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Jones D, Spirito A, Sartori S, Vogel B, Edens M, Kamaleldin K, Pileggi B, Baber U, Dangas G, Sharma SK, Kini A, Mehran R. Prognostic impact of in-stent restenosis in normal weight, overweight, and obese patients undergoing percutaneous coronary intervention. Catheter Cardiovasc Interv 2024; 103:260-267. [PMID: 38173300 DOI: 10.1002/ccd.30939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 11/15/2023] [Accepted: 12/10/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Among patients undergoing percutaneous coronary intervention (PCI), in-stent restenosis (ISR) is related with a worse prognosis, while higher body mass index (BMI) values are associated with better outcomes. It is unclear whether the prognostic impact of ISR varies in function of BMI. METHODS Patients undergoing PCI at a large center from 2012 to 2019 not presenting with an acute myocardial infarction (MI) were included. Subjects with BMI < 18.5 kg/m2 or treated with bare metal stents were excluded. Patients were stratified according to type of lesion treated (ISR vs. no-ISR) and into four BMI categories: normal weight (BMI 18.5-25 kg/m2 ), overweight (25.0-29.9 kg/m2 ), class I obesity (30.0-34.9 kg/m2 ), class II-III obesity (≥35.0 kg/m2 ). The primary outcome was major adverse cardiovascular events (MACE), a composite of all-cause death, MI, and target vessel revascularization (TVR) at 1 year. RESULTS Out of 16,234 patients, 3694 (23%) underwent PCI for ISR. ISR as compared to no-ISR was associated with a consistent increased risk of MACE within the normal weight (18.8% vs. 7.8%, adj. hazard ratio (HR): 1.99, 95% confidence interval [CI]: 1.51-2.64), overweight (19.1% vs. 6.4%, adj. HR: 2.35, 95% CI: 1.91-2.88), class I obesity (18.3% vs. 6.8%, adj. HR: 1.95, 95% CI: 1.47-2.57), and class II-III obesity (16.4% vs. 7.4%, adj. HR: 1.61, 95% CI: 1.09-2.37) groups (interaction p-value: 0.192). The ISR-related risks were mostly driven by an excess of TVR. CONCLUSIONS At 1 year, ISR was associated with an increased risk of MACE irrespective of BMI, mostly due to an excess of TVR after ISR.
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Affiliation(s)
- Davis Jones
- Icahn School of Medicine at Mount Sinai, Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, New York, New York, USA
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alessandro Spirito
- Icahn School of Medicine at Mount Sinai, Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, New York, New York, USA
| | - Samantha Sartori
- Icahn School of Medicine at Mount Sinai, Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, New York, New York, USA
| | - Birgit Vogel
- Icahn School of Medicine at Mount Sinai, Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, New York, New York, USA
| | - Madison Edens
- Icahn School of Medicine at Mount Sinai, Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, New York, New York, USA
| | - Karim Kamaleldin
- Icahn School of Medicine at Mount Sinai, Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, New York, New York, USA
| | - Brunna Pileggi
- Icahn School of Medicine at Mount Sinai, Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, New York, New York, USA
- Department of Cardiopneumonology, Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
| | - Usman Baber
- Department of Cardiology, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - George Dangas
- Icahn School of Medicine at Mount Sinai, Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, New York, New York, USA
| | - Samin K Sharma
- Icahn School of Medicine at Mount Sinai, Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, New York, New York, USA
| | - Annapoorna Kini
- Icahn School of Medicine at Mount Sinai, Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, New York, New York, USA
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, Center for Interventional Cardiovascular Research and Clinical Trials, The Zena and Michael A. Wiener Cardiovascular Institute, New York, New York, USA
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Shlofmitz E, Busch J. Intravascular Imaging for Restenosis: The Importance of Performing a Root Cause Analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 52:47-48. [PMID: 37029042 DOI: 10.1016/j.carrev.2023.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 04/03/2023]
Affiliation(s)
- Evan Shlofmitz
- St. Francis Hospital - The Heart Center, Roslyn, NY, United States of America.
| | - Jordan Busch
- St. Francis Hospital - The Heart Center, Roslyn, NY, United States of America
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Shlofmitz E, Case BC, Chen Y, Chezar-Azerrad C, Hashim H, Garcia-Garcia HM, Mintz GS, Waksman R. Waksman In-Stent Restenosis Classification: A mechanism-based approach to the treatment of restenosis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 33:62-67. [PMID: 34247983 DOI: 10.1016/j.carrev.2021.06.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 06/01/2021] [Indexed: 11/28/2022]
Abstract
Despite contemporary advances in stent technology, in-stent restenosis (ISR) remains a common issue following percutaneous coronary intervention. A novel classification system based on underlying mechanism of action of restenosis was recently introduced. The Waksman In-Stent Restenosis Classification characterizes different patterns of ISR to best delineate the type of restenosis and help guide treatment. Intravascular imaging with either intravascular ultrasound or optical coherence tomography allows for real-time evaluation of ISR. We herein provide an illustrative review of the Waksman In-Stent Restenosis Classification.
