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Mayer K, Ndrepepa G, Schroeter M, Emmer C, Bernlochner I, Schüpke S, Gewalt S, Hilz R, Coughlan JJ, Aytekin A, Heyken C, Morath T, Schunkert H, Laugwitz KL, Sibbing D, Kastrati A. High on-aspirin treatment platelet reactivity and restenosis after percutaneous coronary intervention: results of the Intracoronary Stenting and Antithrombotic Regimen-ASpirin and Platelet Inhibition (ISAR-ASPI) Registry. Clin Res Cardiol 2023; 112:1231-1239. [PMID: 36786829 PMCID: PMC10449652 DOI: 10.1007/s00392-023-02161-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 01/12/2023] [Indexed: 02/15/2023]
Abstract
OBJECTIVE The aim of this study was to assess the association between high on-aspirin treatment platelet reactivity (HAPR) and the subsequent risk of restenosis after percutaneous coronary intervention (PCI) with predominantly drug-eluting stents. BACKGROUND The association between HAPR and subsequent risk of restenosis after PCI is unclear. METHODS This study included 4839 patients undergoing PCI (02/2007-12/2011) in the setting of the Intracoronary Stenting and Antithrombotic Regimen-ASpirin and Platelet Inhibition (ISAR-ASPI) registry. Platelet function was assessed with impedance aggregometry using the multi-plate analyzer immediately before PCI and after intravenous administration of aspirin (500 mg). The primary outcome was clinical restenosis, defined as target lesion revascularization at 1 year. Secondary outcomes included binary angiographic restenosis and late lumen loss at 6- to 8-month angiography. RESULTS The upper quintile cut-off of platelet reactivity measurements (191 AU × min) was used to categorize patients into a group with HAPR (platelet reactivity > 191 AU × min; n = 952) and a group without HAPR (platelet reactivity ≤ 191 AU × min; n = 3887). The primary outcome occurred in 94 patients in the HAPR group and 405 patients without HAPR (cumulative incidence, 9.9% and 10.4%; HR = 0.96, 95% CI 0.77-1.19; P = 0.70). Follow-up angiography was performed in 73.2% of patients. There was no difference in binary restenosis (15.2% vs. 14.9%; P = 0.79) or late lumen loss (0.32 ± 0.57 vs. 0.32 ± 0.59 mm; P = 0.93) between patients with HAPR versus those without HAPR. CONCLUSIONS This study did not find an association between HAPR, measured at the time of PCI, and clinical restenosis at 1 year after PCI.
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Affiliation(s)
- Katharina Mayer
- Deutsches Herzzentrum München, Cardiology and Technische Universität München, Lazarettstr. 36, 80636, Munich, Germany.
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany.
| | - Gjin Ndrepepa
- Deutsches Herzzentrum München, Cardiology and Technische Universität München, Lazarettstr. 36, 80636, Munich, Germany
| | - Mira Schroeter
- Deutsches Herzzentrum München, Cardiology and Technische Universität München, Lazarettstr. 36, 80636, Munich, Germany
| | - Christopher Emmer
- Deutsches Herzzentrum München, Cardiology and Technische Universität München, Lazarettstr. 36, 80636, Munich, Germany
| | - Isabell Bernlochner
- Medizinische Klinik and Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Stefanie Schüpke
- Deutsches Herzzentrum München, Cardiology and Technische Universität München, Lazarettstr. 36, 80636, Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Senta Gewalt
- Deutsches Herzzentrum München, Cardiology and Technische Universität München, Lazarettstr. 36, 80636, Munich, Germany
| | - Raphaela Hilz
- Deutsches Herzzentrum München, Cardiology and Technische Universität München, Lazarettstr. 36, 80636, Munich, Germany
| | - John Joseph Coughlan
- Deutsches Herzzentrum München, Cardiology and Technische Universität München, Lazarettstr. 36, 80636, Munich, Germany
| | - Alp Aytekin
- Deutsches Herzzentrum München, Cardiology and Technische Universität München, Lazarettstr. 36, 80636, Munich, Germany
| | - Clarissa Heyken
- Deutsches Herzzentrum München, Cardiology and Technische Universität München, Lazarettstr. 36, 80636, Munich, Germany
| | - Tanja Morath
- Deutsches Herzzentrum München, Cardiology and Technische Universität München, Lazarettstr. 36, 80636, Munich, Germany
| | - Heribert Schunkert
- Deutsches Herzzentrum München, Cardiology and Technische Universität München, Lazarettstr. 36, 80636, Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Karl-Ludwig Laugwitz
- Medizinische Klinik and Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum rechts der Isar, Technische Universität München, Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Dirk Sibbing
- Klinik der Universität München, Cardiology, Ludwig-Maximilians-Universität, Munich, Germany
- Privatklinik Lauterbacher Mühle am Ostersee, Iffeldorf und Ludwig-Maximilians-Univerität, Munich, Germany
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Cardiology and Technische Universität München, Lazarettstr. 36, 80636, Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
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Zhou L, Liu D, Li Y, Zhu W, Sun W, Li Y, Xiong Y, Chen Z, Wang Q, Cai Q, Wang Z, Wang X, Sun W, Ge L, Ma M, Li M, Li H, Fan X, Yin Q, Xu G, Liu G, Fan X, Liu X. Argatroban for preventing occlusion and restenosis after extracranial artery stenting. Eur Neurol 2014; 71:319-25. [PMID: 24732894 DOI: 10.1159/000357866] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Accepted: 12/09/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Restenosis following extracranial artery stenting is a limitation that affects long-term outcomes. Effective and satisfying pharmacological strategies in preventing restenosis have not been established. This study aimed to evaluate whether argatroban, a direct thrombin inhibitor, could reduce the risk of in-stent restenosis after extracranial artery stenting. METHODS One hundred and fourteen patients hospitalized between August 2010 and August 2011 were enrolled. Patients were randomly assigned to argatroban (n = 58) and blank control groups (n = 56). The patients in the argatroban arm were treated with 10 mg of intravenous argatroban twice daily 2 days before and 3 days after the stenting procedures. Patients were followed for 12 months after the procedure. During follow-up, restenosis and target revascularization were analyzed. Recurrent cerebrovascular and cardiovascular events and deaths were also compared between the groups. RESULTS One patient in the stenting group withdrew immediately after the procedure due to unsuccessful stenting. Restenosis occurred in 4 patients (7.4%) in the argatroban group and in 11 patients (21.6%) in the control group during the 6- to 9-month angiographic follow-up period (p = 0.032). Nine months after the procedures, argatroban-treated patients had a trend towards a lower incidence of target revascularization compared with the controls (5.4 vs. 13.7%, p = 0.188). No major bleeding events or other adverse events occurred in the argatroban group. CONCLUSION This pilot clinical trial is the first that uses argatroban to prevent restenosis in ischemic cerebrovascular disease, and suggests that intravenous administration of argatroban is effective and safe in preventing restenosis after extracranial artery stenting. Larger randomized controlled clinical trials are warranted.
