Comparison of 9-month angiographic outcomes of Resolute zotarolimus-eluting and everolimus-eluting stents in a real world setting of coronary intervention in Korea

BACKGROUND

Clinical outcomes of new-generation drug-eluting stents (DES), Everolimus-eluting stent (EES) or Resolute zotarolimus-eluting stent (R-ZES), have been reported. However, angiographic follow-up data of new-generation DES are limited, especially in Asians. We investigated the angiographic and clinical outcomes of EES and R-ZES in a real-world setting of Korean patients.

METHODS

Angiographic and clinical outcomes of 679 patients (866 lesions) who had been treated with EES or R-ZES from Jun 2008 to May 2010 were evaluated. The primary analysis was to compare in-segment late loss at 9 months and the secondary analyses were to compare the clinical outcomes.

RESULTS

In-segment late loss at 9-month follow-up angiography was 0.23 ± 0.52 mm for EES and 0.29 ± 0.64 mm for R-ZES (p = 0.248). In addition, the rate of binary restenosis did not show between-group differences (5.8% vs. 6.8% for EES and R-ZES, respectively, p = 0.716). During a median follow-up of 33 months, there were no significant differences in Kaplan-Meier estimates of target lesion failure (TLF) (7.5% vs. 7.9% for EES and R-ZES, respectively, p = 0.578) and patient-oriented composite outcomes (POCO including all-cause death, any myocardial infarction, and any revascularization, 22.8% vs. 20.1%, p = 0.888). The adjusted hazard ratios for TLF and POCO were 0.875 (95% CI 0.427 - 1.793; p = 0.715) and 1.029 (95% CI 0.642 - 1.650; p = 0.904), respectively, for EES over R-ZES in the propensity score matched group analysis.

CONCLUSIONS

In Korean patients undergoing new-generation DES implantation for coronary artery disease, EES and R-ZES showed similar angiographic outcomes at 9 months and comparable clinical outcomes during 2.8 years of median follow-up.

Impact of anticoagulation on coronary flow in patients with non-ST elevation acute coronary syndrome

The effect of anticoagulation by heparin on patients with non-ST elevation acute coronary syndrome (NSTE-ACS), receiving early dual antiplatelet therapy, has not been fully evaluated. We classified 355 patients with NSTE-ACS according to the adequacy of anticoagulation (percentage of low activated partial thromboplastin time [APTT] level). The 6-hour APTT level was optimal in only 23.1% of the patients treated with unfractionated heparin. The rate of poor preprocedural coronary blood flow (thrombolysis in myocardial infarction grade <3, 39.1%, 30.5%, 30.3%, and 33.9% in the 100% low-, 99%∼50% low-, 49%∼1% low-, and 0% low-APTT group, respectively, P = .632) and bleeding events did not differ between the groups. Instead, in multivariate analysis, the diagnosis of myocardial infarction was the only independent predictor of poor coronary flow. For bleeding events, the usage of glycoprotein IIb/IIIa inhibitor appeared to be a sole risk factor. In conclusion, inadequate preprocedural anticoagulation was not associated with adverse outcomes in patients with NSTE-ACS treated with dual antiplatelet agents.

Clinical and physiological outcomes of fractional flow reserve-guided percutaneous coronary intervention in patients with serial stenoses within one coronary artery

OBJECTIVES

This study was performed to evaluate the physiological and clinical outcomes of fractional flow reserve (FFR)-guided revascularization strategy with drug-eluting stents in serial stenoses within the same coronary artery.

BACKGROUND

Identifying a functionally significant stenosis is difficult when several stenoses exist within 1 coronary artery.

METHODS

A total of 131 patients (141 vessels and 298 lesions) with multiple intermediate stenoses within the same coronary artery were assessed by FFR with pullback pressure tracings. In vessels with an FFR <0.8, the stenosis that caused the largest pressure step-up was stented first. Major adverse cardiac events were assessed during follow-up.

RESULTS

FFR was measured 239 times and there were no procedure-related complications. There was a weak negative correlation between FFR and angiographic percent diameter stenosis (r = -0.282, p < 0.001). In total, 116 stents were implanted and revascularization was deferred in 61.1% (182 of 298) of lesions. When the vessels with an initial FFR <0.8 were divided into 2 groups according to FFR after first stenting (FFR ≥0.8 vs. FFR <0.8), there were no differences in baseline angiographic and physiological parameters between the 2 groups. During the mean follow-up of 501 ± 311 days, there was only 1 target vessel revascularization due to in-stent restenosis. There were no events related to deferred lesions.

