Chronic treatment with trimetazidine after discharge reduces the incidence of restenosis in patients who received coronary stent implantation: a 1-year prospective follow-up study

Predictors of restenosis following percutaneous coronary stent implantation: The role of trimetazidine therapy

Aims

In-stent restenosis (ISR) is an unresolved problem following percutaneous coronary intervention (PCI), having a negative impact on clinical outcome. The main goal of this study was to find new independent predictors that may influence the development of ISR.

Methods and results

In this retrospective analysis, 653 PCI patients were involved. All patients had coronary stent implantation and a follow-up coronary angiography. Based on the presence of ISR at follow-up, patients were divided into two groups: 221 in the ISR and 432 in the control group. When evaluating the medical therapy of patients, significantly more patients were on trimetazidine (TMZ) in the control compared to the ISR group (p = 0.039). TMZ was found to be an independent predictor of a lower degree of ISR development (p = 0.007). TMZ treatment was especially effective in bare metal stent (BMS)-implanted chronic coronary syndrome (CCS) patients with narrow coronary arteries. The inflammation marker neutrophil to lymphocyte ratio (NLR) was significantly elevated at baseline in the ISR group compared to controls. The reduction of post-PCI NLR was associated with improved efficacy of TMZ to prevent ISR development. Drug eluting stent implantation (p < 0.001) and increased stent diameter (p < 0.001) were the most important independent predictors of a lower degree of ISR development, while the use of longer stents (p = 0.005) was a major independent predictor of an increased ISR risk.

Conclusion

TMZ reduces the occurrence of ISR following PCI, with special effectiveness in BMS-implanted patients having CCS and narrow coronary arteries. TMZ treatment may help to lower ISR formation in countries with high BMS utilization rates.

High-risk Plaque and Calcification Detected by Coronary CT Angiography to Predict Future Cardiovascular Events After Percutaneous Coronary Intervention

RATIONALE AND OBJECTIVES

The purpose of this study was to investigate whether high-risk plaque (HRP) and calcium assessed by coronary computed tomography (CT) could predict future cardiovascular events after second-generation drug-eluting stent (DES) placement.

MATERIALS AND METHODS

We analyzed 317 patients from December 2012 to April 2015 who underwent coronary CT followed by DES placement. HRP was defined as a plaque with positive remodeling and low attenuation or a plaque with a napkin-ring sign. Coronary calcium was assessed by Agatston score (AS). Patients were divided into three groups: low risk, HRP negative and AS <400; intermediate risk, HRP positive and AS ≥400; high risk, HRP positive and AS ≥400. The primary end point was a composite of all-cause mortality, myocardial infarction, fatal arrhythmia, or repeated revascularization. Kaplan-Meier analysis was used to estimate the distribution of time to events.

RESULTS

A total of 74 events (23%) occurred during a median follow-up of 25.8 months. Patients with primary end points had HRP more frequently (70% vs 51%, P = 0.003) and were more calcified (AS, 471 [interquartile range, 143-1614] vs 289 [interquartile range, 63-787]; P = 0.01) than patients without primary end points. The frequency of primary end point increased significantly in the intermediate- and high-risk patients (P = 0.0011). Multivariate analysis showed that the hazard ratio of the intermediate- and high-risk groups was 1.91 (95% confidence interval, 1.04-3.77; P = 0.037) and 2.66 (95% confidence interval, 1.27-5.73; P = 0.009), respectively.

CONCLUSION

Plaque and calcification analysis by coronary CT could predict future cardiovascular events after second-generation DES placement.

MicroRNA-24 regulates vascular remodeling via inhibiting PDGF-BB pathway in diabetic rat model

PURPOSE

Hyperglycemia is the high risk factor of vascular remodeling induced by angioplasty, and neointimal hyperplasia is strongly implicated in the pathogenesis of vascular remodeling caused by carotid artery balloon injury. Studies have shown that MicroRNA 24 (miR-24) plays an important role in angiocardiopathy, However, the role of miR-24 is far from thorough research. In this study, we investigate whether up-regulation of miR-24 by using miR-24 recombinant adenovirus (Ad-miR-24-GFP) can inhibit PDGF-BB signaling pathway and attenuate vascular remodeling in the diabetic rat model.