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Affiliation(s)
- Lulu Zhou
- Departments of Neurology at Jinling Hospital, Southern Medical University, Nanjing, PR China
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DiNicolantonio JJ, Norgard NB, Meier P, Lavie CJ, O’Keefe J, Niazi AK, Chatterjee S, Packard KA, D’Ascenzo F, Cerrato E, Biondi-Zoccai G, Bangalore S, Fuchs FD, Serebruany VL. Optimal aspirin dose in acute coronary syndromes: an emerging consensus. Future Cardiol 2014; 10:291-300. [PMID: 24762255 DOI: 10.2217/fca.14.7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
ABSTRACT: Numerous clinical trials testing the efficacy of aspirin for the secondary prevention of cardiovascular disease have been published. We reviewed the literature pertaining to aspirin dose in acute coronary syndrome patients. Clinical trials assessing the comparative efficacy of different doses of aspirin are scarce. This complex antiplatelet therapy landscape makes it difficult to identify the best aspirin dose for optimizing efficacy and minimizing risk of adverse events, while complying with the various guidelines and recommendations. Despite this fact, current evidence suggests that aspirin doses of 75–100 mg/day may offer the optimal benefit:risk ratio in acute coronary syndrome patients.
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Affiliation(s)
| | - Nicholas B Norgard
- University of Buffalo, School of Pharmacy & Pharmaceutical Sciences, Buffalo, NY, USA
| | - Pascal Meier
- The Heart Hospital, University College London Hospitals, London, UK
- Yale Medical School, New Haven, CT, USA
| | - Carl J Lavie
- John Ochsner Heart & Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA, USA
- The Department of Preventive Medicine, Pennington Biomedical Research Center, Baton Rouge, LA, USA
| | - James H O’Keefe
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
- University of Missouri, Kansas City, Kansas City, MO, USA
| | | | - Saurav Chatterjee
- St Luke’s Roosevelt Hospital Center, Division of Cardiology, New York, NY, USA
| | - Kathleen A Packard
- Creighton University, School of Pharmacy & Health Professions, Omaha, NE, USA
| | - Fabrizio D’Ascenzo
- University of Turin, Division of Cardiology, Citta Della Salute e Della Scienza, Torino, Italy
| | - Enrico Cerrato
- University of Turin, Division of Cardiology, Citta Della Salute e Della Scienza, Torino, Italy
| | - Giuseppe Biondi-Zoccai
- Sapienza University of Rome, Department of Medico-Surgical Sciences & Biotechnologies, Latina, Italy
| | | | - Flavio D Fuchs
- Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Division of Cardiology & Postgraduate Studies Program in Cardiology, Rio Grande do Sul, Brazil
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Clinical use of aspirin in treatment and prevention of cardiovascular disease. THROMBOSIS 2011; 2012:245037. [PMID: 22195280 PMCID: PMC3236445 DOI: 10.1155/2012/245037] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Accepted: 10/17/2011] [Indexed: 12/21/2022]
Abstract
Cardiovascular disease (CVD), principally heart disease and stroke, is the leading cause of death for both males and females in developed countries. Aspirin is the most widely used and tested antiplatelet drug in CVD, and it is proven to be the cornerstone of antiplatelet therapy in treatment and prevention of CVD in clinical trials in various populations. In acute coronary syndrome, thrombotic stroke, and Kawasaki's disease, acute use of aspirin can decrease mortality and recurrence of cardiovascular events. As secondary prevention, aspirin is believed to be effective in acute coronary syndrome, stable angina, revascularization, stroke, TIA, and atrial fibrillation. Aspirin may also be used for patients with a high risk of future CVD for primary prevention, but the balance between benefits and the possibility of side effects must be considered.
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5
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Schulz S, Sibbing D, Braun S, Morath T, Mehilli J, Massberg S, Byrne RA, Schömig A, Kastrati A. Platelet response to clopidogrel and restenosis in patients treated predominantly with drug-eluting stents. Am Heart J 2010; 160:355-61. [PMID: 20691843 DOI: 10.1016/j.ahj.2010.05.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2010] [Accepted: 05/06/2010] [Indexed: 02/02/2023]
Abstract
BACKGROUND Preclinical studies suggest a relationship between early thrombotic response after vascular injury and later development of restenosis. The aim of this study was to assess the impact of platelet response to clopidogrel on the risk of restenosis after drug-eluting stenting (DES). METHODS A total of 1,608 consecutive patients were previously enrolled in a study on the relation between platelet reactivity and outcomes after DES. All patients received a loading dose of 600 mg clopidogrel. Blood samples for the assessment of adenosine diphosphate-induced platelet aggregation with multiple electrode platelet aggregometry were drawn directly before percutaneous coronary intervention. Clopidogrel low response was defined as upper quintile of multiple electrode platelet aggregometry measurements. Accordingly, 323 patients (20%) were considered as low and 1,285 (80%) as normal responders. Primary end point of the present study was target lesion revascularization at 1 year. Secondary end points included binary angiographic restenosis and late lumen loss at 6- to 8-month angiography. RESULTS Target lesion revascularization rates were comparable in both groups (10.9% vs 9.5%, hazard rate [HR] 1.2, 95% CI 0.8-1.7, P = .441). Follow-up angiography revealed no difference in binary angiographic restenosis (13.9% vs 15.9%, P = .445) and late lumen loss (0.32 +/- 0.64 vs 0.35 +/- 0.63 mm, P = .477). Low responders had significantly more stent thromboses (2.5% vs 0.5%, HR 5.4, 95% CI 1.9-15.6, P = .002), Q wave myocardial infarctions (2.5% vs 0.6%, HR 4.0, 95% CI 1.5-10.7, P = .005), and ischemic strokes (1.3% vs 0.2%, HR 5.4, 95% CI 1.2-24.0, P = .028) at 1 year. CONCLUSION Low platelet responsiveness to clopidogrel, a known predictor of thrombotic complications, does not have a significant impact on restenosis after DES.
