17-beta-estradiol eluting stent versus phosphorylcholine-coated stent for the treatment of native coronary artery disease

In this study we randomly compared the estradiol eluting stent (17-beta-E) with phosphorylcholine (PC)-coated stents in native coronary arteries. The incidence of angiographic restenosis was 23% in the 17-beta-E group and 31% in the PC group (p = 0.34). The major adverse cardiovascular event rates were also similar in the 2 groups (17% in the 17-beta-E group vs 22% in the PC group, p = 0.47). The mid-term clinical and angiographic outcomes did not indicate superiority of the 17-beta-E eluting stent over the control PC stent.

The acute administration of trimetazidine modified myocardial perfusion and left ventricular function in 31 patients with ischaemic ventricular dysfunction

Trimetazidine (TMZ) increases the mithocondrial oxidative metabolism and improves Tc-99m sestamibi uptake in myocardial single photon emission tomography (SPECT). The aim of this study was to evaluate whether the acute administration of TMZ improved myocardial perfusion and modified left ventricular ejection fraction (LVEF) in ischaemic left ventricular impairment.

METHODS

Thirty-one patients (23 males, age 66 years) with prior myocardial infarction (>6 months) and echocardiographic LVEF < or = 45% underwent coronary angiography, rest basal myocardial SPECT (after 3-day placebo administration) and rest TMZ myocardial SPECT [after 3-day TMZ administration (60mg/die)]. The left ventricle was analysed in 16 segments. The summed placebo score (SPS) and the summed TMZ score (STS) were calculated with a 5-point scale (from 0 = normal uptake to 4 = absent uptake) by two blinded operators. The GATED Tc-99m SPECT was always provided.

RESULTS

After TMZ administration GATED LVEF improved from 26.5+/-9.7% to 29.1+/-11.3% (p = 0.04) and left ventricular end-systolic volume (LVESV) was reduced from 90.2+/-40.7 to 85.6+/-39.2 ml/mq (p = 0.006). Similarly the addition of TMZ to myocardial SPECT significantly reduced the STS compared to SPS (21.5+/-11 vs. 26.6+/-10.5 p = 0.0001). Eleven patients (35.5%) had an echocardiographic LVEF < or = 30%; in these patients who had severe ventricular dysfunction, GATED LVEF and LVESV did not change after TMZ (20.2+/-5.7% vs. 21+/-6.9% p =0.6; 116.7+/-35.3 ml vs. 112.6+/-32.3 ml p = 0.08, respectively).

CONCLUSION

In comparison with placebo, the addition of TMZ to myocardial Tc-99m tetrofosmin SPECT improved myocardial perfusion and LVEF, reducing LVESV. These effects were lost in patients with more severe ventricular dysfunction.

Immunosuppressive oral prednisone after percutaneous interventions in patients with multi-vessel coronary artery disease. The IMPRESS-2/MVD study

AIMS

To assess efficacy and safety of oral treatment with prednisone at immunosuppressive dose after percutaneous coronary interventions (PCI) in patients with multi-vessel coronary artery disease (CAD).

METHODS AND RESULTS

Eighty-six consecutive patients with multi-vessel CAD were successfully treated with multiple PCI. Forty-three patients (115 coronary stenoses), with C-reactive protein >3mg/L 48 hours after PCI and in absence of contra-indications received 45-day high-dose oral prednisone treatment (study-group). Forty-three patients (106 coronary stenoses), did not receive prednisone (control-group). The primary clinical endpoint was 12-month event-free survival rate (defined as freedom from death, myocardial infarction, and the need for target vessel revascularisation). Angiographic restenosis at 8 months was assessed in the study group only. Event-free survival rates were 93 and 69.8% in the study and the control group, respectively (relative risk 0.34, 95%CI: 0.12 to 0.96, p=0.006). Target vessel revascularisation rate in the study group was 7% compared to 27.9% in the control group (p=0.01). Quantitative coronary angiography performed on 104 lesions of 39 prednisone-treated patients (91%) showed 4 restenotic lesions (3.8%). The mean late lumen loss was 0.61+/-0.35mm and loss index 31.3+/-21.6%.

