Atrial fibrillation incidence after coronary artery bypass graft surgery and percutaneous coronary intervention: the prospective AFAF cohort study

Objectives. Atrial fibrillation is a common arrhythmia in patients with ischemic heart disease. This study aimed to determine the cumulative incidence of new-onset atrial fibrillation after percutaneous coronary intervention or coronary artery bypass grafting surgery during 30 days of follow-up. Design. This was a prospective multi-center cohort study on atrial fibrillation incidence following percutaneous coronary intervention or coronary artery bypass grafting for stable angina or non-ST-elevation acute coronary syndrome. Heart rhythm was monitored for 30 days postoperatively by in-hospital telemetry and handheld thumb ECG recordings after discharge were performed. The primary endpoint was the cumulative incidence of atrial fibrillation 30 days after the index procedure. Results. In-hospital atrial fibrillation occurred in 60/123 (49%) coronary artery bypass graft and 0/123 percutaneous coronary intervention patients (p < .001). The cumulative incidence of atrial fibrillation after 30 days was 56% (69/123) of patients undergoing coronary artery bypass grafting and 2% (3/123) of patients undergoing percutaneous coronary intervention (p < .001). CABG was a strong predictor for atrial fibrillation compared to PCI (OR 80.2, 95% CI 18.1-354.9, p < .001). Thromboembolic stroke occurred in-hospital in one coronary artery bypass graft patient unrelated to atrial fibrillation, and at 30 days in two additional patients, one in each group. There was no mortality. Conclusion. New-onset atrial fibrillation during 30 days of follow-up was rare after percutaneous coronary intervention but common after coronary artery bypass grafting. A prolonged uninterrupted heart rhythm monitoring strategy identified additional patients in both groups with new-onset atrial fibrillation after discharge.

Effects of Remote Ischaemic Conditioning in Stable and Unstable Angina Patients Undergoing Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis

AIM

Type 4a myocardial infarction (T4aMI), defined as myocardial injury associated with percutaneous coronary intervention (PCI), is associated with a poor prognosis and there is conflicting evidence regarding the effectiveness of remote ischaemic conditioning (RIC) in its prevention. This review aimed to determine the effect of RIC on stable and unstable angina patients.

METHOD

A systematic review was conducted in PubMed and Central database. Outcome measures were: changes in peak troponin, creatine kinase myocardial band (CKMB), C-reactive protein (CRP) level, incidence of T4aMI, and major adverse cardiovascular event (MACE). Data were meta-analysed and reported as standardised mean difference (SMD) and odds ratio (OR). Risk of bias was assessed with the Risk of Bias 2 (RoB2) tool.

RESULTS

Fifteen studies with no significant risk of bias were included. Peak troponin level was reduced in the RIC group, particularly after excluding a study with low statin use, while CKMB and CRP levels resulted in a non-significant SMD between the groups. The incidence of T4aMI was significantly lower in the intervention group (OR 0.714; p=0.026); this finding was also seen in subgroups of elective PCI, pre-conditioning, and high statin use. Incidence of MACE also only reached statistically significant protective effects with OR <1 in similar subgroups. No substantial heterogeneity was found and the funnel plot did not show publication bias.

CONCLUSION

Remote ischaemic conditioning in elective PCI patients has been proven to be potentially beneficial in reducing peak troponin levels and risk of T4aMI and MACE.

Feasibility of double-blinded, placebo-controlled interventional study for assessing catheter ablation efficacy in persistent atrial fibrillation: Insights from the ORBITA AF feasibility study

BACKGROUND

To date, there are no randomized, double-blinded clinical trials comparing catheter ablation to DC cardioversion (DCCV) with medical therapy in patients with persistent atrial fibrillation (PersAF). Conducting a large-scale trial to address this question presents considerable challenges, including recruitment, blinding, and implementation. We conducted a pilot study to evaluate the feasibility of conducting a definitive placebo-controlled trial.

METHODS

This prospective trial was carried out at Barts Heart Centre, United Kingdom, employing a randomized, double-blinded, placebo-controlled design. Twenty patients with PersAF (duration <2 years) were recruited, representing 10% of the proposed larger trial as determined by a power calculation. The patients were randomized in a 1:1 ratio to receive either PVI ± DCCV (PVI group) or DCCV + Placebo (DCCV group). The primary endpoint of this feasibility study was to evaluate patient blinding. Patients remained unaware of their treatment allocation until end of study.

RESULTS

During the study, 35% of patients experienced recurrence of PersAF prior to completion of 12 months follow-up. Blinding was successfully maintained amongst both patients and medical staff. The DCCV group had a trend to higher recurrence and repeat procedure rate compared to the PVI group (recurrence of PersAF 60% vs 30%; p = .07 and repeat procedure 70% vs 40%; p = .4). The quality of life experienced by individuals in the PVI group showed improvement, as evidenced by enhanced scores on the AF specific questionnaire (AF PROMS) (3 [±4] vs 21 [±8]) and SF-12 mental-component raw score (51.4 [±7] vs 43.24 [±15]) in patients who maintained sinus rhythm at 12 months.

CONCLUSION

This feasibility study establishes the potential for conducting a blinded, placebo-controlled trial to evaluate the efficacy of PVI versus DCCV in patients with PersAF.

In adults with stable angina, PCI vs. a placebo procedure reduced angina symptoms at 12 wk

SOURCE CITATION

Rajkumar CA, Foley MJ, Ahmed-Jushuf F, et al; ORBITA-2 Investigators. A placebo-controlled trial of percutaneous coronary intervention for stable angina. N Engl J Med. 2023;389:2319-2330. 38015442.

A Placebo-Controlled Trial of Percutaneous Coronary Intervention for Stable Angina

BACKGROUND

Percutaneous coronary intervention (PCI) is frequently performed to reduce the symptoms of stable angina. Whether PCI relieves angina more than a placebo procedure in patients who are not receiving antianginal medication remains unknown.

METHODS

We conducted a double-blind, randomized, placebo-controlled trial of PCI in patients with stable angina. Patients stopped all antianginal medications and underwent a 2-week symptom assessment phase before randomization. Patients were then randomly assigned in a 1:1 ratio to undergo PCI or a placebo procedure and were followed for 12 weeks. The primary end point was the angina symptom score, which was calculated daily on the basis of the number of angina episodes that occurred on a given day, the number of antianginal medications prescribed on that day, and clinical events, including the occurrence of unblinding owing to unacceptable angina or acute coronary syndrome or death. Scores range from 0 to 79, with higher scores indicating worse health status with respect to angina.

RESULTS

A total of 301 patients underwent randomization: 151 to the PCI group and 150 to the placebo group. The mean (±SD) age was 64±9 years, and 79% were men. Ischemia was present in one cardiac territory in 242 patients (80%), in two territories in 52 patients (17%), and in three territories in 7 patients (2%). In the target vessels, the median fractional flow reserve was 0.63 (interquartile range, 0.49 to 0.75), and the median instantaneous wave-free ratio was 0.78 (interquartile range, 0.55 to 0.87). At the 12-week follow-up, the mean angina symptom score was 2.9 in the PCI group and 5.6 in the placebo group (odds ratio, 2.21; 95% confidence interval, 1.41 to 3.47; P<0.001). One patient in the placebo group had unacceptable angina leading to unblinding. Acute coronary syndromes occurred in 4 patients in the PCI group and in 6 patients in the placebo group.