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McQuaid KR, Laine L. Systematic review and meta-analysis of adverse events of low-dose aspirin and clopidogrel in randomized controlled trials. Am J Med 2006; 119:624-38. [PMID: 16887404 DOI: 10.1016/j.amjmed.2005.10.039] [Citation(s) in RCA: 249] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2005] [Revised: 10/20/2005] [Accepted: 10/22/2005] [Indexed: 12/11/2022]
Abstract
PURPOSE We performed a systematic review to define the relative and absolute risk of clinically relevant adverse events with the antiplatelet agents, aspirin and clopidogrel. MATERIALS AND METHODS Databases were searched for randomized controlled trials of low-dose aspirin (75-325 mg/day) or clopidogrel administered for cardiovascular prophylaxis. Relative risks (RR) were determined by meta-analysis of 22 trials for aspirin versus placebo and from single studies for aspirin versus clopidogrel, aspirin versus aspirin/clopidogrel, and clopidogrel versus aspirin/clopidogrel. Absolute risk increase was calculated by multiplying RR increase by the pooled weighted incidence of the control. RESULTS Aspirin increased the risk of major bleeding (RR=1.71; 95% confidence interval [CI], 1.41-2.08), major gastrointestinal (GI) bleeding (RR=2.07; 95% CI, 1.61-2.66), and intracranial bleeding (RR=1.65; 95% CI, 1.06-5.99) versus placebo. No difference between 75-162.5 mg/day and >162.5-325 mg/day aspirin versus placebo was seen. The absolute annual increases attributable to aspirin were major bleeding: 0.13% (95% CI, 0.08-0.20); major GI bleeding: 0.12% (95% CI, 0.07-0.19), intracranial bleeding: 0.03% (95% CI, 0.01-0.08). No study compared clopidogrel with placebo. One study showed increased major GI bleeding (but not non-GI bleeding endpoints) with aspirin versus clopidogrel (RR=1.45; 95% CI, 1.00-2.10). The absolute annual increase was 0.12% (95% CI, 0.00-0.28). CONCLUSIONS Low-dose aspirin increases the risk of major bleeding by approximately 70%, but the absolute increase is modest: 769 patients (95% CI, 500-1250) need to be treated with aspirin to cause one additional major bleeding episode annually. Compared with clopidogrel, aspirin increases the risk of GI bleeding but not other bleeding; however, 883 patients (95% CI, 357-infinity) would need to be treated with clopidogrel versus aspirin to prevent one major GI bleeding episode annually at a cost of over 1 million dollars.
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7
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Popma JJ, Berger P, Ohman EM, Harrington RA, Grines C, Weitz JI. Antithrombotic therapy during percutaneous coronary intervention: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126:576S-599S. [PMID: 15383485 DOI: 10.1378/chest.126.3_suppl.576s] [Citation(s) in RCA: 176] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
This chapter about antithrombotic therapy during percutaneous coronary intervention (PCI) is part of the seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients' values may lead to different choices (for a full understanding of the grading, see Guyatt et al, CHEST 2004;126:179S-187S). Among the key recommendations in this chapter are the following: For patients undergoing PCI, we recommend pretreatment with aspirin, 75 to 325 mg (Grade 1A). For long-term treatment after PCI, we recommend aspirin, 75 to 162 mg/d (Grade 1A). For long-term treatment after PCI in patients who receive antithrombotic agents such as clopidogrel or warfarin, we recommend lower-dose aspirin, 75 to 100 mg/d (Grade 1C+). For patients who undergo stent placement, we recommend the combination of aspirin and a thienopyridine derivative (ticlopidine or clopidogrel) over systemic anticoagulation therapy (Grade 1A). We recommend clopidogrel over ticlopidine (Grade 1A). For all patients undergoing PCI, particularly those undergoing primary PCI, or those with refractory unstable angina or other high-risk features, we recommend use of a glycoprotein (GP) IIb-IIIa antagonist (abciximab or eptifibatide) [Grade 1A]. In patients undergoing PCI for ST-segment elevation MI, we recommend abciximab over eptifibatide (Grade 1B). In patients undergoing PCI, we recommend against the use of tirofiban as an alternative to abciximab (Grade 1A). In patients after uncomplicated PCI, we recommend against routine postprocedural infusion of heparin (Grade 1A). For patients undergoing PCI who are not treated with a GP IIb-IIIa antagonist, we recommend bivalirudin over heparin during PCI (Grade 1A). In PCI patients who are at low risk for complications, we recommend bivalirudin as an alternative to heparin as an adjunct to GP IIb-IIIa antagonists (Grade 1B). In PCI patients who are at high risk for bleeding, we recommend that bivalirudin over heparin as an adjunct to GP IIb-IIIa antagonists (Grade 1B). In patients who undergo PCI with no other indication for systemic anticoagulation therapy, we recommend against routine use of vitamin K antagonists after PCI (Grade 1A).
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Affiliation(s)
- Jeffrey J Popma
- Interventional Cardiology, Brigham and Women's Hospital, 75 Francis St, Tower 2-3A Room 311, Boston, MA 02115, USA.
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8
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Dee SV, Samady H. Evolving Strategies for the Prevention and Treatment of Coronary Restenosis. Semin Cardiothorac Vasc Anesth 2003. [DOI: 10.1177/108925320300700305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Percutaneous coronary intervention has become an increasingly attractive alternative to medical therapy and surgical revascularization for the treatment of coronary artery disease. Over 1.5 million interventional procedures are performed annually worldwide, with the rate of procedures performed continuing to rise dramatically. Restenosis following percutaneous coronary intervention occurs at rates of 20% to 40% and has remained the Achilles heel of the procedure. Numerous early attempts at the prevention of restenosis with oral pharmacologic agents, such as antithrombotic therapies, lipid lowering agents, vasodilators, and growth factor inhibitors, failed to show benefit in clinical trials. The introduction of intracoronary stents resulted in a 30% reduction in restenosis rates by abolishing the early vessel recoil following angioplasty. However, as more complex lesions underwent percutaneous coronary intervention with stenting, rates of “in-stent” restenosis remained high (20% to 30%). With technologic advances and greater understanding of vascular pathobiology, novel therapeutic strategies, such as local delivery of ionizing radiation, immunosuppressive agents, and gene therapy, have been deployed to prevent coronary restenosis. In addition, a number of mechanical and radiation-based strategies have been used to treat those patients who develop restenosis. This review considers these emerging strategies for the prevention and treatment of restenosis.
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Affiliation(s)
| | - Habib Samady
- Department of Medicine, University of Virginia Health Systems, Charlottesville, Virginia
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Affiliation(s)
- Steven R Bailey
- Division of Cardiology, University of Texas Health Sciences Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78284, USA.