CONCLUSIONS

FFR-guided revascularization strategy using pullback pressure tracing in serial stenoses was safe and effective. This strategy can reduce unnecessary intervention and maximize the benefit of percutaneous coronary intervention with drug-eluting stents in patients with multiple stenoses within 1 coronary artery.

Prevalence and prognostic implication of non-calcified plaque in asymptomatic population with coronary artery calcium score of zero

Background and Objectives

Non-calcified plaque (NCP) identified by coronary CT angiography (CCTA) has been reported in up to 10% of individuals with coronary artery calcium score (CACS) of zero. However, clinical risk factors and the prognostic value of NCP in asymptomatic subjects with CACS of zero are unknown.

Subjects and Methods

The study population consisted of consecutive asymptomatic subjects (48±8 years, 57% men) who underwent CCTA from December 2005 to January 2008 as part of a general health evaluation.

Results

Among 4491 of overall asymptomatic individuals with CACS of zero, 313 subjects (7%) had NCP: 279 patients (6%) with non-obstructive and 34 (1%) with obstructive. In multivariable analyses, age, male gender, diabetes, hypertension, and dyslipidemia were significantly associated with presence of NCP (all p<0.05). During the median follow-up duration of 22 months (interquartile percentile: 18 to 28 months) of subjects with NCP (n=313) and age, gender, and CCTA date matched individuals without NCP (n=313), there was no clinical event including all-cause death nor composite outcome of cardiac death, myocardial infarct, unstable angina requiring hospitalization, and revascularization after 90 days from index CCTA in both groups.

Conclusion

In the largest series of asymptomatic individuals with CACS of zero undergoing CCTA, age, male gender, diabetes, hypertension, and dyslipidemia were independently associated with NCP. However, a future risk of exclusive NCP in asymptomatic subjects with CACS of zero was negligible.

Prognostic value of neutrophil to lymphocyte ratio in patients presenting with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention

Atherosclerosis is an inflammatory process, and inflammatory biomarkers have been identified as useful predictors of clinical outcomes. The prognostic value of leukocyte count in patients with ST-segment elevation myocardial infarctions who undergo primary percutaneous coronary intervention is not clearly defined. In 325 patients with STEMIs treated with primary percutaneous coronary intervention, total and differential leukocyte counts, once at admission and 24 hours thereafter, were measured. The neutrophil/lymphocyte ratio (NLR) was calculated as the ratio of neutrophil count to lymphocyte count. The primary end point was all-cause death. Twenty-five patients (7.7%) died during follow-up (median 1,092 days, interquartile range 632 to 1,464). The total leukocyte count decreased (from 11,853 ± 3,946/μl to 11,245 ± 3,979/μl, p = 0.004) from baseline to 24 hours after admission. Patients who died had higher neutrophil counts (9,887 ± 5,417/μl vs 8,399 ± 3,639/μl, p = 0.061), lower lymphocyte counts (1,566 ± 786/μl vs 1,899 ± 770/μl, p = 0.039), and higher NLRs (8.58 ± 7.41 vs 5.51 ± 4.20, p = 0.001) at 24 hours after admission. Baseline leukocyte profile was not associated with outcomes. The best cut-off value of 24-hour NLR to predict mortality was 5.44 (area under the curve 0.72, 95% confidence interval [CI] 0.52 to 0.82). In multivariate analysis, a 24-hour NLR ≥5.44 was an independent predictor of mortality (hazard ratio 3.12, 95% CI 1.14 to 8.55), along with chronic kidney disease (hazard ratio 4.23, 95% CI 1.62 to 11.1) and the left ventricular ejection fraction (hazard ratio 0.94 for a 3% increase, 95% CI 0.76 to 0.93). In conclusion, NLR at 24 hours after admission can be used for risk stratification in patients with STEMIs who undergo primary PCI. Patients with STEMIs with 24-hour NLRs ≥5.44 are at increased risk for mortality and should receive more intensive treatment.

Comparison of a drug-eluting balloon first and then bare metal stent with a drug-eluting stent for treatment of de novo lesions: study protocol of a randomized controlled trial

Background

The use of a drug-eluting balloon for the treatment of de novo coronary artery lesions remains to be evaluated. A previous trial in patients with stable and unstable angina comparing a bare metal stent mounted on a drug-eluting balloon with a sirolimus-eluting stent failed to meet the prespecified non-inferiority criteria versus the sirolimus-eluting stent. The stent struts of a bare metal stent pre-mounted on a drug-eluting balloon may prevent the appropriate delivery of drugs to the vessel wall and may result in reduced efficacy. In the present study we will therefore evaluate the efficacy of a drug-eluting balloon for treating de novo coronary artery lesions using a strategy designed to uniformly deliver drug to the vessel with a bare metal stent.