CONCLUSION

Oral immunosuppression with prednisone effectively reduces clinical restenosis in patients undergoing complex, multi-vessel PCI.

Elevated C-reactive protein levels and coronary microvascular dysfunction in patients with coronary artery disease

AIMS

It is still unknown whether elevated C-reactive protein levels are responsible for coronary microcirculatory dysfunction in patients with coronary artery disease (CAD). This study was aimed at evaluating the association between C-reactive protein levels and endothelium-dependent and endothelium-independent coronary blood flow (CBF) responses in non-culprit arteries of patients with CAD.

METHODS AND RESULTS

We studied 28 patients (14 with normal and 14 with elevated C-reactive protein levels, >5 mg/L) with single-vessel disease and otherwise angiographically normal coronary arteries undergoing percutaneous transluminal coronary angioplasty (PTCA). CBF was measured in the non-PTCA vessel using an intracoronary Doppler guide wire and quantitative coronary angiography at baseline, after intracoronary infusion of substance P and of adenosine, and expressed as per cent change from baseline. The increases in CBF during infusion of substance P and of adenosine were lesser in patients with elevated than in those with normal C-reactive protein levels (34+/-22 vs. 61+/-34%, P=0.04 and 131+/-53 vs. 189+/-89%, P=0.03, respectively). Multivariable analysis identified elevated C-reactive protein level as the only independent predictor of reduced response to substance P (P=0.01) and adenosine (P=0.02).

CONCLUSION

In patients with CAD, evidence of systemic inflammation is independently associated with endothelium-dependent and endothelium-independent coronary microvascular dysfunction, which, in turn, may be critical to precipitate myocardial ischaemia, in particular, in unstable patients.

Percutaneous Angioplasty of the Subclavian Artery in Patients with Mammary‐Coronary Bypass Grafts

Severe coronary artery disease often coexists with peripheral vascular atherosclerosis. The assessment of the supra-aortic circulation in candidates for surgical coronary revascularization is of clinical relevance, and after intervention the patency of the supra-aortic trunks should be regularly evaluated in the clinical follow-up. We describe three cases of coronary artery disease treated with surgical revascularization using the internal mammary artery and concomitant atherosclerotic disease of the subclavian artery. The clinical presentation, the diagnostic procedures, and the therapeutic approach by means of percutaneous transluminal angioplasty of the subclavian artery are described and discussed.

Tissue plasminogen activator antigen is strongly associated with myocardial infarction in young women

Women who develop acute myocardial infarction (AMI) at a young age have fewer classical risk factors and less coronary stenosis than older women. In this rare population, it is plausible that a heightened hemostatic system may play an important mechanistic role in thrombus formation and in the development of AMI. We chose to investigate whether or not there is an association between premature AMI and the plasma concentrations of five hemostatic measurements that had been previously established as risk factors for AMI, and of the inflammation marker C-reactive protein (CRP). Women who had survived AMI at the age of 45 years or less (n = 141) were drawn from those admitted to 125 Italian coronary care units over a 3-year period. In them, and in an equal number of controls, plasma levels of immunoreactive tissue plasminogen activator (tPA), plasminogen activation inhibitor 1 (PAI-1), von Willebrand factor (VWF), fibrinogen, D-dimer and CRP were measured. Higher levels of VWF, fibrinogen, CRP and tPA were associated with AMI. After adjustment for both classical and hemostatic risk factors, only tPA maintained an independent association with AMI: the odds ratios (taken as an index of relative risk) for tPA values in the middle and higher tertiles were 2.86 (CI 1.63-5.02) and 8.18 (CI 2.66-25.20), respectively. In conclusion, there is a strong association between non-fatal AMI and increased plasma levels of tPA antigen. This finding is thought to be the expression of a reduced rather than enhanced fibrinolytic activity.

