pollen of maize (34%). Cry j II cDNA product expressed in E. coli was recognized by human IgE from patients suffering from cedar pollinosis, suggesting that recombinant Cry j II might be used as an allergen for the clinical diagnosis of cedar pollinosis.

Cloning and sequencing of cDNA coding for Cry j I, a major allergen of Japanese cedar pollen

cDNA clones coding for Cry j I, a major allergen of the Japanese cedar (Cryptomeria japonica) pollen, have been isolated. Two of the clones were sequenced and found to code for a putative 21-residue signal peptide and a 353-residue mature protein with a derived molecular weight of 38.5 KDa. Five possible N-linked glycosylation sites were found in the sequence. Comparison of the nucleotide sequences of the two clones revealed sixteen nucleotide differences and these led to five amino acid exchanges in the mature allergen, indicating that an isoform of the Cry j I molecule exists. The deduced amino acid sequence of the Cry j I shows 46-48% identities with those of the Amb a I family and Amb a II, the major allergens of short ragweed. These findings should facilitate study of the structure-function relationship between the allergen and the immunocompetent cells.

[ATP radionuclide ventriculography; its usefulness for the evaluation of ischemic heart disease]

To evaluate the usefulness for the detection of ischemic heart disease (IHD), ATP first pass radionuclide ventriculography (RVG) was performed in 10 patients. Coronary angiography was performed in all patients. Among these patients, 2 had single vessel disease, 2 had double vessel disease, 3 had triple vessel disease, and 3 had normal coronary arteries. RVG was performed at rest, then, ATP was infused at the rate of 0.16 mg/kg/min and ATP-RVG was done 4 minutes later. The left ventricular ejection fraction (LVEF) was calculated, and the regional wall motion (RWM) was graded as normal, hypokinesis, akinesis, and dyskinesis. In the patients with coronary artery disease, RWM decreased in 5 of 7 patients and LVEF decreased in 6 of 7 patients by ATP. However, RWM and LVEF did not decrease in the patients with normal coronary arteries. These results suggested that ATP-RVG might provide useful information for the evaluation of IHD.

Biosynthesis of the pradimicin family of antibiotics. I. Generation and selection of pradimicin-nonproducing mutants

Germinated spores of Actinomadura verrucosospora subsp. neohibisca E-40, a high pradimicins producer, were mutagenized by N-methyl-N'-nitro-N-nitrosoguanidine and/or UV treatment. Thirty-seven mutants which did not produce pradimicin were selected to test for cosynthesis ability, and classified into nine classes. On the basis of their cosynthesis ability and bioconversion results, we concluded that strain JN-213 (class III) was a true converter and that strains JN-219 (class IV), JN-47 (class V) and JNU-46 (class VI) were secretors accumulating biosynthetic intermediates of pradimicin, and that strains JN-59 (class VII), JN-58 (class VIII) and JN-207 (class IX) were producers of shunt metabolites of pradimicin biosynthesis. TLC and HPLC analyses of the fermentation broths of individual strains showed that 8 new compounds were produced along with pradinone I, pradimicinone I, 11-O-demethylpradimicinone II and 7-O-methylpradimicinone II.

Eurystatins A and B, new prolyl endopeptidase inhibitors. I. Taxonomy, production, isolation and biological activities

Eurystatins A and B, were isolated from the cultured broth of Streptomyces eurythermus R353-21. They showed specific and potent inhibitory activity against prolyl endopeptidase and did not show antimicrobial activity. No lethal toxicity was observed for the two compounds after ip administration in mice at 200 mg/kg.

Lactimidomycin, a new glutarimide group antibiotic. Production, isolation, structure and biological activity

Streptomyces amphibiosporus R310-104 (ATCC 53964) produced a novel antibiotic lactimidomycin which showed inhibitory activity against fungi and prolonged the survival time of mice transplanted with experimental tumors. Structural studies clarified that lactimidomycin is a new glutarimide antibiotic having a unique unsaturated 12-membered lactone ring.