Risk factors for progression of atherosclerosis six months after balloon angioplasty of coronary stenosis

Living with heart disease after angioplasty: A qualitative study of patients who have been successful or unsuccessful in multiple behavior change

OBJECTIVE

To document values, attitudes, and beliefs that influence behavior change among a diverse group of patients post-angioplasty.

METHODS

Purposive and maximum-variation sampling were used to assemble a demographically diverse patient cohort (N=61) who had been successful or unsuccessful at post-angioplasty multibehavior change. Semistructured interviews and grounded theory methods were used to collect and analyze qualitative data.

RESULTS

Themes showed the following: a) Patients reported surviving a life-threatening event and feared disease recurrence and death; b) the perception of a turning point and self-determination facilitated behavior change; c) social support and spiritual beliefs promoted coping with the uncertainty of living with heart disease; and d) unsuccessful behavior change was related to physical limitations, a sense that "nothing helps," and the belief that angioplasty "cures" heart disease.

CONCLUSION

Lifestyle interventions should be culturally relevant and adapted to physical abilities. Fostering self-determination and social support may promote successful behavior change.

Notch signaling regulates endothelial progenitor cell activity during recovery from arterial injury in hypercholesterolemic mice

BACKGROUND

Little is known about the role of endothelial progenitor cells (EPCs) in atherosclerosis. Accordingly, we performed a series of assessments with hypercholesterolemic (apolipoprotein E-null [ApoE(-/-)]) and wild-type (WT) mice to evaluate how cholesterol influences reendothelialization, atherosclerosis, and EPC function after arterial injury.

METHODS AND RESULTS

Unexpectedly, reendothelialization (assessed by resistance to Evans blue staining) and circulating EPC counts (EPC culture assay) were greater in ApoE(-/-) mice than in WT mice, and transplantation of ApoE(-/-) bone marrow in WT mice accelerated endothelial recovery and increased recruitment of bone marrow-derived EPCs to the neoendothelium. Cholesterol concentration-dependently promoted the proliferation (MTS assay) of both ApoE(-/-) and WT EPCs, and the concentration dependence of EPC adhesion (to vitronectin-, collagen type I-, fibronectin-, and laminin-coated plates), migration (modified Boyden chamber assay), and antiapoptotic (terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling stain) activity was biphasic. Cholesterol enhanced the messenger RNA expression (quantitative, real-time reverse-transcription polymerase chain reaction) of vascular endothelial growth factor and inhibited Notch1 messenger RNA expression in both ApoE(-/-) and WT EPCs, whereas endothelial nitric oxide synthase messenger RNA expression increased in ApoE(-/-) EPCs and declined in WT EPCs after cholesterol exposure. EPC activity was greater in Notch1(+/-) EPCs than in WT EPCs, and transplantation of Notch1(+/-) bone marrow accelerated endothelial recovery after arterial injury in WT mice.

CONCLUSIONS

The results presented here provide novel insights into the role of EPCs during atherosclerosis and suggest that cholesterol and Notch1 may be involved in the regulation of EPC activity.

Long-term outcome of coronary balloon angioplasty in diabetic patients

Diabetes is recognised to increase morbidity and mortality after coronary revascularization. We compared clinical outcomes in mean 5-year-long follow-up of coronary balloon angioplasty in diabetic and non-diabetic patients. We studied 621 patients undergoing elective angioplasty from 1987 to 1996. There were 60 (9.7%) patients with diabetes who were compared with 561 non-diabetic patients. Diabetics were older, more often obese, less frequently were current smokers, and less frequently had hypercholesterolaemia. Diabetic patients in comparison with non-diabetics had lower ejection fraction and more frequently had angioplasty of complex (B2 or C) lesions, but there were no differences between both groups in the other clinical and angiographic risk factors. Clinical success of angioplasty, as well as complications rate were similar in both groups. In follow-up restenosis occurred more frequently in diabetics (46.3 vs. 32.2%, P=0.03), resulting in significantly higher re-intervention rate (50.0 vs. 35.4%, P=0.03). Especially diabetic patients were more frequently referred to CABG (20.4 vs. 9. 9%, P=0.02). There were no significant differences in deaths (1.9 vs. 2.8%) and myocardial infarction (3.7 vs. 4.4%). Diabetics presented worse CCS status at the end of observation (Class 0 and I - 61.1 vs. 74.4%, P=0.037). Angioplasty proved to be a safe procedure in diabetic patients. Despite higher restenosis and re-intervention rate in diabetics, mortality as well as myocardial infarction rate was the same in both groups during mean 5-year follow-up.