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10
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Bennett MR, O'Sullivan M. Mechanisms of angioplasty and stent restenosis: implications for design of rational therapy. Pharmacol Ther 2001; 91:149-66. [PMID: 11728607 DOI: 10.1016/s0163-7258(01)00153-x] [Citation(s) in RCA: 117] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Restenosis after angioplasty or stenting remains the major limitation of both procedures. A vast array of drug therapies has been used to prevent restenosis, but they have proven to be predominantly unsuccessful. Recent trends in drug therapy have attempted to refine the molecular and biological targets of therapy, based on the assumption that a single biological process or molecule is critical to restenosis. In contrast, both stenting and brachytherapy, which are highly nonspecific, can successfully reduce restenosis after angioplasty or stenting, respectively. This review examines the biology of both angioplasty and stent stenosis, focussing on human studies. We also review the landmark human trials that have definitively proven successful therapies, such as stenting and brachytherapy. We suggest that the successful trials of stenting and brachytherapy and the failure of other treatments have highlighted the shortcomings of conventional animal models of arterial intervention, and gaps in our knowledge of human disease. In contrast to arguments advocating gene therapy, these studies suggest that the most likely successful drug therapy will have a wide therapeutic range, targeting as many of the components or biological processes contributing to restenosis as possible.
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Affiliation(s)
- M R Bennett
- Division of Cardiovascular Medicine, Addenbrooke's Centre for Clinical Investigation, Box 110, Addenbrooke's Hospital, Cambridge CB2 2QQ, UK.
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11
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Popma JJ, Ohman EM, Weitz J, Lincoff AM, Harrington RA, Berger P. Antithrombotic therapy in patients undergoing percutaneous coronary intervention. Chest 2001; 119:321S-336S. [PMID: 11157657 DOI: 10.1378/chest.119.1_suppl.321s] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- J J Popma
- Interventional Cardiology, Brigham and Women's Hospital, Boston, MA 02115, USA.
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12
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Nagaoka N, Matsubara T, Okazaki K, Masuda N, Shikaura K, Hotta A. Comparison of ticlopidine and cilostazol for the prevention of restenosis after percutaneous transluminal coronary angioplasty. JAPANESE HEART JOURNAL 2001; 42:43-54. [PMID: 11324805 DOI: 10.1536/jhj.42.43] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Prevention of restenosis after percutaneous transluminal coronary angioplasty (PTCA) continues to be a significant problem. Recent controlled studies have demonstrated that cilostazol suppresses restenosis after PTCA. The effects of ticlopidine, another antiplatelet agent, were compared in terms of outcomes of patients randomized for treatment with the two drugs after PTCA. A total of 35 patients (47 lesions) were assigned prospectively and randomly to ticlopidine (17 patients, 24 lesions) and cilostazol (18 patients, 23 lesions) groups. Minimal luminal diameter (MLD) and percentage of stenosis to reference diameter were estimated before PTCA, just after the procedure and after 4 months follow-up. All patients underwent 4 months angiographic follow-up, at the end of which MLD was 2.03+/-0.71 mm in the ticlopidine group and 2.05+/-0.68 mm in the cilostazol group (p = 0.95), and the percentage of stenosis to reference diameter was 31.4+/-16.7% and 30.0+/-17.0%, respectively (p = 0.78). The restenosis rate was 12.5% in the ticlopidine group and 17.4% in the cilostazol group (p = 0.69), relatively low as compared to the 20% to 30% reported in previous studies. Adverse drug reactions during the follow-up period were observed in two of the ticlopidine group and none of the cilostazol group. We conclude that both ticlopidine and cilostazol are effective for the prevention of restenosis after PTCA, however the former may be associated with slight side effects.
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Affiliation(s)
- N Nagaoka
- Third Department of Internal Medicine, Nagoya University School of Medicine, Aichi, Japan
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Furman MI, Frelinger III AL, Michelson AD. Antithrombotic therapy in the cardiac catheterization laboratory: focus on antiplatelet agents. Curr Cardiol Rep 2000; 2:386-94. [PMID: 10980905 DOI: 10.1007/s11886-000-0051-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Pharmacologic advances in the use of antithrombotic agents have paralleled the technologic innovations used in patients undergoing coronary interventions. The recognition of the central role of platelets in the development of complications related to coronary interventions led to the investigation and subsequent routine use of several antiplatelet agents as adjuvants to coronary intervention. Thus, the oral agents aspirin and either ticlopidine or clopidogrel are routinely administered after coronary stenting. Intravenous glycoprotein (GP) IIb/IIIa antagonists have been extensively studied and reduce adverse cardiac events in patients undergoing coronary interventions, especially those receiving intracoronary stents. Despite the growing use of GP IIb/IIIa antagonists, much information remains unknown as to the proper dosing and the effects these agents have on other elements of the hemostatic and vascular systems.
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Affiliation(s)
- M I Furman
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655, USA.
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14
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Kok WE, Peters RJ, Pasterkamp G, Di Mario C, Serruys PW, Prins M, Visser CA. Greater late lumen loss after successful coronary balloon angioplasty in the proximal left anterior descending coronary artery is not explained by extent of vessel wall damage or plaque burden. J Am Coll Cardiol 2000; 35:382-8. [PMID: 10676685 DOI: 10.1016/s0735-1097(99)00567-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES We investigated whether the greater late lumen loss after coronary balloon angioplasty in the proximal left anterior descending artery (P-LAD) compared with that in other segments might be related to differences in vascular dimensions or morphology as determined by angiography and intravascular ultrasound imaging. BACKGROUND The greater late lumen loss after angioplasty in the P-LAD that has been observed in several studies has not been explained. METHODS We studied 178 patients and 194 coronary artery lesions by quantitative angiography and 30 MHz intravascular ultrasound imaging after successful balloon angioplasty. Vessel wall morphology was compared among three proximal and three nonproximal segments. Follow-up quantitative angiography for late lumen loss calculation was performed in 168 lesions. Multivariate analysis was used to determine predictors of late lumen loss. RESULTS Absolute and relative late loss were significantly greater at the P-LAD compared with the pooled group of other segments (0.42 +/- 0.60 mm vs. 0.10 +/- 0.48 mm, p = 0.0008 and 0.14 +/- 0.24 vs. 0.03 +/- 0.17, p < 0.001). Also, a greater percentage of calcific lesions (65% vs. 44%, p = 0.034), a lower incidence of rupture (51% vs. 74%, p = 0.009) and a larger reference segment plaque area (5.4 +/- 2.2 mm2 vs. 4.7 +/- 1.9 mm2, p = 0.05) were found in the P-LAD. In multivariate analysis however, these variables were not predictive of late loss. CONCLUSIONS Greater late lumen loss after coronary balloon angioplasty of the P-LAD is not explained by differences in atherosclerotic plaque burden or in vessel wall damage.
