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The quest for effective pharmacological suppression of neointimal hyperplasia. Curr Probl Surg 2020; 57:100807. [PMID: 32771085 DOI: 10.1016/j.cpsurg.2020.100807] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 04/22/2020] [Indexed: 12/15/2022]
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Adam Z, Turley A, Mason J, Kasim A, Newby D, Mills N, Padfield G, Thompson L, Morley R, Hall J, Wright R, Muir D, Sutton A, Swanson N, Carter J, Bilous R, Jones S, de Belder M. The SSTARS (STeroids and Stents Against Re-Stenosis) Trial: Different stent alloys and the use of peri-procedural oral corticosteroids to prevent in-segment restenosis after percutaneous coronary intervention. Int J Cardiol 2016; 216:1-8. [DOI: 10.1016/j.ijcard.2016.04.105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 04/11/2016] [Indexed: 12/26/2022]
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Cassese S, De Luca G, Ribichini F, Cernigliaro C, Sansa M, Versaci F, Proietti I, Stankovic G, Stojkovic S, Fernandez-Pereira C, Tomai F, Vassanelli C, Antoniucci D, Serruys PW, Kastrati A, Rodriguez AE. ORAl iMmunosuppressive therapy to prevent in-Stent rEstenosiS (RAMSES) cooperation: A patient-level meta-analysis of randomized trials. Atherosclerosis 2014; 237:410-7. [DOI: 10.1016/j.atherosclerosis.2014.09.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2014] [Revised: 08/31/2014] [Accepted: 09/05/2014] [Indexed: 01/05/2023]
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García-Trapero J, Carceller F, Dujovny M, Cuevas P. Perivascular delivery of neomycin inhibits the activation of NF-κB and MAPK pathways, and prevents neointimal hyperplasia and stenosis after arterial injury. Neurol Res 2013; 26:816-24. [PMID: 15727265 DOI: 10.1179/016164104x5110] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
The nuclear transcription factor kappaB (NF-kappaB) is a cytoplasmic dimer that, as the family of mitogen-activated protein kinase (MAPK), can directly regulate the expression of early genes and genes involved in the stress response, following a variety of physiological or pathological stimuli. Both of them stimulate the transcription of many proteins, which are considered important during inflammation. A crucial role has been assigned to these factors in cellular proliferation and in neointimal hyperplasia secondary to the endothelial lesion of arterial vessels. On the other hand, it has been described that neomycin can have an inhibitory function on tumor cell proliferation, through the inhibition of different intracellular pathways of signaling, among them the NF-kappaB and MAPK pathways. Rat common carotid artery was subjected to balloon angioplasty. Neomycin sulfate (18 mg) was applied using pluronic acid gel on the adventitial surface of the injured vessel. MAPK and NF-kappaB activation was quantified after 24 hours with immunohistochemical staining. Neointimal formation was quantified after 14 days with morphometry. Immunohistochemistry results demonstrating MAPK and NF-kappaB activation reveal that both transcription factors are activated in the media of the control vessel wall. In contrast, the immunoreactivity for MAPK and NF-kappaB in the sections obtained from arteries treated with neomycin over 24 hours was insufficient or nonexistent. Treatment with neomycin on adventitia over 14 days in arteries on which angioplasty was performed shows a neointimal index (intimal area/medial area) decrease of 71% in comparison with arteries that were not treated. The adventitial neomycin treatment over 14 days produces a very significant increase (287.5%; p<0.0001) in the arterial luminal circumference in comparison with arteries treated with vehicle. These results support the theory that neomycin plays an important role against neointimal hyperplasia through the inhibition of MAPK and NF-kappaB activation.
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Affiliation(s)
- Jorge García-Trapero
- Departmento de Investigación, Hospital Universitario Ramón y Cajal, Universidad de Alcalá de Henares, E-28034-Madrid, Spain
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Abstract
Percutaneous transluminal coronary angioplasty is a widely used technique for recanalizing arteries that are occluded by atherosclerotic plaque, but its usefulness is limited by the occurrence ofrestenosis in a high proportion of patients. The development of new therapies for this currently intractable problem will be facilitated by the use of animal models of restenosis that are predictive of drug efficacy in humans. Two approaches for improving predictivity can be identified. In the first of these, the goal is to maximize the anatomical and procedural resemblance of the model to humans. The second approach seeks to maximize the pathophysiological and molecular biological resemblance of the model to humans. Tangible progress is being made toward the first goal, but lack of understanding of the basic biology of human restenosis is hampering progress toward the second.
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Nanomedicine for the prevention, treatment and imaging of atherosclerosis. NANOMEDICINE-NANOTECHNOLOGY BIOLOGY AND MEDICINE 2012; 8 Suppl 1:S59-68. [DOI: 10.1016/j.nano.2012.05.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Revised: 12/19/2011] [Accepted: 12/21/2011] [Indexed: 12/31/2022]
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Nanomedicine for the prevention, treatment and imaging of atherosclerosis. Maturitas 2012; 73:52-60. [PMID: 22261366 DOI: 10.1016/j.maturitas.2011.12.014] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Revised: 12/19/2011] [Accepted: 12/21/2011] [Indexed: 01/11/2023]
Abstract
Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in developed countries, with an increasing prevalence due to an aging population. The pathology underpinning CVD is atherosclerosis, a chronic inflammatory state involving the arterial wall. Accumulation of low density lipoprotein (LDL) laden macrophages in the arterial wall and their subsequent transformation into foam cells lead to atherosclerotic plaque formation. Progression of atherosclerotic lesions may gradually lead to plaque related complications and clinically manifest as acute vascular syndromes including acute myocardial or cerebral ischemia. Nanotechnology offers emerging therapeutic strategies, which may have advantage overclassical treatments for atherosclerosis. In this review, we present the potential applications of nanotechnology toward prevention, identification and treatment of atherosclerosis.
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Immunosuppressive therapy with oral prednisone to prevent restenosis after PCI. A multicenter randomized trial. Am J Med 2011; 124:434-43. [PMID: 21531233 DOI: 10.1016/j.amjmed.2010.11.027] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2010] [Revised: 11/09/2010] [Accepted: 11/11/2010] [Indexed: 01/21/2023]
Abstract
BACKGROUND Prednisone at immunosuppressive doses after stenting has shown remarkable efficacy in reducing ischemic recurrences in nondiabetic patients with high post-procedural levels of C-reactive protein; the study aim was to compare the clinical outcome obtained in a control group of patients treated with bare metal stents versus 2 other study groups--bare metal stent plus oral prednisone or drug eluting stents--assuming similar optimal adjunctive medical treatment. METHODS Five tertiary Italian hospitals enrolled 375 nondiabetic patients with coronary artery disease and no contraindications to dual antiplatelet treatment or corticosteroid therapy in a randomized, controlled study performed between 2007 and 2009. Patients were allocated into 3 study groups: bare metal stents (controls), bare metal stents followed by a 40-day prednisone treatment, or drug-eluting stents. The primary endpoint was the event-free survival of cardiovascular death, myocardial infarction, and recurrence of ischemia needing repeated target vessel revascularization at 1 year as adjudicated by an independent clinical events committee. RESULTS One-year follow-up was obtained in all patients. Patients receiving bare metal stents alone as compared to those treated with prednisone or drug-eluting stents had lower event-free survival; the primary endpoint was 80.8% in controls compared to 88.0% in the prednisone and 88.8% in the drug-eluting stent groups, respectively (P=.04 and .006). CONCLUSION Compared with bare metal stents alone, prednisone treatment after bare metal stents or drug-eluting stent implantation result in a better event-free survival at 1 year.
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Bhardwaj U, Sura R, Papadimitrakopoulos F, Burgess DJ. PLGA/PVA hydrogel composites for long-term inflammation control following s.c. implantation. Int J Pharm 2010; 384:78-86. [DOI: 10.1016/j.ijpharm.2009.09.046] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2009] [Revised: 09/23/2009] [Accepted: 09/24/2009] [Indexed: 10/20/2022]
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Hadoke PWF, Iqbal J, Walker BR. Therapeutic manipulation of glucocorticoid metabolism in cardiovascular disease. Br J Pharmacol 2009; 156:689-712. [PMID: 19239478 DOI: 10.1111/j.1476-5381.2008.00047.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
The therapeutic potential for manipulation of glucocorticoid metabolism in cardiovascular disease was revolutionized by the recognition that access of glucocorticoids to their receptors is regulated in a tissue-specific manner by the isozymes of 11beta-hydroxysteroid dehydrogenase. Selective inhibitors of 11beta-hydroxysteroid dehydrogenase type 1 have been shown recently to ameliorate cardiovascular risk factors and inhibit the development of atherosclerosis. This article addresses the possibility that inhibition of 11beta-hydroxsteroid dehydrogenase type 1 activity in cells of the cardiovascular system contributes to this beneficial action. The link between glucocorticoids and cardiovascular disease is complex as glucocorticoid excess is linked with increased cardiovascular events but glucocorticoid administration can reduce atherogenesis and restenosis in animal models. There is considerable evidence that glucocorticoids can interact directly with cells of the cardiovascular system to alter their function and structure and the inflammatory response to injury. These actions may be regulated by glucocorticoid and/or mineralocorticoid receptors but are also dependent on the 11beta-hydroxysteroid dehydrogenases which may be expressed in cardiac, vascular (endothelial, smooth muscle) and inflammatory (macrophages, neutrophils) cells. The activity of 11beta-hydroxysteroid dehydrogenases in these cells is dependent upon differentiation state, the action of pro-inflammaotory cytokines and the influence of endogenous inhibitors (oxysterols, bile acids). Further investigations are required to clarify the link between glucocorticoid excess and cardiovascular events and to determine the mechanism through which glucocorticoid treatment inhibits atherosclerosis/restenosis. This will provide greater insights into the potential benefit of selective 11beta-hydroxysteroid dehydrogenase inhibitors in treatment of cardiovascular disease.