Restenosis or rapid progression in non-dilated sites are not predictors of late spontaneous coronary events

The present study was designed to assess the prognostic value of clinical and angiographic factors, and especially restenosis or rapid progression in non-dilated sites, on major spontaneous coronary events at long-term follow-up after a first successful coronary angioplasty performed for angina pectoris. A second aim was to assess the prognostic factors and especially restenosis in asymptomatic patients after angioplasty. The first 352 consecutive patients undergoing a successful coronary angioplasty were selected and followed-up. The following variables: age, sex, unstable angina, previous myocardial infarction, diabetes, hypercholesterolemia, tobacco consumption, hypertension, fibrinogen, coronary extent, single or multiple dilatation, restenosis, new progression, clinical deterioration of anginal status just before angiographic restudy or asymptomatic status were subjected to a stepwise regression analysis. Restenosis (a loss of 30% in diameter and/or a return to a >50% stenosis) and progression in non-dilated segments (a 20% reduction in diameter) were assessed by a computer-assisted method. Cardiac death, new myocardial infarction or new unstable angina, at long-term follow-up after angiographic restudy, were regarded as spontaneous coronary events and pooled in a single dependent variable. Thus 41 patients had a coronary event. In the overall population, clinical deterioration of anginal status (p<0.001, relative risk: 3.65) and fibrinogen (p<0.05, relative risk: 1.03) were independent predictors of spontaneous coronary events. Restenosis or new progression were not predictors. In asymptomatic patients (n=187), fibrinogen (p<0.01, relative risk=1.06) was the only predictor and restenosis was not an independent predictor of spontaneous coronary events. The best predictor of spontaneous coronary events at long-term follow-up after a first successful coronary angioplasty is clinical deterioration in anginal status in the months following the procedure. Restenosis does not appear as an independent predictor. Rapid progression observed in non-dilated sites is not an important prognostic factor.

Effects of cigarette smoking on the angiographic evolution of coronary atherosclerosis. A Canadian Coronary Atherosclerosis Intervention Trial (CCAIT) Substudy. CCAIT Study Group

BACKGROUND

Although smoking increases both the risk of developing coronary disease and the risk of coronary events in patients with known coronary atherosclerosis, the effect of smoking on the evolution of coronary atherosclerosis as assessed by serial angiography is poorly defined.

METHODS AND RESULTS

Ninety smokers with coronary atherosclerosis shown on a recent angiogram and with fasting cholesterol levels between 220 and 300 mg/dL were enrolled in a randomized, double-blind, placebo-controlled trial of cholesterol-lowering therapy, along with 241 nonsmokers and exsmokers. Lovastatin at a mean dose of 36 mg/d lowered total and LDL cholesterol by 21 +/- 11% and 29 +/- 11%, respectively, but these levels changed by < 2% in placebo-treated patients. Coronary arteriography was repeated after 2 years in 72 smokers and their 557 lesions were measured blindly with an automated quantitative system, along with 1752 lesions in 227 nonsmokers. Coronary change score, the per-patient mean of the minimal lumen diameter changes for all qualifying lesions, worsened by 0.16 +/- 0.16 mm in smokers and by 0.07 +/- 0.15 mm in nonsmokers in the placebo group (P < .001). Lovastatin-treated smokers had less worsening (0.07 +/- 0.15 mm) than placebo-treated smokers (P = .024). One or more coronary lesions progressed in 16 of 34 lovastatin-treated smokers and in 28 of 38 placebo-treated smokers (47% versus 74%, P < .001). In the placebo group, new coronary lesions developed in 21 of 38 smokers and in 28 of 115 nonsmokers (55% versus 24%, P < .001); fewer lovastatin-treated smokers developed new lesions (15% versus 55%, P < .001).

CONCLUSIONS

Smoking accelerates coronary progression and new lesion formation as assessed by serial quantitative coronary arteriography. Lovastatin slows the progression of coronary atherosclerosis and prevents the development of new coronary lesions in smokers.