Reperfusion treatment of ST-elevation acute myocardial infarction

Reperfusion treatment of ST-segment elevation myocardial infarction (STEMI) is one of the medical interventions with the largest potential for saving human lives, independently of age and gender. An attempt to reopen an acutely occluded coronary artery can be done within a wide array of possibilities, from the simple administration of aspirin to the combination of drugs and complex coronary artery interventions. Fibrinolytic drugs and aspirin represent the easiest way to attempt reperfusion and together offer an acceptable compromise between opportunity for treatment and efficacy. Other drugs and the use of invasive revascularization alternatives yield further advantages, and in some high-risk subgroups may be the most rational treatment approach. Beyond investigator's bias and dedication to either form of reperfusion treatment, interventions and/or drugs should be used as needed (and as possible) to increase the overall impact of reperfusion treatment in the community, taking advantage of the best potential of each approach. Most resources have been directed toward the improvement of reperfusion rates with the combination of fibrinolytic and antiplatelet drugs or with angioplasty. These efforts have certainly raised costs, but have not decisively improved clinical outcome nor have they broadened the impact of reperfusion treatment in the community. Indeed, the main shortcoming of reperfusion therapy is that the cohort of untreated patients is still larger than the cohort of treated patients. At a time when mortality of patients with STEMI reaching the hospital and receiving treatment has decreased significantly, the prehospital diagnosis and treatment of STEMI with the objective of enlarging the treated population and shortening the pretreatment delays is likely the best strategy to further reduce mortality. The need for a population approach to treatment of STEMI is even more obvious when considering the expanding patient load that continuously worsens its clinical risk profile, together with the increasing incidence of diabetes, obesity, hypertension, and smoking habits. The target for improving reperfusion treatment of STEMI in the future, and thereby saving more lives, seems now to involve a cultural change and fulfillment of an organizational mission more than an incremental improvement in the current pharmacologic or interventional approach. These epidemiologic and social aspects of contemporary medicine deserve full attention at a time when researchers, clinicians, and health care providers tend to focus primarily on technological advances.

Angiotensin Antagonism in Coronary Artery Disease

The renin-angiotensin system (RAS) is an ancient and complex cascade of homeostatic reactions aimed at regulating primordial functions that ensure organ perfusion through the control of blood pressure and the regulation of renal-cardiac activity. However, the over-expression or lack of compensatory mechanisms of any of its components may initiate detrimental effects that potentially lead to disease, a balance that makes the RAS a sequence with a labile physiological equilibrium and with a strong harm potential. These characteristics of the RAS in general, and of the angiotensin converting enzyme (ACE) in particular, make it not only an important complex for the regulation of blood pressure and neuropeptide metabolism, but also a fascinating subject of study from a biochemical, evolutionary and genetic point of view. Pharmacological interventions that influence the RAS by inhibiting the ACE or the angiotensin II type 1 receptor (AT1R) have demonstrated sustained efficacy in reducing the incidence of cardiovascular events and, consequently, vascular mortality in several clinical situations. ACE inhibitors and angiotensin II receptor antagonists (ARAs) reduce blood pressure and have cardio- and vasculoprotective effects. Anti-atherosclerotic effects have also been attributed to these drugs. For these reasons, it has been hypothesised that RAS inhibitors could also reduce the recurrence of ischaemic events after myocardial revascularisation procedures, namely coronary artery by-pass graft surgery (CABG) or percutaneous coronary interventions (PCI). Information available on the effect of ACE inhibitors and ARAs in patients with coronary artery disease (CAD) previously treated with revascularisation techniques indicates a substantial reduction of mortality and infarction in these patients. However, data regarding the progression of CAD, restenosis or reocclusion of vascular conduits of the coronary circulation after myocardial revascularisation are inconsistent. In most studies, the administration of ACE inhibitors neither improved the ischaemic threshold nor reduced the need for new revascularisation procedures. On the contrary, ACE inhibitors have been associated with higher restenosis rates after PCI in some retrospective series. Conversely, a single, exploratory randomised trial demonstrated that the selective AT1R antagonist valsartan significantly reduced stent restenosis after PCI. In patients undergoing CABG, ACE inhibitors did not reduce the risk of graft degeneration or occlusion. Studies that evaluated a possible anti-atherosclerotic effect of ACE inhibitors (including some large randomised trials) have generally been negative.