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Affiliation(s)
- Patrick W F Hadoke
- Centre for Cardiovascular Sciences, University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, UK.
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Ribichini F, Tomai F, De Luca G, Boccuzzi G, Presbitero P, Pesarini G, Ferrero V, Ghini AS, Pastori F, De Luca L, Zavalloni D, Soregaroli D, Garbo R, Franchi E, Marino P, Minelli M, Vassanelli C. A multicenter, randomized study to test immunosuppressive therapy with oral prednisone for the prevention of restenosis after percutaneous coronary interventions: cortisone plus BMS or DES versus BMS alone to eliminate restenosis (CEREA-DES) – study design and rationale. J Cardiovasc Med (Hagerstown) 2009; 10:192-9. [DOI: 10.2459/jcm.0b013e32831f9176] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Joner M, Morimoto K, Kasukawa H, Steigerwald K, Merl S, Nakazawa G, John MC, Finn AV, Acampado E, Kolodgie FD, Gold HK, Virmani R. Site-Specific Targeting of Nanoparticle Prednisolone Reduces In-Stent Restenosis in a Rabbit Model of Established Atheroma. Arterioscler Thromb Vasc Biol 2008; 28:1960-6. [DOI: 10.1161/atvbaha.108.170662] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Michael Joner
- From Deutsches Herzzentrum Muenchen und 1. Medizinische Klinik, Klinikum rechts der Isar (M.L., K.S., S.M.), Muenchen, Germany; CVPath Insitute Inc (G.N., E.A., F.D.K., R.V.), Gaithersburg, Md; Cardiac Unit (M.C.J., A.V.F., H.K.G.), Department of Internal Medicine, Massachusetts General Hospital, Boston, Mass; Research and Development Center, Terumo Corporation (K.M., H.K.), Tokyo, Japan
| | - Katsumi Morimoto
- From Deutsches Herzzentrum Muenchen und 1. Medizinische Klinik, Klinikum rechts der Isar (M.L., K.S., S.M.), Muenchen, Germany; CVPath Insitute Inc (G.N., E.A., F.D.K., R.V.), Gaithersburg, Md; Cardiac Unit (M.C.J., A.V.F., H.K.G.), Department of Internal Medicine, Massachusetts General Hospital, Boston, Mass; Research and Development Center, Terumo Corporation (K.M., H.K.), Tokyo, Japan
| | - Hiroaki Kasukawa
- From Deutsches Herzzentrum Muenchen und 1. Medizinische Klinik, Klinikum rechts der Isar (M.L., K.S., S.M.), Muenchen, Germany; CVPath Insitute Inc (G.N., E.A., F.D.K., R.V.), Gaithersburg, Md; Cardiac Unit (M.C.J., A.V.F., H.K.G.), Department of Internal Medicine, Massachusetts General Hospital, Boston, Mass; Research and Development Center, Terumo Corporation (K.M., H.K.), Tokyo, Japan
| | - Kristin Steigerwald
- From Deutsches Herzzentrum Muenchen und 1. Medizinische Klinik, Klinikum rechts der Isar (M.L., K.S., S.M.), Muenchen, Germany; CVPath Insitute Inc (G.N., E.A., F.D.K., R.V.), Gaithersburg, Md; Cardiac Unit (M.C.J., A.V.F., H.K.G.), Department of Internal Medicine, Massachusetts General Hospital, Boston, Mass; Research and Development Center, Terumo Corporation (K.M., H.K.), Tokyo, Japan
| | - Sabine Merl
- From Deutsches Herzzentrum Muenchen und 1. Medizinische Klinik, Klinikum rechts der Isar (M.L., K.S., S.M.), Muenchen, Germany; CVPath Insitute Inc (G.N., E.A., F.D.K., R.V.), Gaithersburg, Md; Cardiac Unit (M.C.J., A.V.F., H.K.G.), Department of Internal Medicine, Massachusetts General Hospital, Boston, Mass; Research and Development Center, Terumo Corporation (K.M., H.K.), Tokyo, Japan
| | - Gaku Nakazawa
- From Deutsches Herzzentrum Muenchen und 1. Medizinische Klinik, Klinikum rechts der Isar (M.L., K.S., S.M.), Muenchen, Germany; CVPath Insitute Inc (G.N., E.A., F.D.K., R.V.), Gaithersburg, Md; Cardiac Unit (M.C.J., A.V.F., H.K.G.), Department of Internal Medicine, Massachusetts General Hospital, Boston, Mass; Research and Development Center, Terumo Corporation (K.M., H.K.), Tokyo, Japan
| | - Michael C. John
- From Deutsches Herzzentrum Muenchen und 1. Medizinische Klinik, Klinikum rechts der Isar (M.L., K.S., S.M.), Muenchen, Germany; CVPath Insitute Inc (G.N., E.A., F.D.K., R.V.), Gaithersburg, Md; Cardiac Unit (M.C.J., A.V.F., H.K.G.), Department of Internal Medicine, Massachusetts General Hospital, Boston, Mass; Research and Development Center, Terumo Corporation (K.M., H.K.), Tokyo, Japan
| | - Aloke V. Finn
- From Deutsches Herzzentrum Muenchen und 1. Medizinische Klinik, Klinikum rechts der Isar (M.L., K.S., S.M.), Muenchen, Germany; CVPath Insitute Inc (G.N., E.A., F.D.K., R.V.), Gaithersburg, Md; Cardiac Unit (M.C.J., A.V.F., H.K.G.), Department of Internal Medicine, Massachusetts General Hospital, Boston, Mass; Research and Development Center, Terumo Corporation (K.M., H.K.), Tokyo, Japan
| | - Eduardo Acampado
- From Deutsches Herzzentrum Muenchen und 1. Medizinische Klinik, Klinikum rechts der Isar (M.L., K.S., S.M.), Muenchen, Germany; CVPath Insitute Inc (G.N., E.A., F.D.K., R.V.), Gaithersburg, Md; Cardiac Unit (M.C.J., A.V.F., H.K.G.), Department of Internal Medicine, Massachusetts General Hospital, Boston, Mass; Research and Development Center, Terumo Corporation (K.M., H.K.), Tokyo, Japan
| | - Frank D. Kolodgie
- From Deutsches Herzzentrum Muenchen und 1. Medizinische Klinik, Klinikum rechts der Isar (M.L., K.S., S.M.), Muenchen, Germany; CVPath Insitute Inc (G.N., E.A., F.D.K., R.V.), Gaithersburg, Md; Cardiac Unit (M.C.J., A.V.F., H.K.G.), Department of Internal Medicine, Massachusetts General Hospital, Boston, Mass; Research and Development Center, Terumo Corporation (K.M., H.K.), Tokyo, Japan
| | - Herman K. Gold
- From Deutsches Herzzentrum Muenchen und 1. Medizinische Klinik, Klinikum rechts der Isar (M.L., K.S., S.M.), Muenchen, Germany; CVPath Insitute Inc (G.N., E.A., F.D.K., R.V.), Gaithersburg, Md; Cardiac Unit (M.C.J., A.V.F., H.K.G.), Department of Internal Medicine, Massachusetts General Hospital, Boston, Mass; Research and Development Center, Terumo Corporation (K.M., H.K.), Tokyo, Japan
| | - Renu Virmani
- From Deutsches Herzzentrum Muenchen und 1. Medizinische Klinik, Klinikum rechts der Isar (M.L., K.S., S.M.), Muenchen, Germany; CVPath Insitute Inc (G.N., E.A., F.D.K., R.V.), Gaithersburg, Md; Cardiac Unit (M.C.J., A.V.F., H.K.G.), Department of Internal Medicine, Massachusetts General Hospital, Boston, Mass; Research and Development Center, Terumo Corporation (K.M., H.K.), Tokyo, Japan
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Preusch MR, Rattazzi M, Albrecht C, Merle U, Tuckermann J, Schütz G, Blessing E, Zoppellaro G, Pauletto P, Krempien R, Rosenfeld ME, Katus HA, Bea F. Critical role of macrophages in glucocorticoid driven vascular calcification in a mouse-model of atherosclerosis. Arterioscler Thromb Vasc Biol 2008; 28:2158-64. [PMID: 18787189 DOI: 10.1161/atvbaha.108.174128] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Macrophage-derived products are known to play a crucial role during atherogenesis and vascular calcification. Glucocorticoids (GC) are important modulators of immune cell functions, but their specific effects on macrophages behavior during plaque formation are not defined. The present study was therefore designed to investigate the effects of macrophage-specific deletion of the glucocorticoid receptor (GR(LysMCre)) on atherogenesis and vascular calcification in a hyperlipidemic mouse-model. METHODS AND RESULTS Bone marrow was isolated from GR(LysMCre) mice and wild-type controls (GR(flox)) and subsequently transplanted into lethally irradiated LDL-receptor-deficient mice. Animals were fed a Western-type diet for 15 or 24 weeks, and atherosclerotic lesions within the aortic sinus were evaluated. At both time points, no significant difference in serum lipid and corticosterone concentrations, atherosclerotic lesion size and macrophage-content within the lesions could be observed. However, GR(LysMCre) mice showed less calcification as well as a significant reduction of RANKL, BMP2, and Msx2 expression within the vasculature. In vitro studies using conditioned media from macrophages which had been stimulated with dexamethasone demonstrated a dose-dependent increase in calcium deposition by vascular smooth muscle cells. CONCLUSIONS This study demonstrates that macrophage-specific glucocorticoid receptor inactivation reduces vascular calcification without affecting atherosclerotic lesion size in LDL receptor-deficient mice.