METHODS

Male Sprague-Dawley rats (n = 60) were randomly divided into 5 groups and fed with high sugar and high fat diet (Sham, Saline, Scramble, Ad-miR-24 groups), or ordinary diet (Control group). The front four groups were treated with streptozotocin (STZ) four weeks later and the blood glucose level was closely monitored. After the successful establishment of diabetic rats, the external carotid artery was injured by pressuring balloon 1.5 after internal carotid artery ligation, then the blood vessels were harvested 14 days later and indexes were detected including the following: HE staining for the level of vascular intima thickness, immunohistochemical detection for PCNA and P27 to test the proliferative degree of vascular smooth muscle cells (VSMCs), qRT-PCR for the level of miR-24, RAS,PDGF-R, western blot for the protein levels of JNK1/2, p- JNK1/2, ERK1/2, p-ERK1/2, RAS, PDGF-R, AP-1,P27 and PCNA. Serological detection was conducted for TNF-α, IL-6, IL-8.

RESULTS

The delivery of Ad-miR-24 into balloon injury site has significantly increased the level of miR-24. Up-regulation of miR-24 could regulate vascular remodeling effectively, lower the level of inflammatory factors, inhibit the expression of mRNA and protein levels of JNK1/2, ERK1/2, RAS, PDGF-R, AP-1, P27, PCNA.

CONCLUSION

miR-24 can inhibit the expression of AP-1 via the inhibition of PDGF-BB signaling pathway, thus inhibit VSMCs proliferation and vascular remodeling.

Effect of trimetazidine on preventing contrast-induced nephropathy in diabetic patients with renal insufficiency

BACKGROUND

Our study sought to assess the effect of trimetazidine (TMZ) on preventing contrast-induced nephropathy (CIN) in diabetic patients with renal insufficiency.

MATERIALS AND METHODS

106 diabetic patients with renal insufficiency who were undergoing coronary angiography (CAG) and/or percutaneous coronary intervention (PCI) were enrolled in this study. Standard hydration was administered to both groups (the TMZ group and the control group). In the TMZ group, patients were orally administered TMZ for 48 hours before and 24 hours after CAG and/or PCI. Serum creatinine (Scr), cystatin C and the glomerular filtration rate (eGFR) were measured before as well as 24 hours, 48 hours and 72 hours after contrast media injection. The incidence of CIN and major cardiovascular events (MACE) was also evaluated in both groups.

RESULTS

Scr, cystatin C and the eGRF in the TMZ group were better than those in the control group after 24 hours (OR: 0.78, 95% CI: 0.54-0.82; OR: 0.66, 95% CI: 0.62-0.73; OR: 1.2, 95% CI: 1.02-1.53, respectively), 48 hours (OR: 0.69, 95% CI: 0.52-0.73; OR: 0.76, 95% CI: 0.69-0.84; OR: 1.5, 95% CI: 1.25-1.68, respectively) and 72 hours (OR: 0.82, 95% CI: 0.77-0.91; OR: 0.85, 95% CI: 0.71-0.92; OR: 1.67, 95% CI: 1.33-1.72, respectively). The incidence of CIN (9.26% vs 16.67%) and MACE (7.41% vs 18.51%) in the TMZ group was significantly lower than that in the control group (P < 0.05).

CONCLUSIONS

Our study suggests that TMZ could reduce the incidence of CIN and MACE in diabetic patients with renal insufficiency who are undergoing CAG and/or PCI.