CONCLUSIONS

Among patients with stable angina who were receiving little or no antianginal medication and had objective evidence of ischemia, PCI resulted in a lower angina symptom score than a placebo procedure, indicating a better health status with respect to angina. (Funded by the National Institute for Health and Care Research Imperial Biomedical Research Centre and others; ORBITA-2 ClinicalTrials.gov number, NCT03742050.).

Erroneous Rapid Exchange Balloon Inflation During Coronary Angioplasty in a Male Patient in His 70s With Chronic Stable Angina

This case report discusses an erroneous rapid exchange balloon inflation during coronary angioplasty in a patient who presented with a right coronary artery lesion on angiography.

Paclitaxel drug-coated balloon-only angioplasty for de novo coronary artery disease in elective clinical practice

OBJECTIVE

We aimed to investigate the safety of drug-coated balloon (DCB)-only angioplasty compared to drug-eluting stent (DES), as part of routine clinical practice.

BACKGROUND

The recent BASKETSMALL2 trial demonstrated the safety and efficacy of DCB angioplasty for de novo small vessel disease. Registry data have also demonstrated that DCB angioplasty is safe; however, most of these studies are limited due to long recruitment time and a small number of patients with DCB compared to DES. Therefore, it is unclear if DCB-only strategy is safe to incorporate in routine elective clinical practice.

METHODS

We compared all-cause mortality and major cardiovascular endpoints (MACE), including unplanned target lesion revascularisation (TLR) of all patients treated with DCB or DES for first presentation of stable angina due to de novo coronary artery disease between 1st January 2015 and 15th November 2019. Data were analysed with Cox regression models and cumulative hazard plots.

RESULTS

We present 1237 patients; 544 treated with DCB and 693 treated with DES for de novo, mainly large-vessel coronary artery disease. On multivariable Cox regression analysis, only age and frailty remained significant adverse predictors of all-cause mortality. Univariable, cumulative hazard plots showed no difference between DCB and DES for either all-cause mortality or any of the major cardiovascular endpoints, including unplanned TLR. The results remained unchanged following propensity score-matched analysis.

CONCLUSION

DCB-only angioplasty, for stable angina and predominantly large vessels, is safe compared to DES as part of routine clinical practice, in terms of all-cause mortality and MACE, including unplanned TLR.

Impact of policy alterations on elective percutaneous coronary interventions in Japan

OBJECTIVE

Establishing appropriate percutaneous coronary intervention (PCI) in stable angina pectoris (SAP) has become a distinctive performance measure worldwide. Clinical guidelines call for documenting ischaemia in patients with SAP prior to elective PCI. The Japanese Ministry of Health, Labour and Welfare introduced a new reimbursement policy in April 2018 to promote the appropriate and judicious implementation of PCI. The 2018 reimbursement changes clarified the required proof of ischaemia. Tests to evaluate functional ischaemia and coronary stenosis have been added as a requirement for reimbursement. We examined whether this reimbursement revision had an impact on PCI procedures for SAP in Japan.

METHODS

We used administrative claims data in Japan's Diagnosis Procedure Combination database from April 2014 through March 2020. We used interrupted time series analyses with a control to ascertain the impacts on elective PCI procedures before and after the Japanese reimbursement revision. The primary outcome was the change in elective PCI procedures per month. Emergent PCI procedures served as a control group.

RESULTS

A total of 773 240 PCI procedures were identified between April 2014 and March 2020: 388 817 and 180 462 elective PCIs before and after the reimbursement revision, respectively. After the 2018 reimbursement revision, significant trend changes were found in elective PCI procedures per month (-106.3, 95% CI -155.8 to -56.8, p<0.01), while the number of emergent PCIs remained stable throughout the study period.

CONCLUSIONS

After revising the reimbursement tariff for elective PCIs in 2018, there was a significant reduction in elective PCI procedures per month.

A double-blind randomised placebo-controlled trial of percutaneous coronary intervention for the relief of stable angina without antianginal medications: design and rationale of the ORBITA-2 trial

Percutaneous coronary intervention (PCI) is frequently performed for stable angina. However, the first blinded trial, ORBITA, did not show a placebo-controlled increment in exercise time in patients with single-vessel disease, at 6 weeks, on maximal antianginal therapy. ORBITA-2 will assess the placebo-controlled efficacy of PCI on angina frequency in patients with single- or multivessel disease, at 12 weeks, on no antianginal therapy. ORBITA-2 is a double-blind placebo-controlled trial randomising participants with (i) angina at presentation, (ii) documented angina during the 2-week pre-randomisation symptom assessment phase, (iii) objective evidence of ischaemia, (iv) single- or multivessel disease, and (v) clinical eligibility for PCI. At enrolment, antianginals will be stopped, and angina questionnaires completed. Participants will record their symptoms on a smartphone application daily throughout the trial and will undergo exercise treadmill testing and stress echocardiography at pre-randomisation. They will then undergo coronary angiography with unblinded invasive physiology assessment. Eligible participants will then be sedated to a deep level of conscious sedation and randomised 1:1 between PCI and placebo. After the 12-week blinded follow-up period, they will return for questionnaires, exercise testing and stress echocardiography assessment. If angina becomes intolerable, antianginals will be introduced using a prespecified medication protocol. The primary outcome is an angina symptom score using an ordinal clinical outcome scale for angina. Secondary outcomes include exercise treadmill time, angina frequency, angina severity and quality of life. Trial registration: ClinicalTrials.gov: NCT03742050.

Burden and Predictors of Chest Pain-Related Health-Care Utilization Following Percutaneous Coronary Intervention

Chest pain (CP) has been reported in 20% to 40% of patients 1 year after percutaneous coronary intervention (PCI), though rates of post-PCI health-care utilization (HCU) for CP in nonclinical trial populations are unknown. Furthermore, the contribution of noncardiac factors - such as pulmonary, gastrointestinal, and psychological - to post-PCI CP HCU is unclear. Accordingly, the objectives of this study were to describe long-term trajectories and identify predictors of post-PCI CP-related HCU in real-world patients undergoing PCI for any indication. This retrospective cohort study included patients receiving PCI for any indication from 2003 to 2017 through a single integrated health-care system. Post-PCI CP-related HCU tracked through electronic medical records included (1) office visits, (2) emergency department (ED) visits, and (3) hospital admissions with CP or angina as the primary diagnosis. The strongest predictors of CP-related HCU were identified from >100 candidate variables. Among 6386 patients followed an average of 6.7 years after PCI, 73% received PCI for acute coronary syndrome (ACS), 19% for stable angina, and 8% for other indications. Post-PCI CP-related HCU was common with 26%, 16%, and 5% of patients having ≥1 office visits, ED visits, and hospital admissions for CP within 2 years of PCI. The following factors were significant predictors of all 3 CP outcomes: ACS presentation, documented CP >7 days prior to the index PCI, anxiety, depression, and syncope. In conclusion, CP-related HCU following PCI was common, especially within the first 2 years. The strongest predictors of CP-related HCU included coronary disease attributes and psychological factors.