Intracoronary β-irradiation prevents excessive in-stent neointimal proliferation in de novo lesions of patients with high plasma ACE levels. The BetAce randomized trial

BACKGROUND

This study evaluated vascular brachytherapy (VBT) as a potent antiproliferative treatment to prevent in-stent restenosis (ISR) after coronary angioplasty of de novo lesions in patients carrying the D allele of the I/D polymorphism of the ACE gene and high ACE plasma levels (>34 U/l).

METHODS AND MATERIALS

A prospective randomized trial was designed to detect a 30% improvement in the minimal lumen diameter (MLD) of the stenotic artery, as measured by quantitative coronary analysis (QCA), 6 months following VBT at the time of stented angioplasty. All patients were carriers of the D allele of the ACE gene, with plasma ACE levels >34 U/l.

RESULTS

Thirty-one patients (33 stenoses) were allocated to stent implantation (control group) and 30 patients (31 stenoses) to VBT and stented angioplasty. After angioplasty, in-stent MLD was similar in the two groups. At 6 months in the control group, in-stent MLD had decreased to 1.74+/-0.8 versus 2.25+/-1.05 mm in the VBT group (P=.04). The mean in-stent diameter was 2.3+/-0.8 mm in the control group versus 2.9+/-1.05 mm after VBT (P=.02), and the restenosis rate was 37.5% versus 17.9%, respectively (P=.08). At 6 months, a higher need for target vessel revascularization (TVR) was observed in the control group: 35.5% versus 13.3% (P=.04).

CONCLUSIONS

This randomized study confirms that patients with high plasma ACE concentrations are exposed to an increased risk for ISR after coronary stenting. The preventive use of VBT in these patients reduced neointimal formation by 65% such that the MLD at follow-up was increased by 29% compared with the control group.

Association study of the I/D polymorphism and plasma angiotensin-converting enzyme (ACE) as risk factors for stent restenosis

The ID (insertion/deletion) polymorphism of the ACE (angiotensin-converting enzyme) gene controls plasma ACE levels. Both have been correlated with ISR (in-stent restenosis) in preliminary analyses, but not confirmed in larger studies. In the present study, baseline and 6-month quantitative coronary analysis were performed in 897 patients who had stent implantation and the ID polymorphism genotyped. Plasma ACE levels were measured in 848 patients (95%). Restenosis rates among genotypes were 31.2% DD, 25.5% ID and 28.8% II (not significant). Plasma ACE levels were significantly higher in restenotic patients compared with patients without restenosis (30.7+/-18.6 units/l compared with 22.8+/-12.8 units/l; P=0.0001) and a strong independent predictor of ISR [OR (odds ratio)=3.70; 95% CI (confidence interval), 2.40-5.71; P<0.0001], except in diabetics. In the subgroup of diabetics and patients with AMI (acute myocardial infarction), the DD genotypes actually had a lower risk of ISR than the II genotypes (diabetics, OR=0.16; 95% CI, 0.04-0.69; P=0.014; and patients with AMI, OR=0.21; 95% CI, 0.061-0.749; P=0.016). After exclusion of diabetics and patients with AMI, ISR rates for genotypes in 632 patients were 31.7% DD, 24.3% ID and 17.6% II (P=0.02; DD compared with non-DD OR=1.57; 95% CI, 1.09-2.25). The association between the D allele and ISR observed in selected populations does not hold with a larger sample size. Other than sample size, clinical variables can modulate the association between ID polymorphism and ISR. Plasma ACE level is a risk factor for ISR, independently of the ID genotype.