Progression of coronary artery disease in non-dilated sites in the months following balloon angioplasty: time-dependent relation with restenosis

There is scant information on the progression of coronary artery disease in non-dilated sites in the months following percutaneous transluminal coronary angioplasty (PTCA) or on its relationship with restenosis. To assess the incidence of this progression and its relationship with restenosis at various times after PTCA, the authors selected 371 consecutive patients who had undergone a first successful PTCA for angina on native coronaries followed by a repeat angiographic study. The angiograms were analysed by a computer-assisted method; progression was defined as a 20% decrease in diameter and restenosis as a 30% decrease in diameter or a return to > 50% stenosis. The relationship between progression and restenosis was analysed in the whole population and then, using the Mantel-Haenszel chi-square test, in two subgroups: patients with a stable clinical state, who were restudied routinely and those whose worsened state had prompted repeat angiography. The relationship was assessed at different times between angioplasty and the repeat angiography. Progression was observed in 80 patients (22%) and restenosis in 155 patients (42%). There was a highly significant relationship between progression and restenosis in the total population (chi 2 = 26.4, odds ratio = 3.9 and P < 0.0003) and in the group of patients that were routinely restudied (chi 2 = 31.6, odds ratio = 5.3 and P < 0.0001), but not in the group of patients in whom restudy was performed because of clinical worsening (chi 2 = 0.13, odds ratio = 1.5 and P = NS). With respect to the length of follow-up, in the total population the relationship was significant only at 6 and 7 months (P < 0.0001), and in the group receiving a routine restudy only at 4-5 and 6-7 months (P < 0.001). Progression in non-dilated sites appeared to be strongly and transiently linked with restenosis, suggesting that PTCA may enhance both restenosis and progression over a short period.

Utility of various clinical, noninvasive, and invasive procedures for determining the causes of recurrence of myocardial ischemia or infarction > or = 1 year after percutaneous transluminal coronary angioplasty

In patients with recurrent symptoms > or = 1 year after successful percutaneous transluminal coronary angioplasty (PTCA), the decision of whether to proceed directly with coronary angiography or to evaluate the patient noninvasively can be difficult. To determine which demographic, historical, clinical, and laboratory factors are useful in helping to make this decision, 76 consecutive patients who presented > 1 year (768 +/- 309 days) after successful PTCA with resolution of symptoms were studied. The initial PTCA successfully treated all stenoses (except chronically occluded vessels) in all major vessels and segments. The patient group was predominantly men (68%), with a mean age of 64 +/- 10 years. A prior myocardial infarction was present in 39 patients (51%), and there was a mean of 2.8 risk factors per patient. In patients who presented with recurrent symptoms, the Canadian Cardiovascular Society functional class was 2.0 +/- 0.9; 2 patients presented with acute infarctions, 57 were admitted to the hospital with unstable angina, and 17 had stable angina. New electrocardiographic changes at rest were found in 19 of 74 patients (26%) with recurrent angina. A thallium stress test was performed in 40 patients (53%), with a sensitivity of 77% and a specificity of 36% for the presence of a significant stenosis. No nonangiographic variable was predictive of angiographic findings. At angiography, the number of coronary arteries with > or = 50% diameter narrowing was 1.4 +/- 1.0. Forty-two patients had stenosis at a new site, 7 had restenosis, and 27 had no new stenoses.(ABSTRACT TRUNCATED AT 250 WORDS)

Biological risk factors for restenosis after percutaneous transluminal coronary angioplasty