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Affiliation(s)
- W E Kok
- Department of Cardiology, Free University Hospital Amsterdam, The Netherlands
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15
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Popma JJ, Weitz J, Bittl JA, Ohman EM, Kuntz RE, Lansky AJ, King SB. Antithrombotic therapy in patients undergoing coronary angioplasty. Chest 1998; 114:728S-741S. [PMID: 9822074 DOI: 10.1378/chest.114.5_supplement.728s] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- J J Popma
- Interventional Cardiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
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16
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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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17
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Yamasaki M, Hara K, Ikari Y, Kobayashi N, Kozuma K, Ohmoto Y, Oh-Hashi Y, Ako J, Nakajima H, Chiku N, Saeki F, Tamura T. Effects of cilostazol on late lumen loss after Palmaz-Schatz stent implantation. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1998; 44:387-91. [PMID: 9716201 DOI: 10.1002/(sici)1097-0304(199808)44:4<387::aid-ccd4>3.0.co;2-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cilostazol inhibits intimal hyperplasia after stent implantation into canine iliac arteries. To determine the antiproliferative effect of this agent, cilostazol or aspirin was randomly given for 6 mo to 36 patients treated with Palmaz-Schatz stent implantation. Initial success was obtained in 34 patients. Repeat angiography was performed in 33 patients, and the complete angiographic data were obtained in 22 lesions of the cilostazol group and in 21 lesions of the aspirin group. The reference diameter and minimal luminal diameter were similar in both groups before and immediately after stent implantation. At follow-up, minimal luminal diameters were significantly greater in the cilostazol group than in the aspirin group (P < 0.001). Late loss and loss index were significantly smaller in the cilostazol group than in the aspirin group (P < 0.001). These results suggest that cilostazol reduces angiographic late lumen loss and thereby may reduce the incidence of restenosis after Palmaz-Schatz stent implantation.
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Affiliation(s)
- M Yamasaki
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
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18
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Kugelmass AD, Raskob GE. Antithrombotic Therapy in Patients Undergoing Coronary Angioplasty or Coronary Stent Placement. Clin Appl Thromb Hemost 1997. [DOI: 10.1177/1076029697003001s05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Aaron D. Kugelmass
- Section of Cardiovascular Diseases, Department of Medicine,
University of Oklahoma Health Sciences Center Oklahoma City. Oklahoma, U.S.A
| | - Gary E. Raskob
- Departments of Medicine and Biostatistics and Epidemiology,
University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, U.S.A
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Zarge JI, Husak V, Huang P, Greisler HP. Fibrin glue containing fibroblast growth factor type 1 and heparin decreases platelet deposition. Am J Surg 1997; 174:188-92. [PMID: 9293842 DOI: 10.1016/s0002-9610(97)00090-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The early success rates of endarterectomy and angioplasty are influenced by the thrombogenicity of the deendothelialized surface. We previously reported decreased platelet deposition after 30 and 120 minutes and after 28 days on expanded polytetrafluoroethylene (ePTFE) grafts coated with fibrin glue (FG) containing fibroblast growth factor type 1 (FGF-1) and heparin in canine aortoiliac bypass grafts when compared with control uncoated grafts. The FG/FGF-1/heparin coating has been shown to enhance spontaneous endothelialization at 28 days in canine ePTFE bypass grafts. The current study evaluates the thrombogenicity of this FG/FGF-1/heparin suspension applied to a balloon de-endothelialization model of endarterectomy in canine carotid arteries. METHODS Nine dogs underwent bilateral, deendothelialization balloon injury to 6-cm segments of their carotid arteries. Fibrin glue (fibrinogen 32.1 mg/mL + thrombin 0.32 U/mL) containing FGF-1 (11 ng/mL) and heparin (250 U/mL) was applied to the luminal surface of one carotid artery in each dog. Both femoral arteries were circumferentially dissected but not balloon injured; one femoral artery was clamped for the same period as the carotid arteries. In the 6 acute dogs, 10 minutes prior to the restitution of flow in both carotid arteries and one femoral artery, 4 to 8 x 10(9) (111)In-labelled autologous platelets were injected intravenously. Four-cm segments of both carotid and femoral arteries were excised after 15 or 120 minutes of circulation (n = 3/time/artery, 24 arteries). In the 3 chronic dogs, the radiolabelled platelets were injected 30 days after carotid injury. The carotid and femoral vessels were then excised after 120 minutes of perfusion. Radioactive platelet deposition was quantitated by gamma counting. RESULTS After 2 hours, the injured carotid arteries demonstrated significantly more platelet deposition than either uninjured femoral artery controls (P < 0.001). There was also a significant 45.2% decrease (P = 0.008) in platelet deposition on the balloon injured carotid arteries treated with FG/FGF-1/heparin when compared with balloon injured carotid arteries alone. At 30 days there was an insignificant trend toward decreased thrombogenicity in the FG/FGF-1/heparin treated injured carotids. CONCLUSION Surface coating with FG/FGF-1/heparin significantly decreases platelet deposition on balloon injured canine carotid arteries after 2 hours of perfusion and may be clinically applicable in endarterectomy and angioplasty procedures. The long-term induction of reendothelialization of arterial surfaces by this technique is under investigation.
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Affiliation(s)
- J I Zarge
- Department of Surgery, Loyola University Medical Center, Maywood, Illinois 60153, USA
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20
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UNVERDORBEN MARTIN, LEUCHT MARKUS, KUNKEL BERNHARD, GANSSER ROLF, BACHMANN KURT, VALLBRACHT CHRISTIAN. Diltiazem Reduces Restenosis After Percutaneous Transluminal Coronary Angioplasty. J Interv Cardiol 1996. [DOI: 10.1111/j.1540-8183.1996.tb00631.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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21
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Phillips-Hughes J, Kandarpa K. Restenosis: pathophysiology and preventive strategies. J Vasc Interv Radiol 1996; 7:321-33. [PMID: 8761807 DOI: 10.1016/s1051-0443(96)72862-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Affiliation(s)
- J Phillips-Hughes
- Department of Radiology, John Radcliffe Hospital, Headington, Oxford, England
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22
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Savage MP, Goldberg S, Bove AA, Deutsch E, Vetrovec G, Macdonald RG, Bass T, Margolis JR, Whitworth HB, Taussig A. Effect of thromboxane A2 blockade on clinical outcome and restenosis after successful coronary angioplasty. Multi-Hospital Eastern Atlantic Restenosis Trial (M-HEART II). Circulation 1995; 92:3194-200. [PMID: 7586303 DOI: 10.1161/01.cir.92.11.3194] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Antithromboxane therapy with aspirin reduces acute procedural complications of coronary angioplasty (PTCA) but has not been shown to prevent restenosis. The effect of chronic aspirin therapy on long-term clinical events after PTCA is unknown, and the utility of more specific antithromboxane agents is uncertain. The goal of this study was to assess the effects of aspirin (a nonselective inhibitor of thromboxane A2 synthesis) and sulotroban (a selective blocker of the thromboxane A2 receptor) on late clinical events and restenosis after PTCA. METHODS AND RESULTS Patients (n = 752) were randomly assigned to aspirin (325 mg daily), sulotroban (800 mg QID), or placebo, started within 6 hours before PTCA and continued for 6 months. The primary outcome was clinical failure at 6 months after successful PTCA, defined as (1) death, (2) myocardial infarction, or (3) restenosis associated with recurrent angina or need for repeat revascularization. Neither active treatment differed significantly from placebo in the rate of angiographic restenosis: 39% (73 of 188) in the aspirin-assigned group, 53% (100 of 189) in the sulotroban group, and 43% (85 of 196) in the placebo group. In contrast, aspirin therapy significantly improved clinical outcome in comparison to placebo (P = .046) and sulotroban (P = .006). Clinical failure occurred in 30% (49 of 162) of the aspirin group, 44% (73 of 166) of the sulotroban group, and 41% (71 of 175) of the placebo group. Myocardial infarction was significantly reduced by antithromboxane therapy: 1.2% in the aspirin group, 1.8% in the sulotroban group, and 5.7% in the placebo group (P = .030). CONCLUSIONS Thromboxane A2 blockade protects against late ischemic events after angioplasty even though angiographic restenosis is not significantly reduced. While both aspirin and sulotroban prevent the occurrence of myocardial infarction, overall clinical outcome appears superior for aspirin compared with sulotroban. Therefore, aspirin should be continued for at least 6 months after coronary angioplasty.
