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Systemic Sirolimus to Prevent In-Stent Stenosis in Pediatric Pulmonary Vein Stenosis. Pediatr Cardiol 2020; 41:282-289. [PMID: 31720783 DOI: 10.1007/s00246-019-02253-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 11/05/2019] [Indexed: 10/25/2022]
Abstract
Evaluate the efficacy of systemic sirolimus (rapamycin) in preventing in-stent stenosis (ISS) in pediatric intraluminal pulmonary vein stenosis (PVS). Report the adverse events related to sirolimus therapy. There is a high incidence of ISS following stent implantation in PVS. The use of sirolimus in preventing ISS has not been reported. Retrospective review of all patients who received sirolimus (8 week course) for treatment of ISS for PVS between January 2013 and June 2018. Forty stents (37 bare metal, 3 drug-eluting) in 20 patients were treated with sirolimus; 20 at the time of implantation (primary prevention [1P]) and 20 following documented ISS requiring transcatheter reintervention (secondary prevention [2P]). Treated patients were young (median 2 y/o [0.7-5.7]) and most had PVS associated with congenital heart disease (75%, 15/20; 4/15 with TAPVC). In the 1P group, 85% (17/20) of stents were without significant (< 50%) ISS at median of 102 days (range 56-527); the growth rate of ISS in this group was 7.5 ± 7.1%/month. In the 2P group, most stents had a slower growth rate of ISS after sirolimus therapy compared to pre-treatment (median 3.7 [- 0.2 to 13.1] vs. 10.4 [1.3 to 19.5] %/month; p < 0.001). One patient developed pneumonia on drug while concurrently taking another immunosuppressive agent. No other serious adverse events were related to sirolimus therapy. Systemic sirolimus slows the growth rate of ISS following stent implantation in PVS compared to pre-treatment rates and was administered safely in a small number of pediatric patients with complex heart disease.
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Gouveia V, Oliveira DC, Tenorio E, Brito N, Sarinho E. Percutaneous Coronary Intervention: Safety of Methotrexate and Its Possible Benefits on Restenosis After Bare-Metal Stent Deployment. Cardiol Res 2016; 7:104-109. [PMID: 28197276 PMCID: PMC5295516 DOI: 10.14740/cr468w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2016] [Indexed: 12/03/2022] Open
Abstract
Background Percutaneous coronary intervention (PCI) revolutionized treatment of coronary artery disease. Drug-eluting stents are effective and safe but their cost is high, especially for some countries. The primary objective was to evaluate the safety of methotrexate (MTX) in patients who underwent PCI and the secondary goal was to evaluate the possibility that MTX has an impact on restenosis. Methods This was a transversal, prospective and descriptive study that recruited 16 patients in whom PCI was planned. MTX was administered to patients at a dose of 5 mg/week for 2 weeks before PCI and 8 weeks after PCI. Bare-metal stent (BMS) deployment was performed according to standard practice. Patients were monitored clinically every 15 days during the first 2 months after the procedure and monthly until 9 months after PCI. Results There were no immediate or late complications associated with PCI. Adverse events and side effects due to MTX occurred in three patients (prevalence 18.7%). These side effects are classified as minor complications. MTX was not discontinued due to these side effects. There were no reported cases of clinical restenosis. Conclusions MTX was safe in the study population and raised the possibility that a low-cost drug may have positive effects on restenosis after BMS implantation. However, studies with larger sample sizes and other imagine modalities (intravascular ultrasound and/or optical coherence tomography) are required to confirm this hypothesis.
