Correlation of systemic inflammation with local inflammatory activity in non-culprit lesions: Beneficial effect of statins

Perivascular fat attenuation index value and plaque volume increased in non-target lesions of coronary arteries after stenting

BACKGROUND

Progression of non-target lesions (NTLs) after stenting has been reported and is associated with the triggering of an inflammatory response. The perivascular fat attenuation index (FAI) may be used as a novel imaging biomarker for the direct quantification of coronary inflammation.

OBJECTIVES

To investigate whether FAI values can help identify changes in inflammation status in patients undergoing stent implantation, especially in NTLs.

METHODS

Patients who underwent pre- and post-stenting coronary computed tomography angiography (CCTA) examination between January 2015 and February 2021 were consecutively enrolled. The pre- and post-stenting FAIs of the full coronary arteries were compared in both the non- and stent-implanted coronary arteries. Moreover, local FAI values were measured and compared between the NTLs and target lesions in the stent implantations. We also compared changes in plaque type and volume in NTLs before and after stenting.

RESULTS

A total of 89 patients (mean age 61 years; male 59) were enrolled. The perivascular FAI values in the full coronary arteries decreased after stenting in both the non- and stent-implanted coronary arteries, similar to those in the target lesions. Conversely, the perivascular FAI values in the NTLs increased after stenting (p < 0.05). In addition, the plaque volumes significantly increased in the NTLs after stenting, regardless of whether they were non-calcified, mixed, or calcified (p < 0.05).

CONCLUSION

Perivascular FAI values and plaque volumes increased in the NTLs after stenting. Perivascular FAI can be a promising imaging biomarker for monitoring coronary inflammation after stenting and facilitate long-term monitoring in clinical settings.

CLINICAL RELEVANCE STATEMENT

Perivascular fat attenuation index, a non-invasive imaging biomarker, may help identify coronary arteries with high inflammation in non-target lesions and facilitate long-term monitoring, potentially providing an opportunity for more targeted treatment.

KEY POINTS

• Perivascular fat attenuation index (FAI) values and plaque volumes increased in the non-target lesions (NTLs) after stenting, suggesting potential focal inflammation progression after stenting. However, stenting along with anti-inflammatory treatment ameliorated inflammation in the full coronary arteries. • Perivascular FAI, a non-invasive imaging biomarker, may help identify coronary arteries with high inflammation in NTLs and facilitate long-term monitoring, potentially providing an opportunity for more targeted treatment.

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

Background

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

Methods

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

Results

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

Conclusion

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

Optical Coherence Tomography For the Detection of the Vulnerable Plaque

Morphological characteristics of the atheromatous plaque have been associated with the development of plaque rupture and the pathogenesis of acute coronary syndromes (ACS). Plaques with a specific morphological phenotype that are at high risk of causing ACS are called vulnerable plaques, and can be identified in vivo through the use of intracoronary imaging. Optical coherence tomography (OCT) is a high-resolution intravascular imaging modality that enables detailed visualization of atheromatous plaques. Consequently, OCT is a valuable research tool for examining the role of morphological characteristics of atheromatous plaques in the progression of coronary artery disease and plaque destabilisation, which leads to the clinical manifestation of ACS. This article summarises the pathophysiological insights obtained by OCT imaging in the formation and rupture of the vulnerable plaque.

Correlation between C-reactive protein in peripheral vein and coronary sinus in stable and unstable angina

Background

High sensitivity C-reactive protein (hs-CRP) is commonly used in clinical practice to assess cardiovascular risk. However, a correlation has not yet been established between the absolute levels of peripheral and central hs-CRP.

Objective

To assess the correlation between serum hs-CRP levels (mg/L) in a peripheral vein in the left forearm (LFPV) with those in the coronary sinus (CS) of patients with coronary artery disease (CAD) and a diagnosis of stable angina (SA) or unstable angina (UA).

Methods

This observational, descriptive, and cross-sectional study was conducted at the Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, and at the Hospital Beneficência Portuguesa de Sao Paulo, where CAD patients referred to the hospital for coronary angiography were evaluated.

Results

Forty patients with CAD (20 with SA and 20 with UA) were included in the study. Blood samples from LFPV and CS were collected before coronary angiography. Furthermore, analysis of the correlation between serum levels of hs-CRP in LFPV versus CS showed a strong linear correlation for both SA (r = 0.993, p < 0.001) and UA (r = 0.976, p < 0.001) and for the entire sample (r = 0.985, p < 0.001).

Conclusion

Our data suggest a strong linear correlation between hs-CRP levels in LFPV versus CS in patients with SA and UA.