Methods/Design

The Comparison of Drug-Eluting Balloon first study is a prospective, randomized, open-label trial designed to demonstrate the non-inferiority of first using a drug-eluting balloon (Sequent^® please; B. Braun, Melsungen, Germany) followed by a bare metal stent (Coroflex^® Blue; B. Braun) compared with using a drug-eluting stent (Resolute Integrity™; Boston Scientific, Natick, MA, USA) for de novo coronary artery lesions. The primary endpoint of the study is in-segment late loss at 9 months measured by quantitative coronary angiography. Secondary endpoints include angiographic findings such as angiographic success, device success, binary angiographic restenosis, and clinical outcomes such as procedural success, all-cause death, myocardial infarction, target vessel revascularization, target lesion revascularization, and stent thrombosis. A total of 180 patients will be enrolled in the study.

Discussion

The Comparison of Drug-Eluting Balloon first study will evaluate the clinical efficacy, angiographic outcomes and safety of a drug-eluting balloon first followed by a bare metal stent compared with a drug-eluting stent for the treatment of de novo coronary artery lesions.

Trial registration

Clinical Trials.gov: NCT01539603

Safety and efficacy of second-generation everolimus-eluting Xience V stents versus zotarolimus-eluting resolute stents in real-world practice: patient-related and stent-related outcomes from the multicenter prospective EXCELLENT and RESOLUTE-Korea registries

OBJECTIVES

This study sought to compare the safety and efficacy of the Xience V/Promus everolimus-eluting stent (EES) (Abbott Vascular, Temecula, California) with the Endeavor Resolute zotarolimus-eluting stent (ZES-R) (Medtronic Cardiovascular, Santa Rosa, California) in "all-comer" cohorts.

BACKGROUND

Only 2 randomized controlled trials have compared these stents.

METHODS

The EXCELLENT (Efficacy of Xience/Promus Versus Cypher to Reduce Late Loss After Stenting) and RESOLUTE-Korea registries prospectively enrolled 3,056 patients treated with the EES and 1,998 patients treated with the ZES-R, respectively, without exclusions. Stent-related composite outcomes (target lesion failure [TLF]) and patient-related composite outcomes were compared in crude and propensity score-matched analyses.

RESULTS

Of 5,054 patients, 3,830 (75.8%) had off-label indication (2,217 treated with EES and 1,613 treated with ZES-R). The stent-related outcome (82 [2.7%] vs. 58 [2.9%], p = 0.662) and the patient-related outcome (225 [7.4%] vs. 153 [7.7%], p = 0.702) did not differ between EES and ZES-R, respectively, at 1 year, which was corroborated by similar results from the propensity score-matched cohort. The rate of definite or probable stent thrombosis (18 [0.6%] vs. 7 [0.4%], p = 0.306) also was similar. In multivariate analysis, off-label indication was the strongest predictor of TLF (adjusted hazard ratio: 2.882; 95% confidence interval: 1.226 to 6.779; p = 0.015).

CONCLUSIONS

In this robust real-world registry with unrestricted use of EES and ZES-R, both stents showed comparable safety and efficacy at 1-year follow-up. Overall incidences of TLF and definite stent thrombosis were low, even in the patients with off-label indication, suggesting excellent safety and efficacy of both types of second-generation drug-eluting stents.

Effect of tailored antiplatelet therapy on periprocedural myonecrosis in patients with diabetes mellitus (from the DM-Verify Now Trial)