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Affiliation(s)
- Evan Shlofmitz
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Brian C Case
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Yuefeng Chen
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Chava Chezar-Azerrad
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Hayder Hashim
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Hector M Garcia-Garcia
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Gary S Mintz
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America.
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4
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Drug-eluting stent thrombosis: current and future perspectives. Cardiovasc Interv Ther 2021; 36:158-168. [PMID: 33439454 DOI: 10.1007/s12928-021-00754-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 12/31/2020] [Indexed: 12/19/2022]
Abstract
Over the past 40 years, the safety and efficacy of percutaneous coronary intervention has dramatically improved by overcoming several challenges. The introduction of drug-eluting stent (DES) in particular was a major breakthrough in interventional cardiology. Compared to bare-metal stents, first-generation DES (G1-DES) has dramatically reduced the rates of in-stent restenosis and subsequent target lesion revascularization. However, major safety concerns surrounding stent thrombosis (ST) emerged with G1-DES in clinical practice as a result of the high incidences of death, myocardial infarction, and repeat revascularization associated with ST. To overcome these limitations, second-generation DES (G2-DES) has been developed with an improved stent platform with thinner strut and biocompatible durable or biodegradable polymers. Indeed, G2-DES, when compared with G1-DES, has improved clinical outcomes by reducing the risk of late thrombotic events while maintaining anti-restenotic efficacy, whereas ST still occurs, even with the use of G2-DES. This review gives an overview of pathophysiology, risk factors, and outcomes of ST after DES implantation. Additionally, we discuss the management and prevention of ST.
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Adjunctive Cilostazol to Dual Antiplatelet Therapy to Enhance Mobilization of Endothelial Progenitor Cell in Patients with Acute Myocardial Infarction: A Randomized, Placebo-Controlled EPISODE Trial. J Clin Med 2020; 9:jcm9061678. [PMID: 32492942 PMCID: PMC7356664 DOI: 10.3390/jcm9061678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/17/2020] [Accepted: 05/29/2020] [Indexed: 11/24/2022] Open
Abstract
Background: Endothelial progenitor cells (EPCs) have the potential to protect against atherothrombotic event occurrences. There are no data to evaluate the impact of cilostazol on EPC levels in high-risk patients. Methods: We conducted a randomized, double-blind, placebo-controlled trial to assess the effect of adjunctive cilostazol on EPC mobilization and platelet reactivity in patients with acute myocardial infarction (AMI). Before discharge, patients undergoing percutaneous coronary intervention (PCI) were randomly assigned to receive cilostazol SR capsule (200-mg) a day (n = 30) or placebo (n = 30) on top of dual antiplatelet therapy (DAPT) with clopidogrel and aspirin. Before randomization (baseline) and at 30-day follow-up, circulating EPC levels were analyzed using flow cytometry and hemostatic measurements were evaluated by VerifyNow and thromboelastography assays. The primary endpoint was the relative change in EPC levels between baseline and 30-day. Results: At baseline, there were similar levels of EPC counts between treatments, whereas patients with cilostazol showed higher levels of EPC counts compared with placebo after 30 days. Cilostazol versus placebo treatment displayed significantly higher changes in EPC levels between baseline and follow-up (ΔCD133+/KDR+: difference 216%, 95% confidence interval (CI) 44~388%, p = 0.015; ΔCD34+/KDR+: difference 183%, 95% CI 25~342%, p = 0.024). At 30-day follow-up, platelet reactivity was lower in the cilostazol group compared with the placebo group (130 ± 45 versus 169 ± 62 P2Y12 Reaction Unit, p = 0.009). However, there were no significant correlations between the changes of EPC levels and platelet reactivity. Conclusion: Adjunctive cilostazol on top of clopidogrel and aspirin versus DAPT alone is associated with increased EPC mobilization and decreased platelet reactivity in AMI patients, suggesting its pleiotropic effects against atherothrombotic events (NCT04407312).