Risk of Myocardial Infarction and Death After Noncardiac Surgery Performed Within the First Year After Coronary Drug-Eluting Stent Implantation for Acute Coronary Syndrome or Stable Angina Pectoris

This study aimed to examine the 30-day risk of myocardial infarction (MI) and death in patients who underwent noncardiac surgery within 1 year after coronary drug-eluting stent implantation for acute coronary syndrome (ACS) or stable angina pectoris (SAP) and to compare it with the risk in surgical patients without known coronary artery disease. Patients with drug-eluting stent implantation for ACS (n = 2,291) or SAP (n = 1,804) who underwent noncardiac surgery were compared with a cohort from the general population without known coronary artery disease matched on the surgical procedure, hospital contact type, gender, and age. In patients with ACS, the 30-day MI risk was markedly increased when surgery was performed within 1 month after stenting (10% vs 0.8%; adjusted odds ratio [OR_adj] 20.1, 95% confidence interval [CI] 8.85 to 45.6), whereas mortality was comparable (10% vs 8%, OR_adj 1.17, 95% CI 0.76 to 1.79). When surgery was performed between 1 and 12 months after stenting, the 30-day absolute risk for MI was low but higher than in the comparison cohort (0.6% vs 0.2%, OR_adj 2.18, 95% CI 0.89 to 5.38), whereas the mortality risks were similar (2.0% vs 1.8%, OR_adj 1.03, 95% CI 0.69 to 1.55). In patients with SAP, the 30-day MI risk was low but higher than in the comparison cohort (0.4% vs 0.2%, OR_adj 1.90, 95% CI 0.70 to 5.14), whereas the mortality risks were similar (2.2% vs 2.1%, OR_adj 0.91, 95% CI 0.61 to 1.37). In conclusion, patients with ACS and SAP who underwent surgery between 1 and 12 months after stent implantation had a risk for MI and death that was similar to the risk observed in surgical patients without coronary artery disease.

Relation of the Number of Cardiovascular Conditions and Short-term Symptom Improvement After Percutaneous Coronary Intervention for Stable Angina Pectoris

With aging of the population, cardiovascular conditions (CC) are increasingly common in individuals undergoing PCI for stable angina pectoris (AP). It is unknown if the overall burden of CCs associates with diminished symptom improvement after PCI for stable AP. We prospectively administered validated surveys assessing AP, dyspnea, and depression to patients undergoing PCI for stable AP at our institution, 2016-2018. The association of CC burden and symptoms at 30-days post-PCI was assessed via linear mixed effects models. Included individuals (N = 121; mean age 68 ± 10 years; response rate = 42%) were similar to non-included individuals. At baseline, greater CC burden was associated with worse dyspnea, depression, and physical limitations due to AP, but not AP frequency or quality of life. PCI was associated with small improvements in AP and dyspnea (p ≤ 0.001 for both), but not depression (p = 0.15). After multivariable adjustment, including for baseline symptoms, CC burden was associated with a greater improvement in AP physical limitations (p = 0.01) and depression (p = 0.002), albeit small, but not other symptom domains (all p ≥ 0.05). In patients undergoing PCI for stable AP, increasing CC burden was associated with worse dyspnea, depression, and AP physical limitations at baseline. An increasing number of CCs was associated with greater improvements, though small, in AP physical limitations and depression. In conclusion, the overall number of cardiovascular conditions should not be used to exclude patients from PCI for stable AP on the basis of an expectation of less symptom improvement.

Comparison of Long-Term Outcomes Following Coronary Revascularization in Men-vs-Women with Unprotected Left Main Disease

Gender differences have been recognized in several aspects of coronary artery disease (CAD). However, evidence for gender differences in long-term outcomes after left main coronary artery (LMCA) revascularization is limited. We sought to evaluate the impact of gender on outcomes after percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for unprotected LMCA disease. We evaluated 4,320 patients with LMCA disease who underwent CABG (n = 1,456) or PCI (n = 2,864) from the Interventional Research Incorporation Society-Left MAIN Revascularization registry. The primary outcome was a composite of death, myocardial infarction (MI), or stroke. Among 4,320 patients, 968 (22.4%) were females and 3,352 (77.6%) were males. Compared to males, females were older, had a higher prevalence of hypertension and insulin-requiring diabetes, more frequently presented with acute coronary syndrome, but had less extensive CAD and less frequent left main bifurcation involvement. The adjusted risk for the primary outcome was not different after PCI or CABG in females and males (hazard ratio [HR] 1.09; 95% confidence interval [CI]: 0.73-1.63 and HR 0.97; 95% CI: 0.80-1.19, respectively); there was no significant interaction between gender and the revascularization strategy (P for interaction = 0.775). In multivariable analysis, gender did not appear to be an independent predictor for the primary outcome. In revascularization for LMCA disease, females and males had a comparable primary composite outcome of death, MI, or stroke with either CABG or PCI without a significant interaction of gender with the revascularization strategy.

Machine Learning Identifies Metabolic Signatures that Predict the Risk of Recurrent Angina in Remitted Patients after Percutaneous Coronary Intervention: A Multicenter Prospective Cohort Study

Recurrent angina (RA) after percutaneous coronary intervention (PCI) has few known risk factors, hampering the identification of high-risk populations. In this multicenter study, plasma samples are collected from patients with stable angina after PCI, and these patients are followed-up for 9 months for angina recurrence. Broad-spectrum metabolomic profiling with LC-MS/MS followed by multiple machine learning algorithms is conducted to identify the metabolic signatures associated with future risk of angina recurrence in two large cohorts (n = 750 for discovery set, and n = 775 for additional independent discovery cohort). The metabolic predictors are further validated in a third cohort from another center (n = 130) using a clinically-sound quantitative approach. Compared to angina-free patients, the remitted patients with future RA demonstrates a unique chemical endophenotype dominated by abnormalities in chemical communication across lipid membranes and mitochondrial function. A novel multi-metabolite predictive model constructed from these latent signatures can stratify remitted patients at high-risk for angina recurrence with over 89% accuracy, sensitivity, and specificity across three independent cohorts. Our findings revealed reproducible plasma metabolic signatures to predict patients with a latent future risk of RA during post-PCI remission, allowing them to be treated in advance before an event.

Achieving optimal adherence to medical therapy by telehealth: Findings from the ORBITA medication adherence sub-study

INTRODUCTION

The ORBITA trial of percutaneous coronary intervention (PCI) versus a placebo procedure for patients with stable angina was conducted across six sites in the United Kingdom via home monitoring and telephone consultations. Patients underwent detailed assessment of medication adherence which allowed us to measure the efficacy of the implementation of the optimization protocol and interpretation of the main trial endpoints.

METHODS

Prescribing data were collected throughout the trial. Self-reported adherence was assessed, and urine samples collected at pre-randomization and at follow-up for direct assessment of adherence using high-performance liquid chromatography with tandem mass spectrometry (HPLC MS/MS).

RESULTS

Self-reported adherence was >96% for all drugs in both treatment groups at both stages. The percentage of samples in which drug was detected at pre-randomization and at follow-up in the PCI versus placebo groups respectively was: clopidogrel, 96% versus 90% and 98% versus 94%; atorvastatin, 95% versus 92% and 92% versus 91%; perindopril, 95% versus 97% and 85% versus 100%; bisoprolol, 98% versus 99% and 96% versus 97%; amlodipine, 99% versus 99% and 94% versus 96%; nicorandil, 98% versus 96% and 94% versus 92%; ivabradine, 100% versus 100% and 100% versus 100%; and ranolazine, 100% versus 100% and 100% versus 100%.