We investigated whether additional platelet inhibition with a glycoprotein IIb/IIIa inhibitor would be beneficial in reducing the risk of periprocedural myocardial infarction (PMI) in diabetic patients with high residual platelet reactivity (HPR). Patients with diabetes mellitus were administered aspirin and clopidogrel at a 300-mg loading dose 1 day before the procedure, and the VerifyNow P2Y(12) assay was performed just before percutaneous coronary intervention. Patients with HPR, defined as a P2Y(12) reaction unit of ≥270 were randomly assigned to group A or control group C1. Patients without HPR were assigned to control group C2. Conventional anticoagulation with heparin was given to groups C1 and C2, and group A received additional abciximab treatment. Clinically relevant PMI was defined as any elevation in the biomarkers creatine kinase-MB isoenzyme and cardiac troponin I >3 times the upper normal limit measured 8, 16, or 24 hours after percutaneous coronary intervention. Of the patients, 47 and 51 were assigned to group A and C1; the clinical and procedural characteristics in the 2 groups were balanced. Of the 47 patients in group A and 51 patients in group C1, 9 (19%) and 9 (18%), respectively, experienced a PMI event according to the creatine kinase-MB cutoff (p = 1.00), and 27 in group A (57%) and 29 in group C1 (57%) experienced a PMI event according to the troponin I cutoff (p = 1.00). Five minor bleeding events, including small and localized hematomas, were observed immediately after the procedure (4 in group A and 1 in group C1). Only 1 major bleeding event, retroperitoneal hemorrhage, was observed in group A. The patients in group C2 had a PMI event rate (50% of 32 patients, p = 1.00) similar to that of group C1. In conclusion, additional platelet inhibition using a tailored approach and a point-of-care assay did not improve the periprocedural outcome in diabetic patients with HPR.

Cigarette smoking is paradoxically associated with low mortality risk after acute myocardial infarction

BACKGROUND

Cigarette smoking has been shown to be associated with a decreased risk of death after acute myocardial infarction (AMI), which is also known as the "smokers' paradox." This study aimed to investigate the relationship between smoking and all-cause mortality after AMI.

METHODS

We extracted the data of patients who were hospitalized for AMI between November 2005 and September 2010 from nationwide multicenter prospective registries in Korea.

RESULTS

Among a total of 29,199 patients with AMI, 10,251 (42.3%) were current smokers, and 14,006 (57.7%) were nonsmokers. Current smokers were younger, more likely to be male, and had lower frequencies of hypertension, diabetes mellitus, dyslipidemia, and previous history of ischemic heart disease than nonsmokers. The initial presentation was less severe in terms of hemodynamic status, and angiography showed less complex coronary involvement in smokers. The overall mortality rate was 5.4% for current smokers and 9.9% for nonsmokers (hazard ratio [HR], 0.52; 95% confidence interval [CI], 0.47-0.58; p < .001). The gap in risk was attenuated after multivariable adjustment but remained statistically significant (HR, 0.85; 95% CI, 0.76-0.95; p = .005). Propensity score matching corroborated the results of reduced mortality among current smokers (6.7% vs. 7.6%; p = .005).

CONCLUSIONS

In this study, in which the patients received up-to-date treatment options, smoking was associated with a 48% decrease in the risk of all-cause mortality at 1 year after AMI.

A randomized, prospective, two-center comparison of sirolimus-eluting stent and zotarolimus-eluting stent in acute ST-elevation myocardial infarction: the SEZE trial

BACKGROUND

The zotarolimus-eluting stent has shown larger in-stent late lumen loss compared to sirolimus-eluting stents in previous studies. However, this has not been thoroughly evaluated in ST elevation myocardial infarction.

METHODS

This was a prospective, randomized, controlled trial evaluating angiographic outcomes in patients presenting with ST elevation myocardial infarction, treated with zotarolimus-eluting stents or sirolimus-eluting stents. From March 2007 to February 2009, 122 patients were randomized to zotarolimus-eluting stents or sirolimus-eluting stents in a 1:1 fashion. The primary endpoint was 9-month in-stent late lumen loss confirmed by coronary angiography, and secondary endpoints were percent diameter stenosis, binary restenosis rate, major adverse cardiac events (a composite of cardiac death, non-fatal myocardial infarction, and target vessel revascularization), and late-acquired incomplete stent apposition.

RESULTS

Angiographic in-stent late lumen loss was significantly higher in the zotarolimus-eluting stent group compared to the sirolimus-eluting stent group ((0.49 ± 0.65) mm vs. (0.10 ± 0.46) mm, P = 0.001). Percent diameter stenosis at 9-month follow-up was also larger in the zotarolimus-eluting stent group ((30.0 ± 17.9)% vs. (17.6 ± 14.0)%, P < 0.001). In-segment analysis showed similar findings. There were no significant differences in binary restenosis rate, major adverse cardiac events, and late-acquired incomplete stent apposition.

CONCLUSIONS

Compared to sirolimus-eluting stents, the zotarolimus-eluting stent is associated with significantly higher in-stent late lumen loss at 9-month angiographic follow-up in the treatment of ST elevation myocardial infarction. Although there was no significant difference in 1-year clinical outcomes, the clinical implication of increased late lumen loss should be further studied.