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Mintz GS. Intravascular ultrasound guidance improves patient survival (mortality) after drug-eluting stent implantation: review and updated bibliography. Cardiovasc Interv Ther 2019; 35:37-43. [PMID: 31482290 DOI: 10.1007/s12928-019-00616-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 08/26/2019] [Indexed: 12/11/2022]
Abstract
Individual studies IVUS vs angiography-guided DES implantation studies, whether randomized clinical trials or registries are underpowered, to show a reduction in mortality, especially at 1 year of follow-up. However, either meta-analyses or the few studies with long-term (> 5 year) follow-up showed that IVUS guidance reduced mortality and improved patient survival, even with second-generation DES.
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Affiliation(s)
- Gary S Mintz
- Cardiovascular Research Foundation, 1700 Broadway, 9th floor, New York, NY, 10019, USA.
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Kuramitsu S, Ohya M, Shinozaki T, Otake H, Horie K, Kawamoto H, Yamanaka F, Natsuaki M, Shiomi H, Nakazawa G, Ando K, Kadota K, Saito S, Kimura T. Risk Factors and Long-Term Clinical Outcomes of Second-Generation Drug-Eluting Stent Thrombosis. Circ Cardiovasc Interv 2019; 12:e007822. [DOI: 10.1161/circinterventions.119.007822] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Background:
The risk factors and long-term clinical outcomes of patients with definite stent thrombosis (ST) after second-generation drug-eluting stent (DES) implantation have not yet been adequately assessed.
Methods and Results:
The REAL-ST (Retrospective Multicenter Registry of ST After First- and Second-Generation DES Implantation) included 313 definite ST of second-generation DES (early ST, n=179; late ST, n=66; very late ST, n=68). Four patients without definite ST of second-generation DES were identified as control patients for each ST case. Risk factors of definite ST were mostly different according to the timing of ST: ST-segment–elevation myocardial infarction, non–ST-segment–elevation myocardial infarction, and unstable angina at presentation, current smoking, left ventricular ejection fraction <40%, prior percutaneous coronary intervention, stent overlap, severely calcified lesion, left main coronary artery lesion, proximal left anterior descending lesion, postdiameter stenosis ≥20%, for early ST; age <70 years, ST-segment–elevation myocardial infarction at presentation, hemodialysis, left ventricular ejection fraction <40%, in-stent restenosis, and severely calcified lesion for late ST; and proximal left anterior descending lesion and in-stent restenosis for very late ST. Cumulative 4-year incidence of death after the index ST events was significantly higher in the ST patients than control patients (33.0% versus 12.3%,
P
<0.001 for early ST versus control; 30.6% versus 14.2%,
P
<0.001 for late ST versus control; and 28.0% versus 13.0%,
P
<0.001 for very late ST versus control, respectively).
Conclusions:
Risk factors of definite ST after second-generation DES implantation were mostly different according to the timing of ST. Definite ST patients showed unfavorable long-term clinical outcomes compared with those without definite ST.
Clinical Trial Registration:
URL:
https://www.umin.ac.jp
. Unique identifier: UMIN000025181.
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Affiliation(s)
- Shoichi Kuramitsu
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan (S.K., K.A.)
| | - Masanobu Ohya
- Department of Cardiology, Kurashiki Central Hospital, Japan (M.O., K.K.)
| | - Tomohiro Shinozaki
- Department of Biostatistics, School of Public Health, the University of Tokyo, Japan (T.S.)
| | - Hiromasa Otake
- Division of Cardiology, Department of Internal Medicine, Kobe University Graduates School of Medicine, Japan (H.O.)
| | - Kazunori Horie
- Department of Cardiovascular Medicine, Sendai Kousei Hospital, Japan (K.H.)
| | | | - Futoshi Yamanaka
- Division of Cardiology and Catheterization Laboratories, Shonan Kamakura General Hospital, Kanagawa, Japan (F.Y., S.S.)
| | - Masahiro Natsuaki
- Department of Cardiology, Saiseikai Fukuoka General Hospital, Japan (M.N)
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Japan (H.S., T.K.)
| | - Gaku Nakazawa
- Division of Cardiology, Tokai University School of Medicine, Isehara, Japan (G.K.)
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan (S.K., K.A.)
| | - Kazushige Kadota
- Department of Cardiology, Kurashiki Central Hospital, Japan (M.O., K.K.)
| | - Shigeru Saito
- Division of Cardiology and Catheterization Laboratories, Shonan Kamakura General Hospital, Kanagawa, Japan (F.Y., S.S.)
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Japan (H.S., T.K.)
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