CONCLUSIONS

Adherence levels were high throughout the study when quantified by self-reporting methods and similarly high proportions of drug were detected by urinary assay. The results indicate successful implementation of the optimization protocol delivered by telephone, an approach that could serve as a model for treatment of chronic conditions, particularly as consultations are increasingly conducted online.

Validation of the all-comers design: Results of the TARGET-AC substudy

BACKGROUND

Results of clinical trials are often criticized by low inclusion rate and potential sampling bias in patient recruitment. The aim of this validation registry is to evaluate how far an all-comers design in the context of clinical research can ensure the representation of the true all-comers population.

METHODS

This validation registry is a prospective international multicentre registry, conducted at 10 out of the total 21 centers, participating in TARGET-AC (registered under NCT02520180). During a predefined four-week period data were recorded prospectively on all PCIs performed in the participating centers, whether or not patients were enrolled in TARGET-AC. Data were collected on patient demographics, angiographic lesion- and procedural characteristics. For patients who were not enrolled in the study, operators were asked to declare the reason for not enrolling the patient, using a single-choice questionnaire.

RESULTS

A total of 131 patients were enrolled in the TARGET-AC study during the investigated period (ER group), standing as 20% (range 4% and 54%) of all eligible cases per protocol. In the ER group more patients presented with stable angina (61% vs. 43%, respectively; P < .001). Whereas ST-elevation infarction was less common (5% vs. 26%, respectively; P < .001), there was no difference in non-ST elevation acute coronary syndrome (32% vs. 27%, respectively; P = .248). Risk factors and comorbidities did not show any difference between the ER and the non-enrolled (NER) groups, except for greater rate of significant valvular disease in the NER group (12% vs 19%, respectively; P = .037). The NER group presented more thrombotic stenoses than the ER group (20% vs 12%, respectively; P = .040). No difference was found in any other investigated angiographic parameters, like target vessels, bifurcation lesion, severe calcification or chronic total occlusions. Admission during regular working hours and availability of study nurse were associated with markedly higher recruitment rate.

CONCLUSION

Results suggest that TARGET AC was outbalanced for stable patients over primary PCIs as compared to real world. However in terms of risk factors and comorbidities the trial managed to represent the collective of real world clinical practice. Fairly representative cases were included at an average inclusion-to-eligible rate of 20%.

Neopterin and Cardiovascular Events Following Coronary Stent Implantation in Patients with Stable Angina Pectoris

AIM

Neopterin is an activation marker for monocytes/macrophages. We prospectively investigated the predictive value of plasma neopterin levels on 2-year and long-term cardiovascular events in patients with stable angina pectoris (SAP) undergoing coronary stent implantation.

METHODS

We studied 123 consecutive patients with SAP who underwent primary coronary stenting (44 patients with bare metal stent: BMS group and 79 with drug-eluting stent: DES group). Plasma neopterin levels were measured on admission using HPLC. Moreover, one frozen coronary artery specimen after DES and three frozen coronary specimens after BMS were obtained by autopsy or endarterectomy, followed by immunohistochemical staining for neopterin.

RESULTS

Plasma neopterin levels were significantly higher in patients with cardiovascular events than in those without them (P＜0.001). In subgroup analyses, higher levels of plasma neopterin in patients with cardiovascular events (P＜0.001) and a positive correlation between neopterin levels and late lumen loss after stenting (P =0.008) were observed in the BMS group but not in the DES group (P=0.53 and P=0.17, respectively). In long-term cardiovascular events, multivariate Cox regression analysis identified the significance of the high-neopterin group as independent determinants of cardiovascular events (hazard ratio, 2.225; 95% CI, 1.283-3.857; P =0.004). Immunohistochemical staining showed abundant neopterin-positive macrophages in the neointima after BMS implantation but no neopterin-positive macrophages in the neointima after DES implantation.

CONCLUSION

These findings suggest that neopterin is associated with cardiovascular events after coronary stent implantation in patients with SAP. However, there might be a strong association between neopterin and cardiovascular events after BMS but not after DES in these patients.

The utility of high-sensitivity C-reactive protein levels in patients with moderate coronary lesions and gray-zone fractional flow reserve

OBJECTIVE

It remains controversial whether patients with fractional flow reserve (FFR) values of 0.75-0.80 (gray-zone) should be treated with percutaneous coronary intervention (PCI). This study aimed to evaluate the prediction of high-sensitivity C-reactive protein (hs-CRP) levels to guide treatment selection in gray-zone patients.

METHODS

This prospective interventional trial was conducted between January 2015 and March 2016. A total of 785 patients with stable angina and single-vessel stenosis with moderate coronary lesions were admitted to hospital in this period. After measurement of hs-CRP levels, coronary angiography, and FFR, gray-zone patients (n=308) were included in the study and were divided into four groups on the basis of a cutoff hs-CRP level of 3 mg/L and then on the basis of whether they underwent PCI or not. Patients in groups I (≥3 mg/L, n=70) and III (<3 mg/L, n=84) underwent PCI, whereas those in groups II (≥3 mg/L, n=70) and IV (<3 mg/L, n=84) were administered only drugs. Major adverse clinical events (MACEs) included cardiac death, nonfatal myocardial infarction (MI), target vessel revascularization (TVR), and PCI or coronary artery bypass grafting (CABG). These parameters were also evaluated during follow-up.

RESULTS

The total Kaplan-Meier curves showed macrodistribution differences among the four groups (p<0.05). There was a significantly increased MACE incidence in group II compared with group I or IV (p=0.039 or 0.006, respectively), and an increased incidence in group I compared with group III (p=0.028). However, there were no differences in MACE incidence between groups III and IV (p=0.095) despite the fact that these patients received different treatments.

CONCLUSION

Among FFR gray-zone patients, hs-CRP level was a predictor of MACE and risk stratification could guide treatment selection. Increased hs-CRP levels (≥3 mg/L) are an indication for urgent PCI whereas normal levels (<3 mg/L) are an indication for delayed PCI treatment. Patients with identical FFR values could require different treatment.

Satisfactory arterial repair 1 year after ultrathin strut biodegradable polymer sirolimus-eluting stent implantation: an angioscopic observation

The ultrathin strut biodegradable polymer sirolimus-eluting stent (Orsiro, O-SES) exhibits satisfactory clinical outcomes. However, no report to date has documented the intravascular status of artery repair after O-SES implantation. We examined 5 O-SES placed in 4 patients (age 65 ± 12 years, male 75%) presenting with stable angina pectoris due to de novo lesions in native coronary arteries. Coronary angioscopy was performed immediately after percutaneous coronary intervention and 1 year later. Angioscopic images were analyzed to determine the following: (1) dominant grade of neointimal coverage (NIC) over the stent; (2) maximum yellow plaque grade; and (3) existence of thrombus. Yellow plaque grade was evaluated both immediately after stent implantation and at the time of follow-up observation. The other parameters were evaluated at the time of follow-up examination. NIC was graded as: grade 0, stent struts exposed; grade 1, struts bulging into the lumen, although covered; grade 2, struts embedded in the neointima, but translucent; grade 3, struts fully embedded and invisible. Yellow plaque severity was graded as: grade 0, white; grade 1, light yellow; grade 2, yellow; and grade 3, intensive yellow. Angioscopic findings at 1 year demonstrated the following: dominant NIC grade 1, grade 2, and grade 3 in 1, 2, and 2 stents, respectively; all stents were covered to some extent; focal thrombus adhesion was observed in only 1 stent. Yellow plaque grade did not change from immediately after stent implantation to follow-up. O-SES demonstrated satisfactory arterial repair 1 year after implantation.

