Evaluation of a Policy of Selective Drug-eluting Stent Implantation for Patients at High Risk of Restenosis

Urotensin II receptor deficiency ameliorates ligation-induced carotid intimal hyperplasia partially through the RhoA-YAP1 pathway

Intimal hyperplasia (IH) is a common pathological feature of vascular proliferative diseases, such as atherosclerosis and restenosis after angioplasty. Urotensin II (UII) and its receptor (UTR) are widely expressed in cardiovascular tissues. However, it remains unclear whether the UII/UTR system is involved in IH. Right unilateral common carotid artery ligation was performed and maintained for 21 days to induce IH in UTR knockout (UTR-/-) and wild-type (WT) mice. Histological analysis revealed that compared with WT mice, UTR-deficient mice exhibited a decreased neointimal area, angiostenosis and intima-media ratio. Immunostaining revealed fewer smooth muscle cells (SMCs), endothelial cells and macrophages in the lesions of UTR-/- mice than in those of WT mice. Protein interaction analysis suggested that the UTR may affect cell proliferation by regulating YAP and its downstream target genes. In vitro experiments revealed that UII can promote the proliferation and migration of SMCs, and western blotting also revealed that UII increased the protein expression of RhoA, CTGF, Cyclin D1 and PCNA and downregulated p-YAP protein expression, while these effects could be partly reversed by urantide. To evaluate the translational value of UTRs in IH management, WT mice were also treated with two doses of urantide, a UTR antagonist, to confirm the benefit of UTR blockade in IH progression. A high dose of urantide (600 μg/kg/day), rather than a low dose (60 μg/kg/day), successfully improved ligation-induced IH compared with that in mice receiving vehicle. The results of the present study suggested that the UII/UTR system may regulate IH partly through the RhoA-YAP signaling pathway.

Cardiac mortality, diabetes mellitus, and multivessel disease in ST elevation myocardial infarction

BACKGROUND

In patients with diabetes mellitus presenting with ST elevation myocardial infarction (STEMI) the degree to which cardiac death rates may be attributed to an increased burden of coronary artery disease is not clear.

METHODS

This prospective observational study examines rates of cardiac death between those with and without diabetes at long term follow up, stratified by presence of multivessel disease (MVD), in consecutive STEMI patients from 5 Australian hospitals.

RESULTS

Amongst 2083 patients, 393 patients had diabetes (18.8%), and 810 (38.8%) had MVD. Patients with diabetes were more likely to have MVD 48.6% (191/393) than patients without diabetes 36.6% (619/1690; p < .001). At final follow up (median 3.6 years [IQR 2.4-5.4]) cardiac death occurred in 37/393 diabetic patients and 92/1690 nondiabetic patients (adjusted HR1.67, 95% CI 1.10-2.52). In those with MVD cardiac death occurred in 27/191 diabetic patients, and 54/619 non-diabetic patients (adjusted HR 1.94; 95% CI 1.17-3.23). In single vessel disease (SVD) cardiac death occurred in 10/202 diabetic patients, and 38/1071 non-diabetic patients (adjusted HR 1.37; 95% CI 0.65-2.89). Both diabetes and MVD were independently associated with cardiac death.

CONCLUSIONS

STEMI patients with diabetes are more likely to have MVD, with an absolute difference in MVD rates of 12%, and higher rates of cardiac death. Randomized trials studying these high risk patients are needed to reduce cardiac mortality in patients with diabetes, MVD and STEMI.

Comparison of Late Cardiac Death and Myocardial Infarction Rates in Women Vs Men With ST-Elevation Myocardial Infarction