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Affiliation(s)
- Michael R Preusch
- Department of Internal Medicine, University of Heidelberg, Geidelberg, Germany
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Celik T, Iyisoy A, Barindik N, Isik E. Glucocorticoids in the prevention of in-stent restenosis: the role of inflammation. Int J Cardiol 2008; 135:403-5. [PMID: 18571255 DOI: 10.1016/j.ijcard.2008.01.057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2007] [Revised: 01/13/2008] [Accepted: 01/20/2008] [Indexed: 11/18/2022]
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15
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Abstract
Chronic excessive activation of glucocorticoid receptors induces obesity, insulin resistance, glucose intolerance, dyslipidaemia and hypertension. Subtle abnormalities of the hypothalamic-pituitary-adrenal axis and/or of tissue sensitivity to glucocorticoids are also associated with these cardiovascular risk factors in patients with the metabolic syndrome. Furthermore, glucocorticoids have direct effects on the heart and blood vessels, mediated by both glucocorticoid and mineralocorticoid receptors and modified by local metabolism of glucocorticoids by the 11beta-hydroxysteroid dehydrogenase enzymes. These effects influence vascular function, atherogenesis and vascular remodelling following intra-vascular injury or ischaemia. This article reviews the systemic and cardiovascular effects of glucocorticoids, and the evidence that glucocorticoids not only promote the incidence and progression of atherogenesis but also modify the recovery from occlusive vascular events and intravascular injury. The conclusion is that manipulation of glucocorticoid action within metabolic and cardiovascular tissues may provide novel therapeutic avenues to combat cardiovascular disease.
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Affiliation(s)
- Brian R Walker
- Endocrinology Unit, Queen's Medical Research Institute, Centre for Cardiovascular Science, University of Edinburgh, 47 Little France Crescent, Edinburgh EH16 4TJ, Scotland, UK.
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Ferrero V, Ribichini F, Pesarini G, Brunelleschi S, Vassanelli C. Glucocorticoids in the prevention of restenosis after coronary angioplasty: therapeutic potential. Drugs 2007; 67:1243-55. [PMID: 17547469 DOI: 10.2165/00003495-200767090-00001] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Vessel luminal narrowing after percutaneous coronary intervention (PCI) is characterised by platelet aggregation, release of growth factors, inflammatory cell infiltration, medial smooth muscle cell (SMC) proliferation, proteoglycan deposition and extracellular matrix remodelling. It is broadly accepted that the central mechanism at the basis of the whole pathophysiological process of restenosis is inflammation, triggered by vascular injury and activated through autocrine or paracrine mediators. Glucocorticosteroids exert beneficial effects on platelet function, on SMC proliferation and on collagen synthesis as well as inflammatory cell migration and activation, thus interfering with several steps of the cascade leading to neointima formation and subsequent late lumen loss. Initial experiences with systemic administration of glucocorticoids after PCI failed to confirm the expected benefits of this treatment, probably as a result of inadequate dosage and pharmacokinetic calculations. Recently a short-term, high-dose immunosuppressive treatment scheme with oral prednisone has demonstrated remarkable clinical and angiographic results when prednisone was given orally at a dose of 1 mg/kg for 10 days, 0.5 mg/kg for 20 days and 0.25 mg/kg for 15 days. This treatment has dramatically reduced the incidence of clinical vascular events at 1 year compared with controls (relative risk 0.34; 95% CI 0.12, 0.96; p = 0.006) and reduced the incidence of angiographic restenosis below 10% in different clinical and angiographic subsets. Secondary effects of a short course of glucocorticoids are generally minor, predictable and reversible: gastric pain, water and salt retention and worsened hypertension manifest in nearly 10% of patients. The addition of diuretics and acid suppressants before discharge, and the upgrading of antihypertensive medication thereafter, if needed, are useful preventive measures to control these temporary disorders. A routine blood cell count 4 weeks after PCI is advised in patients receiving thienopyridines (clopidogrel or ticlopidine) in addition to prednisone to rule out infrequent haematological dyscrasias. Emerging evidence supports this strategy as a convenient and well tolerated alternative to more expensive and complex revascularisation procedures such as drug eluting stent (DES) implantation or cardiac surgery, provided that the treatment is reserved for carefully selected candidates, i.e. after the exclusion of those with diabetes mellitus, a recent transmural myocardial infarction, or contraindications to the administration of a short-course of high-dose glucocorticosteroids. The recent concerns regarding the long-term safety of first-generation DES and the as yet undetermined duration of dual anti-platelet treatment, further supports the need for a simple pharmacological treatment that can be applied in a large percentage of patients currently treated with PCI. Multicentre randomised studies aimed at defining the efficacy and safety of oral prednisone treatment compared with metallic stents and DES are ongoing, and will become available in upcoming years.
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Affiliation(s)
- Valeria Ferrero
- Division of Cardiology, University of Verona, Ospedale Civile Maggiore di Verona, Verona, Italy
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17
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Affiliation(s)
- Joost Daemen
- Thorax Center, Erasmus Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
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18
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Ribichini F, Ferrero V, Rognoni A, Marino P, Brunelleschi S, Vassanelli C. Percutaneous treatment of coronary bifurcations: lesion preparation before provisional bare metal stenting and subsequent immunosuppression with oral prednisone. The IMPRESS-Y study. J Interv Cardiol 2007; 20:114-21. [PMID: 17391219 DOI: 10.1111/j.1540-8183.2007.00250.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Aim of the study was to assess the clinical and angiographic efficacy of oral treatment with prednisone at immunosuppressive dosage after percutaneous coronary interventions (PCI) in patients with bifurcation lesions treated with elective bare metal stent (BMS) implantation in the main-branch (MB) and provisional stenting in the side-branch (SB). Twenty-five patients were treated on 29 bifurcation lesions (58 vessel segments). Lesion preparation before stenting was performed with atherectomy in 7 cases, and balloon PCI over double wires in all other cases; none was treated directly with stents. The mean length of stents implanted in the MB was 19.6 +/- 4.9 mm (10-30 mm). Balloon PCI was successful in 23 of 29 SB and provisional stenting was needed in 6 SB (21%). All patients received oral prednisone according to the immunosuppressive protocol previously reported (1 mg/kg/day/10 days, 0.5 mg/kg/day/20 days, 0.25 mg/kg/day/15 days). At 12 months, one patient had recurrence of angina (4%) and two patients underwent repeated target lesion revascularization (8%). No patient died or had stent thrombosis. Quantitative coronary analysis was performed in all patients at 8 months. Global restenosis rate per vessel was 8.6% (5/58), and 17.2% (5/29) per lesion. The restenosis rate and late lumen loss were 3.4% and 0.36 +/- 0.6 mm, and 13.8% and 0.47 +/- 0.46 mm in the MB and the SB, respectively. Single stent implantation in the MB and provisional stenting of the SB is feasible in most cases after adequate lesion preparation. The systemic treatment with oral prednisone after BMS implantation offers good clinical and angiographic results even in the difficult setting of bifurcation lesions.
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Ferrero V, Ribichini F, Rognoni A, Marino P, Brunelleschi S, Vassanelli C. Comparison of efficacy and safety of lower-dose to higher-dose oral prednisone after percutaneous coronary interventions (the IMPRESS-LD study). Am J Cardiol 2007; 99:1082-6. [PMID: 17437731 DOI: 10.1016/j.amjcard.2006.11.064] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2006] [Revised: 11/27/2006] [Accepted: 11/27/2006] [Indexed: 12/29/2022]
Abstract
This study assessed clinical and angiographic efficacies of oral treatment with prednisone at low-dose (LD) versus the previous high-dose (HD) immunosuppressive dosage used after percutaneous coronary interventions (PCIs) with bare metal stents in patients with multivessel coronary artery disease. Forty-three patients with multivessel disease successfully treated with multiple PCIs were matched to the previous HD IMPRESS-2/MVD study population. The 43 patients were treated for 103 coronary stenoses and received 30-day oral prednisone treatment (LD group 1 mg/kg for 5 days, 0.5 mg/kg for 10 days, 0.25 mg/kg for 15 days) and were compared retrospectively with the 43 patients in the HD IMPRESS-2/MVD study with 116 treated coronary lesions (HD group 1 mg/kg for 10 days, 0.5 mg/kg for 20 days, 0.25 mg/kg for 15 days). The primary clinical end point was 12-month event-free survival rate (defined as freedom from death, myocardial infarction, and need for target vessel revascularization). The secondary end point was angiographic restenosis at 8 months assessed by quantitative coronary angiography. Event-free survival rates were 74% and 93% in the LD and HD groups, respectively (relative risk 4.6, 95% confidence interval 1.18 to 17.8, p = 0.019). Restenosis was observed in 4 lesions (4%) in the HD group and in 20 lesions (22%) in the LD group (p <0.001). Mean late lumen loss was 0.61 +/- 0.35 mm, and the loss index was 31.3 +/- 21.6% in the HD group compared with 0.87 +/- 0.61 mm and 52.03 +/- 25.1% in the LD group (p = 0.03 and 0.02, respectively). In conclusion, antirestenotic efficacy of oral treatment with prednisone after conventional PCI is dose sensitive. A 50% dose decrease in oral prednisone, as tested in this study, is less effective than the previously tested HD IMPRESS therapeutic scheme.