Percutaneous coronary intervention in stable angina (ORBITA): a double-blind, randomised controlled trial

BACKGROUND

Symptomatic relief is the primary goal of percutaneous coronary intervention (PCI) in stable angina and is commonly observed clinically. However, there is no evidence from blinded, placebo-controlled randomised trials to show its efficacy.

METHODS

ORBITA is a blinded, multicentre randomised trial of PCI versus a placebo procedure for angina relief that was done at five study sites in the UK. We enrolled patients with severe (≥70%) single-vessel stenoses. After enrolment, patients received 6 weeks of medication optimisation. Patients then had pre-randomisation assessments with cardiopulmonary exercise testing, symptom questionnaires, and dobutamine stress echocardiography. Patients were randomised 1:1 to undergo PCI or a placebo procedure by use of an automated online randomisation tool. After 6 weeks of follow-up, the assessments done before randomisation were repeated at the final assessment. The primary endpoint was difference in exercise time increment between groups. All analyses were based on the intention-to-treat principle and the study population contained all participants who underwent randomisation. This study is registered with ClinicalTrials.gov, number NCT02062593.

FINDINGS

ORBITA enrolled 230 patients with ischaemic symptoms. After the medication optimisation phase and between Jan 6, 2014, and Aug 11, 2017, 200 patients underwent randomisation, with 105 patients assigned PCI and 95 assigned the placebo procedure. Lesions had mean area stenosis of 84·4% (SD 10·2), fractional flow reserve of 0·69 (0·16), and instantaneous wave-free ratio of 0·76 (0·22). There was no significant difference in the primary endpoint of exercise time increment between groups (PCI minus placebo 16·6 s, 95% CI -8·9 to 42·0, p=0·200). There were no deaths. Serious adverse events included four pressure-wire related complications in the placebo group, which required PCI, and five major bleeding events, including two in the PCI group and three in the placebo group.

INTERPRETATION

In patients with medically treated angina and severe coronary stenosis, PCI did not increase exercise time by more than the effect of a placebo procedure. The efficacy of invasive procedures can be assessed with a placebo control, as is standard for pharmacotherapy.

FUNDING

NIHR Imperial Biomedical Research Centre, Foundation for Circulatory Health, Imperial College Healthcare Charity, Philips Volcano, NIHR Barts Biomedical Research Centre.

Cytokine expression profile and blood parameter evaluation of patients undergoing cardiac surgery

Cardiac surgery is accompanied by an important immune response that is poorly understood. This inflammatory response is caused by several stimuli: surgical trauma, cardiopulmonary bypass apparatus, aortic-cross clamping, reperfusion injury and hypothermia. The aim of the present study is to investigate the cytokine level profile involved in the inflammatory pathway of patients undergoing cardiac surgery. One hundred and two patients undergoing elective cardiac surgery utilizing cardiopulmonary bypass (CPB) apparatus were enrolled in the study. In the hematological and biochemical profiles investigated, we observed a significant increase of WBC and blood glucose concentration and a strong decrease of RBC, HB, HCT and PLT 24 h post-surgery compared to baseline and immediately after surgery groups. Furthermore, we found a modulation of cytokine levels mostly for IL-10 and an increase of IL-6, detected at 6 h post-surgery, IL-8 at 6 and 24 h, and TNFα only at 24 h post-surgery. In conclusion, these findings evidence a time course profile on cytokine levels and a balance between pro- and anti-inflammatory cytokine activation during and after cardiac surgery. In fact, IL-6 and IL-10, a pro- and an anti-inflammatory cytokine, respectively, increased immediately after surgery. The plasma level of TNF-α could be inhibited by the high concentration of IL-10 up to 6 h post-surgery. An IL-10 reduction at baseline level, after 24 h post-surgery, could explain a rise of TNF-α plasma concentration. On the other hand, considering the dual role of IL-6 on inflammation acting both as an activator of inflammatory cascade or an anti-inflammatory agent, the increased IL-6 levels 24 h after surgery could be related to the negative feedback action on TNFα activity.

Is In-Stent Restenosis After a Successful Coronary Stent Implantation Due to Stable Angina Associated With TG/HDL-C Ratio?

We examined the impact of the preprocedural triglyceride (TG)/high-density lipoprotein cholesterol (HDL-C) ratio on risk of in-stent restenosis (ISR). Patients with typical anginal symptoms and/or positive treadmill or myocardial perfusion scintigraphy test results who underwent successful coronary stent implantation due to stable angina were examined; 1341 patients were enrolled. The hospital files of the patients were used to gather data. Cox regression analysis showed that the TG/HDL-C ratio was independently associated with the presence of ISR ( P < .001). Moreover, diabetes mellitus ( P = .007), smaller stent diameter ( P = .046), and smoking status ( P = .001) were also independently associated with the presence of ISR. Using a cutoff of 3.8, the TG/HDL-C ratio predicted the presence of ISR with a sensitivity of 71% and a specificity of 68%. Also, the highest quartile of TG/HDL-C ratio had the highest rate of ISR ( P < .001). Measuring preprocedural TG/HDL-C ratio, in fasting or nonfasting samples, could be beneficial for the risk assessment of ISR. However, further large-scale prospective studies are required to establish the exact role of this simple, easily calculated, and reproducible parameter in the pathogenesis of ISR.

Randomised, double-blind, placebo-controlled study investigating the effects of inorganic nitrate on vascular function, platelet reactivity and restenosis in stable angina: protocol of the NITRATE-OCT study

INTRODUCTION

The mainstay treatment for reducing the symptoms of angina and long-term risk of heart attacks in patients with heart disease is stent implantation in the diseased coronary artery. While this procedure has revolutionised treatment, the incidence of secondary events remains a concern. These repeat events are thought to be due, in part, to continued enhanced platelet reactivity, endothelial dysfunction and ultimately restenosis of the stented artery. In this study, we will investigate whether a once a day inorganic nitrate administration might favourably modulate platelet reactivity and endothelial function leading to a decrease in restenosis.

METHODS AND DESIGN

NITRATE-OCT is a double-blind, randomised, single-centre, placebo-controlled phase II trial that will enrol 246 patients with stable angina due to have elective percutaneous coronary intervention procedure with stent implantation. Patients will be randomised to receive 6 months of a once a day dose of either nitrate-rich beetroot juice or nitrate-deplete beetroot juice (placebo) starting up to 1 week before their procedure. The primary outcome is reduction of in-stent late loss assessed by quantitative coronary angiography and optical coherence tomography at 6 months. The study is powered to detect a 0.22±0.55 mm reduction in late loss in the treatment group compared with the placebo group. Secondary end points include change from baseline assessment of endothelial function measured using flow-mediated dilation at 6 months, target vessel revascularisation (TVR), restenosis rate (diameter>50%) and in-segment late loss at 6 months, markers of inflammation and platelet reactivity and major adverse cardiac events (ie, myocardial infarction, death, cerebrovascular accident, TVR) at 12 and 24 months.

