Stable coronary artery disease: revascularisation and invasive strategies

Risk of Early Adverse Events After Clopidogrel Discontinuation in Patients Undergoing Short-Term Dual Antiplatelet Therapy: An Individual Participant Data Analysis

OBJECTIVES

The study sought to evaluate the presence of a clinically relevant rebound phenomenon after dual antiplatelet therapy (DAPT) discontinuation in randomized trials.

BACKGROUND

It is currently unknown whether clopidogrel discontinuation after short-term DAPT is associated with an early hazard of ischemic events.

METHODS

The authors performed an individual participant data analysis and aggregate meta-analysis. The primary outcome was major adverse cardiac and cerebrovascular events (MACCE), defined as the composite of cardiac death, myocardial infarction (MI), or stroke.

RESULTS

The study included 11,473 PCI patients with individual participant data from 6 randomized trials comparing short-term DAPT (3 or 6 months) versus long-term DAPT (12 months or more). During the first 90 days following clopidogrel discontinuation, there was no significant increase in the risk of MACCE between patients randomized to short-term DAPT compared with long-term DAPT (hazard ratio [HR]: 1.18; 95% confidence interval [CI]: 0.71 to 1.98; p = 0.52; absolute risk difference 0.10%; 95% CI: -0.16% to 0.36%). The risk of MI or stent thrombosis was similar among patients randomized to short-term DAPT versus long-term DAPT (HR: 0.93; 95% CI: 0.46 to 1.90; p = 0.85). In the aggregate data meta-analysis of 11 trials including 38,919 patients, a higher risk of early MACCE was observed after long-term (≥12 months) DAPT duration (HR: 2.28; 95% CI: 1.69 to 3.09; p < 0.001) but not short-term (<12 months) DAPT duration (HR: 1.08; 95% CI: 0.67 to 1.74; p for interaction = 0.036).

CONCLUSIONS

Among patients undergoing PCI with predominantly new-generation DES, discontinuation of clopidogrel after 3 or 6 months DAPT duration was not associated with an early increase in adverse clinical events. An early increase in MACCE was observed after long-term (≥12 months) DAPT exposure.

Inter-observer agreement of the Coronary Artery Disease Reporting and Data System (CAD-RADSTM) in patients with stable chest pain

Purpose

To assess inter-observer variability of the Coronary Artery Disease - Reporting and Data System (CAD-RADS) for classifying the degree of coronary artery stenosis in patients with stable chest pain.

Material and methods

A prospective study was conducted upon 96 patients with coronary artery disease, who underwent coronary computed tomography angiography (CTA). The images were classified using the CAD-RAD system according to the degree of stenosis, the presence of a modifier: graft (G), stent (S), vulnerable plaque (V), or non-diagnostic (n) and the associated coronary anomalies, and non-coronary cardiac and extra-cardiac findings. Image analysis was performed by two reviewers. Inter-observer agreement was assessed.

Results

There was excellent inter-observer agreement for CAD-RADS (k = 0.862), at 88.5%. There was excellent agreement for CAD-RADS 0 (k = 1.0), CAD-RADS 1 (k = 0.92), CAD-RADS 3 (k = 0.808), CAD-RADS 4 (k = 0.826), and CAD-RADS 5 (k = 0.833) and good agreement for CAD-RADS 2 (k = 0.76). There was excellent agreement for modifier G (k = 1.0) and modifier S (k = 1.0), good agreement for modifier N (k = 0.79), and moderate agreement for modifier V (k = 0.59). There was excellent agreement for associated coronary artery anomalies (k = 0.845), non-coronary cardiac findings (k = 0.857), and extra-cardiac findings (k = 0.81).

Conclusions

There is inter-observer agreement of CAD-RADS in categorising the degree of coronary arteries stenosis, and the modifier of the system and associated cardiac and extra-cardiac findings.