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Affiliation(s)
- Viviane Gouveia
- Hospital das Clinicas, Federal University of Pernambuco, Brazil
| | | | | | - Norma Brito
- Hospital das Clinicas, Federal University of Pernambuco, Brazil
| | - Emanuel Sarinho
- Hospital das Clinicas, Federal University of Pernambuco, Brazil
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Waksman R, Epstein SE. Prednisone: the last gasp of immunosuppresive therapy for restenosis prevention. Eur Heart J 2013; 34:1702-4. [PMID: 23571835 DOI: 10.1093/eurheartj/eht125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Ribichini F, Tomai F, Pesarini G, Zivelonghi C, Rognoni A, De Luca G, Boccuzzi G, Presbitero P, Ferrero V, Ghini AS, Marino P, Vassanelli C, Ribichini F, Ferrero V, Pesarini G, Dal Dosso S, Vassanelli C, Tanguay JF, Tomai F, Presbitero P, Minelli M, Marino P, Anselmi M, Abukarsh R, Cima A, Ferrara A, Ferrero V, Menegatti G, Molinari G, Pesarini G, Ribichini F, Sparta D, Altamura L, Aurigemma C, Beraldi M, Corvo P, De Luca L, De Persio G, Ghini AS, Pastori F, Pellanda J, Petrolini A, Skossyreva O, Tomai. Ospedale F, Ospedale S, Bosco G, Boccuzzi G, Colangelo S, Garbo R, Minelli M, Noussan P, Belli G, Presbitero P, Rossi M, Soregaroli D, Zavalloni D, De Luca G, Franchi E, Leverone M, Rognoni A, Brunelleschi S, Feola M, Trinita OS, Menegatti G, Noussan P, Giovanni OS, Zanolla L, Magnani C. Long-term clinical follow-up of the multicentre, randomized study to test immunosuppressive therapy with oral prednisone for the prevention of restenosis after percutaneous coronary interventions: Cortisone plus BMS or DES veRsus BMS alone to EliminAte Restenosis (CEREA-DES). Eur Heart J 2013; 34:1740-8. [DOI: 10.1093/eurheartj/eht079] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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Abstract
The unprecedented progress in aging research has revealed that rapamycin, a clinically approved drug, is actually an anti-aging agent, which potentially could be employed to delay age-related diseases, thus extending healthy life span. The possibility of preventing diseases by staying young is remarkable in itself. At the same time this advance could save Medicare as we know it. Here I discuss how anti-aging interventions could solve otherwise intractable political problems without tax increases or curtailment of health care benefits.
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Affiliation(s)
- Mikhail V Blagosklonny
- Department of Cell Stress Biology, Roswell Park Cancer Institute, Buffalo, NY 14263, USA.
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Abstract
The immunosuppressant and anticancer drug rapamycin works by inducing inhibitory protein complexes with the kinase mTOR, an important regulator of growth and proliferation. The obligatory accessory partner of rapamycin is believed to be FK506-binding protein 12 (FKBP12). Here we show that rapamycin complexes of larger FKBP family members can tightly bind to mTOR and potently inhibit its kinase activity. Cocrystal structures with FKBP51 and FKBP52 reveal the modified molecular binding mode of these alternative ternary complexes in detail. In cellular model systems, FKBP12 can be functionally replaced by larger FKBPs. When the rapamycin dosage is limiting, mTOR inhibition of S6K phosphorylation can be enhanced by FKBP51 overexpression in mammalian cells, whereas FKBP12 is dispensable. FKBP51 could also enable the rapamycin-induced hyperphosphorylation of Akt, which depended on higher FKBP levels than rapamycin-induced inhibition of S6K phosphorylation. These insights provide a mechanistic rationale for preferential mTOR inhibition in specific cell or tissue types by engaging specific FKBP homologs.
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Chen WQ, Zhong L, Zhang L, Ji XP, Zhang M, Zhao YX, Zhang C, Zhang Y. Oral rapamycin attenuates inflammation and enhances stability of atherosclerotic plaques in rabbits independent of serum lipid levels. Br J Pharmacol 2009; 156:941-51. [PMID: 19239473 DOI: 10.1111/j.1476-5381.2008.00102.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND AND PURPOSE Atherosclerotic plaque rupture and thrombosis are the main cause of acute coronary syndrome. The study was aimed to test the hypothesis that oral administration of rapamycin may attenuate inflammation, inhibit progression and enhance stability of atherosclerotic plaques. EXPERIMENTAL APPROACH Thirty New Zealand rabbits were subjected to balloon-induced endothelial injury of the abdominal aorta and were fed a diet of 1% cholesterol for 20 weeks. From week 9 to week 20, the animals were treated with oral rapamycin (0.5 mg x kg(-1) x day(-1); group A), oral simvastatin (5 mg x kg(-1) x day(-1); group B) and no drugs (group C). At the end of week 20, all rabbits were challenged with injection of Chinese Russell's viper venom and histamine. Serological, ultrasonographic, pathological, immunohistochemical and gene expression studies were performed. KEY RESULTS Rapamycin significantly increased the thickness of the fibrous caps and decreased plaque vulnerability index in group A rabbits. Serum lipid levels were higher whereas plaque burden was lower in group A than in group B (P < 0.05). The incidence of plaque rupture in group A (0%) and group B (0%) was significantly lower than that in group C (56.0%, P < 0.05). CONCLUSIONS AND IMPLICATIONS Oral administration of rapamycin effectively attenuated inflammation, inhibited progression and enhanced stability of atherosclerotic plaques in rabbits, without altering serum lipid levels. Our findings suggest a novel approach to the treatment of atherosclerosis.