ETHICS AND DISSEMINATION

The study was approved by the Local Ethics Committee (15/LO/0555). Trial results will be published according to the CONSORT statement and will be presented at conferences and reported in peer-reviewed journals.

TRIAL REGISTRATION NUMBERS

NCT02529189 and ISRCTN17373946, Pre-results.

Does Coronary Angiography and Percutaneous Coronary Intervention Affect Cognitive Function?

Cerebral microemboli are frequently observed during coronary angiography (CA) and percutaneous coronary intervention (PCI), and their numbers have been related to the vascular access site used. Although cerebral microemboli can cause silent cerebral lesions, their clinical impact is debated. To study this, 93 patients referred for CA or PCI underwent serial cognitive testing using the Montreal Cognitive Assessment (MoCA) test to detect postprocedural cognitive impairment. Patients were randomized to radial or femoral access. In a subgroup of 35 patients, the number of cerebral microemboli was monitored with transcranial Doppler technique. We found the median precatheterization result of the MoCA test to be 27, and it did not change significantly 4 and 31 days, respectively, after the procedure. There was no significant correlation between the number of cerebral microemboli and the difference between preprocedural and postprocedural MoCA tests. The test results did not differ between vascular access sites. One-third of the patients had a precatheterization median MoCA test result <26 corresponding to mild cognitive impairment. In conclusion, using the MoCA test, we could not detect any cognitive impairment after CA or PCI, and no significant correlations were found between the results of the MoCA test and cerebral microemboli or vascular access site, respectively. In patients with suspected coronary heart disease, mild cognitive impairment was common.

Chronic Kidney Disease Progression and Cardiovascular Outcomes Following Cardiac Catheterization-A Population-Controlled Study

BACKGROUND

Studies of kidney disease associated with cardiac catheterization typically rely on billing records rather than laboratory data. We examined the associations between percutaneous coronary interventions, acute kidney injury, and chronic kidney disease progression using comprehensive Veterans Affairs clinical and laboratory databases.

METHODS AND RESULTS

Patients undergoing percutaneous coronary interventions between 2005 and 2010 (N=24 405) were identified in the Veterans Affairs Clinical Assessment, Reporting, and Tracking registry and examined for associated acute kidney injury and chronic kidney disease development or progression relative to 24 405 matched population controls. Secondary outcomes analyzed included dialysis, acute myocardial infarction, and mortality. The incidence of chronic kidney disease progression following percutaneous coronary interventions complicated by acute kidney injury, following uncomplicated coronary interventions, and in matched controls were 28.66, 11.15, and 6.81 per 100 person-years, respectively. Percutaneous coronary intervention also increased the likelihood of chronic kidney disease progression in both the presence and absence of acute injury relative to controls in adjusted analyses (hazard ratio [HR], 5.02 [95% CI, 4.68-5.39]; and HR, 1.76 [95% CI, 1.70-1.86]). Among patients with estimated glomerular filtration rate <60 mL/min per 1.73 m2, acute kidney injury increased the likelihood of disease progression by 8-fold. Similar results were observed for all secondary outcomes.

CONCLUSIONS

Acute kidney injury following percutaneous coronary intervention was associated with increased chronic kidney disease development and progression and mortality.

Percutaneous coronary intervention for poor coronary microcirculation reperfusion of patients with stable angina pectoris

Percutaneous coronary intervention (PCI) has been extensively applied to repair the forward flow of diseased coronary artery and can achieve significant curative results. However, some patients with acute myocardial infarction (AMI) develop non-perfusion or poor perfusion of cardiac muscle tissue after PCI, which increases the incidence of cardiovascular events and the death rate. PCI can dredge narrowed or infarct-related artery (IRA) and thus induce full reperfusion of ischemic myocardium. It is found in practice that some cases of AMI still have no perfusion or poor perfusion in myocardial tissue even though coronary angiography suggests opened coronary artery after PCI, which increases the incidence of vascular events and mortality. Therefore, to explore the detailed mechanism of PCI in treating coronary microcirculation of patients with stable angina pectoris, we selected 140 patients with stable angina pectoris for PCI, observing the index of microcirculatory resistance (IMR) of descending branch and changes of myocardial injury markers and left ventricular systolic function, and made a subgroup analysis based on the correlation between clinical indexes, IMR and other variables of diabetic and non-diabetic patients, PCI-related and non-PCI-related myocardial infarction patients. The results suggest that IMR of anterior descending branch after PCI was higher compared to that before PCI, and the difference was significant (P less than 0.05); creatine kinase-MB (CK-MB), myohemoglobin and high sensitive troponin T were all increased after PCI, and the difference was also significant (P less than 0.05); brain natriuretic peptide (BNP) level became higher after PCI, with significant difference (P less than 0.05); left ventricular ejection fraction (LVEF) declined after PCI, and the difference before and after PCI was statistically significant (P less than 0.05). Moreover, subgroup analysis results of the three groups all demonstrated statistically significant differences. PCI can effectively increase microcirculatory resistance of patients with stable angina pectoris, especially those who develop both stable angina pectoris and diabetes. Patients with higher microcirculatory resistance before PCI are more likely to develop PCI-related myocardial infarction after PCI.

The Personality and Psychological Stress Predict Major Adverse Cardiovascular Events in Patients With Coronary Heart Disease After Percutaneous Coronary Intervention for Five Years

To investigate the effects of personality type and psychological stress on the occurrence of major adverse cardiovascular events (MACEs) at 5 years in patients with coronary artery disease (CAD) after percutaneous coronary intervention (PCI). Two hundred twenty patients with stable angina (SA) or non-ST segment elevation acute coronary syndrome (NSTE-ACS) treated with PCI completed type A behavioral questionnaire, type D personality questionnaire, Self-Rating Depression Scale (SDS), Self-Rating Anxiety Scale (SAS), Trait Coping Style Questionnaire (TCSQ), and Symptom Checklist 90 (SCL-90) at 3 days after PCI operation. Meanwhile, biomedical markers (cTnI, CK-MB, LDH, LDH1) were assayed. MACEs were monitored over a 5-year follow-up. NSTE-ACS group had higher ratio of type A behavior, type A/D behavior, and higher single factor scores of type A personality and type D personality than control group and SAP group. NSTE-ACS patients had more anxiety, depression, lower level of mental health (P < 0.05; P < 0.01), more negative coping styles and less positive coping styles. The plasma levels of biomedical predictors had positive relation with anxiety, depression, and lower level of mental health. Type D patients were at a cumulative increased risk of adverse outcome compared with non-type D patients (P < 0.05). Patients treated with PCI were more likely to have type A and type D personality and this tendency was associated with myocardial injury. They also had obvious anxiety, depression emotion, and lower level of mental health, which were related to personality and coping style. Type D personality was an independent predictor of adverse events.