A single-center observational study on the efficacy of percutaneous coronary intervention for ischemic heart failure: A cohort study

The effects of revascularization by percutaneous coronary intervention (PCI) on cardiac function and clinical outcomes in patients with confirmed coronary artery disease (CAD) and heart failure (HF), on the basis of the optimal medical treatment recommended by current guidelines, remain to be determined.A cohort study was performed to evaluate the efficacy of PCI on the basis of optimal medical treatment in patients with CAD and HF. Patients who received PCI were subsequently grouped according to partial and complete revascularization (CR) depending on the PCI outcome. The primary outcome was defined as a composite outcome of major adverse cardiovascular events (MACEs). Changes in left ventricular ejection fraction (LVEF) also were compared.A total of 69 patients (12 who received medical treatment and 57 who received PCI) were included. Patients in the PCI group showed significantly improved LVEF (P < .001), but patients in the medical treatment group did not (P > .05) after 3 months of follow-up. MACEs occurred in 50% patients in the medical treatment group and 19.3% patients of the PCI group, with this difference almost reaching statistical significance (P = .06). Compared with patients who received medical therapy only, patients who received PCI experienced better survival (P = .02). Moreover, survival seemed to be better in patients who achieved CR with PCI of the coronary arteries than in those who had partial revascularization of the coronary arteries (P = .06).PCI may be effective for improving survival in patients with CAD and HF.

The Potential Effects of New Stent Platforms for Coronary Revascularization in Patients With Diabetes

Coronary artery disease in patients with diabetes mellitus (DM) is characterized by extensive atherosclerosis, longer lesions, and diffuse distal disease. Consequently, these patients have worse outcomes after coronary revascularization, regardless of the modality used. Traditionally, coronary artery bypass grafting (CABG) has been regarded as more effective than percutaneous coronary intervention (PCI) in patients with DM, likely because of more complete revascularization and protection against disease progression in the bypass segment. Revascularization with balloon angioplasty, bare-metal stents, and first-generation drug-eluting stents have all been shown to be inferior to CABG in patients with DM. Current professional society guidelines reflect these findings, strongly recommending CABG over PCI in this setting. Newer stent platforms, however, have challenged this notion. The use of thinner struts, biocompatible polymer coating, and newer antiproliferative agents have improved the rates of cardiovascular events in patients with DM revascularized percutaneously. Since the publication of current guidelines, new studies suggested acceptable outcomes in patients with DM revascularized with second-generation drug-eluting stents, even though these conclusions are drawn from small subgroup analyses or nonrandomized studies. Robust registry data suggest similar mortality with lower rates of stroke after PCI compared with surgery, at the expense of increased rates of repeat revascularization. If complete revascularization can be achieved, similar rates of myocardial infarction are also observed. Therefore, contemporary revascularization in patients with DM with multivessel coronary artery disease should involve a multidisciplinary approach, in which interventional cardiologists and cardiac surgeons involve their patients to individualize treatment choices, and balance the risks and effectiveness of each modality.

Passive and Active Triaxial Wall Mechanics in a Two-Layer Model of Porcine Coronary Artery

Triaxial active and passive mechanical properties of coronary arteries are needed for understanding arterial mechanics in health and disease. The aim of the study was to quantify both active and passive strain energy functions in circumferential, axial and radial directions based on the experimental measurement. Moreover, a two-layer computational model was used to determine the transmural distribution of stresses and strains across the vessel wall. The first Piola-Kirchhoff stresses in the three normal directions had the approximate relationship as:\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\,{T}_{\theta \theta }\cong 2{T}_{zz}\cong 5|{T}_{rr}|$$\end{document}Tθθ≅2Tzz≅5|Trr|. The two-layer model showed that circumferential Cauchy stresses increased significantly from the intima layer to the interface between media and adventitia layers (from ~80 to 160 kPa), dropped abruptly at the interface (from ~160 to <5 kPa), and increased slightly towards the outer boundary of the adventitia layer. In contrast, absolute values of radial Cauchy stress decreased continuously from the inner to outer boundaries of the vessel wall (from ~11 kPa to zero). Smooth muscle cell contraction significantly increased the ratio of radial to circumferential Cauchy stresses at the intima-media layer, which had the highest values at the intima layer.

Topiramate modulates post-infarction inflammation primarily by targeting monocytes or macrophages

Aims

Monocytes/macrophages response plays a key role in post-infarction inflammation that contributes greatly to post-infarction ventricular remodelling and cardiac rupture. Therapeutic targeting of the GABAA receptor, which is enriched in monocytes/macrophages but not expressed in the myocardium, may be possible after myocardial infarction (MI).