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20
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Han SH, Ahn TH, Kang WC, Oh KJ, Chung WJ, Shin MS, Koh KK, Choi IS, Shin EK. The favorable clinical and angiographic outcomes of a high-dose dexamethasone-eluting stent: randomized controlled prospective study. Am Heart J 2006; 152:887.e1-7. [PMID: 17070150 DOI: 10.1016/j.ahj.2006.05.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2006] [Accepted: 05/16/2006] [Indexed: 11/18/2022]
Abstract
BACKGROUND Previous studies with dexamethasone-eluting stents could not elucidate the role of dexamethasone in the prevention of neointimal hyperplasia because they did not compare their results with a control group. We prospectively evaluated the clinical and angiographic outcomes of dexamethasone-eluting stents, comparing them with unloaded stents of an identical design. METHODS A total of 92 patients (98 lesions) were randomly assigned to the dexamethasone group (67 patients, 71 lesions) or control group (25 patients, 27 lesions). The inclusion criteria for a stent implantation were a de novo lesion with a diameter of 2.60 to 4.0 mm. BiodivYsio Drug Delivery phosphorylcholine-coated stents (Biocompatibles Ltd, Galway, Ireland) were immersed in a 20-mg/mL dexamethasone solution, yielding a total dexamethasone dose of 0.5 microg/mm2 per stent. RESULTS The total major adverse cardiac events rate at 12 months was significantly lower in the dexamethasone group, as compared with the control group (10.4% [7/67] vs 28.0% [7/25], P = .037). The binary restenosis rate at 6 months was 11.9% (7/59) in the dexamethasone group and 42.9% (9/21) in the control group (P = .002). The use of dexamethasone-eluting stents was the only independent predictor for the major adverse cardiac event at 12 months (relative risk 0.20, 95% CI 0.06-0.68, P = .009) and binary restenosis at 6 months (relative risk 0.17, 95% CI 0.05-0.60, P = .006) by multivariate analysis. CONCLUSIONS Dexamethasone-eluting stents exhibited an improvement in the clinical and angiographic outcomes, as compared with the control stents. These results suggest that dexamethasone may play an important role in the inhibition of the polymer-induced inflammation in the era of drug-eluting stents.
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21
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Seo TS, Oh JH, Park YK, Song HY, Park SJ, Yuk SH. Efficacy of a dexamethasone-eluting nitinol stent on the inhibition of pseudo-intimal hyperplasia in a transjugular intrahepatic portosystemic shunt: an experimental study in a swine model. Korean J Radiol 2006; 6:241-7. [PMID: 16374082 PMCID: PMC2684971 DOI: 10.3348/kjr.2005.6.4.241] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE We wanted to evaluate the feasibility and efficacy of using a dexamethasone (DM)-eluting nitinol stent to inhibit the pseudo-intimal hyperplasia following stent placement in the transjugular intrahepatic portosystemic shunt tract (TIPS) of a swine. MATERIALS AND METHODS Fifteen stents were constructed using 0.15 mm-thick nitinol wire; they were 60 mm in length and 10 mm in diameter. The metallic stents were then classified into three types; type 1 and 2 was coated with the mixture of 12% and 20%, respectively, of DM solution and polyurethane (PU), while type 3 was a bare stent that was used for control study. In fifteen swine, each type of stent was implanted in the TIPS tract of 5 swine, and each animal was sacrificed 2 weeks after TIPS creation. The proliferation of the pseudo-intima was evaluated both on follow-up portogram and pathologic examination. RESULTS One TIPS case, using the type 1 stent, and two TIPS cases, using the type 2 stent, maintained their luminal patency while the others were all occluded. On the histopathologic analysis, the mean of the maximum pseudo-intimal hyperplasia was expressed as the percentage of the stent radius that was patent, and these values were 51.2%, 50% and 76% for the type 1, 2, and 3 stents, respectively. CONCLUSION The DM-eluting stent showed a tendency to reduce the development of pseudo-intimal hyperplasia in the TIPS tract of a swine model with induced-portal hypertension.
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Affiliation(s)
- Tae-Seok Seo
- Department of Diagnostic Radiology, Korea University Guro Hospital, Seoul, Korea
| | - Joo-Hyeong Oh
- Department of Diagnostic Radiology, Kyung Hee University Hospital, Seoul, Korea
| | - Young-Koo Park
- Department of Pathology, Kyung Hee University Hospital, Seoul, Korea
| | - Ho-Young Song
- Department of Radiology, University of Ulsan, College of Medicine, Seoul, Korea
| | - Sang Joon Park
- Department of Diagnostic Radiology, Hallym University, College of Medicine, Seoul, Korea
| | - Sun-Hong Yuk
- Department of Polymer Science and Engineering, Hannam University, Taejon, Korea
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22
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Alisky JM. Dexamethasone could improve myocardial infarction outcomes and provide new therapeutic options for non-interventional patients. Med Hypotheses 2006; 67:53-6. [PMID: 16503095 DOI: 10.1016/j.mehy.2005.12.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2005] [Accepted: 12/07/2005] [Indexed: 11/17/2022]
Abstract
BACKGROUND Statins reduce death and morbidity of acute myocardial infarction in part through immunosuppressive mechanisms, suggesting glucocorticoids could produce similar benefits. Glucocorticoids inhibit proliferation of smooth muscle cells and activation of macrophages within atherosclerotic plaques and protect ischemic myocardium through inhibition of a heat shock protein. Dexamethasone-eluting coronary stents have a decreased rate of restenosis, and oral prednisone reduces restenosis of conventional stents. Some studies from the 1970's and 1980's showed that steroids improve survival in myocardial infarction, but no conclusive large-scale randomized well-powered trials have been conducted. PRESENTATION OF THE HYPOTHESIS Dexamethasone administered alongside statins in the setting of acute myocardial infarction could attenuate myocardial damage in patients with diffuse disease. TESTING THE HYPOTHESIS Patients with acute myocardial infarction who cannot undergo angioplasty or coronary artery bypass grafting could be given a statin and intravenous and oral dexamethasone. Dexamethasone minimizes fluid retention and avoids mineralocorticoid-induced cell proliferation in plaques. Blood glucose monitoring should be ordered for all patients, but diabetic patients need not be excluded. There should be measures to prevent steroid-induced homocystinuria or more common complications such as ulcers, osteoporosis, infections and psychosis. IMPLICATIONS OF THE HYPOTHESIS Showing that acute coronary syndrome is a steroid-responsive disorder would have immediate relevance for patients limited to medical management because of anatomy and comorbidities, and results would similarly have application for acute ischemic stroke.
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Affiliation(s)
- Joseph Martin Alisky
- Marshfield Clinic Research Foundation, 1000 Oak Avenue, Marshfield, WI 54449, USA.
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23
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Abstract
Restenosis after stent implantation is mainly caused by neointimal proliferation through the stent struts. Experimental studies performed in the last decade indicate that inflammatory mechanisms play a key role in the process of neointimal proliferation and restenosis. Coronary stenting is a strong inflammatory stimulus, and the acute local and systemic inflammatory responses to local inflammation produced by coronary stenting are highly individual and predictive of restenosis and event-free survival. The benefit of anti-inflammatory periprocedural therapy, such as with 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) and steroids, and long-term follow-up is dependent on the individual's inflammatory status. Measurement of acute-phase reactants, such as C-reactive protein plasma concentration, appears to be important for the identification of subjects at high risk and the development of specific treatment tailored to individual patients.
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Affiliation(s)
- Achille Gaspardone
- Division of Cardiology and S. Eugenio Hospital, ASL Room C, piazzale dell'Umanesimo 10, 00144 Rome, Italy.
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24
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Linde J, Strauss BH. Pharmacological treatment for prevention of restenosis. Expert Opin Emerg Drugs 2005; 6:281-302. [PMID: 15989527 DOI: 10.1517/14728214.6.2.281] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Coronary artery disease (CAD) is the leading cause of mortality and morbidity among adults in the Western world. Coronary artery bypass grafting and percutaneous coronary interventions (PCI) have gained widespread acceptance for the treatment of symptomatic CAD. There has been an explosive growth worldwide in the utilisation of PCI, such as balloon angioplasty and stenting, which now accounts for over 50% of coronary revascularisation. Despite the popularity of PCI, the problem of recurrent narrowing of the dilated artery (restenosis) continues to vex investigators. In recent years, significant advances have occurred in the understanding of restenosis. Two processes seem to contribute to restenosis: remodelling (vessel size changes) and intimal hyperplasia (vascular smooth muscle cell [VSMC] proliferation and extracellular matrix [ECM] deposition). Despite considerable efforts, pharmacological approaches to decrease restenosis have been largely unsuccessful and the only currently applied modality to reduce the restenosis rate is stenting. However, stenting only prevents remodelling and does not inhibit intimal hyperplasia. Several potential targets for inhibiting restenosis are currently under investigation including platelet activation, the coagulation cascade, VSMC proliferation and migration, and ECM synthesis. In addition, new approaches for local drug therapy, such as drug eluting stents, are currently being evaluated in preclinical and clinical studies. In this article, we critically review the current status of drugs that are being evaluated for restenosis at various stages of development (in vitro, preclinical animal models and human trials).