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Affiliation(s)
- Wen Qiang Chen
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Shandong University Qilu Hospital, Jinan, Shandong, China
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Charron T, Nili N, Strauss BH. The cell cycle: a critical therapeutic target to prevent vascular proliferative disease. Can J Cardiol 2007; 22 Suppl B:41B-55B. [PMID: 16498512 PMCID: PMC2780832 DOI: 10.1016/s0828-282x(06)70986-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Percutaneous coronary intervention is the preferred revascularization approach for most patients with coronary artery disease. However, this strategy is limited by renarrowing of the vessel by neointimal hyperplasia within the stent lumen (in-stent restenosis). Vascular smooth muscle cell proliferation is a major component in this healing process. This process is mediated by multiple cytokines and growth factors, which share a common pathway in inducing cell proliferation: the cell cycle. The cell cycle is highly regulated by numerous mechanisms ensuring orderly and coordinated cell division. The present review discusses current concepts related to regulation of the cell cycle and new therapeutic options that target aspects of the cell cycle.
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Affiliation(s)
| | | | - Bradley H Strauss
- Correspondence: Dr Bradley H Strauss, St Michael’s Hospital, 30 Bond Street, Toronto, Ontario M5B IW8. Telephone 416-864-5913, fax 416-864-5978, e-mail
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Margolis J, McDonald J, Heuser R, Klinke P, Waksman R, Virmani R, Desai N, Hilton D. Systemic nanoparticle paclitaxel (nab-paclitaxel) for in-stent restenosis I (SNAPIST-I): a first-in-human safety and dose-finding study. Clin Cardiol 2007; 30:165-70. [PMID: 17443649 PMCID: PMC6652913 DOI: 10.1002/clc.20066] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Paclitaxel-eluting stents inhibit restenosis; however, this technology has drawbacks (e.g., stent thrombosis, requirement for long-term antiplatelet therapy, and cost--particularly for patients with multivessel disease). Systemic treatment with a novel 130-nm, albumin-bound particle form of paclitaxel (nab-paclitaxel) has been shown to reduce restenosis in animals. HYPOTHESIS This study was designed to establish the safety and optimal dose of systemic nab-paclitaxel for reducing in-stent restenosis in humans. If well tolerated, systemic nab-paclitaxel may be used with any available bare-metal stent and at potentially lower cost than drug-eluting stents. METHODS Patients received nab-paclitaxel 10, 30, 70, or 100 mg/m(2) intravenously after stenting of a single de novo lesion >or= 3 mm in diameter. Study endpoints included safety and major adverse cardiac events (MACE) at 2 and 6 months. RESULTS Data were obtained for all 23 enrolled patients (mean age 66 +/- 10 years, 74% men, 26% with diabetes). No significant adverse events (AE) were attributable to nab-paclitaxel at 10 or 30 mg/m(2). Moderate neutropenia, moderate sensory neuropathy, and mild to moderate, reversible alopecia occurred only at doses of 70 and 100 mg/m(2); therefore, doses of 70 mg/m(2) or higher were considered unacceptable in this patient population. No MACE were reported at 2 months. At 6 months, 4 target lesion revascularizations (TLR) for restenoses were reported (2 each in the 10- and 100-mg/m(2)-dose groups). CONCLUSIONS Systemic nab-paclitaxel was well tolerated at doses below 70 mg/m(2) in this group of patients; no unexpected AE were noted. Additional studies are under way to explore intravenous and intracoronary administration of nab-paclitaxel.