[Rate of in-hospital cardiovascular complications in patients with postoperative renal dysfunction after surgical myocardial revascularization]

The study was aimed at revealing the factors associated with renal dysfunction having developed after coronary artery bypass grafting (CABG) and assessing the in-hospital cardiovascular complications rate amongst patients with postoperative renal dysfunction. The study included a total of 99 patients presenting with stable angina pectoris and having indications for CABG. The mean age of the patients amounted to 57±7 years, with the average duration of coronary artery disease (CAD) of 6±5.7 years. A multi-vessel lesion of coronary arteries was revealed in 69.7% of patients, ≥ 50% stenosis of the trunk of the left coronary artery was diagnosed in a further 15.1%. CABG was performed in conditions of assisted circulation (AC) in 88.9% of patients and on the functioning heart in 11.1%. We implanted from 1 to 4 grafts to each patient. At admission, and then on the first and second postoperative days after CABG we determined blood serum creatinine and calculated the creatinine clearance (CrCl) according to the Cockcroft-Gault equation. A decrease in the CrCl < 60 ml/min was regarded as renal dysfunction. Assessing the cardiovascular complications rate we took into consideration cases of cardiac death, perioperative myocardial infarctions (POMI), severe acute cardiac insufficiency having required placement of a counterpulsator, and as well as the proportion of patients with paroxysmal atrial fibrillation. We also evaluated the frequency of repeat sternotomy. The incidence rate of transitory renal dysfunction following CABG amounted to 18.2%. The factors associated with a decrease in the CrCl < 60 ml/min after CABG were found to be as follows: age above - Me 62.5 (range 59-68) years, increased duration of AC above - Me 103 (range 88-133) min and prolonged time of aortic occlusion (AO) above - Me 53 (range 44-60) min, severe postoperative acute cardiac insufficiency, and re-sternotomy. The cumulative rate of in-hospital cardiovascular complications turned out to be significantly higher (55.6 versus 18.5%, p=0.001) amongst patients with postoperative renal dysfunction. We also revealed a substantially higher incidence rate of re-sternotomies in the cohort of patients with a CrCl < 60 ml/min after CABG (11.1 vs.1.2%, p=0.027). Hence, moderate transitory renal dysfunction appears to develop nearly in every fifth patient in the early period after CABG. The risk factors for the development of postoperative renal dysfunction include: age, increased duration of the period of artificial circulation (AC) and time of aortic occlusion (AO), severe acute postoperative cardiac insufficiency, and re-sternotomy. Even moderately pronounced transitory renal dysfunction after CABG is associated with an unfavourable prognosis of in-hospital cardiovascular complications.

Obesity and antiplatelet effects of acetylsalicylic acid and clopidogrel in patients with stable angina pectoris after percutaneous coronary intervention

INTRODUCTION

Obesity is a cluster of medical conditions affecting several pathophysiological processes, including platelet (PLT) function.

OBJECTIVES

We evaluated the association between obesity and PLT response to dual antiplatelet therapy over 1 month in patients with stable angina pectoris after percutaneous coronary intervention (PCI). 

PATIENTS AND METHODS

Patients with stable angina pectoris (n = 130) and prior therapy with acetylsalicylic acid (ASA, 75 mg/d) after PCI were enrolled into the study and divided based on a body mass index (BMI): BMI <25 kg/m² (group A); BMI = 25-29.9 kg/m² (group B); and BMI ≥30 kg/m² (group C). PLT function was assessed by impedance aggregometry 24 hours after PCI and a loading dose (LD) of clopidogrel (CLO, 600 mg) and after 30 days of a maintenance dose (MD) of CLO and ASA of 75 mg/d. The delta values were calculated as the difference between the tests performed 30 days and 24 hours after PCI.

RESULTS

The PLT function changed significantly over a 30-day follow-up. The initial PLT reactivity to adenosine diphosphate (ADP1) was lower in group A and was the highest in group C (P <0.05). The PLT reactivity to collagen (COL1) and arachidonic acid was lower in group A (P <0.05) with no differences between groups B and C. There were no differences among the subgroups in PLT reactivity assessed after 30 days. A multivariate regression analysis showed that BMI (P = 0.03), creatinine serum concentration (P <0.01), male sex (P <0.01), and active smoking (P <0.001) are the independent predictors of ΔADP. CONCLUSIONS Obesity is associated with a lower response to CLO LD but PLT function after 30 days of CLO MD is similar in patients with obesity and normal-weight.

Percutaneous coronary intervention in the elderly

Our population dynamics are changing. The number of octogenarians and older people in the general population is increasing and therefore the number of older patients presenting with acute coronary syndrome or stable angina is increasing. This group has a larger burden of coronary disease and also a greater number of concomitant comorbidities when compared to younger patients. Many of the studies assessing percutaneous coronary intervention (PCI) to date have actively excluded octogenarians. However, a number of studies, both retrospective and prospective, are now being undertaken to reflect the, "real" population. Despite being a higher risk group for both elective and emergency PCIs, octogenarians have the greatest to gain in terms of prognosis, symptomatic relief, and arguably more importantly, quality of life. Important future development will include assessment of patient frailty, encouraging early presentation, addressing gender differences on treatment strategies, identification of culprit lesion(s) and vascular access to minimise vascular complications. We are now appreciating that the new frontier is perhaps recognising and risk stratifying those elderly patients who have the most to gain from PCI. This review article summarises the most relevant trials and studies.

Release of Intracoronary Microparticles during Stent Implantation into Stable Atherosclerotic Lesions under Protection with an Aspiration Device

OBJECTIVE

Stent implantation into atherosclerotic coronary vessels impacts on downstream microvascular function and induces the release of particulate debris and soluble substances, which differs qualitatively and quantitatively between native right coronary arteries (RCAs) and saphenous vein grafts on right coronary arteries (SVG-RCAs). We have now quantified the release of microparticles (MPs) during stent implantation into stable atherosclerotic lesions and compared the release between RCAs and SVG-RCAs.

METHODS

In symptomatic, male patients with stable angina and a stenosis in their RCA or SVG-RCA, respectively (n = 14/14), plaque volume and composition were analyzed using intravascular ultrasound before stent implantation. Coronary aspirate was retrieved during stent implantation with a distal occlusion/aspiration device and divided into particulate debris and plasma. Particulate debris was weighed. Platelet-derived MPs (PMPs) were distinguished by flow cytometry as CD41+, endothelium-derived MPs (EMPs) as CD144+, CD62E+ and CD31+/CD41-, leukocyte-derived MPs as CD45+, and erythrocyte-derived MPs as CD235+.

RESULTS

In patients with comparable plaque volume and composition in RCAs and SVG-RCAs, intracoronary PMPs and EMPs were increased after stent implantation into their RCAs and SVG-RCAs (CD41+: 2729.6 ± 645.6 vs. 4208.7 ± 679.4 and 2355.9 ± 503.9 vs. 3285.8 ± 733.2 nr/µL; CD144+: 451.5 ± 87.9 vs. 861.7 ± 147.0 and 444.6 ± 74.8 vs. 726.5 ± 136.4 nr/µL; CD62E+: 1404.1 ± 247.7 vs. 1844.3 ± 378.6 and 1084.6 ± 211.0 vs. 1783.8 ± 384.3 nr/µL, P < 0.05), but not different between RCAs and SVG-RCAs.

CONCLUSION

Stenting in stable atherosclerotic lesions is associated with a substantial release not only of PMPs, but also of EMPs in RCAs and SVG-RCAs. Their release does not differ between RCAs and SVG-RCAs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01430884.