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Affiliation(s)
- J Linde
- The Roy and Ann Foss Interventional Cardiology Research Program, Terrence Donnelly Heart Center, 30 Bond Street, St. Michael's Hospital, Toronto, Ontario, M5B 1W8, Canada
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25
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Liu X, De Scheerder I, Desmet W. Dexamethasone-eluting stent: an anti-inflammatory approach to inhibit coronary restenosis. Expert Rev Cardiovasc Ther 2004; 2:653-60. [PMID: 15350167 DOI: 10.1586/14779072.2.5.653] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The long-term efficacy of percutaneous coronary interventions is still hampered by restenosis. Restenosis is the result of a complex pathophysiological process, which is thought to be caused by an exaggerated healing response induced by the vascular injury caused by the percutaneous coronary interventions and the implantation of a foreign body (the stent). There is increasing evidence that inflammation plays an important role in the initiation and development of neointimal hyperplasia and subsequent restenosis. Dexamethasone (Decadron, Merck Sharpe and Dohme Ltd) is a glucocorticoid with well-known potent anti-inflammatory and antiproliferative properties. Early studies using either systemic or local delivery of dexamethasone have shown limited beneficial effects on restenosis. The dexamethasone-eluting stent (Dexamet, Abbott Vascular Devices Ltd) is one of the first generation of drug-eluting stents for local drug delivery to prevent restenosis. Preclinical studies demonstrated that implantation of dexamethasone-loaded coronary stents was safe and had a beneficial effect on stent implantation-related inflammation. A pilot trial suggested a beneficial effect on restenosis. Large randomized trials are underway to confirm these findings. This article reviews the potential role of inflammation in the pathogenesis of restenosis and the efficacy of dexamethasone in the prevention of restenosis.
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Affiliation(s)
- Xiaoshun Liu
- Cardiac Catheterization Laboratory, University Hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium.
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26
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Nagasaki K, Matsumoto K, Kaneda M, Shintani T, Shibutani S, Murayama T, Wakabayashi G, Shimazu M, Mukai M, Kitajima M. Effects of Preinjury Administration of Corticosteroids on Pseudointimal Hyperplasia and Cytokine Response in a Rat Model of Balloon Aortic Injury. World J Surg 2004; 28:910-6. [PMID: 15593466 DOI: 10.1007/s00268-004-7457-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Restenosis occurs in approximately one-third of patients with coronary or peripheral vascular disease who undergo balloon angioplasty or a surgical bypass procedure primarily because of the development of pseudointimal hyperplasia (PIH). Corticosteroids were effective in suppressing PIH in several experimental studies, but no clinical studies have been reported. To resolve this discrepancy, we studied the effects of preinjury administration of several doses of methylprednisolone (MP) at targeted times in a rat model of balloon aortic injury. Rats were given either no treatment or an intravenous injection of MP (0.5, 5.0, 50, or 500 mg/kg) 2 hours before aortic injury. Four hours later interleukin-6 (IL-6), IL-10, and macrophage migration inhibitory factor (MIF) concentrations in serum and tissue of injured aortas were assessed. Two weeks after injury, damaged aortas were harvested and studied histopathologically. Compared with results in controls, MP at a dose of 5 mg/kg significantly inhibited increases in plasma and tissue levels of IL-6 and significantly reduced the pseudointimal area, pseudointimal/medial area ratio, and proliferating cell nuclear antigen index in injured vessels. Administration of MP had no significant effect on the IL-10 or MIF level. Thus in a rat model of balloon aortic injury, preinjury administration of MP 5 mg/kg mitigated the development of PIH and cell proliferation and suppressed the postinjury increase in serum and tissue IL-6 concentrations. These results suggest that there is an appropriate dosage as well as appropriate timing for MP administration to suppress PIH.
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Affiliation(s)
- Kazuhito Nagasaki
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku 160-8582, Tokyo, Japan
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27
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Hoffmann R, Langenberg R, Radke P, Franke A, Blindt R, Ortlepp J, Popma JJ, Weber C, Hanrath P. Evaluation of a high-dose dexamethasone-eluting stent. Am J Cardiol 2004; 94:193-5. [PMID: 15246899 DOI: 10.1016/j.amjcard.2004.03.061] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2003] [Revised: 03/29/2004] [Accepted: 03/29/2004] [Indexed: 11/30/2022]
Abstract
This study evaluated the safety and efficacy of a dexamethasone-eluting stent with a special high dexamethasone-loading dose for treatment of de novo coronary lesions in 30 patients. Eight patients had in-stent restenosis (restenosis rate 31%) at 6-month follow-up, and the in-stent late lumen loss was 0.96 +/- 0.63 mm due to an average intimal hyperplasia area obstruction of 32 +/- 21%, indicating that high-dose dexamethasone-loaded stents do not significantly reduce neointimal proliferation.
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28
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Kuchulakanti P, Waksman R. Therapeutic Potential of Oral Antiproliferative Agents in the Prevention of Coronary Restenosis. Drugs 2004; 64:2379-88. [PMID: 15481997 DOI: 10.2165/00003495-200464210-00001] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The treatment of coronary artery disease has reached many milestones - from balloon angioplasty to drug-eluting stents. The last decade witnessed the revolution of bare metal stents with new designs, alloys and strut thicknesses. Yet restenosis, the aphorismic 'Achilles heel', remains to be conquered. The restenosis rates with balloon angioplasty alone are 30-40% and are reduced to 20-30% with stents. Although intravascular brachytherapy proved to be a durable and safely used technique to treat in-stent restenosis, clinical event rates were not reduced to single digits.Drug-eluting stents are showing positive results in this direction, but it is too early to predict their efficacy in various subsets of lesions. With the increased usage of these stents, there are reports of problems such as late stent malapposition, subacute and late thromboses, and aneurysm formations due to the vessel toxicity associated with this method of treatment. Furthermore, when multivessel stenting is considered, the cost of drug-eluting stents is a significant problem given the fact that these are no longer 'zero restenosis' devices. There is a definite need for a simple, safe and durable solution to restenosis. Oral agents are an alternative delivery strategy that can target multiple coronary lesions, which are targets for catheter-based revascularisation with any approved metal stent and with potentially lower cost. Although oral agents have been an interesting option to treat restenosis and several agents have been tested in trials since the 1980s, the results were disappointing. The development of devices such as intravascular ultrasound has led to a greater understanding of restenosis mechanisms, and the focus on pathophysiological mechanisms, which centred mainly on platelets, growth factors and lipids, has changed to inflammation, endothelium and smooth muscle cell proliferation.Accordingly, the targets of pharmaceutical agents have shifted from platelets to cell cycle inhibition, smooth muscle cell proliferation and migration, synthesis of extra cellular matrix, and inflammatory mediators. Initial encouraging results with oral drugs such as cilostazol, sirolimus (rapamycin) and thiazolidinediones indicate a definite place for this strategy to reduce restenosis. A desirable oral agent would be anti-inflammatory, inhibit smooth muscle cell migration and proliferation, promote endothelial growth, and be well tolerated and free from significant adverse effects. It may be useful to start with a high loading dose before stent implantation and then follow with a short-term lower maintenance dose. Future trials should be aimed at finding an ideal agent, effective loading dose, maintenance dose and optimum duration of therapy.
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Affiliation(s)
- Pramod Kuchulakanti
- Division of Cardiology, Washington Hospital Center, Washington, DC 20010, USA
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29
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Colombo A, Sangiorgi G. The monocyte: the key in the lock to reduce stent hyperplasia?**Editorials published in the Journal of the American College of Cardiologyreflect the views of the authors and do not necessarily represent the views of JACCor the American College of Cardiology. J Am Coll Cardiol 2004; 43:24-6. [PMID: 14715177 DOI: 10.1016/j.jacc.2003.10.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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30
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Danenberg HD, Golomb G, Groothuis A, Gao J, Epstein H, Swaminathan RV, Seifert P, Edelman ER. Liposomal Alendronate Inhibits Systemic Innate Immunity and Reduces In-Stent Neointimal Hyperplasia in Rabbits. Circulation 2003; 108:2798-804. [PMID: 14610008 DOI: 10.1161/01.cir.0000097002.69209.cd] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Innate immunity is of major importance in vascular repair. The present study evaluated whether systemic and transient depletion of monocytes and macrophages with liposome-encapsulated bisphosphonates inhibits experimental in-stent neointimal formation.
Methods and Results—
Rabbits fed on a hypercholesterolemic diet underwent bilateral iliac artery balloon denudation and stent deployment. Liposomal alendronate (3 or 6 mg/kg) was given concurrently with stenting. Monocyte counts were reduced by >90% 24 to 48 hours after a single injection of liposomal alendronate, returning to basal levels at 6 days. This treatment significantly reduced intimal area at 28 days, from 3.88±0.93 to 2.08±0.58 and 2.16±0.62 mm
2
. Lumen area was increased from 2.87±0.44 to 3.57±0.65 and 3.45±0.58 mm
2
, and arterial stenosis was reduced from 58±11% to 37±8% and 38±7% in controls, rabbits treated with 3 mg/kg, and rabbits treated with 6 mg/kg, respectively (mean±SD, n=8 rabbits/group,
P
<0.01 for all 3 parameters). No drug-related adverse effects were observed. Reduction in neointimal formation was associated with reduced arterial macrophage infiltration and proliferation at 6 days and with an equal reduction in intimal macrophage and smooth muscle cell content at 28 days after injury. Conversely, drug regimens ineffective in reducing monocyte levels did not inhibit neointimal formation.
Conclusions—
Systemic transient depletion of monocytes and macrophages, by a single liposomal bisphosphonates injection concurrent with injury, reduces in-stent neointimal formation and arterial stenosis in hypercholesterolemic rabbits.