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Affiliation(s)
- James Margolis
- Miami International Cardiology Consultants, Miami, Florida
| | - John McDonald
- Victoria Heart Institute Foundation, Royal Jubilee Hospital, Victoria, British Columbia, Canada
| | | | - Peter Klinke
- Victoria Heart Institute Foundation, Royal Jubilee Hospital, Victoria, British Columbia, Canada
| | | | - Renu Virmani
- CVPath, International Registry of Pathology, Gaithersburg, Maryland
| | - Neil Desai
- Abraxis BioScience, Inc., Los Angeles, California
| | - David Hilton
- Victoria Heart Institute Foundation, Royal Jubilee Hospital, Victoria, British Columbia, Canada
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Voisard R, Zellmann S, Müller F, Fahlisch F, von Müller L, Baur R, Braun J, Gschwendt J, Kountides M, Hombach V, Kamenz J. Sirolimus inhibits key events of restenosis in vitro/ex vivo: evaluation of the clinical relevance of the data by SI/MPL- and SI/DES-ratios. BMC Cardiovasc Disord 2007; 7:15. [PMID: 17498286 PMCID: PMC1878500 DOI: 10.1186/1471-2261-7-15] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2006] [Accepted: 05/11/2007] [Indexed: 11/10/2022] Open
Abstract
Background Sirolimus (SRL, Rapamycin) has been used successfully to inhibit restenosis both in drug eluting stents (DES) and after systemic application. The current study reports on the effects of SRL in various human in vitro/ex vivo models and evaluates the theoretical clinical relevance of the data by SI/MPL- and SI/DES-ratio's. Methods Definition of the SI/MPL-ratio: relation between significant inhibitory effects in vitro/ex vivo and the maximal plasma level after systemic administration in vivo (6.4 ng/ml for SRL). Definition of the SI/DES-ratio: relation between significant inhibitory effects in vitro/ex vivo and the drug concentration in DES (7.5 mg/ml in the ISAR drug-eluting stent platform). Part I of the study investigated in cytoflow studies the effect of SRL (0.01–1000 ng/ml) on TNF-α induced expression of intercellular adhesion molecule 1 (ICAM-1) in human coronary endothelial cells (HCAEC) and human coronary smooth muscle cells (HCMSMC). Part II of the study analysed the effect of SRL (0.01–1000 ng/ml) on cell migration of HCMSMC. In part III, IV, and V of the study ex vivo angioplasty (9 bar) was carried out in a human organ culture model (HOC-model). SRL (50 ng/ml) was added for a period of 21 days, after 21 and 56 days cell proliferation, apoptosis, and neointimal hyperplasia was studied. Results Expression of ICAM-1 was significantly inhibited both in HCAEC (SRL ≥ 0.01 ng/ml) and HCMSMC (SRL ≥ 10 ng/ml). SRL in concentrations ≥ 0.1 ng/ml significantly inhibited migration of HCMSMC. Cell proliferation and neointimal hyperplasia was inhibited at day 21 and day 56, significance (p < 0.01) was achieved for the inhibitory effect on cell proliferation in the media at day 21. The number of apoptotic cells was always below 1%. Conclusion SI/MPL-ratio's ≤ 1 (ICAM-1 expression, cell migration) characterize inhibitory effects of SRL that can be theoretically expected both after systemic and local high dose administration, a SI/MPL-ratio of 7.81 (cell proliferation) represents an effect that was achieved with drug concentrations 7.81-times the MPL. SI/DES-ratio's between 10-6 and 10-8 indicate that the described inhibitory effects of SRL have been detected with micro to nano parts of the SRL concentration in the ISAR drug-eluting stent platform. Drug concentrations in DES will be a central issue in the future.
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Affiliation(s)
- Rainer Voisard
- Department of Internal Medicine II – Cardiology, University of Ulm, Robert-Koch-Straße 8, D-89081 Ulm, Germany
| | - Svenja Zellmann
- Department of Internal Medicine II – Cardiology, University of Ulm, Robert-Koch-Straße 8, D-89081 Ulm, Germany
| | - Fabian Müller
- Department of Internal Medicine II – Cardiology, University of Ulm, Robert-Koch-Straße 8, D-89081 Ulm, Germany
| | - Felicitas Fahlisch
- Department of Internal Medicine II – Cardiology, University of Ulm, Robert-Koch-Straße 8, D-89081 Ulm, Germany
| | - Lutz von Müller
- Department of Virology, Institute of Mikrobiology and Immunology, University of Ulm, Robert-Koch-Straße 8, D-89081 Ulm, Germany
| | - Regine Baur
- Department of Internal Medicine II – Cardiology, University of Ulm, Robert-Koch-Straße 8, D-89081 Ulm, Germany
| | - Jürgen Braun
- Department of Urology, Klinik Biberach, Ziegelhausstraße 50, D-88400 Biberach, Germany
| | - Jürgen Gschwendt
- Department of Urology, University of Ulm, Prittwitzstrasse 43, D-89075 Ulm, Germany
| | - Margaratis Kountides
- Department of Urology, Klinik Heidenheim, Schlosshaustraße 100, D-89522 Heidenheim, Germany
| | - Vinzenz Hombach
- Department of Internal Medicine II – Cardiology, University of Ulm, Robert-Koch-Straße 8, D-89081 Ulm, Germany
| | - Joachim Kamenz