Left ventricular thrombus and subsequent thromboembolism, comparison of anticoagulation, surgical removal, and antiplatelet agents

Left ventricular (LV) thrombus is one of the risk factors for systemic thromboembolism. The aims of this study were to compare the long-term clinical outcomes of LV thrombus using current therapeutics, anticoagulation, operative treatment, and antiplatelet agents and to identify independent predictors of systemic thromboembolism.

METHODS

We screened 86,374 patients for intracardiac thrombus in the electronic medical records and imaging databases. Records of 62 patients with LV thrombus, diagnosed between May 2003 to November 2011, were comprehensively reviewed regarding baseline characteristics, imaging data and thrombus outcomes, thromboembolic events and treatment complications by treatment group.

RESULTS

The majority (80.6%) had ischemic etiology. Systemic thromboembolism developed in 18 patients; 8 (45%) were post-treatment thromboembolisms while 10 events occurred before treatment began. No post-treatment thromboembolism occurred in the operative treatment group; in contrast, 7 post-treatment thromboembolisms occurred in anticoagulation group (17%) (Log rank p= 0.175). Independent predictors of post-treatment thromboembolism were dilated cardiomyopathy (HR 61.30, p= 0.001), previous cerebrovascular events (HR 7.06, p= 0.042), female gender (HR 7.11, p= 0.031), and echocardiographic left ventricular end-diastolic diameter (HR 1.15, p= 0.047).

CONCLUSIONS

In this study, the rate of post-treatment thromboembolism was not significantly different among the treatment groups; however, operative treatment tended towards less post-treatment thromboembolism than other treatment groups.

Lack of association between low density lipoprotein particle size and on-treatment platelet reactivity in patients with coronary artery disease

BACKGROUND AND OBJECTIVES

Small dense low density lipoproteins (sd-LDL) are a risk factor for coronary artery disease and are known to stimulate platelet function in vitro. This study aimed to evaluate whether high proportion of sd-LDL is associated with high on-treatment platelet reactivity (HOPR).

SUBJECTS AND METHODS

From January 2009 to March 2010, 439 subjects (mean age: 64.3±9.7, Male : Female=306 : 133) were enrolled from the low density LIPOProtein-cholesterol Size measurement Registry with coronary artery disease, who had undergone elective percutaneous coronary intervention and measured both LDL particle size and on-treatment platelet reactivity (OPR). Mean LDL particle size was measured by gradient gel electrophoresis (Quantimetrix, Lipoprint™) and OPR by the VerifyNow™ system (aspirin and P2Y12).

RESULTS

Between pattern A (large, buoyant LDL dominant) and B (sd-LDL dominant) population, there were no significant difference in OPR to aspirin (441.3±71.9 vs. 434.07±63.45 aspirin reaction units, p=0.351) or clopidogrel (237.9±87.3 vs. 244.9±80.7 P2Y12 reaction units, p=0.465). There was no difference in LDL particle size between patients with HOPR compared with non-HOPR patients (aspirin: 26.8±0.5 vs. 26.7±0.6 nm, p=0.078, clopidogrel: 26.7±0.6 vs. 26.8±0.5 nm, p=0.857). Pearson's correlation coefficients between LDL particle size and platelet reactivity were not statistically significant (aspirin assay: r=0.080, p=0.098, P2Y12 assay: r=-0.027, p=0.568).

CONCLUSION

There was no significant association between LDL particle size and OPR in patients with coronary artery disease.

Multicenter international registry of unprotected left main coronary artery percutaneous coronary intervention with everolimus-eluting stents

OBJECTIVE

The aim of this study was to assess the clinical outcomes of percutaneous coronary intervention (PCI) with everolimus-eluting stents (EES) for the treatment of unprotected left main coronary artery (ULMCA) disease.

BACKGROUND

The standard of care for the treatment of ULMCA disease is coronary artery bypass grafting (CABG). Data suggest that PCI with drug-eluting stents is a viable alternative to CABG for the treatment of ULMCA disease. Randomized trials demonstrated superior event-free survival with EES compared with paclitaxel-eluting stents in non-ULMCA lesions. However, data with ULMCA PCI with EES are limited.

METHODS

This multicenter international registry included 178 patients from the United States, South Korea, and Italy who underwent ULMCA PCI with EES from 2008 to 2010. The primary endpoint was freedom from target lesion failure (TLF), defined as cardiac death, myocardial infarction (MI), and ischemia-driven target lesion revascularization (TLR) at 1 year.

