Response of high-sensitivity C-reactive protein to percutaneous coronary intervention in patients with acute coronary syndrome

Evaluation of C-reactive protein as predictor of adverse prognosis in acute myocardial infarction after percutaneous coronary intervention: A systematic review and meta-analysis from 18,715 individuals

BACKGROUND

Proper prognostic biomarker is of great importance for clinical decision-making in patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI). Although recently emerges plenty of novel inflammatory biomarkers, the canonical inflammatory mediator C-reactive protein still plays an important role in prognosing adverse post-infarction complications.

METHODS

PubMed, Embase, and Medline were systematically searched from the establishment of databases up to December 2021, conforming with standards set forth by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

RESULTS

A total of 23 studies were eventually eligible for this meta-analysis, including 18,715 individuals. Our findings showed that elevated C-reactive protein (CRP) had a statistically significant superiority in predicting all-cause mortality (OR: 3.22, 95% CI: [2.71, 3.84], p < 0.00001), cardiovascular death (OR: 3.26, 95% CI: [2.30, 4.61], p < 0.00001), major adverse cardiovascular events (MACEs) (OR: 2.85, 95% CI [2.08, 3.90], p < 0.00001), heart failure (OR: 2.29, 95% CI: [1.48, 3.54], p = 0.0002), recurrent myocardial infarction (OR: 1.76, 95% CI: [1.28, 2.43], p < 0.001), and restenosis (OR: 1.71, 95% CI: [1.18, 2.47], p = 0.004). Subgroup analysis implies that CRP had better performance in predicting plenty of hospitalization and short-term (<12 months) adverse prognosis than long-term prognosis and Asian patients with elevated CRP were under more risk in adverse prognosis after PCI than Europeans.

CONCLUSION

Our meta-analysis suggests that CRP is a prospective predictor of the prognosis in patients with AMI undergoing PCI, especially in hospitalization and short-term and in the Asian group.

The effect of lycopene on serum level of cardiac biomarkers in patients undergoing elective percutaneous coronary intervention: A randomized controlled clinical trial

BACKGROUND

Myocardial ischemia may recur in a significant subset of patients following percutaneous coronary intervention (PCI). Lycopene, a carotenoid with antioxidant activity, has evidence for beneficial effects on cardiovascular system. In the present study, we aimed to evaluate the possible preventive effect of lycopene against post-PCI myocardial damage by detection of cardiac biomarkers of ischemia.

METHODS

A total of 45 patients who planned to undergo elective PCI were randomly assigned to two groups to receive either lycopene (30 mg 12 hours before PCI as well as 15 mg just before and 8 hours after PCI) along with standard treatment (n = 23) or only standard treatment (n = 22). Standard treatment included aspirin, a statin, and a beta-blocker. The serum levels of creatine kinase-MB (CK-MB), troponin I, and high sensitivity C-reactive protein (hs-CRP) were measured 12 hours before and 12 hours after the procedure and were compared between the two groups.

RESULTS

The use of lycopene significantly prevented the increase of CK-MB following PCI compared to control (P = 0.048). However, it had not any significant effect on serum levels of troponin I (TnI) (P = 0.176) and hs-CRP (P = 0.186) compared to control.

CONCLUSION

Lycopene can prevent the increase of CK-MB following PCI. Therefore, it has the potential for prevention of post-PCI cardiovascular events. However, more studies are needed to confirm such an effect.

The upregulated scavenger receptor CD36 is associated with the progression of nontarget lesions after stent implantation in atherosclerotic rabbits

Background

The incidence of recurrent cardiovascular events from the progression of nontarget lesions (NTLs) is high for percutaneous coronary intervention-treated patients. However, the underlying mechanisms have not been thoroughly elucidated.

Methods

In this study, ten atherosclerotic rabbits with multiple plaques in the upper and lower segments of abdominal aorta (group A) were randomly divided into two subgroups: group A1 underwent intravascular ultrasound examination and stent implantation in the lower segments of the abdominal aorta (n=5), whereas group A2 was without stenting (n=5). Group B was a control group without balloon injury. The serum levels of high-sensitivity CRP, interleukin-6 (IL-6), oxidized low-density lipoprotein, and CD36 were assessed via ELISA at five time points between the 10th and 18th weeks. The upper abdominal aorta was examined via the immunohistochemical stain and Western blotting of matrix metallopeptidase 9 (MMP-9), CD36, IL-6, and tumor necrosis factor α.

Results

As a result, we found that stent implantation aggravated serum levels of CD36, oxidative stress, and inflammatory cytokines. Meanwhile, the upper abdominal arterial plaque burden significantly increased after stenting by intravascular ultrasound. Immunohistochemistry and Western blotting showed that the local NTLs’ matrix metallopeptidase 9, CD36, IL-6, and tumor necrosis factor α expressions in group A1 were significantly higher than those in groups A2 and B (P<0.05–0.01). More importantly, a strong correlation was identified between CD36 expression and NTLs’ plaque burden before the rabbits were killed.