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Affiliation(s)
- M P Savage
- Cardiac Catheterization Suite, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA
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23
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Levine GN, Chodos AP, Loscalzo J. Restenosis following coronary angioplasty: clinical presentations and therapeutic options. Clin Cardiol 1995; 18:693-703. [PMID: 8608668 DOI: 10.1002/clc.4960181203] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Restenosis following angioplasty is an iatrogenic disease of increasing frequency. Restenosis may be defined in terms of either angiographic or clinical criteria. Definitions of angiographic restenosis have varied in different studies, accounting in part for the differences in reported restenosis rates. Most studies now define angiographic restenosis as either a > 50% loss of initial gain or an absolute lesion stenosis of > or = 50% at follow-up angiogram. Common clinical end points used in defining restenosis include recurrent angina, need for repeat revascularization, or myocardial infarction. Despite technical advances and multiple pharmacologic interventions, most studies have found that the incidence of angiographic restenosis remains in the range of 40%; in none of these studies, however, was complete angiographic follow-up obtained, and thus actual restenosis rates may be somewhat higher. In several studies, clinical restenosis has been found to occur in approximately 36-40% of patients. Thus, a minority of patients with angiographic restenosis have no clinical manifestations. Most patients who develop symptoms of restenosis develop these symptoms within the first 3 months after angioplasty. The presenting symptom in the majority of these patients is progressive exertional angina. Patients occasionally will present with unstable angina and only rarely with acute myocardial infarction. In patients who present with recurrent chest pain, several features have been found to be helpful in predicting whether they will have angiographic restenosis at follow-up angiography. Patients who present 1-6 months after angioplasty with typical anginal symptoms have a high likelihood of having angiographic restenosis. By contrast, patients who present more than 6 months after percutaneous transluminal coronary angioplasty with recurrent chest pain are more likely to have new, significant coronary lesions to account for their symptoms. Noninvasive testing in patients with clinical presentations suggestive of restenosis can, in general, add only modest information in predicting whether restenosis is indeed present. A negative exercise thallium test appears to have a high specificity in ruling out restenosis and may be helpful in patients who present with more atypical symptoms. Repeat angioplasty is the therapy most frequently utilized to treat restenosis, although coronary artery bypass surgery or medical therapy may be reasonable alternative therapies. Clinical success rates with repeat angioplasty are > 90%, and major complications are rare; however, restenosis will recur in a significant percentage of these patients. Some patients who develop such recurrent restenoses will ultimately benefit from a strategy of repeat angioplasties, although many will require surgical revascularization.
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Affiliation(s)
- G N Levine
- Evans Department of Medicine, Boston University School of Medicine, Massachusetts, USA
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24
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van Bockxmeer FM, Mamotte CD, Gibbons FA, Burke V, Taylor RR. Angiotensin-converting enzyme and apolipoprotein E genotypes and restenosis after coronary angioplasty. Circulation 1995; 92:2066-71. [PMID: 7554183 DOI: 10.1161/01.cir.92.8.2066] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND An insertion/deletion (I/D) polymorphism in the gene for angiotensin-converting enzyme (ACE) has been associated with myocardial infarction and other cardiac pathology. There is evidence for a role of the renin-angiotensin system in cell growth and in the repair of damaged arterial walls, so the ACE gene was postulated to be a candidate gene affecting the important clinical problem of restenosis after percutaneous transluminal balloon coronary angioplasty (PTCA). Because restenosis is influenced by the apolipoprotein E (apoE) genotype, the possibility of a relation between ACE and apoE genotypes and restenosis was also sought. METHODS AND RESULTS Subjects (< 70 years of age) were prospectively followed and had coronary angiography 6 months after PTCA to determine the presence or absence of restenosis. Those who had angiography earlier and did not have restenosis (> or = 50% loss of gain at PTCA plus > or = 50% luminal diameter stenosis) also had angiography at 6 months. The whole group (n = 207) had a higher DD genotype frequency than did 136 population control subjects (38% versus 26%, P < .02); in PTCA patients, the frequency was the same in those with and without prior myocardial infarction. The distribution of ACE genotypes was not different in the 88 patients with and 119 patients without restenosis, while the epsilon 4/4 genotype was more frequent in those with restenosis (8 of 88 versus 3 of 118, P < .05). There was no effect of the ACE genotype in noncarriers of the epsilon 4 allele, but there was a significant effect in epsilon 4 carriers (P < .005). The combined D and epsilon 4 carrier state showed a 16-fold increase in the odds ratio for restenosis (P < .02). Multiple linear regression examining the loss of lumen as a continuous variable showed significant independent effects of the ACE and apoE genotypes. CONCLUSIONS Overall, the ACE genotype had no clear influence on restenosis, but there was an interaction between ACE and apoE genotypes. The combined carrier state for the D and apoE epsilon 4 alleles substantially increased restenosis. For loss of lumen as a continuous variable, there were significant effects of both ACE and apoE genotypes. While the observations may not affect current management, they no doubt have implications in pathophysiology.