Impact of accuracy of fractional flow reserve to reduction of microvascular resistance after intracoronary adenosine in patients with angina pectoris or non-ST-segment elevation myocardial infarction

Our study aimed to elucidate mechanisms underlying discordance between fractional flow reserve (FFR) and hyperemic stenosis resistance (hSR) in some patient subsets. To do this, we enrolled 30 consecutive patients with stable angina or non-ST elevation myocardial infarction (non-STEMI) and with a nonculprit intermediate coronary lesion (40% to 70%) by coronary angiography. We measured aortic pressure, flow velocity, and pressure distal to lesion simultaneously at basal level and during adenosine-induced (fixed intracoronary dose of 120 μg) hyperemia using a dual-sensor-equipped guidewire. Microvascular resistance (MR; pressure distal to lesion/flow velocity, mm Hg/cm/s) and variation (Δ) in MR levels were calculated both at baseline and after hyperemia, whereas FFR (cutoff <0.80) and hSR [(aortic pressure - pressure distal to lesion)/flow velocity, cutoff >0.80 mm Hg/cm/s] were assessed after intracoronary adenosine. Twenty-three patients (76.7%) showed concordance and 7 patients (23.3%) showed discordance between FFR and hSR (all cases with FFR >0.80 and hSR >0.80). Discordant patients presented more frequently with non-STEMI (85.7% vs 39.1%, p = 0.04), significantly higher C-reactive protein serum levels (median [interquartile range] 5.9 [5.1 to 6.8] vs 4.9 [3.7 to 6.2] mg/L, p = 0.007), and lower ΔMR (p = 0.03) values compared with concordant patients. In conclusion, patients with non-STEMI and those with increased C-reactive protein levels show a lower reduction in MR after intracoronary adenosine-induced hyperemia, leading to FFR underestimation.

Lymphocyte subset characterization in patients with early clinical presentation of coronary heart disease

This study aimed to investigate lymphocyte populations in non-diabetic patients with early clinical presentation of coronary heart disease (CHD). Twenty-five consecutive middle-aged (<55 years) out-patients with CHD (acute myocardial infarction in the previous 3 months) and stable clinical conditions (>1 month) underwent venous blood sampling in order to determinate CD3+ (T-lymphocytes), CD19+ (B-lymphocytes), CD4+ (helper/inducer lymphocytes) and CD8+ (suppressor/cytotoxic lymphocytes) populations. Patients with diabetes, heart failure symptoms, recent revascularization (<30 days) were excluded. Twenty-five patients matched for age, gender and risk factors were enrolled as controls. All patients with CHD previously underwent coronary angiography. CHD patients showed lower CD3+ levels (70.96 ± 4.72 vs. 74.12 ± 4.93 %, p < 0.05) and CD8+ (37.80 ± 7.15 vs. 46.36 ± 5.22 %, p < 0.001) but higher CD4+ (37.32 ± 7.99 vs. 31.64 ± 4.72 %, p < 0.01) and CD4+/CD8+ ratio (1.06 ± 0.43 vs. 0.69 ± 0.13, p < 0.001). Difference in CD19+ levels was not statistically significant. Subjects with an impaired (≤55 %) left ventricular ejection fraction were characterized by lower levels of CD8+ (33.23 ± 7.04 vs. 43.76 ± 7.40 %, p < 0.05) and higher levels of CD4+ (38.31 ± 8.23 vs. 32.73 ± 6.08 %, p < 0.05) and CD4+/CD8+ ratio (1.06 ± 0.38 vs. 0.79 ± 0.34, p < 0.05). CD8+ levels inversely related to severity of coronary atherosclerosis (r = -0.37, p < 0.01). In conclusion, subjects with early clinical presentation of CHD are characterized by an altered CD4+/CD8+ ratio and lower CD3+ levels.

Frequency and healing of nonculprit coronary artery plaque disruptions in patients with acute myocardial infarction

The pathophysiology of plaque disruption and healing in nonculprit segments has not been clarified. Therefore, we investigated the frequency of plaque disruptions in nonculprit segments and whether those plaques are stabilized during follow-ups in patients with acute myocardial infarction (AMI) by serial angioscopic observations. Analyzed were 13 consecutive patients with AMI in whom infarct-related arteries were serially observed by angioscopy immediately after reperfusion and at 1- and 6-month follow-ups. Color of plaques was graded as 0 (white), 1 (slight yellow), 2 (yellow), or 3 (intensive yellow). Plaques with thrombus were defined as disrupted. Although number of nonculprit yellow plaques did not change from immediately after reperfusion to 6 months, the maximum color grade of those plaques and incidence of disrupted plaques in nonculprit segments (immediate vs 1 month vs 6 months 31% vs 8% vs 0%) decreased significantly by 6 months. Plaque stabilization as shown by disappearance of thrombus was significantly associated with plaque regression as shown by a decrease of maximum yellow color grade in nonculprit segments. In conclusion, patients with AMI frequently had disrupted and actively thrombogenic yellow plaques in nonculprit segments of the culprit vessel, and those plaques healed with decreases of yellow color grade and thrombogenicity during 6-months follow-up. Plaque disruption and healing occur not only at the culprit lesion but may be a pan-coronary process in patients with AMI.