[Percutaneous coronary intervention vs coronary artery bypass grafting for patients with stable angina pectoris]

Percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) must be considered among stable angina pectoris patients who remained symptomatic despite optimal medical treatment and to improve prognosis of patients with large myocardial lschemia when occurring at low workload. PCI is preferred for single coronary artery stenosis, while CABG is recommended for severe multivessel disease patients, particularly when diabetes is present. There is no simple decisional algorithm, and, for patients with multivessel disease, each situation must be debated within a multidisciplinary decision-making team (Heart Team), taking into consideration risks and benefits of PCI vs CABG, patients' comorbidities and local experience.

Usefulness and safety of a guide catheter extension system for the percutaneous treatment of complex coronary lesions by a transradial approach

OBJECTIVE

The aim of this study was to describe our initial experience with the GuideLiner® catheter (Vascular Solutions Inc.) in the transradial treatment of complex lesions.

MATERIALS AND METHODS

The clinical, angiographic and procedural data of percutaneous coronary interventions where GuideLiner was used during 2013 were collected. The transradial approach was used in all cases. The indication for its use, efficacy and periprocedural complications were determined. Sixteen consecutive procedures (in 15 patients; 12 males and 3 females) were evaluated. The indication for the use of GuideLiner was a difficulty to advance and properly position a stent through a tortuous and/or calcified artery despite using high-support guide catheters or other useful techniques.

RESULTS

Of the 16 angiographic procedures, 14 (87.5%) were successful (stent deployment in 13 cases and a drug-eluting balloon in 1 case). Unsuccessful cases were a chronic total occlusion and a diffusely diseased left anterior descendant artery. A type B dissection of a proximal left circumflex artery was the only periprocedural complication.

CONCLUSION

Use of the GuideLiner was an effective and safe technique for the percutaneous treatment of complex coronary lesions in which the adequate progress of angioplasty devices had failed. GuideLiner was particularly helpful when using the transradial approach. Only one minor complication was recorded.

[The pros and cons of angioplasty in stable coronary artery disease]

American research demonstrated that 1 out of 4 patients undergoes diagnostic coronary angiography without clear evidence of symptoms or objective signs of ischaemia, leading to unnecessary angioplasties in a substantial number of patients. A second study, published simultaneously, demonstrated that proper patient education could decrease the rates of angioplasty in patients with stable coronary artery disease significantly. In the present editorial we critically assess both publications and put them in perspective to current clinical practice in the Netherlands along with the European guidelines for myocardial revascularization.

Studies of troponin I level changes in patients with coronary artery disease after percutaneous coronary intervention

Research has been carried out in TSMU Cardiology department of A.Aladashvili University Clinic involving 150 patients with ischemic heart disease. The changes of Tn level before and after percutaneous coronary intervention (PCI) in patients with CAD as well as its dependence on the cardiovascular events rate have been studied in previous work. In patients with normal Tn I level before and after PCI hospital cardiovascular events rate occurred to be as low as the rate of later events. Elevated level of Tn I after PCI was associated with increased rate of complications, which were mostly appeared in those patients with high level of Tn I before PCI. High level of 30-day mortality was revealed in patients with normal level of Tn I before PCI, which was elevated after procedure. The highest rate of later mortality was demonstrated in patients with high level of Tn I before PCI that was sustained after procedure. Hence, on the basis of our data we can conclude, that the Tn level before and after PCI has a prognostic significance; High level of Tn I before PCI is associated with increased hospitalization and later mortality rates. The elevation of Tn I after PCI in patients with normal initial level is more significant predictor of early (30-day) mortality compared to later (within 12 months) mortality.

Predictors of reintervention after coronary artery bypass grafting

AIM

Percutaneous and surgical reintervention after coronary artery bypass grafting (CABG) is frequent. The purpose of this study was to determine the predictors of reintervention in patients with symptoms of recurrent ischemia after coronary artery bypass graft surgery (CABG).

PATIENTS AND METHODS

The data of 20000 patients who had coronary angiography (CAG) from 2003 to 2010 in our centre were retrospectively analysed. 485 of these patients with CABG who had CAG were included in this study. Demographic characteristics, the presence of coronary artery disease (CAD), risk factors for CAD, electrocardiographic (ECG) changes, troponin and CKMB levels, and left ventricular function were evaluated in terms of time elapsed after CABG.

RESULTS

Reintervention was performed significantly more frequent in patients with acute coronary syndrome, diabetes mellitus (DM), hypertension (HT), family history of CAD, ECG changes, positive troponin level, elevated CKMB, ejection fraction (EF) > 50% and in smoker patients (p < 0.05). Multivariate backward logistic regression analysis revealed that DM, smoking, family history of CAD, HT, ECG changes and patients with EF > 50% were found the independent predictors of reintervention.

CONCLUSIONS

Reintervention after CABG is especially higher in patients with risk factors for atherosclerosis and those who have ECG changes and normal EF. Knowledge of these risk factors is useful in the determination of CAG requirement and modification of risk factors for  atherosclerosis may play an important role in reducing reintervention.

The patient with chronic ischemic heart disease. Role of ranolazine in the management of stable angina

Ischemic heart disease (IHD) is a major cause of death in Western Countries and accounts for very high costs worldwide. In this review we discussed the pathogenesis, symptoms, diagnosis, prognosis and management of chronic IHD. In particular, we discussed about the percutaneous coronary interventions and coronary artery bypass grafting, as well as to clinical trials that evaluated the advantages of one approach versus another. Pharmacological treatment is among major objectives of the review and for each class of therapeutic agents an evaluation of well-conducted clinical trials is provided. The most important drug classes in IHD treatment are betablockers, calcium channel blockers, nitrates, antiplatelet agents, and ACE-inhibitors. In addition to these agents, also new treatment options are evaluated in patients with stable IHD. Ranolazine, in particular, is a innovative anti-anginal drug with a great successful in the management of patients with refractory angina. A pharmacological as well as clinical profile of this drug is provided.

Monocyte expression of Toll-like receptor-4 in patients with stable angina undergoing percutanoeus coronary intervention

BACKGROUND

Toll like receptors (TLRs) are well recognized players in inflammatory conditions. Among them TLR-4 is involved in chronic inflammatory processes such as formation of atherosclerotic plaques.

OBJECTIVE

The present study was aimed to examine the effects of percutanoeus coronary intervention (PCI) as a revascularization method on monocyte expression of hTLR-4 and on the serum levels of two proinflammatory cytokines (TNF-α and IL-1β).

METHODS

Blood samples were obtained from 41 patients with stable angina who were candidates for PCI. The samples were collected immediately before and 2h and 4h after PCI. The expression of hTLR-4 on CD14+ monocytes and the serum levels of TNF-α and IL-1β were measured using flowcytometry and ELISA techniques, respectively.

RESULTS

By comparing the frequency of circulating hTLR-4+/CD14+ monocytes at different time points, it was observed that PCI procedure up regulates the monocyte expression of hTLR-4 (p<0.05). The increase in expression was associated with the elevation of the serum levels of proinflammatory cytokines (p<005). There was a significant correlation between monocyte expression of hTLR-4 and serum levels of TNF-α and IL-1β only before PCI. In spite of parallel increase in the serum levels of proinflammatory cytokines and the monocyte expression of hTLR-4, the correlation did not attain a significant level after PCI intervals.

CONCLUSION

PCI is positively associated with an increase in the monocyte expression of hTLR-4. It is also associated with the elevation in the serum levels of proinflmmatory cytokines. These findings suggest that hTLR-4 monocyte expression may be used as a potential prognostic tool in patients with stable angina undergoing PCI.