Methods and results

After MI was induced by ligation of the coronary artery, C57BL/6 mice were intraperitoneally administered with one specific agonist or antagonist of the GABAA receptor (topiramate or bicuculline), in the setting of presence or depletion of monocytes/macrophages. Our data showed that within the first 2 weeks after MI, when monocytes/macrophages dominated, in contrast with bicuculline, topiramate treatment significantly reduced Ly-6Chigh monocyte numbers by regulating splenic monocytopoiesis and promoted foetal derived macrophages preservation and conversion of M1 to M2 or Ly-6Chigh to Ly-6Clow macrophage phenotype in the infarcted heart, though GABAAergic drugs failed to affect M1/M2 or Ly-6Chigh/Ly-6Clow macrophage polarization directly. Accordingly, pro-inflammatory activities mediated by M1 or Ly-6Chigh macrophages were decreased and reparative processes mediated by M2 or Ly-6Clow macrophages were augmented. As a result, post-infarction ventricular remodelling was attenuated, as reflected by reduced infarct size and increased collagen density within infarcts. Echocardiographic indices, mortality and rupture rates were reduced. After depletion of monocytes/macrophages by clodronate liposomes, GABAAergic drugs exhibited no effect on cardiac dysfunction and surrogate clinical outcomes.

Conclusion

Control of the GABAA receptor activity in monocytes/macrophages can potently modulate post-infarction inflammation. Topiramate emerges as a promising drug, which may be feasible to translate for MI therapy in the future.

Correlates and Impact of Coronary Artery Calcifications in Women Undergoing Percutaneous Coronary Intervention With Drug-Eluting Stents: From the Women in Innovation and Drug-Eluting Stents (WIN-DES) Collaboration

OBJECTIVES

The aim of this study was to investigate the clinical correlates and prognostic impact of coronary artery calcification (CAC) in women undergoing percutaneous coronary intervention with drug-eluting stents (DES).

BACKGROUND

The clinical correlates and the prognostic significance of CAC in women undergoing percutaneous coronary intervention with DES remain unclear.

METHODS

Patient-level data from female participants in 26 randomized trials of DES were pooled. Study population was categorized according to the presence of moderate or severe versus mild or no target lesion CAC, assessed through coronary angiography. Co-primary endpoints of interest were the composite of death, myocardial infarction (MI), or target lesion revascularization and death, MI, or stent thrombosis at 3-year follow-up.

RESULTS

Among 11,557 women included in the pooled dataset, CAC status was available in 6,371 women. Of these, 1,622 (25.5%) had moderate or severe CAC. In fully adjusted models, independent correlates of CAC were age, hypertension, hypercholesterolemia, smoking, previous coronary artery bypass graft surgery, and worse left ventricular and renal function. At 3 years, women with CAC were at higher risk for death, MI, or target lesion revascularization (18.2% vs. 13.1%; adjusted hazard ratio: 1.56; 95% confidence interval: 1.33 to 1.84; p < 0.0001) and death, MI, or stent thrombosis (12.7% vs. 8.6%; adjusted hazard ratio: 1.48; 95% confidence interval: 1.21 to 1.80; p = 0.0001). The adverse effect of CAC on ischemic outcomes appeared to be consistent across clinical and angiographic subsets of women, including new-generation DES.

CONCLUSIONS

Women undergoing PCI of calcified lesions tend to have worse clinical profile and remain at increased ischemic risk, irrespective of new-generation DES.

Impact of lifelong exercise training on endothelial ischemia-reperfusion and ischemic preconditioning in humans

Reperfusion is essential for ischemic tissue survival, but causes additional damage to the endothelium [i.e., ischemia-reperfusion (I/R) injury]. Ischemic preconditioning (IPC) refers to short repetitive episodes of ischemia that can protect against I/R. However, IPC efficacy attenuates with older age. Whether physical inactivity contributes to the attenuated efficacy of IPC to protect against I/R injury in older humans is unclear. We tested the hypotheses that lifelong exercise training relates to 1) attenuated endothelial I/R and 2) maintained IPC efficacy that protects veteran athletes against endothelial I/R. In 18 sedentary male individuals (SED, <1 exercise h/wk for >20 yr, 63 ± 7 yr) and 20 veteran male athletes (ATH, >5 exercise h/wk for >20 yr, 63 ± 6 yr), we measured brachial artery endothelial function with flow-mediated dilation (FMD) before and after I/R. We induced I/R by 20 min of ischemia followed by 20 min of reperfusion. Randomized over 2 days, participants underwent either 35-min rest or IPC (3 cycles of 5-min cuff inflation to 220 mmHg with 5 min of rest) before I/R. In SED, FMD decreased after I/R [median (interquartile range)]: [3.0% (2.0–4.7) to 2.1% (1.5–3.9), P = 0.046] and IPC did not prevent this decline [4.1% (2.6–5.2) to 2.8% (2.2–3.6), P = 0.012]. In ATH, FMD was preserved after I/R [3.0% (1.7–5.4) to 3.0% (1.9–4.1), P = 0.82] and when IPC preceded I/R [3.2% (1.9–4.2) to 2.8% (1.4–4.6), P = 0.18]. These findings indicate that lifelong exercise training is associated with increased tolerance against endothelial I/R. These protective, preconditioning effects of lifelong exercise against endothelial I/R may contribute to the cardioprotective effects of exercise training.