Modulation of myocardial energetics: An important category of agents in the multimodal treatment of coronary artery disease and heart failure

The combined and relative contribution of glucose and fatty acid oxidation generates myocardial energy, which regulates the cardiac function and efficiency. Any dysregulation in this metabolic homeostasis can adversely affect the function of heart and contribute to cardiac conditions such as angina and heart failure. Metabolic agents ameliorate this internal metabolic anomaly, by shifting the energy production pathway from free fatty acids to glucose, resulting in a better performance of the heart. Metabolic therapy is relatively a new modality, which functions through optimization of cardiac substrate metabolism. Among the metabolic therapies, trimetazidine and ranolazine are the agents presently available in India. In the present review, we would like to present the metabolic perspective of pathophysiology of coronary artery disease and heart failure, and metabolic therapy by using trimetazidine and ranolazine.

High rate of in-stent restenosis after coronary intervention in carriers of the mutant mannose-binding lectin allele

Background

In-stent restenosis occurs in 10–30% of patients following bare metal stent (BMS) implantation and has various risk factors. Mannose-binding lectin (MBL) is known to have effect on the progression of atherosclerosis. Single nucleotide polymorphisms (SNP) of the MBL2 gene intron 1 (codon 52, 54, 57) are known to modulate the bioavailability of the MBL protein. Our aim was to identify the association of these polymorphisms of the MBL gene in the occurrence of in-stent restenosis after coronary artery bare metal stent implantation.

Methods

In a non-randomized prospective study venous blood samples were collected after recoronarography from 225 patients with prior BMS implantation. Patients were assigned to diffuse restenosis group and control group based on the result of the coronarography. MBL genotypes were determined using quantitative real-time PCR. Proportion of different genotypes was compared and adjusted with traditional risk factors using multivariate logistic regression.

Results

Average follow-up time was 1.0 (+ − 1.4) year in the diffuse restenosis group (N = 117) and 2.7 (+ − 2.5) years in the control group (N = 108). The age, gender distribution and risk status was not different between study groups. Proportion of the MBL variant genotype was 26.8% (29 vs. 79 normal homozygous) in the control group and 39.3% (46 vs. 71 normal homozygous) in the restenosis group (p = 0.04). In multivariate analysis the mutant allele was an independent risk factor (OR = 1.96, p = 0.03) of in-stent restenosis.

Conclusions

MBL polymorphisms are associated with higher incidence of development of coronary in-stent restenosis. The attenuated protein function in the mutant allelic genotype may represent the underlying mechanism.

Effect of trimetazidine on heart rate variability in elderly patients with acute coronary syndrome

Background and Objective:

Trimetazidine has mainly been used in coronary insufficiency, angina and elderly myocardial infarction. However, the effect of trimetazidine on the efficacy, heart rate variability (HRV) and protection of myocardial ischemia in elderly patients with acute coronary syndrome (ACS) remains unclear. This study aimed to investigate the effect of trimetazidine on the efficacy HRV and protection of myocardial ischemia in patients with ACS.

Methods:

One hundred twenty two elderly ACS patients who were above 70 years were chosen and randomly divided into two groups. One group was given conventional therapy, such as aspirin, isosorbide mononitrate and fluvastatin, and the other group was administered trimetazidine in addition to conventional therapy. The treatment period was eight weeks. A PI-2.22B three-channel AECG system was used on every patient for 24 hour dynamic electrocardiogram monitoring and HRV analyses on the first day after admission and eight weeks after treatment. HRV, 24 hour RR intermediate stage standard deviation (SDNN), five minutes average normal cardiac cycle standard deviation in 24 hour (SDANN), 24 hour close together normal cardiac cycle difference value mean square root (rMSSD), the percentage of difference of close together RR intermediate > 50 ms account total RR intermediate (PNN50), high frequency (HF) and low frequency (LF) parameters of patients were observed before and after treatment.

Results:

The SDNN, SDANN, rMSSD, PNN50 and HF parameters significantly increased compared with the conventional treatment group (all P < 0.05). LF and LF/HF were significantly decreased in the trimetazidine treatment group compared with those in the conventional treatment group (all P < 0.05).

Conclusion:

Trimetazidine improves HRV of elderly ACS patients and reduces cardiovascular events.