Comparison of frequency of insulin resistance after coronary stenting in patients with type 2 diabetes mellitus with versus without coronary restenosis

The large incidence of restenosis after coronary angioplasty in diabetic patients renders this procedure less effective than in nondiabetics, and insulin resistance could be a relevant cause of restenosis in such patients. This study assessed insulin resistance and biologic markers of metabolic control in type 2 diabetic patients treated with stented angioplasty. Seventy-four patients were studied prospectively. Biochemical determinations, insulin tolerance test results, and the rate constant for plasma glucose disappearance (K(itt)%) were obtained. The angiographic outcome of angioplasty was assessed by quantitative coronary analysis at baseline and at 6 months in 64 patients (86%). Patients with restenosis had smaller minimum luminal diameters after stenting (2.8 +/- 0.5 vs 3.04 +/- 0.5 mm, p = 0.05), were more often hypertensive (97% vs 79%, p = 0.02) and treated with angiotensin-converting enzyme inhibitors (53% vs 23%, p = 0.02), and had smaller K(itt)% (2.9 +/- 1.6%/min vs 3.7 +/- 1.4%/min, p = 0.04) and larger titers of growth hormone (1.36 +/- 1.5 vs 0.68 +/- 0.6 ng/ml, p = 0.02).

Giant coronary artery fistula connecting the left coronary sinus with the superior atriocaval junction

A left Valsalva sinus-right atriocaval junction giant congenital fistula was diagnosed in a young man with recent bacterial endocarditis. Surgical closure of the fistula was performed to correct the left-to-right shunt, to reduce the risk of recurrence of endocarditis and to prevent aortic root distortion. Surgery was preferred to percutaneous treatment because of the perceived risk of coronary complications. The dimensions of the residual chamber connected with the aortic root appeared unchanged at the 1-year follow-up echocardiography. Simple closure, with no procedure on the proximal coronary tract of the fistula may offer an effective and definitive correction of giant fistulas.

The usefulness of adenosine 99mTc tetrofosmin SPECT for the diagnosis of left anterior descending coronary artery disease in patients with chest pain and left bundle branch block

OBJECTIVES

The aim of this study was to assess the usefulness of 99mTc tetrofosmin single photon emission computed tomography (SPECT) for the diagnosis of left anterior descending (LAD) coronary artery disease in 60 subjects with left bundle branch block (LBBB) admitted for chest pain.

METHODS AND RESULTS

Adenosine 99mTc tetrofosmin SPECT, transthoracic echocardiogram and coronary angiography were performed, by protocol, in 60 non-infarcted consecutive patients. The mean left ventricular ejection fraction (LVEF) was 41.6 +/- 10.8%. A significant angiographic disease of the LAD was found in 15 (25%) patients. The sensitivity and the specificity of SPECT was found to be 75% and 89%, respectively; the positive predictive value (PPV) was 70% with a negative predictive value (NPV) of 91%. During the adenosine infusion the QRS complex width reduced from 131.3 +/- 29.6 ms to 125.5 +/- 28.6 ms in the patients without LAD involvement (P = 0.008) but remained unchanged in LAD disease patients (P = 0.1). Combining SPECT information and QRS analysis the sensitivity increased to 87% with unchanged specificity, the PPV was 74% and the NPV resulted 95%. At 2-year follow-up 13 (22%) patients experienced a cardiac event. Using Kaplan-Meier analysis, an LVEF of < or = 35% was the only predictor of cardiac events (P = 0.01, log-rank 6.2).

CONCLUSIONS

A quarter of patients with LBBB complaining of chest pain had LAD coronary disease. The highly negative predictive value of adenosine SPECT could help in the exclusion of LAD disease, especially when the SPECT image is combined with the QRS analysis.

[Left internal mammary artery graft stenosis. Atherosclerosis, spasm or kinking?]

The internal mammary artery is the most frequently used bypass conduit for the left anterior descending coronary artery in patients treated with bypass surgery, with excellent long-term patency rates. However, the mammary artery may also be affected by functionally significant stenoses. Most stenoses of the mammary artery are secondary to the surgical procedure at the anastomosis site, but atherosclerotic lesions may also develop. The mammary artery is often tortuous and extreme kinking of the vessel may cause flow obstruction. The treatment of such kind of stenoses is not codified. The clinical course and interventional procedure of 2 patients with previous mammary artery bypass graft and severe angina due to kinking stenosis of the graft are described. The 2 cases are characterized by the short time frame during which the stenosis became apparent, suggesting a vasoactive component in the first case that was resolved with medical treatment and an aggressive atherosclerotic progression in the second that required a percutaneous intervention. Therefore, etiology of the stenosis of the body of the mammary artery graft may differ from that of the native circulation. The role of marked bends in bypass grafts could deserve selective studies to determine whether they are associated with the development of functional stenosis. This information may be useful when performing mammary artery bypass graft surgery for avoiding extremely twisted vessel courses.