Conclusion

Taken together, stent implantation accelerated inflammation, induced oxidative stress, and increased the NTLs’ progression, which were associated with the upregulated CD36 expression.

C-Reactive Protein and Inflammatory Cytokines during Percutaneous Coronary Intervention

BACKGROUND

C-reactive protein (CRP) is significantly associated with cardiovascular diseases; however, whether CRP plays a causal role in coronary artery disease has yet to be determined. In addition, the relationship between CRP, atherosclerosis, and inflammation remains controversial.

METHODS AND RESULTS

Serum interleukin (IL)-6, IL-1β, and CRP levels were determined in 160 patients at time points around percutaneous coronary intervention (PCI) with drug-eluting stent implantation. The levels were found to be at peak at 24 h post-PCI and gradually declined to the level before PCI at day 30 post-PCI. These inflammation markers around PCI have no statistical difference in the different postdilation pressures (≤14, 14-18, and ≥18 atm) and stent number (1 and ≥2 stents) groups. Treatment of cultured human vascular smooth muscle cells (VSMCs) with a combination of IL-6 and IL-1β at concentrations associated with PCI did not result in any significant change in the CRP mRNA levels. The IL-6-augmented CRP expression in human internal mammary arteries (IMAs) stretched with a mechanical strength of 3 g was blocked by the nuclear factor-κB (NF-κB) peptide inhibitor SN50 and not by the inactive SN50 analog SN50M. IL-6 treatment increased NF-κB activity in human IMAs stretched with 3 g, and this effect was further blocked by stretch-activated channel (SAC) inhibitors (streptomycin or GdCl3) and SN50.

CONCLUSIONS

The current study provides evidence that increased serum IL-6, IL-1β, and CRP levels around PCI are not different between different postdilation pressure and stent number groups. The combination of IL-6 and IL-1β at concentrations associated with PCI cannot induce CRP expression in human VSMCs, but they can augment mechanical strain-induced CRP synthesis via the SAC-NF-κB pathway in human IMAs.

Efficacy and Safety of Loading-Dose Rosuvastatin Therapy in Elderly Patients with Acute Coronary Syndromes Undergoing Elective Percutaneous Coronary Intervention

OBJECTIVES

The aim of this work was to investigate the efficacy and safety of loading-dose rosuvastatin therapy in elderly patients with non-ST-segment elevation acute coronary syndromes (NSTEACS) undergoing elective percutaneous coronary intervention (PCI).

METHODS

A total of 126 patients (≥70 years old) with NSTEACS were randomly divided into two groups: (1) loading-dose rosuvastatin-treated group, treated with rosuvastatin 20 mg 12 h prior to PCI, with a second dose administered just before PCI (n = 62), and (2) control-treated group, treated with the standard method according to ACC/AHA guidelines in UAP/NSTEMI 2007 (n = 64). All patients were required to take rosuvastatin 10 mg once a day starting 24 h after the surgery irrespective of the initial randomization assignment. The serum soluble lectin-like oxidized low-density lipoprotein receptor-1 (sLox-1), high-sensitivity C-reactive protein (hs-CRP), creatinine kinase (CK)-MB, cardiac troponin I (cTnI), and brain natriuretic peptide (BNP) levels were measured prior to PCI and at 24 h and 30 days after PCI in both groups. The left ventricular ejection fraction (LVEF) levels were recorded prior to PCI and 30 days after PCI in both groups.

RESULTS

Compared to pre-PCI, the serum sLox-1, hs-CRP, CK-MB, and cTnI levels were increased at 24 h after PCI (all p < 0.05) in both groups. However, the increased sLox-1, hs-CRP, CK-MB, and cTnI values were significantly lower in the loading-dose rosuvastatin-treated group than in the control-treated group (p < 0.05). In addition the serum sLox-1 and hs-CRP levels were lower in the loading-dose rosuvastatin-treated group than in the control-treated group at 30 days after PCI. However, the decreased values of sLox-1and hs-CRP from 24 h after PCI to 30 days after PCI did not show any significant difference between the two groups. No significant difference was found in the serum ALT and Scr levels between the two groups before and after PCI. Compared to the control-treated group, the serum BNP level decreased (p < 0.05) and LVEF (p < 0.05) increased in the loading-dose rosuvastatin-treated group at 30 days after PCI.

CONCLUSION

The loading-dose rosuvastatin therapy in elderly patients with non-ST-segment elevation acute coronary syndromes undergoing elective PCI can attenuate the increase in serum hs-CRP, sLox-1, CK-MB, and cTnI levels, reduce myocardial injury and inflammatory reaction caused by PCI, and improve the LVEF level at 30 days after PCI, ensuring an effective and safe therapy.