RESULTS

At 30 days, 4 patients (2.2%) died from cardiac causes, and no patient experienced MI or TLR. One-year freedom from TLF was 94.4%. One-year freedom from cardiac death, MI, and ischemia-driven TLR was 96.6%, 98.9%, and 98.3%, respectively. Two patients (1.1%) had definite or probable stent thrombosis.

CONCLUSION

PCI with EES is safe and effective and may be a viable option for the treatment of ULMCA disease.

The 'Harmonizing Optimal Strategy for Treatment of coronary artery stenosis - sAfety & effectiveneSS of drug-elUting stents & antiplatelet REgimen' (HOST-ASSURE) trial: study protocol for a randomized controlled trial

BACKGROUND

Second-generation drug-eluting stents (DES) have raised the bar of clinical performance. These stents are mostly made from cobalt chromium alloy. A newer generation DES has been developed from platinum chromium alloy, but clinical data regarding the efficacy and safety of the platinum chromium-based everolimus-eluting stent (PtCr-EES) is limited, with no comparison data against the cobalt chromium-based zotarolimus-eluting stent (CoCr-ZES). In addition, an antiplatelet regimen is an integral component of medical therapy after percutaneous coronary intervention (PCI). A 1-week duration of doubling the dose of clopidogrel (double-dose antiplatelet therapy (DDAT)) was shown to improve outcome at 1 month compared with conventional dose in acute coronary syndrome (ACS) patients undergoing PCI. However in Asia, including Korea, the addition of cilostazol (triplet antiplatelet therapy (TAT)) is used more commonly than doubling the dose of clopidogrel in high-risk patients.

METHODS

In the 'Harmonizing Optimal Strategy for Treatment of coronary artery stenosis - sAfety & effectiveneSS of drug-elUting stents & antiplatelet REgimen' (HOST-ASSURE) trial, approximately 3,750 patients are being prospectively and randomly assigned in a 2 × 2 factorial design according to the type of stent (PtCr-EES vs CoCr-ZES) and antiplatelet regimen (TAT vs DDAT). The first primary endpoint is target lesion failure at 1 year for the stent comparison, and the second primary endpoint is net clinical outcome at 1 month for comparison of antiplatelet therapy regimen.

DISCUSSION

The HOST-ASSURE trial is the largest study yet performed to directly compare the efficacy and safety of the PtCr-EES versus CoCr-ZES in an 'all-comers' population. In addition, this study will also compare the clinical outcome of TAT versus DDAT for 1-month post PCI.

TRIAL REGISTRATION

ClincalTrials.gov number NCT01267734.

Cotreatment with darbepoetin and granulocyte colony-stimulating factor is efficient to recruit proangiogenic cell populations in patients with acute myocardial infarction

To determine whether newer combination cytokine treatment with granulocyte colony-stimulating factor (G-CSF) and darbepoetin can improve efficacy of stem cell therapy, we evaluated safety and peripheral blood stem/progenitor cell (PBSC) mobilizing effects of combination cytokine in comparison with G-CSF alone in patients with acute myocardial infarction (AMI). We randomized 60 patients with AMI into two groups under 2:1 ratio; combination treatment with darbepoetin and G-CSF (n = 41: Combicytokine group) and the G-CSF alone (n = 19: G-CSF group). After coronary angioplasty, G-CSF was treated for 3 days with dose of 10 μg/kg/day in both groups. Only in the combicytokine group, additional single intravenous injection of 4.5 μg/kg of darbepoetin was administrated immediate after coronary angioplasty. Combination cytokine treatment was well tolerated as was G-CSF alone. PBSCs were obtained by apheresis for intracoronary infusion after completion of cytokine treatment and were analyzed by flow cytometry. The purity of proangiogenic cells was higher in combination cytokine group than the G-CSF group. Specifically, proportion of CD34(+)/KDR(+) endothelial progenitor cells, CD3(+)/CD31(+) angiogenic T cells and Tie2(+)/CXCR4(+) cells in apheresis products were higher in the combicytokine group. These meant that the combicytokine treatment recruited PBSCs in higher purity and fewer unwanted inflammatory cells than G-CSF alone in apheresis products. Combination treatment with darbepoetin and G-CSF is safe and more efficient to mobilize and recruit proangiogenic cells than G-CSF alone in patients with AMI. (

TRIAL REGISTRATION

www.ClinicalTrials. gov identifier: NCT00501917).