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MESH Headings
- Alendronate/administration & dosage
- Alendronate/pharmacology
- Animals
- Cell Count
- Cell Division/drug effects
- Cell Movement/drug effects
- Cell Movement/immunology
- Diet, Atherogenic
- Disease Models, Animal
- Graft Occlusion, Vascular/immunology
- Graft Occlusion, Vascular/pathology
- Graft Occlusion, Vascular/prevention & control
- Hyperplasia/immunology
- Hyperplasia/pathology
- Hyperplasia/prevention & control
- Iliac Artery/drug effects
- Iliac Artery/injuries
- Iliac Artery/pathology
- Immunity, Innate/drug effects
- Leukocyte Count
- Liposomes
- Macrophages/drug effects
- Macrophages/pathology
- Monocytes/drug effects
- Monocytes/pathology
- Muscle, Smooth, Vascular/drug effects
- Muscle, Smooth, Vascular/pathology
- Rabbits
- Stents/adverse effects
- Tunica Intima/drug effects
- Tunica Intima/immunology
- Tunica Intima/pathology
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Affiliation(s)
- Haim D Danenberg
- Harvard-MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, Mass 02139, USA.
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31
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Arruda JA, Costa MA, Brito FS, Tedesco H, Barbosa AHP, Ribeiro EP, Pestana JOM, Lima VC. Effect of systemic immunosuppression on coronary in-stent intimal hyperplasia in renal transplant patients. Am J Cardiol 2003; 91:1363-5. [PMID: 12767437 DOI: 10.1016/s0002-9149(03)00333-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- J Airton Arruda
- Hospital São Paulo and Hospital do Rim e Hipertensão, Federal University of São Paulo (UNIFESP-EPM), R. Napoleão de Barros 715-Térreo, São Paulo, SP, Brazil 04024-002
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32
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Aggarwal M, Tsao PS, Yeung A, Carter AJ. Stent-based immunosuppressive therapies for the prevention of restenosis. ACTA ACUST UNITED AC 2003; 4:98-107. [PMID: 14581091 DOI: 10.1016/s1522-1865(03)00165-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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33
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Versaci F, Gaspardone A, Tomai F, Ribichini F, Russo P, Proietti I, Ghini AS, Ferrero V, Chiariello L, Gioffrè PA, Romeo F, Crea F. Immunosuppressive Therapy for the Prevention of Restenosis after Coronary Artery Stent Implantation (IMPRESS Study). J Am Coll Cardiol 2002; 40:1935-42. [PMID: 12475452 DOI: 10.1016/s0735-1097(02)02562-7] [Citation(s) in RCA: 166] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Francesco Versaci
- Cattedra di Cardiochirurgia, Divisione di Cardiochirurgia, Università Tor Vergata, European Hospital, Rome, Italy.
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34
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Danenberg HD, Welt FGP, Walker M, Seifert P, Toegel GS, Edelman ER. Systemic inflammation induced by lipopolysaccharide increases neointimal formation after balloon and stent injury in rabbits. Circulation 2002; 105:2917-22. [PMID: 12070123 DOI: 10.1161/01.cir.0000018168.15904.bb] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Emerging data indicate that the inflammatory response after mechanical arterial injury correlates with the severity of neointimal hyperplasia in animal models and postangioplasty restenosis in humans. The present study was designed to examine whether a nonspecific stimulation of the innate immune system, induced in close temporal proximity to the vascular injury, would modulate the results of the procedure. Methods and Results- Rabbits subjected to iliac artery balloon injury (balloon denudation with or without stent deployment) were injected twice with a bacterial lipopolysaccharide (LPS) (500 ng/rabbit) before and after surgery. The dose was chosen to be sufficient to induce systemic inflammation but not septic shock. A systemic marker of inflammation (serum interleukin-1beta levels measured by ELISA) and monocytic stimulation (CD14 levels on monocytes measured by flow cytometry) were increased after LPS administration. Arterial macrophage infiltration at 7 days after injury was 1.7+/-1.2% of total cells in controls and 4.2+/-1.8% in LPS-treated rabbits (n=4, P<0.05). Morphometric analysis of the injured arteries 4 weeks after injury revealed significantly increased luminal stenosis (38+/-4.2% versus 23+/-2.6, mean+/- SEM; n=8, P<0.05) and neointima-to-media ratio (1.26+/-0.21 versus 0.66+/- 0.09, P<0.05) in LPS-treated animals compared with controls. This effect was abolished by anti-CD14 Ab administration. Serum interleukin-1beta levels and monocyte CD14 expression were significantly increased in correlation with the severity of intimal hyperplasia. LPS treatment increased neointimal area after stenting from 0.57+/-0.07 to 0.77+/- 0.1 mm(2) and stenosis from 9+/-1% to 13+/-1.7% (n=5, P< 0.05). CONCLUSIONS Nonspecific systemic stimulation of the innate immune system concurrently with arterial vascular injury facilitates neointimal formation, and conditions associated with increased inflammation may increase restenosis.
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Affiliation(s)
- Haim D Danenberg
- Harvard-MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA.
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Orlandi A, Marcellini M, Pesce D, Calvani M, Spagnoli LG. Propionyl-L-carnitine reduces intimal hyperplasia after injury in normocholesterolemic rabbit carotid artery by modulating proliferation and caspase 3-dependent apoptosis of vascular smooth muscle cells. Atherosclerosis 2002; 160:81-9. [PMID: 11755925 DOI: 10.1016/s0021-9150(01)00568-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Previously we documented that propionyl-L-carnitine (PLC) reduces the growth of atherosclerotic lesions in cholesterol-fed aged rabbits in association with a decrease of plaque smooth muscle cell (SMC) proliferation and plasma triglycerides. To clarify whether PLC might influence SMC growth through mechanisms other than triglyceride lowering, we investigated the effect of a daily treatment per os with PLC on carotid intimal hyperplasia after ballooning in normocholesterolemic rabbits. PLC did not induce variations of plasma triglyceride and cholesterol. One week later, the number of proliferating SMCs was reduced in PLC as compared with controls. After 3 weeks, morphometric analysis demonstrated a reduced neointimal relative volume and percentage of stenosis but not vessel area in PLC as compared with controls. This associated with an intimal reduced SMC number and an increased apoptotic rate as detected by nick-end labelling (TUNEL) and ligation-mediated polymerase chain reaction (PCR). Western blotting also demonstrated an increase of caspase-3 cleavage in PLC carotids. Antiproliferative and pro-apoptotic effects of PLC were confirmed in vitro on actively proliferating and serum deprived SMCs, respectively. Molecules with an additional cell-specific, pro-apoptotic action may represent a new therapeutic tool in reducing intimal SMC hyperplasia following angioplasty or stenting procedures.
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Affiliation(s)
- Augusto Orlandi
- Department of Biopathology and Image Diagnostics, Anatomic Pathology Institute, Tor Vergata University of Rome, Via della Ricerca Scientifica, 00133 Rome, Italy
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Wiskirchen J, Dittmann H, Kehlbach R, Vogel-Claussen J, Gebert R, Dohmen BM, Schöber W, Bares R, Rodemann HP, Claussen CD, Duda SH. Rhenium-188 for inhibition of human aortic smooth muscle cell proliferation. Int J Radiat Oncol Biol Phys 2001; 49:809-15. [PMID: 11172964 DOI: 10.1016/s0360-3016(00)01452-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE To evaluate dose-dependent growth-modulating effects of the beta-gamma emitter Rhenium-188 on cultured human aortic smooth muscle cells (haSMC). METHODS AND MATERIALS HaSMC were plated in 25 cm(2) flasks. Two days after plating, cells were incubated with the Re-188 (beta E(max) 2.12 MeV, tissue range(max) < 10 mm, T(1/2) 17 h) for five days. The doses administered were 0.2 Gy, 1, 4, 6, 8, 16, and 32 Gy. After five days, the radionuclide was removed. Cell growth, cell cycle distribution, and clonogenic activity were analyzed for the following 25 days. RESULTS The 0.2 and 1 Gy groups did not show relevant growth-inhibiting effects compared to the control groups. The 4 to 32 Gy groups presented dose-dependent growth inhibition, with a complete growth arrest of the 16 and 32 Gy groups. Clonogenic activity of the smooth muscle cell was strongly inhibited from doses > or =8 Gy. Flow cytometry showed a lasting dose-dependent G2/M phase block. CONCLUSION Smooth muscle cell (SMC) growth can be controlled effectively with Re-188 for at least 25 days after radiation in vitro. As the first four weeks after arterial angioplasty are crucial concerning neointimal formation, Re-188 may be a valuable radionuclide to inhibit restenosis after arterial angioplasty.
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Affiliation(s)
- J Wiskirchen
- Department of Diagnostic Radiology, Eberhard-Karls University, Hoppe-Seyler Str. 3, 72076 Tuebingen, Germany.
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Cotton RG, Bray PJ. Using CCM and DHPLC to detect mutations in the glucocorticoid receptor in atherosclerosis: a comparison. JOURNAL OF BIOCHEMICAL AND BIOPHYSICAL METHODS 2001; 47:91-100. [PMID: 11179765 DOI: 10.1016/s0165-022x(00)00155-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Growing evidence suggests that restenosis may be caused by a failure in growth inhibitory and apoptotic systems that would normally mediate lesion regression. One such inhibitory system is the glucocorticoid receptor. This paper develops, assesses and compares chemical cleavage of mismatch (CCM) and denaturing high-performance liquid chromatography (DHPLC) for their utility in detecting mutations in this system. The results of the two methods correlated in 74% of cases in a cohort of endarterectomy patients studied by these two methods.