Efficacy of high-dose rosuvastatin preloading in patients undergoing percutaneous coronary intervention: a meta-analysis of fourteen randomized controlled trials

Background

Numerous studies have evidenced that statins can reduce the incidence of cardiovascular disease. However, the effects of high-dose rosuvastatin (RSV) preloading in patients undergoing percutaneous coronary intervention (PCI) are controversial.

Objective

We attempted to identify and quantify the potential cardioprotective benefits of high-dose RSV preloading on final thrombolysis in myocardial infarction (TIMI) flow grade, major adverse cardiac events (MACE), and peri-procedural myocardial injury (PMI) in patients undergoing PCI.

Methods

Pubmed, EMBASE, Cochrane Central Register of Controlled Trials and ISI Web of Science databases were systematically searched for randomized controlled trials (RCTs) up to June 2015. We assessed the incidence of MACE and PMI in all enrolled patients for subgroups stratified by clinical presentation and previous statin therapy during the follow-up period.

Results

Fourteen trials with 3368 individuals were included in our meta-analysis. High-dose RSV preloading before PCI lead to a 58 % reduction in MACE (odds ratio [OR] = 0.42, 95 % confidence intervals [CI]: 0.29-0.61, P < 0.00001) and a 60 % reduction in PMI (OR = 0.40, 95 % CI: 0.25–0.63, P < 0.0001). This procedure also improved the final TIMI flow grade in patients undergoing PCI (OR = 1.61, 95 % CI: 1.09–2.38, P = 0.02). The benefits on MACE were significant for both stable angina patients (OR = 0.42, 95 % CI: 0.21-0.87, P = 0.02) and acute coronary syndrome (ACS) patients (OR = 0.42, 95 % CI: 0.27-0.65, P < 0.0001); and for both statin naïve patients (OR = 0.42, 95 % CI: 0.28-0.64, P < 0.0001) and previous statin therapy patients (OR = 0.28, 95 % CI: 0.10-0.73, P = 0.01).

Conclusion

High-dose RSV preloading can significantly improve myocardial perfusion and reduce both MACE and PMI in patients undergoing PCI. The cardioprotective benefits of RSV preloading were significant in not only stable angina and ACS patients but also statin naïve and previous statin therapy patients. The cardioprotective benefits of RSV preloading in the follow-up period mainly resulted from a reduction in spontaneous MI and TVR, especially for ACS and statin naïve patients.

Effect of previous statin therapy in patients with acute coronary syndrome and percutaneous coronary intervention

Background and Objectives

Statin therapy after percutaneous coronary intervention (PCI) has been associated with reduced major adverse cardiovascular events (MACE). However, it has been less clear as to whether statin therapy before acute coronary syndrome (ACS) is beneficial. We studied the effect of previous statin therapy, initiated ≥1 month before PCI, on the outcome of patients with ACS who had undergone early invasive strategies.

Subjects and Methods

We stratified 479 consecutive patients with ACS who had undergone PCI, according to preprocedural statin administration as follows: previous statin-treated patients (statin group, n=237) and statin-naive patients (control group, n=242). The incidence of periprocedural myocardial infarction (MI) and in-hospital MACE was assessed.

Results

The incidence of Braunwald class III angina and MI presentation were significantly lower in the statin group than in the control group. Angiographic and procedural characteristics were similar between the two groups; however, slow/no reflow phenomenon occurred more frequently in the control group. After PCI, the incidence of periprocedural MI was higher in the control group than in the statin group (6.6% vs. 2.1%, p=0.016). Multivariate analysis revealed that no prior use of statin {odds ratio (OR)=2.8; 95% confidence interval (CI)=1.1-7.2; p=0.038), procedural complication (OR=4.0; 95% CI=1.5-10.5; p=0.004), stent overlap (OR=4.7; 95% CI=1.3-16.4; p=0.015), and old age (OR=3.2; 95% CI=1.2-8.0; p=0.016) were independent predictors for in-hospital MACE.

Conclusion

Previous statin therapy before ACS was associated with milder clinical presentation and lower incidence of in-hospital MACE after early invasive strategies. The beneficial outcome is attributable to a significant reduction in periprocedural MI after PCI.