Differential Characteristics of Inflammatory Responses to Stent Implantation Between De Novo and Intrastent Restenosis Lesion in Patients With Stable Angina

Mechanical plaque rupture of coronary atherosclerotic plaque during stent implantation can increase serum levels of high-sensitivity C-reactive protein (hsCRP). Patients with stable angina pectoris were divided into 2 groups: one group included 186 patients with de novo lesion who underwent stent implantation (de novo group); the other group included 40 patients with intrastent restenosis (ISR) undergoing stent implantation (ISR group). The de novo group had a significant increase in hsCRP levels post stenting, while the ISR group showed no increase in hsCRP post stenting. Intravascular ultrasound with radiofrequency data analysis showed that the de novo group had larger percentage of both necrotic core area and fibrofatty area at the target lesion than the ISR group, while the ISR group had a larger percentage of fibrous area. Differential inflammatory response to stent implantation between the de novo plaque and in ISR lesion is related to lesion morphology.

A peri-operative statin update for non-cardiac surgery. Part II: Statin therapy for vascular surgery and peri-operative statin trial design

This is the second of two review articles evaluating peri-operative statin therapy. In surgical patients, the utility of peri-operative statin therapy is strongly suggested by retrospective studies, although it is probably overestimated, as important confounding factors have not been controlled for and hence the literature is considered to be currently inconclusive. This review examines the potential mechanisms and indications for peri-operative statin protection, the efficacy of acute peri-operative beta-blockade in addition to statin therapy, the effect of peri-operative statin therapy withdrawal and the implications of comorbidities associated with peri-operative cardiovascular risk on statin therapy. Recommendations concerning appropriate dosing, duration, therapeutic targets and necessary investigations when prescribing peri-operative statins are made. Peri-operative study design recommendations are suggested, so that future meta-analyses may be more informative. Recommendations are made regarding retrospective reporting of statin studies to minimise the bias inherent in a number of the current retrospective studies on this subject.

Correlation between morphologic characteristics and local temperature differences in culprit lesions of patients with symptomatic coronary artery disease

OBJECTIVES

The purpose of this study was to investigate the possible correlation between morphologic and functional characteristics of culprit lesions (CL) in patients with acute coronary syndromes (ACS) and chronic stable angina (CSA).

BACKGROUND

Intravascular ultrasound (IVUS) provides morphologic assessment and intracoronary thermography (ICT) evaluates the local inflammatory activation of CL.

METHODS

Eighty-one consecutive patients, 48 with ACS and 33 with CSA, were enrolled. Ratio of lesion to reference external elastic membrane area, indicated by IVUS, was defined as positive remodeling index (pRi) (> or =1) or negative remodeling index (nRi) (<1). We also investigated the existence of ruptured plaque (rp) in the CL. By ICT temperature difference (DeltaT) between the CL and the proximal vessel wall was measured.

RESULTS

Patients with ACS had greater remodeling index than patients with CSA (1.15 +/- 0.18 vs. 0.90 +/- 0.12; p < 0.01), as well as increased DeltaT (0.08 +/- 0.03 degrees C vs. 0.04 +/- 0.02 degrees C; p < 0.01). Patients with pRi had higher DeltaT than patients with nRi (0.07 +/- 0.03 degrees C vs. 0.04 +/- 0.02 degrees C; p < 0.001). In patients with nRi there was no difference in DeltaT between ACS and CSA (p = 0.22). Patients with rp had increased DeltaT compared with patients without rp (0.09 +/- 0.03 degrees C vs. 0.05 +/- 0.02 degrees C; p < 0.01). Multivariate analysis showed that DeltaT was independently correlated with the presence of rp, pRi, and ACS.

CONCLUSIONS

The present study showed that culprit lesions with plaque rupture and positive arterial remodeling have increased thermal heterogeneity, although in certain patients a discrepancy between morphogic and functional characteristics was observed. A combination of morphologic and functional examination may offer additional diagnostic and prognostic information.