Estrogen receptor-alpha polymorphisms and angiographic outcome after coronary artery stenting

OBJECTIVE

Because of the receptor-mediated antiproliferative effects of estradiol on vascular smooth muscle cells, our study aimed at identifying a role of PvuII and XbaI polymorphisms of the alpha-estrogen receptor (alphaER) gene in the occurrence of restenosis after coronary stent implantation (in-stent restenosis [ISR]).

METHODS AND RESULTS

In 858 patients (148 women), 955 lesions were treated with stent implantation, and the PvuII C/T and XbaI G/A polymorphisms of the alphaER gene were determined. Quantitative angiography was performed before and after stenting and at 6-month follow-up. The allelic frequencies were similar between sexes (C/T allele, 0.43/0.57 and 0.44/0.56; P=0.9; G/A allele, 0.35/0.65 and 0.38/0.62; P=0.8; in women and men, respectively). A significantly higher ISR rate in women than in men homozygous for the T-allele of the PvuII polymorphism (42.6% versus 26.9%, P=0.03) or the G-allele of the XbaI polymorphism (41.2% versus 19.4%, P=0.04) was observed. At multivariate analysis, T/T genotype was the only independent predictor of ISR in women but not in men (odds ratio, 1.5; 95% CI, 1.0 to 2.1; P=0.03). XbaI polymorphism was no longer associated with ISR in both sexes.

CONCLUSIONS

Women homozygous for the T-allele of the PvuII polymorphism of the alphaER gene treated with coronary stent implantation have a higher risk of ISR than men.

Effects of the addition of a low dose of spironolactone on brain natriuretic peptide plasma level and cardiopulmonary function in patients with moderate congestive heart failure

BACKGROUND

The purpose of our study was to assess the effects of a low dose of spironolactone in patients with moderate congestive heart failure (CHF) on the plasma level of brain natriuretic peptide (BNP), echocardiographic left ventricular ejection fraction (LVEF), and cardiopulmonary function assessed by cardiopulmonary (CP) test.

MATERIAL/METHODS

51 CHF patients (74.5% males, mean age 60 years) underwent transthoracic echocardiography, CP test, and plasma BNP assay at the time of enrollment and after 6 months of standard therapy for CHF plus a low dose of spironolactone (group A). A control group (21 patients, group B) was treated using standard therapy only. All subjects were in NYHA class I-III and had LVEF < or = 40%.

RESULTS

BNP concentration decreased significantly (from 45.7+/-57.4 pg/ml to 18.6+/-26.9 pg/ml at follow-up; p=0.01), and the NYHA class and LVEF improved (2.2+/-0.6 vs 1.7+/-0.5, p=0.0001; 27.7+/-7.2% vs 35.1+/-11%, p=0.001 respectively) in subjects in group A. In spite of clinical amelioration, peak oxygen consumption, oxygen pulse and anaerobic threshold in the CP test did not change significantly (16.6+/-5.7 ml/kg/min vs 17.1+/-5.3 ml/kg/min p=0.5; 8.8 +/- 4.3 ml/beat vs 9.5+/-3.6 ml/beat p=0.2; 0.75+/-0.2 ml/Kg/min vs 0.73+/-0.2 ml/Kg/min p=0.7). No differences were noticed in the control group.

CONCLUSIONS

The addition of spironolactone reduced the BNP plasma level in patients with moderate CHF and increased LVEF. This therapy improved the NYHA class without modifying the functional parameters in the CP test.