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Affiliation(s)
- R G Cotton
- Mutation Research Centre, St. Vincent's Hospital, 41 Victoria Parade, Victoria 3065, Fitzroy, Australia
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Lee CW, Chae JK, Lim HY, Hong MK, Kim JJ, Park SW, Park SJ. Prospective randomized trial of corticosteroids for the prevention of restenosis after intracoronary stent implantation. Am Heart J 1999; 138:60-3. [PMID: 10385765 DOI: 10.1016/s0002-8703(99)70247-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Inflammatory responses have been implicated as one of the major contributors to neointimal hyperplasia after coronary stenting. The aim of this study was to evaluate the effect of pretreatment with single-dose intravenous methylprednisolone on preventing in-stent restenosis. METHODS One hundred and forty consecutive patients for elective coronary stenting (focal, de novo lesion and reference diameter >/=3 mm) were randomly assigned to either a methylprednisolone or a placebo group. Either 1 g methylprednisolone or placebo was intravenously infused 6 to 12 hours before stenting with one of two types of stents. Follow-up angiography was performed at 6 months and clinical evaluation made at regular intervals. RESULTS Baseline characteristics were similar between both groups. Stenting was successful in all patients, and in-hospital events did not occur in any patients. Follow-up angiography was performed in 127 patients (follow-up rate of 91.4%). The minimal lumen diameter increased from 0.86 +/- 0.50 mm before intervention to 3.34 +/- 0.42 mm after intervention (P =.02). At follow-up, minimal lumen diameter decreased to 2.14 +/- 0.78 mm (P <. 01). Angiographic restenosis rate was 17.5% in the steroid group and 18.8% in the placebo group (P =.85), with no differences between the 2 types of stent. Clinical follow-up was available in all patients (10.3 +/- 2.5 months) and clinical events during the follow-up period were similar in both groups. CONCLUSIONS Single-dose pretreatment with intravenous methylprednisolone before coronary stenting had no effect on the change in minimal lumen diameter at a mean follow-up time.
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Affiliation(s)
- C W Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan, Pungnap-dong, Songpa-gu, Seoul, Korea
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Bray PJ, Du B, Mejia VM, Hao SC, Deutsch E, Fu C, Wilson RC, Hanauske-Abel H, McCaffrey TA. Glucocorticoid resistance caused by reduced expression of the glucocorticoid receptor in cells from human vascular lesions. Arterioscler Thromb Vasc Biol 1999; 19:1180-9. [PMID: 10323768 DOI: 10.1161/01.atv.19.5.1180] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Mechanisms that control the balance between cell proliferation and death are important in the development of vascular lesions. Rat primary smooth muscle cells were 80% inhibited by low microgram doses of hydrocortisone (HC) and 50% inhibited by nanogram concentrations of transforming growth factor-beta1 (TGF-beta1), although some lines acquired resistance in late passage. However, comparable doses of HC, or TGF-beta1, failed to inhibit most human lesion-derived cell (LDC) lines. In sensitive LDC, HC (10 microg/mL) inhibited proliferation by up to 50%, with obvious apoptosis in some lines, and TGF-beta1 inhibited proliferation by more than 90%. Collagen production, as measured by [3H]proline incorporation or RIA for type III pro-collagen, was either unaffected or increased in the LDCs by HC. These divergent responses between LDC lines were partially explained by the absence of the glucocorticoid receptor (GR) and heat shock protein 90 mRNA in 10 of 12 LDC lines, but the presence of the mineralocorticoid receptor and 11beta-hydroxysteroid dehydrogenase type II. Western blot analysis confirmed the absence of the GR protein in cells lacking GR mRNA. Immunohistochemistry of human carotid lesions showed high levels of GR in the tunica media, but large areas lacking GR in the fibrous lesion. Considering the absence of the GR in most lines, the effects of HC may be elicited through the mineralocorticoid receptor. Functional resistance to the antiproliferative and antifibrotic effects of HC may contribute to excessive wound repair in atherosclerosis and restenosis.
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MESH Headings
- 11-beta-Hydroxysteroid Dehydrogenases
- Animals
- Apoptosis/drug effects
- Arteriosclerosis/metabolism
- Arteriosclerosis/pathology
- Arteriosclerosis/surgery
- Carotid Arteries/pathology
- Carotid Arteries/surgery
- Carotid Artery Injuries
- Cell Division/drug effects
- Cells, Cultured
- DNA Replication/drug effects
- Down-Regulation
- Drug Resistance
- Endarterectomy
- Enzyme Induction
- Femoral Artery/injuries
- Femoral Artery/pathology
- Femoral Artery/surgery
- HSP70 Heat-Shock Proteins/biosynthesis
- HSP90 Heat-Shock Proteins/biosynthesis
- HSP90 Heat-Shock Proteins/deficiency
- HSP90 Heat-Shock Proteins/genetics
- Humans
- Hydrocortisone/pharmacology
- Hydroxysteroid Dehydrogenases/analysis
- Iliac Artery/injuries
- Iliac Artery/pathology
- Iliac Artery/surgery
- Male
- Muscle, Smooth, Vascular/drug effects
- Muscle, Smooth, Vascular/metabolism
- Procollagen/biosynthesis
- Procollagen/genetics
- Protein Isoforms/biosynthesis
- Protein Isoforms/genetics
- RNA, Messenger/analysis
- Rats
- Rats, Inbred F344
- Receptors, Glucocorticoid/biosynthesis
- Receptors, Glucocorticoid/deficiency
- Receptors, Glucocorticoid/genetics
- Receptors, Mineralocorticoid/analysis
- Recurrence
- Species Specificity
- Transforming Growth Factor beta/pharmacology
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Affiliation(s)
- P J Bray
- Division of Hematology/Oncology, Department of Medicine, Cornell University Medical College, New York, NY 10021, USA
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Strecker EP, Gabelmann A, Boos I, Lucas C, Xu Z, Haberstroh J, Freudenberg N, Stricker H, Langer M, Betz E. Effect on intimal hyperplasia of dexamethasone released from coated metal stents compared with non-coated stents in canine femoral arteries. Cardiovasc Intervent Radiol 1998; 21:487-96. [PMID: 9853167 DOI: 10.1007/s002709900309] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE Polymer-coated, dexamethasone (DXM)-releasing stents were tested in order to assess the efficacy of DXM released locally for the prevention of stent restenosis due to intimal hyperplasia. METHODS Strecker stents coated with a biodegradable membrane containing DXM were implanted percutaneously into the femoral artery in 14 dogs. The contralateral artery received a conventional non-coated stent serving as control. The drugs are eluted by degradation of the carrier membrane. Follow-up intraarterial digital subtraction angiography (DSA) was obtained at 3, 6, 9, 12, and 24 weeks with subsequent autopsy. Specimens for gross and microscopic pathology were obtained and histomorphometry was performed. RESULTS Four of 14 DXM-coated stents showed thrombotic occlusion within the first 3 weeks; ten DXM-coated stents remained patent. At follow-up DSA, DXM-coated stents showed a significantly wider lumen than the non-coated stents. At morphometry there was less intimal hyperplasia over DXM-coated stents than over non-coated stents (p < 0.05). CONCLUSION DXM-coated stents reduce neointimal hyperplasia in dogs when compared with non-coated stents.
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Affiliation(s)
- E P Strecker
- Department of Radiology, Diakonissen-Hospital, Karlsruhe, Germany
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42
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Frishman WH, Chiu R, Landzberg BR, Weiss M. Medical therapies for the prevention of restenosis after percutaneous coronary interventions. Curr Probl Cardiol 1998; 23:534-635. [PMID: 9805205 DOI: 10.1016/s0146-2806(98)80002-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- W H Frishman
- Department of Medicine, New York Medical College/Westchester Medical Center, Valhalla, USA
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Abstract
The lamina intima of an artery is the region between the endothelial cell surface and the internal elastic lamina, which forms the luminal margin of the media. In humans the intima of atherosclerosis-prone arteries becomes thicker due to accumulation of smooth muscle cells, which originate from the media. The introduction of percutaneous transluminal coronary angioplasty (PTCA) boosted scientific interest in intimal thickening, because restenosis remains an unresolved problem of this intervention. In order to unravel the mechanisms of intimal thickening there is a need for appropriate animal models. A brief overview of these models is given together with factors that control proliferation and/or migration. Despite intensive research on neointima formation, an effective therapy for restenosis has not emerged to date. This may be due to the fact that other processes, such as acute elastic recoil and chronic constrictive remodeling may contribute to lumen narrowing as well. Other limitations of neointima models are related to species and anatomical differences. Most studies are performed in arteries that are either lesion-free, or contain relatively mild plaques, in contrast to the complicated, stenotic lesions that are the substrate for human PTCA. Other differences are the severity of the injury and incorporation of a mural fibrin-rich thrombus. Nevertheless, studies based on superficial injury, like the frequently used balloon denudation model, are useful. There are similarities with angioplasty, such as endothelial cell damage and proliferation of medial and intimal smooth muscle cells. The use of techniques such as differential display, gene transfer and application of antisense oligonucleotides may provide new therapeutic approaches to reduce neointima formation.