Usefulness of preprocedure high-sensitivity C-reactive protein to predict death, recurrent myocardial infarction, and stent thrombosis according to stent type in patients with ST-segment elevation myocardial infarction randomized to bare metal or drug-eluting stenting during primary percutaneous coronary intervention

It is unknown whether high-sensitivity C-reactive protein (hs-CRP) predicts outcome depending on implanted stent type. We investigated the prognostic value of hs-CRP in relation to type of stent implanted in patients with ST-segment elevation myocardial infarction (STEMI). Immediately before primary percutaneous coronary intervention (pPCI), 301 patients had blood drawn. Patients were categorized according to hs-CRP levels and combination of hs-CRP (≤2 vs >2 mg/L) and stent type (bare metal stent [BMS] vs drug-eluting stent [DES]). Hs-CRP >2 mg/L (median, hazard ratio 2.7, 95% confidence interval 1.3 to 5.6, p = 0.007) and the combined variable of hs-CRP >2 mg/L and BMS (hazard ratio 2.4, 95% confidence interval 1.2 to 4.5, p = 0.006) independently predicted the composite end point of death and MI at 36-month follow-up. There was a significant interaction (p = 0.006) for hs-CRP and stent type. Survival analysis demonstrated significant differences for occurrence of death and MI: 4.8% in BMS + CRP ≤2 mg/L, 11.9% in DES + CRP ≤2 mg/L, 17.6% in DES + CRP >2 mg/L, and 27.9% in BMS + CRP >2 mg/L. None of the 14 stent thromboses occurred in patients with BMS + CRP ≤2 mg/L. In conclusion, preprocedure hs-CRP predicts outcome after pPCI in patients with STEMI. Our hypothesis-generating data indicate that BMS implantation should be preferred when hs-CRP is ≤2 mg/L and DES when hs-CRP is >2 mg/L to decrease long-term adverse outcomes including stent thrombosis in patients with STEMI treated with pPCI. These findings need confirmation in larger randomized clinical trials.

Comparison of the effects of nitroprusside versus nicorandil on the slow/no-reflow phenomenon during coronary interventions for acute myocardial infarction

Although slow/no-reflow is a serious problem complicating primary percutaneous coronary interventions (PCI) for acute myocardial infarction (AMI) and is associated with a poor prognosis, its efficacious treatment remains problematic. We compared the acute, in-hospital and long-term (1 year) effects of nitroprusside (NTP) with those of nicorandil (NC) on the slow/no-reflow phenomenon. Forty-nine of 442 consecutive patients with AMI who underwent primary PCI complicated by slow/no-reflow and who received intracoronary NTP (n = 25) or NC (n = 24) administration were studied. Both NTP and NC induced significant improvements in coronary flow, with increases in TIMI flow grade from 1.64 ± 0.62 to 2.74 ± 0.36 (p < 0.001) and 1.60 ± 0.86 to 2.23 ± 0.91 (p < 0.001), and in corrected TIMI frame count from 37.8 ± 15.1 to 13.7 ± 7.1 (p < 0.001) and 30.8 ± 20.7 to 19.3 ± 17.9 (p < 0.001), respectively. The degree of improvement in TIMI flow grade (post-pre/pre) and TIMI frame count (pre-post/pre) showed that NTP was more effective than NC (NTP vs. NC: 0.88 ± 0.79, 0.37 ± 0.37, p = 0.008; 0.59 ± 0.23, 0.36 ± 0.27, p = 0.003, respectively). Congestive heart failure did not tend to last beyond 3 days after onset in the NTP group, which was more than in the NC group, during hospitalization (1/25, 4/24, p = 0.143, respectively). At the 1-year follow-up, the NTP group tended to show more improvement than the NC group in MACE (5/25, 9/24, p = 0.175, respectively). NTP is a more effective treatment for slow/no-reflow associated with PCI in patients with AMI and may improve long-term clinical outcomes compared with NC.

Survival and changes in physical ability after coronary revascularization for octa-nonagenerian patients with acute coronary syndrome

Elderly populations are increasingly represented among patients with acute coronary syndrome (ACS), and advanced age has been identified as an important risk factor for death and adverse outcome in patients with ACS treated invasively. Although considerable data have demonstrated a prognostic benefit of early revascularization in ACS particularly in high-risk patients, elderly patients with ACS are treated invasively less often than younger patients because older age is thought to be an independent predictor of mortality after percutaneous coronary intervention (PCI) in ACS. Over the past 5 years, a total of 54 ACS patients over 85 years old were treated. The 6-month survival rate was around 50% in the non-PCI group (n = 12) and around 80% in the PCI group (n = 42) (P < 0.05). Cardiac death occurred in 6 patients in the PCI group and in 6 patients in the non-PCI group. The rates of both cardiac death and all-cause death were significantly lower in the PCI group. The change in ADL score before and 6 months after the procedure was from 1.57 to 1.59 in the PCI group and from 2.25 to 2.20 in the non-PCI group. PCI for elderly patients with ACS is safe and life saving, and does not reduce the ability to perform activities of daily living. PCI should be recommended even for octo-nonagenerians with ACS.