The Ultimaster Biodegradable-Polymer Sirolimus-Eluting Stent: An Updated Review of Clinical Evidence

The Ultimaster coronary stent system (Terumo Corporation, Tokyo, Japan) represents a new iteration in drug-eluting stent (DES) technology that has recently received the Conformité Européenne (CE) mark approval for clinical use. The Ultimaster is a thin-strut, cobalt chromium, biodegradable-polymer, sirolimus-eluting coronary stent. The high elasticity of the biodegradable-polymer (PDLLA-PCL) and the abluminal gradient coating technology are additional novel features of this coronary device. The Ultimaster DES has undergone extensive clinical evaluation in two studies: The CENTURY I and II trials. Results from these two landmark studies suggested an excellent efficacy and safety profile of the Ultimaster DES across several lesion and patient subsets, with similar clinical outcomes to contemporary, new-generation DES. The aim of this review is to summarize the rationale behind this novel DES technology and to provide an update of available evidence about the clinical performance of the Ultimaster DES.

Revascularization in complex multivessel coronary artery disease after FREEDOM. Is there an indication for PCI and drug-eluting stents?

Diabetes mellitus is a highly prevalent metabolic disorder frequently associated with the development of coronary atherosclerosis. Myocardial revascularization assumes a central role in the treatment of diabetic patients with coronary artery disease. Although coronary artery bypass grafting (CABG) is in principle the revascularization modality of choice in diabetic patients with complex, multivessel disease, percutaneous coronary interventions (PCI) using new-generation drug-eluting stents (DES) remain a valuable treatment option for properly selected diabetic patients. Defining the appropriate revascularization strategy is often a challenging task that requires tailored approaches, accounting for individual patient surgical risk, anatomical configurations, and the technical feasibility of each procedure in addition to careful judgment of the possible benefits and risks inherent to PCI and CABG. Evidence is building that advances in DES technology may mitigate at least in part some of the adverse vascular effects of diabetes; whether this may translate to PCI outcomes comparable with those achieved by CABG is under investigation in randomized trials currently underway. This review article summarizes the indications for myocardial revascularization across the spectrum of clinical presentations and critically discusses current evidence and future perspectives regarding the value of each revascularization mode (CABG vs. PCI) in patients with diabetes.

Ultrathin Strut Biodegradable Polymer Sirolimus-Eluting Stent Versus Durable-Polymer Everolimus-Eluting Stent for Percutaneous Coronary Revascularization: 2-Year Results of the BIOSCIENCE Trial

Background

No data are available on the long‐term performance of ultrathin strut biodegradable polymer sirolimus‐eluting stents (BP‐SES). We reported 2‐year clinical outcomes of the BIOSCIENCE (Ultrathin Strut Biodegradable Polymer Sirolimus‐Eluting Stent Versus Durable Polymer Everolimus‐Eluting Stent for Percutaneous Coronary Revascularisation) trial, which compared BP‐SES with durable‐polymer everolimus‐eluting stents (DP‐EES) in patients undergoing percutaneous coronary intervention.