Effect of angiotensin-converting enzyme inhibition on restenosis after coronary stenting

The Plasma level of angiotensin-converting enzyme (ACE) has been identified as a major risk factor for restenosis after coronary stent implantation in selected patients; ACE inhibition may therefore contribute to prevent its occurrence. The effect of oral ACE inhibition at conventional doses was analyzed retrospectively in a series of 897 patients with ischemia who received >or=1 coronary stent on 998 lesions and underwent angiographic follow-up; no exclusion criteria were introduced in this analysis. The restenosis rate in 282 patients (31.4%) taking ACE inhibitors was 36.6% compared with 22.9% in 615 non-ACE-inhibited patients (p = 0.00001, odds ratio [OR] 1.94, 95% confidence interval [CI] 1.45 to 2.59), and the late loss in minimum lumen diameter was 1.25 +/- 0.8 versus 0.96 +/- 0.8 mm, respectively (p = 0.0001). During univariate analysis, a negative effect of the drug on restenosis was observed in all subgroups of patients (i.e., hypertensives, diabetics, women, and patients with previous myocardial infarction). Similar effects were observed independently of the ACE gene insertion/deletion polymorphism. During multivariate analysis, ACE inhibition was confirmed as an independent risk factor for restenosis (OR 1.84, 95% CI 1.35 to 2.51, p = 0.0001). Other predictors were the implantation of multiple stents (OR 2.41, 95% CI 1.60 to 3.64, p <0.0001), diabetes (OR 2.34, 95% CI 1.61 to 3.41, p <0.0001), and vessel reference diameter before angioplasty (OR 0.51, 95% CI 0.38 to 0.69, p <0.0001). Although unexplained and apparently contradictory, our data suggest that the use of conventional oral doses of ACE inhibitors in a "real-world" population who underwent coronary stent implantation increases the incidence of in-stent restenosis. Such a finding does not negate the known clinical benefits of ACE inhibitors, but it may deserve attention when a patient treated with ACE inhibitors becomes a candidate for stent implantation.

Immunosuppressive Therapy for the Prevention of Restenosis after Coronary Artery Stent Implantation (IMPRESS Study)

OBJECTIVES

This study tested the effect of oral prednisone on clinical and angiographic restenosis rate after successful stent implantation in patients with persistent elevation of systemic markers of inflammation after the procedure.

BACKGROUND

Experimental studies have shown that corticosteroids have the potential to reduce the inflammatory response associated with stent implantation.

METHODS

Eighty-three patients undergoing successful stenting with C-reactive protein (CRP) levels >0.5 mg/dl 72 h after the procedure were randomized to receive oral prednisone or placebo for 45 days. The primary clinical end point was 12-month event-free survival rate (defined as freedom from death, from myocardial infarction, and from recurrence of symptoms requiring additional revascularization). The angiographic end points were restenosis rate and late loss at six months.

RESULTS

Twelve-month event-free survival rates were 93% and 65% in patients treated with prednisone and placebo, respectively (relative risk [RR] 0.18, 95% confidence intervals [CI], 0.05 to 0.61, p = 0.0063). Six-month restenosis rate and late loss were lower in prednisone-treated than in placebo-treated patients (7% vs. 33%, p = 0.001, and 0.39 +/- 0.6 mm vs. 0.85 +/- 0.6 mm, p = 0.001, respectively).

CONCLUSIONS

In patients with persistently high CRP levels after successful coronary artery stent implantation, oral immunosuppressive therapy with prednisone results in a striking reduction of clinical events and angiographic restenosis rate.