- Department of Internal Medicine II – Cardiology, University of Ulm, Robert-Koch-Straße 8, D-89081 Ulm, Germany
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Schiele TM. Current understanding of coronary in-stent restenosis. Pathophysiology, clinical presentation, diagnostic work-up, and management. ACTA ACUST UNITED AC 2006; 94:772-90. [PMID: 16258781 DOI: 10.1007/s00392-005-0299-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2005] [Accepted: 07/18/2005] [Indexed: 12/29/2022]
Abstract
In-stent restenosis is the limiting entity following coronary stent implantation. It is associated with significant morbidity and cost and thus represents a major clinical and economical problem. Worldwide, approximately 250 000 in-stent restenotic lesions per year have to be dealt with. The pathophysiology of instent restenosis is multifactorial and comprises inflammation, smooth muscle cell migration and proliferation and extracellular matrix formation, all mediated by distinct molecular pathways. Instent restenosis has been recognised as very difficult to manage, with a repeat restenosis rate of 50% regardless of the mechanical angioplasty device used. Much more favourable results were reported for the adjunctive irradiation of the in-stent restenotic lesion, with a consistent reduction of the incidence of repeat in-stent restenosis by 50%. Data from the first clinical trials on drug-eluting stents for the treatment of in-stent restenosis have shown very much promise yielding this strategy likely to become the treatment of choice. This review outlines the histological and molecular findings of the pathophysiology, the epidemiology, the predictors and the diagnostic work-up of in-stent restenosis and puts emphasis on the various treatment options for its prevention and therapy.
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Affiliation(s)
- T M Schiele
- Kardiologie, Klinikum der Ludwig-Maximilians-Universität München--Innenstadt, Ziemssenstrasse 1, 80336 München, Germany.
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Abstract
Are drug eluting stents destined to become the standard of care for all patients undergoing percutaneous coronary intervention, or are alternative therapeutic approaches preferable under certain circumstances?
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Rodríguez AE, Rodríguez Alemparte M, Vigo CF, Fernández Pereira C, Llauradó C, Vetcher D, Pocovi A, Ambrose J. Role of oral rapamycin to prevent restenosis in patients with de novo lesions undergoing coronary stenting: results of the Argentina single centre study (ORAR trial). Heart 2005; 91:1433-7. [PMID: 15774608 PMCID: PMC1769178 DOI: 10.1136/hrt.2004.050617] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To assess the role of oral rapamycin in the prevention of coronary restenosis in patients undergoing coronary stenting. METHODS From December 2001 through February 2003, 76 patients with 103 de novo lesions treated percutaneously with bare stents received a loading dose of oral rapamycin 6 mg followed by a daily dose of 2 mg during 28 days in phase I (49 arteries in 34 patients) and 2 mg/day plus 180 mg/day of diltiazem in phase II (54 arteries in 42 patients). Rapamycin blood concentrations were measured in all patients. A six month follow up angiogram was performed in 82.5% (85 of 103 arteries). Follow up angiographic binary restenosis (> 50%), target vessel revascularisation, late loss, treatment compliance, and major adverse cardiovascular events were analysed and correlated with rapamycin concentrations. RESULTS Rapamycin was well tolerated and only three patients discontinued the treatment for mild side effects. Angiographic restenosis was found in 15% of the arteries with angiographic restudy (13 of 85). The target vessel had been revascularised at follow up in 13.6% of the 103 vessels initially treated (14 of 103) and in 18.4% of the 76 patients (14 of 76). In-stent restenosis in phase I was 19% compared with 6.2% in phase II (p = 0.06). Angiographic in-stent restenosis in lesions of patients with rapamycin blood concentrations > or = 8 ng/ml was 6.2% and with rapamycin concentrations < 8 ng/ml was 22% (p = 0.041). Late loss was also significantly lower when rapamycin concentrations were > or = 8 ng/ml (0.6 mm v 1.1 mm, p = 0.031). A Pearson test showed a linear correlation between follow up late loss and rapamycin blood concentration (r = -0.826, p = 0.008). CONCLUSION Oral rapamycin administered for one month after percutaneous coronary intervention was safe and with few minor side effects. High rapamycin blood concentrations were associated with significantly lower late loss and angiographic in-stent restenosis.
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Affiliation(s)
- A E Rodríguez
- Otamendi Hospital, Buenos Aires School of Medicine, Buenos Aires, Argentina.
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