Methods and Results

A total of 2119 patients with minimal exclusion criteria were assigned to treatment with BP‐SES (n=1063) or DP‐EES (n=1056). Follow‐up at 2 years was available for 2048 patients (97%). The primary end point was target‐lesion failure, a composite of cardiac death, target‐vessel myocardial infarction, or clinically indicated target‐lesion revascularization. At 2 years, target‐lesion failure occurred in 107 patients (10.5%) in the BP‐SES arm and 107 patients (10.4%) in the DP‐EES arm (risk ratio [RR] 1.00, 95% CI 0.77–1.31, P=0.979). There were no significant differences between BP‐SES and DP‐EES with respect to cardiac death (RR 1.01, 95% CI 0.62–1.63, P=0.984), target‐vessel myocardial infarction (RR 0.91, 95% CI 0.60–1.39, P=0.669), target‐lesion revascularization (RR 1.17, 95% CI 0.81–1.71, P=0.403), and definite stent thrombosis (RR 1.38, 95% CI 0.56–3.44, P=0.485). There were 2 cases (0.2%) of definite very late stent thrombosis in the BP‐SES arm and 4 cases (0.4%) in the DP‐EES arm (P=0.423). In the prespecified subgroup of patients with ST‐segment elevation myocardial infarction, BP‐SES was associated with a lower risk of target‐lesion failure compared with DP‐EES (RR 0.48, 95% CI 0.23–0.99, P=0.043, P_interaction=0.026).

Conclusions

Comparable safety and efficacy profiles of BP‐SES and DP‐EES were maintained throughout 2 years of follow‐up.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov. Unique identifier: NCT01443104.

Effect of levocarnitine on TIMP-1, ICAM-1 expression of rats with coronary heart disease and its myocardial protection effect

OBJECTIVE

To study the effect of levocarnitine (L-CN) on tissue inhibitor of metalloproteinase-1 (TIMP-1) and intercellular adhesion molecule-1 (ICAM-1) expression of rats with coronary heart disease and evaluate the protective effect of L-CN on myocardial cells.

METHODS

High-fat diet feeding and intraperitoneal injection of pituitrin was performed on rats in model group and CHD Model of rats was built. Rats with successful model-building were selected and divided into L-CN group and Ctrl group randomly. Rats in L-CN group were given L-CN treatment, with intraperitoneal injection of 200 mg·kg(-1)·d(-1) and successive administration for 3 d. Rats in Ctrl group were given equal volumes of normal saline. Blood was collected from carotid artery at different time and expression quantity of creatine kinase-MB (CK-MB) and Troponin Ⅰ (TnⅠ) in serum was detected. Rats in each group were put to death and were separated to obtain the myocardial tissue. Real-time PCR and Western Blotting hybridization were performed to detect the TIMP-1, ICAM-1 expression in myocardial tissue in each group. Statistical analysis was employed to explore the expression changes of TIMP-1 and ICAM-1, and ELISA test was used to analyze the expression changes of myocardial necrosis marker-CK-MB and TnⅠto learn the effect of L-CN and its myocardial protective effect.

RESULTS

The total cholesterol, triglyceride and blood glucose levels of rats in model group were significantly higher than that in control group, which indicated that due to high-fat diet feeding, blood lipid of rats in model group was obviously higher than that in control group. In myocardial tissue of rats in model group, TIMP-1 level significantly reduced and ICAM-1 level significantly increased (P < 0.01). In model group, after L-CN treatment, TIMP-1 level had double increase, while ICAM-1 level had 43% of decrease in L-CN group compared with Ctrl group. After L-CN intervention treatment, CK-MB and TnⅠ content in L-CN group relatively reduced compared with Ctrl group. The difference among groups was obvious (P < 0.01).

CONCLUSIONS

L-CN could increase the TIMP-1 expression level and inhibit the ICAM-1 expression level. L-CN has a certain myocardial protective effect.

Non-clinical development of CER-001

Cardiovascular disease remains the most pressing healthcare issue for the developed world and is becoming so for developing countries. There are no currently approved therapies that can rapidly reduce the burden of unstable, inflamed plaque in the overall coronary vascular bed. High-density lipoprotein (HDL) has multiple actions that could lead to plaque stabilization, such as rapid removal of large quantities of cholesterol from the vasculature through the process of reverse lipid transport, improvement in endothelial function, protection against oxidative damage, and reduction in inflammation. Short-term infusion of HDL-mimetics in animal models as well as in humans has shown promising effects on the plaque size and morphology. Cerenis Therapeutics has developed CER-001, a negatively charged lipoprotein complex consisting of phospholipid and recombinant human apoA-I that mimics the structure and function of natural HDL. Three clinical trials using CER-001 infusions have demonstrated improvements in the carotid wall thickness of patients with familial hypercholesterolaemia and in patients with hypo-alphalipoproteinaemia, as well as an impact on coronary plaque burden measured by intravascular ultrasonography at the lowest tested dose (3 mg/kg) in post-ACS patients. Here, we reviewed the non-clinical data leading to the demonstration that CER-001 is a full HDL mimetic.