In an attempt to discern biological (such as thrombotic or fibrinolytic) risk factors in patients developing restenosis after percutaneous transluminal coronary angioplasty, the following factors were measured prior to angiography in a population of 23 patients (20 men, 3 women, mean age 57 +/- 5 yr) treated by a successful angioplasty (gain > 20% and residual stenosis < 50%) for stable angina pectoris and who had a routine angiographic restudy. The following factors were thus assessed: lipid factors: cholesterol, triglycerides, high density lipoprotein cholesterol, low density lipoprotein cholesterol, apolipoprotein AI, apolipoprotein B; coagulation factors: fibrinogen, antithrombin III, fibrinopeptide A, factor VIII coagulant, factor VIII antigen, protein C; factors of physiological fibrinolysis: plasminogen, alpha 2-antiplasmin, tissue plasminogen activator and euglobulin clot lysis time before and after venous occlusion, plasminogen activator inhibitor before venous occlusion; and factors of platelet release: beta-thromboglobulin, platelet factor 4. Also studied were clinical characteristics: age, gender, diabetes, hypertension, smoking habits, previous myocardial infarction; angiographic data: global extent of coronary artery disease, location of the stenosis in a bend or branch point, complexity of the lesion, initial and residual stenosis and treatment during follow-up. The coronary angiograms were analyzed by a computer-assisted method with automatic edge detection. On angiographic criteria, 6 patients (restenosis group) were judged to have developed a restenosis (30% decrease in diameter and/or return to a 50% stenosis). The other 17 patients (those without restenosis) were considered to have a persistent success. Apart from age (group without restenosis: 55 +/- 6; restenosis group 61 +/- 5, p < 0.04), there were no differences in clinical, angiographic or treatment variables. There were no differences in lipid factors, but significant differences were observed in hemostatic variables: fibrinogen (without restenosis: 3.18 +/- 0.83; restenosis: 3.83 +/- 0.51 milligrams, p = 0.05), tissue plasminogen activator before venous occlusion (without restenosis: 10.9 +/- 26.8; restenosis: 232.5 +/- 371.2 IU, p < 0.04), euglobulin clot lysis time after venous occlusion (without restenosis: 176.5 +/- 100.5; restenosis: 78.6 +/- 40.2 min, p < 0.05) and for marker of the platelet release: platelet factor 4 (without restenosis: 10.8 +/- 7.9; restenosis: 20.5 +/- 7.5 ng/l, p < 0.04). These findings indicate that patients developing restenosis after coronary angioplasty tend to have an imbalance in the prothrombotic-antithrombotic equilibrium prior to the procedure.

Acute myocardial infarction in the diabetic patient: pathophysiology, clinical course and prognosis

Although there have been significant advances in the care of many of the extrapancreatic manifestations of diabetes, acute myocardial infarction continues to be a major cause of morbidity and mortality in diabetic patients. Factors unique to diabetes increase atherosclerotic plaque formation and thrombosis, thereby contributing to myocardial infarction. Autonomic neuropathy may predispose to infarction and result in atypical presenting symptoms in the diabetic patient, making diagnosis difficult and delaying treatment. The clinical course of myocardial infarction is frequently complicated and carries a higher mortality rate in the diabetic than in the nondiabetic patient. Although the course and pathophysiology of myocardial infarction differ to some degree in diabetic patients from those in patients without diabetes, much more remains to be known to formulate more effective treatment strategies in this high risk subgroup.

Prior restenosis predicts restenosis after coronary angioplasty of a new significant narrowing

To determine the influence of a history of restenosis on subsequent restenosis after percutaneous transluminal coronary angioplasty (PTCA) of a new significant narrowing, the records of 100 patients who underwent successful PTCA at another site ("new narrowing PTCA") greater than or equal to 2 months after successful initial PTCA were retrospectively reviewed. Patients were grouped according to whether initial PTCA resulted in restenosis, which was determined by angiographic follow-up greater than or equal to 3 months after initial PTCA. Patients in group 1 did not have restenosis after initial PTCA (n = 50), whereas patients in group 2 did (n = 40). All patients were followed for recurrent symptoms, with serial exercise tests, for greater than or equal to 6 months after new narrowing PTCA. Clinically suspected and angiographically confirmed restenosis occurred in 11 of 50 (22%) patients and 12 of 63 (19%) narrowings in group 1, and in 20 of 40 (50%) patients and 22 of 48 (46%) narrowings in group 2 (p less than 0.01 for patients, p less than 0.002 for narrowings). Multivariate analysis identified that prior restenosis (p less than 0.02, odds ratio 3.4), left anterior descending artery location of stenosis (p less than 0.04, odds ratio 3.0), and severity of stenosis before PTCA (p less than 0.02, odds ratio 1.8) were independently associated with restenosis after new narrowing PTCA. In conclusion, prior restenosis is an independent risk factor for subsequent restenosis after new narrowing PTCA.

Coronary restenosis: what have we learned from angiography?

Coronary restenosis remains a major problem for interventional cardiology not only by virtue of its frequency, but also because of the current inability to prevent it. Symptomatic status and non-invasive evaluation have been used to study restenosis, but both lack specificity and sensitivity, particularly in patients with multivessel disease. Angiography remains the reference standard. Several arbitrary definitions have been used, some related to visual estimates of coronary stenosis and others to quantitative angiographic techniques. In another approach, linear modeling is used to assess minimal luminal diameter of lesions on restudy. Although angiographic studies have been essential in the study of restenosis, questions concerning the underlying mechanism and pathophysiology remain. The development of animal models that closely resemble human restenosis should allow evaluation of pathophysiologic mechanisms and development of new strategies to prevent the problem.