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Affiliation(s)
- F M van Bockxmeer
- Department of Biochemistry, Royal Perth (Australia) Hospital, Western Australia
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25
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Popma JJ, Coller BS, Ohman EM, Bittl JA, Weitz J, Kuntz RE, Leon MB. Antithrombotic therapy in patients undergoing coronary angioplasty. Chest 1995; 108:486S-501S. [PMID: 7555198 DOI: 10.1378/chest.108.4_supplement.486s] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Affiliation(s)
- J J Popma
- Cardiology Research Foundation, Washington, DC 20010, USA
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26
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Jackson DM, Dawson P. Current usage of contrast agents, anticoagulant and antiplatelet drugs in angiography and angioplasty in the UK. Clin Radiol 1995; 50:699-704. [PMID: 7586963 DOI: 10.1016/s0009-9260(05)83316-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Currently, there is no consensus in the UK on what constitutes best angiographic practice. To provide a basis for discussion a questionnaire was sent to all Radiology and Cardiology departments in the UK. Information was requested on practice during diagnostic angiography and angioplasty regarding the type of contrast agent used, whether and how flush solution or contrast agents themselves were heparinised, and whether bolus doses of heparin were administered. The use of other supplementary drugs including corticosteroids was also explored. Two hundred of 353 (57%) of questionnaires were returned. Over 80% who replied used non-ionic contrast agents for all angiographic procedures. The majority of the smaller group, using ionic contrast agents for uncomplicated procedures, resorted to non-ionic contrast agents in a range of circumstances in both diagnostic angiography and angioplasty. Heparinized flush solutions were used by over 75% for both types of angiographic procedures, but employing a wide range of doses. Bolus doses of heparin were administered by over 80% performing angioplasty, again in a wide range of doses, with only (a few) cardiologists monitoring the anticoagulant effect by measuring the activated whole blood clotting time in the angiographic suite. Over 70% used aspirin or dipyridamole as supplementary agents, at the time of the angioplasty and, subsequently, continued these medications for a variable period. Corticosteroid prophylaxis for high risk patients, very variably defined, was felt necessary by 58%. A wide range of regimes of both dose and timing was noted.
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Affiliation(s)
- D M Jackson
- Department of Diagnostic Radiology, Hammersmith Hospital, London, UK
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27
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Minar E, Ahmadi A, Koppensteiner R, Maca T, Stümpflen A, Ugurluoglu A, Ehringer H. Comparison of effects of high-dose and low-dose aspirin on restenosis after femoropopliteal percutaneous transluminal angioplasty. Circulation 1995; 91:2167-73. [PMID: 7697845 DOI: 10.1161/01.cir.91.8.2167] [Citation(s) in RCA: 75] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Long-term treatment with aspirin is recommended in patients with large-vessel peripheral arterial disease since these patients have a high risk of death from cardiovascular causes. Recent studies have demonstrated the prophylactic effect of low-dose aspirin in reducing the risk of cardiovascular events. Since aspirin is also recommended for prevention of late recurrence after peripheral angioplasty, the present study was undertaken to compare the effects of high-dose (1000 mg/d) and low-dose (100 mg/d) aspirin on long-term patency after femoropopliteal angioplasty. METHODS AND RESULTS Two hundred sixteen patients treated successfully by percutaneous transluminal angioplasty for femoropopliteal lesions were randomly allocated to therapy with either 1000 or 100 mg aspirin daily. The follow-up was 24 months. The long-term results were analyzed using the Kaplan-Meier method, and differences between curves of cumulative patency were determined with the Wilcoxon and log-rank statistics. Complete follow-up information (patency after 24 months, restenosis, and death) was obtained in 207 patients. During the 2-year follow-up period, 72 patients--36 in the high-dose and 36 in the low-dose aspirin group, respectively--developed angiographically verified reobstruction within the recanalized segment. By intention-to-treat analysis, the cumulative patency rates at 24 months were 62.5% in the high-dose and 62.6% in the low-dose aspirin group (Wilcoxon, P = .97; log-rank, P = .97). The cumulative survival at 24 months of follow-up was 86.6% in the high-dose and 87.7% in the low-dose aspirin group. The number of patients discontinuing therapy was 30 in the high-dose and 11 in the low-dose aspirin group (P < .01). Fewer patients receiving 100 mg of aspirin discontinued therapy because of gastrointestinal symptoms (4 versus 20). CONCLUSIONS The data indicate that 100 mg aspirin is no less effective in the prevention of restenosis after femoropopliteal PTA than a 1000-mg dose and has fewer side effects.
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Affiliation(s)
- E Minar
- Department of Angiology, University Clinic Vienna, Währingergürtel, Austria
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28
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Betriu A, Serra A, Masotti M, Delcán JL, García E, Colman T, Zueco J, Fernández-Avilés F, Alonso J, Calabuig J. The Spanish trial: are national randomized trials a necessary evil? J Interv Cardiol 1994; 7:347-53. [PMID: 10151066 DOI: 10.1111/j.1540-8183.1994.tb00468.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- A Betriu
- Hospital Clinic Barcelona, Spain
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29
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Barry WL, Sarembock IJ. Antiplatelet and Anticoagulant Therapy in Patients Undergoing Percutaneous Transluminal Coronary Angioplasty. Cardiol Clin 1994. [DOI: 10.1016/s0733-8651(18)30099-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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30
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Winther K, Husted SE, Vissinger H. Low dose acetylsalicylic acid in the antithrombotic treatment of patients with stable angina pectoris and acute coronary syndromes (unstable angina pectoris and acute myocardial infarction). PHARMACOLOGY & TOXICOLOGY 1994; 74:141-7. [PMID: 8008719 DOI: 10.1111/j.1600-0773.1994.tb01089.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Acetylsalicylic acid has an antithrombotic effect by inhibition of thromboxane A2 synthesis in platelets. Thromboxane A2 is a potent stimulator of platelet aggregation and vasoconstriction and synthesis may be completely inhibited by a single oral dose of 150 mg acetylsalicylic acid or an intravenous dose of 100 mg. A daily maintenance dose of 75 mg acetylsalicylic acid is sufficient to effectively inhibit thromboxane A2 synthesis in long-term treatment. Acetylsalicylic acid therapy reduces acute myocardial infarction and sudden death in patients with stable angina pectoris and the drug is equally effective in patients with symptomatic and 'silent' angina pectoris. Early intervention with acetylsalicylic acid in patients with unstable angina pectoris reduces the risk of acute myocardial infarction and death. In patients with acute myocardial infarction, acute therapy with acetylsalicylic acid significantly reduces mortality both in monotherapy and in combination with thrombolytics. In the secondary prophylaxis following acute myocardial infarction, acetylsalicylic acid reduces the incidence of reinfarction and coronary death. Treatment of 100 patients with acute coronary syndrome (unstable angina pectoris or acute myocardial infarction) for 2 years may hinder the development of 3-4 fatal and 4 non-fatal vascular events. The risk of gastrointestinal side-effects and bleeding during acetylsalicylic acid therapy is dose-dependent and the incidence is low with a daily dose of 75-150 mg.