Women and patients with incomplete revascularization (IR) have a worse prognosis after ST elevation myocardial infarction (STEMI). However, the extent to which IR affects outcomes for women with STEMI compared with men is not well characterized. Thus, we examined late outcomes of 589 consecutive STEMI patients who received percutaneous coronary intervention and assessed SYNTAX scores (SS), both at baseline and after all procedures (residual SS). A residual SS >8 defined IR. The primary end point was cardiac death or myocardial infarction (MI), with median follow-up of 3.6 years [interquartile range [IQR] 2.6 to 4.7]. Women (n = 123) had lower baseline SSs 15.0 [IQR 9 to 20], than men (n = 466), 16.0 [IQR 9 to 20; p = 0.02. After all planned procedures, the residual SS was 5.0 [IQR 0 to 9] in women and 5.0 (IQR 1 to 11] in men, p = 0.37. Cardiac death or MI occurred in (97/589) patients (16%), 24% (30/123) in women and 14% (67/466) in men (hazard ratio [HR] 1.75; 95% confidence intervals [CI] 1.14 to 2.69; p = 0.01). In patients with residual SYNTAX score (rSS) >8 cardiac death or MI occurred in 43% (15/35) of women and 23% 36/158 men (HR 2.14; 95% CI 1.17 to 3.91; p = 0.01). In patients with rSS = 0 to 8 cardiac death or MI occurred in 17% (15/88) of women and 10% of men (31/308) (HR 1.68; 95% CI 0.91 to 3.12; p = 0.10; interaction p value 0.58). Multivariate analysis found women were 1.77 times more likely than men to experience cardiac death or MI (95% CI 1.13 to 2.77; p = 0.01). In conclusion, we found despite a lower burden of disease at presentation and no difference in rates of IR between men and women, outcome differences were substantial. Women with rSS >8 were twice as likely as men with the same rSS to experience cardiac death or MI post-STEMI. Differences remained significant postrisk adjustment.

Adjunctive Bare-Metal Stenting Associated With Improved Outcomes in Patients With Multivessel Disease Treated With Drug-Eluting Stents

BACKGROUND

The use of both bare-metal stents (BMSs) and drug-eluting stents (DESs) in the setting of multivessel percutaneous coronary intervention (PCI) continues because of cost considerations.

METHODS

A retrospective analysis of patients with ≥ 2 coronary arteries with angiographic stenoses of ≥ 70% severity who were treated with multivessel PCI and ≥ 2 stents between April 2007 and March 2011 was performed using a prospective single-centre PCI registry. Follow-up data were obtained from the Discharge Abstract Database of the Canadian Institute for Health Information and the Registered Persons Database. We performed propensity matching of the DES + BMS and DES-only groups, as well as Cox multiple regression analyses to determine the independent predictors of adverse events.

RESULTS

A total of 1299 patients (514 in the DES + BMS group and 785 in the DES group) fulfilled the study criteria. Death or repeated revascularization at 5 years occurred less frequently in the DES + BMS group than in the DES group (23.9% ± 2.6% vs 33.1% ± 2.4%; P = 0.01), and major adverse cardiac events (MACE) tended to be less common in the DES + BMS group (31.1% ± 3.0% vs 36.7% ± 2.4%; P = 0.056). Kaplan-Meier estimates revealed an adjusted benefit with the DES + BMS strategy for death (11.4 ± 2.9 vs 14.9 ± 2.8; P = 0.035) and for death and repeated revascularization (25.6 ± 3.5 vs 32.4 ± 3.4; P = 0.034).

CONCLUSIONS

A DES + BMS PCI strategy is associated with a lower incidence of repeated revascularization and MACE at 5-year follow up. For patients undergoing multivessel PCI who have favourable anatomy and clinical features, a combined approach using DES and BMS appears to be a viable option for contemporary PCI practice.

Varying definitions for periprocedural myocardial infarction alter event rates and prognostic implications

BACKGROUND

Periprocedural myocardial infarction (PMI) has had several definitions in the last decade, including the Society for Cardiovascular Angiography and Interventions (SCAI) definition, that requires marked biomarker elevations congruent with surgical PMI criteria.

METHODS AND RESULTS

The aim of this study was to examine the definition-based frequencies of PMI and whether they influenced the reported association between PMI and increased rates of late death/ myocardial infarction (MI). We studied 742 patients; 492 (66%) had normal troponin T (TnT) levels and 250 (34%) had elevated, but stable or falling, TnT levels. PMI, using the 2007 and the 2012 universal definition, occurred in 172 (23.2%) and in 99 (13.3%) patients, respectively, whereas 19 (2.6%) met the SCAI PMI definition (P<0.0001). Among patients with PMI using the 2012 definition, occlusion of a side branch ≤1 mm occurred in 48 patients (48.5%) and was the most common angiographic finding for PMI. The rates of death/MI at 2 years in patients with, compared to those without, PMI was 14.7% versus 10.1% (P=0.087) based on the 2007 definition, 16.9% versus 10.3% (P=0.059) based on the 2012 definition, and 29.4% versus 10.7% (P=0.015) based on the SCAI definition.

CONCLUSION

In this study, PMI, according to the SCAI definition, was associated with more-frequent late death/MI, with ≈20% of all patients, who had PMI using the 2007 universal MI definition, not having SCAI-defined PMI. Categorizing these latter patients as SCAI-defined no PMI did not alter the rate of death/MI among no-PMI patients.