Effective plaque removal with a new 8 French-compatible atherectomy catheter

The purpose of this study was to evaluate the safety and efficacy of the new 8 Fr guide catheter-compatible Flexicut directional atherectomy device and to compare it with the conventional Atherocath GTO catheter. The 6 Fr Flexicut catheter has a larger cutting window and a titanium nitride-coated cutter to effect more tissue removal as well as treat mildly calcified lesions. A group of 143 lesions in 117 consecutive patients treated with the Flexicut catheter in four centers were compared with a control group of 277 lesions in 212 consecutive patients treated with the GTO device. Postatherectomy luminal diameters were larger (2.92 +/- 0.79 vs. 2.52 +/- 0.64 mm; P < 0.0001), with more luminal gain (relative gain: 0.58 +/- 0.24 vs. 0.48 +/- 0.25; P = 0.0007) using fewer directional coronary atherectomy (DCA) cuts (12 +/- 7 vs. 16 +/- 9; P = 0.0001) in the Flexicut group. A residual diameter stenosis < 20% immediately after DCA was obtained in 77% of the lesions in the Flexicut group vs. 45% in the GTO group (P < 0.0001). Histology in the former group revealed large calcium speckles in the retrieved specimens. In the Flexicut group, there was a lower incidence of access site complications and damage to the coronary ostium (2.5% vs. 7.5%; P = 0.08). The new Flexicut catheter is more effective than the conventional GTO catheter with a trend for reduced guiding catheter-related complications.

The diagnosis of coronary artery disease in hypertensive patients with chest pain and complete left bundle branch block: utility of adenosine Tc-99m tetrofosmin SPECT

PURPOSE

Hypertensive patients with complete left bundle branch block who experience chest pain present special problems in the radionuclide diagnosis of coronary artery disease (CAD). The aim of this study was to assess the utility of Tc-99m tetrofosmin SPECT for the diagnosis of CAD in 35 hypertensive patients with left bundle branch block hospitalized for chest pain.

MATERIALS AND METHODS

Images were analyzed semiquantitatively for the presence of both fixed or reversible perfusion defects (method A) or only reversible defects (method B) in the distribution of the left anterior descending artery (LAD) territory. Perfusion defects observed in the territory of any other coronary artery were always considered. Thirty-five patients without infarction underwent adenosine Tc-99m tetrofosmin SPECT, transthoracic echocardiography, and coronary angiography.

RESULTS

The mean left ventricular ejection fraction was calculated as 39.9% +/- 11.6%, and the prevalence of CAD was 29%. The sensitivity of SPECT was identical for the two methods at 89%. The specificity increased 19% with method A and 54% with method B. The positive predictive value remained unsatisfactorily low with both methods (27% for method A and 40% for method B), and the negative predictive value improved from 83% with method A to 93% with method B.

CONCLUSIONS

Only reversible perfusion defects in the LAD territory should be considered significant for CAD, and these patients should undergo coronary angiography. Reversible or fixed perfusion defects in the left circumflex and right coronary artery territories should be evaluated according to other clinical parameters (global left ventricular ejection fraction, extension of perfusion defects). The highly negative predictive value of adenosine SPECT could help in the exclusion of CAD.

Clinical characteristics and outcome of patients with early (<2 h), intermediate (2-4 h) and late (>4 h) presentation treated by primary coronary angioplasty or thrombolytic therapy for acute myocardial infarction

AIMS

We examined the clinical characteristics and outcome of patients with early (<2 h), intermediate (2-4 h) and late (>4 h) presentation treated by primary angioplasty or thrombolytic therapy for acute myocardial infarction.

METHODS AND RESULTS

We studied 2635 patients enrolled in 10 randomized trials of primary angioplasty (n=1302) vs thrombolytic therapy (n=1333) in acute myocardial infarction, and baseline characteristics of the two groups were comparable. Increase in presentation delay is associated with older age, female gender, diabetes and an increased heart rate. We classified the patients according to the time delay from symptom onset to presentation into three categories: early presentation (<2 h), intermediate presentation (2-4 h), and late presentation (>or=4 h). At 30 days the combined rate of death, non-fatal reinfarction and stroke in patients presenting early was 5.8% in the angioplasty group vs 12.5% in the thrombolysis group, in patients with intermediate presentation, 8.6% vs 14.2%, respectively, and in patients presenting late 7.7% vs 19.4%, respectively. With increasing time from symptom onset to presentation, all major adverse cardiac event rates show a trend to a larger increase in the thrombolysis group compared to the angioplasty group, both at 30 days and at 6 months after the acute event.

CONCLUSIONS

Major adverse cardiac event rates are lower after angioplasty compared to thrombolysis, irrespective of time to presentation. With increasing time to presentation major adverse cardiac event rates increase after thrombolysis but appear to remain relatively stable after angioplasty.