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Affiliation(s)
- K Winther
- Department of Clinical Chemistry, Glostrup Hospital, University of Copenhagen, Denmark
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31
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Timmis GC. Interventional Cardiology: A Comprehensive Bibliography. J Interv Cardiol 1993. [DOI: 10.1111/j.1540-8183.1993.tb00864.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Abstract
Coronary angioplasty is used to treat coronary disease in many patients. Indications for angioplasty have expanded since it was first performed, mainly as a result of improvement in equipment and techniques. One problem with coronary angioplasty is the phenomenon of renarrowing of the treated coronary lesion, a process called restenosis. The events that constitute restenosis appear to be a universal response to the arterial wall injury of angioplasty. They are currently characterized as follows: platelet adhesion and aggregation on the damaged endothelium and within deep splits into the tunica media; release of platelet-derived growth factors; inflammation of the mechanically injured medial zone; transformation of smooth muscle cells of the tunica media after their activation by several of the growth-promoting substances; migration and proliferation of transformed smooth muscle cells, with secretion of copious amounts of extracellular matrix material; and, finally, termination of the growth process with regrowth of endothelium over the injured area. A decade of research work has helped identify clinical correlates of restenosis after coronary angioplasty procedures. This work is hindered by lack of a uniform angiographic definition of restenosis. In addition, much of the information has come from small studies, with incomplete follow-up and retrospective orientation. Nevertheless, some data are available. Patient-related correlates include male gender, unstable angina, diabetes, and continued smoking after angioplasty. Lesion-related correlates include multilesional and multivessel procedures, higher postangioplasty residual stenosis, proximal vessel location, location in the left anterior descending artery, location in a vein graft, long lesions, and total occlusions. The only consistent procedure-related correlate has been incorrect sizing of the angioplasty balloon to the treated artery. For the purposes of individual patient care, clinical correlates are not helpful. No group of variables has been found to be associated with complete freedom from restenosis, and no group is completely predictive of restenosis. All patients undergoing angioplasty procedures require some follow-up through subsequent months and years. Symptom status and the results of noninvasive studies have been investigated for purposes of follow-up. Symptoms are virtually useless by themselves for predicting restenosis or its absence. When symptom status is combined with exercise thallium 201 scintigraphy performed 4 to 6 months after an angioplasty procedure, the two factors are less than ideal but have a negative predictive value of more than 90%. This means that more than 90% of patients who have neither symptoms nor evidence of ischemia by thallium 201 scintigraphy will not have angiographic restenosis.(ABSTRACT TRUNCATED AT 400 WORDS)
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Affiliation(s)
- H V Anderson
- Interventional Cardiology University, Texas Health Science Center, Houston
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Abstract
Coronary angioplasty is used to treat coronary atherosclerotic disease in many patients. One problem with coronary angioplasty is the phenomenon of restenosis. Restenosis appears to be a universal response to arterial wall injury. The biological events that underlie restenosis are characterized by: platelet adhesion and aggregation at sites of damaged endothelium, and within dissections into the medial layers, release of platelet derived growth-promoting substances, inflammation of the injured medial zone, transformation, migration, and proliferation of smooth muscle cells of the media following their activation by growth-promoting substances, secretion of copious amounts of extracellular matrix material, and finally, termination of the growth process following regrowth of endothelium over the damaged area. More than a decade of research work has helped identify clinical correlates of restenosis after coronary angioplasty. Patient-related correlates include male gender, unstable angina, diabetes, and continued smoking after angioplasty. Lesion-related correlates include multilesion and multivessel procedures, higher post-angioplasty residual stenosis, proximal vessel location, location in the left anterior descending coronary artery, location in a vein graft, long lesions, and total occlusions. However, for the purposes of individual patient care, clinical correlates are not particularly helpful. No group of variables has predicted complete freedom from restenosis, and conversely no group of variables has reliably indicated its presence. All patients undergoing angioplasty will require some form of follow-up evaluation. Symptom status by itself has not been found to be useful for predicting restenosis. However, when symptom status is combined with exercise thallium-201 scintigraphy, performed 4-6 months after angioplasty, it is less than ideal, but has a negative predictive value of over 90%. This means that over 90% of patients who are asymptomatic and have no evidence of ischemia by thallium-201 scintigraphy, will not have angiographic restenosis. Numerous clinical trials have been performed in order to reduce or prevent restenosis. Almost all have been disappointing, while a few have been encouraging. Studies of antiplatelet agents such as aspirin, dipyridamole (Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT, USA), and Ticlopidine (Syntex, Humgcao, Puerto Rico) have not shown efficacy, yet studies of an inhibitor of platelet-derived growth factor have been provocatively encouraging. No reduction in restenosis rates was found with the anticoagulants Coumadin (Du Pont Pharmaceuticals, Wilmington, DE, USA) and Heparin (Wyeth-Ayerst, Philadelphia, PA, USA). Fish oils (omega fatty acids) have been found in several clinical trials to provide modest, but encouraging, reductions in restenosis, but await further confirmation.(ABSTRACT TRUNCATED AT 400 WORDS)
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Affiliation(s)
- H V Anderson
- University of Texas Health Science Center, Houston 77225
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Affiliation(s)
- R E Kuntz
- Department of Medicine, Harvard Medical School, Boston, Mass
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Schwartz RS, Edwards WD, Huber KC, Antoniades LC, Bailey KR, Camrud AR, Jorgenson MA, Holmes DR. Coronary restenosis: prospects for solution and new perspectives from a porcine model. Mayo Clin Proc 1993; 68:54-62. [PMID: 8417256 DOI: 10.1016/s0025-6196(12)60019-6] [Citation(s) in RCA: 55] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Coronary restenosis, a major unresolved problem for percutaneous coronary revascularization procedures, has thus far been resistant to all therapeutic strategies. In part, ineffective treatment or prevention of coronary restenosis may be due to reliance on a conceptualization of the restenosis process that incompletely reflects the pathophysiologic factors associated with neointimal formation after arterial injury. In a porcine coronary restenosis model, three stages of neointimal growth after arterial injury have been identified: an early thrombotic stage, with platelets, fibrin, and erythrocytes; a cellular recruitment stage, with endothelialization and an infiltration by lymphocytes and monocytes; and a proliferative stage, in which smooth muscle cells migrate into and proliferate within the fibrin-rich degenerating thrombus. Evaluation of basic mechanisms responsible for neointimal formation has been possible with this model. In particular, a direct relationship exists between the depth of arterial injury and subsequent neointimal thickness. This relationship can be used for investigating the efficacy of new therapies. Treatment strategies for restenosis should be directed toward interference with the cellular or humoral events that lead to neointimal formation, with the specific goal of decreasing the neointimal volume. These strategies may include delivery of drugs to the site of arterial injury to limit the amount of early mural thrombus or decreasing subsequent cellular recruitment and proliferation as well as synthesis of extracellular matrix.
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Affiliation(s)
- R S Schwartz
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905
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