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Affiliation(s)
- G R De Meyer
- Division of Pharmacology, University of Antwerp-UIA, Wilrijk, Belgium
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Kimura T, Miyauchi K, Yamagami S, Daida H, Yamaguchi H. Local delivery infusion pressure is a key determinant of vascular damage and intimal thickening. JAPANESE CIRCULATION JOURNAL 1998; 62:299-304. [PMID: 9583466 DOI: 10.1253/jcj.62.299] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Local drug delivery following percutaneous transluminal coronary angioplasty (PTCA) may prevent restenosis by achieving higher local tissue concentrations of drugs than systemic administration. However, it remains unknown whether vascular damage and the ensuing intimal thickening is associated with the degree of infusion pressure achieved by local delivery. Therefore, local delivery of normal saline was performed using a channeled balloon catheter (Transport) to the rabbit iliac artery with different infusion pressures of 0, 3, 5, 7, and 12 atm (n=4 for each). The extent of vascular damage and the development of intimal thickening were determined histopathologically 14 days after the procedure. In 10 additional rabbits, to assess the degree of vessel penetration, local delivery of indocyanine green dye solution was performed in a similar fashion. After 1 h, the green dye penetrated deeply at the higher infusion pressures of 7 and 12 atm. The incidence of internal clastic lamina laceration and occurrence of total occlusion as a result of thrombus formation demonstrated an increase proportional to the degree of local infusion pressure. When the vascular injury score in each arterial section was plotted against the infusion pressure, a significant relation was observed (r=0.717, p<0.0001). At 0, 3, 5, 7, and 12 atm, neointimal areas of 0.160+/-0.005, 0.163+/-0.008, 0.189+/-0.017, 0.260+/-0.027, and 0.329+/-0.033 mm2, respectively, were observed. Smooth muscle cell (SMC) proliferative activity also increased in proportion to the local infusion pressure. We have demonstrated for the first time that local delivery infusion pressure itself is related to the severity of vascular damage, resulting in the development of intimal thickening and an associated increase in SMC proliferative activity. Therefore, we suggest that infusion pressure is a key determinant of vascular injury during local drug delivery, with lower pressure causing the least neointimal response.
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Affiliation(s)
- T Kimura
- Department of Cardiology, Juntendo University School of Medicine, Tokyo, Japan
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45
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Affiliation(s)
- S B King
- Andreas Gruentzig Cardiovascular Center, Emory University Hospital, Atlanta, Georgia, USA.
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46
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Dev V, Eigler N, Fishbein MC, Tian Y, Hickey A, Rechavia E, Forrester JS, Litvack F. Sustained local drug delivery to the arterial wall via biodegradable microspheres. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1997; 41:324-32. [PMID: 9213032 DOI: 10.1002/(sici)1097-0304(199707)41:3<324::aid-ccd14>3.0.co;2-n] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This study was designed to evaluate the feasibility of applying locally delivered polylactic acid microspheres for drug delivery to the arterial wall. To study drug persistence, rhodamine-loaded microspheres were infused into one carotid artery of 14 rabbits and plain rhodamine solution into the other by using a porous balloon. To study tissue response, plain microspheres and dexamethasone-loaded microspheres were infused into the carotid arteries of another group of rabbits. To study the antiproliferative effects of locally delivered drug, 20 rabbits were subjected to overstretch balloon injury to both carotid arteries and divided into 4 groups: injury alone, plain microspheres, dexamethasone-loaded microspheres, and microspheres containing colchicine and dexamethasone. Fluorescent microspheres persisted in the vessel wall for 4 wk, whereas rhodamine without microspheres disappeared at 72 h. Histopathologic studies in arteries infused with unloaded microspheres showed inflammatory cell infiltrate with polymorphonuclear cells at 1 wk and macrophages and giant cells at 4 wk. Arteries infused with dexamethasone-loaded microspheres did not show any inflammatory cell infiltrate. Local delivery of dexamethasone or dexamethasone plus colchicine did not result in significant change in the intima-to-media ratio or in residual lumen following balloon injury. Polylactic acid microspheres may be used for prolonged delivery of drugs or other bioactive agents locally to the arterial wall. They induce an inflammatory reaction that is suppressable by dexamethasone in the microspheres. Dexamethasone or dexamethasone and colchicine delivered via this system, however, failed to reduce the degree of intimal hyperplasia after overstretch balloon injury to the rabbit carotid arteries.
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Affiliation(s)
- V Dev
- Department of Medicine, Cardiovascular Intervention Center, Los Angeles, California, USA
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47
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Mak KH, Topol EJ. Clinical trials to prevent restenosis after percutaneous coronary revascularization. Ann N Y Acad Sci 1997; 811:255-84; discussion 284-8. [PMID: 9186603 DOI: 10.1111/j.1749-6632.1997.tb52007.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- K H Mak
- Department of Cardiology, Joseph J. Jacobs Center for Vascular Biology, Cleveland Clinic Foundation, Ohio 44195, USA
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48
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Lincoff AM, Furst JG, Ellis SG, Tuch RJ, Topol EJ. Sustained local delivery of dexamethasone by a novel intravascular eluting stent to prevent restenosis in the porcine coronary injury model. J Am Coll Cardiol 1997; 29:808-16. [PMID: 9091528 DOI: 10.1016/s0735-1097(96)00584-0] [Citation(s) in RCA: 212] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES This study sought to assess the feasibility, safety and efficacy of sustained intracoronary delivery of dexamethasone by a novel polymer-coated eluting stent. BACKGROUND Development of techniques to provide sustained local drug delivery has focused on polymers as matrices for drug incorporation and elution. METHODS A tantalum wire stent was coated with dexamethasone (0.8 mg) suspended in a matrix of either low (approximately 80 kD) or high (approximately 321 kD) molecular weight poly-L-lactic acid (PLLA [0.4 mg]). Uncoated stents, stents coated with PLLA or stents coated with dexamethasone in PLLA were overexpanded by 30% to the normal vessel diameter in the coronary arteries of juvenile farm pigs. Animals were euthanized 28 days later, and neointimal thicknesses were measured. Additional pigs underwent placement of stents coated with high molecular weight PLLA-dexamethasone for assessment of arterial tissue and serum concentrations of dexamethasone at 1 h and 1, 2, 10 and 28 days after stent implantation. RESULTS In vitro dexamethasone release occurred over the first 6 days. Stents coated with low molecular weight PLLA produced an intense inflammatory neointimal response. Stents utilizing the high molecular weight PLLA were well tolerated within the coronary vessel during the 28-day experiment. However, dexamethasone did not decrease neointimal hyperplasia. Dexamethasone concentrations in the arterial tissue were approximately 300,000-fold higher than those in the serum 24 h after stent implantation, remaining approximately 3,000-fold higher at 28 days. CONCLUSIONS The eluting stent utilizing high molecular weight PLLA appeared to be a well tolerated and effective means of providing sustained, site-specific drug delivery to the porcine coronary artery wall for at least 28 days.
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Affiliation(s)
- A M Lincoff
- Department of Cardiology, Cleveland Clinic Foundation, Ohio 44195, USA
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49
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Keiser JA, Uprichard AC. Restenosis: is there a pharmacologic fix in the pipeline? ADVANCES IN PHARMACOLOGY (SAN DIEGO, CALIF.) 1997; 39:313-51. [PMID: 9160119 DOI: 10.1016/s1054-3589(08)60075-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
One of the most frustrating aspects of restenosis is that it is the result of advances in medical care (there was no restenosis before the days of balloon angioplasty), yet it seems to be resistant to all that science has to offer. Still we believe there is reason to be optimistic. We are at last beginning to see some promise from clinical trials, and data being generated confirm some of the hypotheses previously generated from animal experiments. Thus the effects seen with the GP IIb/IIIa antibody 7E3 suggest that thrombosis may be as important in its long-term sequelae as it is for acute reocclusion. The jury is still out on whether antiproliferative approaches will be a therapeutic option, but local delivery paradigms using novel formulations delivered by catheter or impregnated in stents may allow the concept to be tested without the risk of systemic toxicity. Plans are also underway for gene therapy trials, although we may have to wait for better vector technology before taking these into the coronary bed. Perhaps we should move away from the "single pill" approach and accept that, like many infections, malignancies, or even heart failure, a multifaceted approach with combination therapy will provide the first glimmer of that brighter tomorrow.
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Affiliation(s)
- J A Keiser
- Parke-Davis Pharmaceutical Research, Warner Lambert Company, Ann Arbor, Michigan 48105, USA
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50
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Abstract
The main procedural drawback to percutaneous coronary angioplasty is restenosis of the treated site within 6 months. Despite advances in equipment, technique, and adjunctive therapies, restenosis has occurred in approximately one-third to one-half of all patients. The biology of restenosis can be divided into plaque persistence and recoil, thrombus formation and transformation, and cellular proliferation and vascular remodeling. Animal models of restenosis have helped to elucidate these mechanisms of restenosis and provide a means to test pharmacologic and mechanical strategies to reduce stenosis recurrence. While numerous agents have been tested in animal models, until recently none has translated into benefit in large-scale clinical trials. Two therapeutic "hopefuls" which have recently emerged in clinical practice are the potent platelet inhibitors, glycoprotein IIb/IIIa receptor antagonists, and intracoronary metallic stents. The IIb/IIIa receptor antagonists target thrombus formation at the angioplasty site, thereby minimizing abrupt vessel closure acutely and neointimal growth chronically, while intracoronary stents safely produce a large coronary arterial lumen acutely and prevent vessel recoil. Separately, these therapeutic strategies have been shown to reduce clinical restenosis 20-30% at 6-month follow-up. With these encouraging results, the future will certainly provide more pharmacologic and mechanical therapies targeting restenosis. With increased understanding of the restenotic process and continued refinement of effective treatments, it may be possible one day to prevent stenosis recurrence.
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Affiliation(s)
- M Gottsauner-Wolf
- Department of Cardiology, Cleveland Clinic Foundation, OH 44195, USA
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