Diagnostic coronary angiography induces a systemic inflammatory response in patients with stable angina

Co-release of cytokines after drug-eluting stent implantation in acute myocardial infarction patients with PCI

Acute Myocardial Infarction (AMI) after Percutaneous Coronary Intervention (PCI) often requires stent implantation leading to cardiovascular injury and cytokine release. Stent implantation induces cytokines production including TNFα, Hs-CRP, IL-1ß, IL2 receptor, IL6, IL8, and IL10, but their co-release is not extensively established. In 311 PCI patients with Drug-Eluting Stent (DES) implantation, we statistically evaluate the correlation of these cytokines release in various clinical conditions, stent numbers, and medications. We observed that TNFα is moderately correlated with IL-1ß (r2 = 0.59, p = 0.001) in diabetic PCI patients. Similarly, in NSTEMI (Non-ST Segment Elevation) patients, TNFα is strongly correlated with both IL-1ß (r2 = 0.97, p = 0.001) and IL8 (r2 = 0.82, p = 0.001). In CAD (Coronary Artery Disease)-diagnosed patients TNFα is highly correlated (r2 = 0.84, p = 0.0001) with IL8 release but not with IL-1ß. In patients with an increased number of stents, Hs-CRP is significantly coupled with IL8 > 5 pg/ml (t-statistic = 4.5, p < 0.0001). Inflammatory suppressor drugs are correlated as TNFα and IL8 are better suppressed by Metoprolol 23.75 (r2 = 0.58, p < 0.0001) than by Metoprolol 11.87 (r2 = 0.80, p = 0.5306). Increased TNFα and IL-1ß are better suppressed by the antiplatelet drug Brilinta (r2 = 0.30, p < 0.0001) but not with Clopidogrel (r2 = 0.87, p < 0.0001). ACI/ARB Valsartan 80 (r2 = 0.43, p = 0.0011) should be preferred over Benazepril 5.0 (r2 = 0.9291, p < 0.0001) or Olmesartan (r2 = 0.90, p = 0.0001). Thus, the co-release of IL-1ß, IL8 with TNFα, or only IL8 with TNFα could be a better predictor for the outcome of stent implantation in NSTEMI and CAD-diagnosed AMI patients respectively. Cytokine suppressive medications should be chosen carefully to inhibit further cardiovascular damage.

Comparison of transradial versus transfemoral diagnostic coronary angiography in terms of oxidative stress: Which option is more physiological?

In this randomized, single-center, clinical study we aimed to compare the oxidative stress response in patients undergoing diagnostic transradial or transfemoral elective coronary angiography. Sixty patients with stable angina pectoris undergoing elective coronary angiography to either transradial ( n = 30) or transfemoral ( n = 30) approach were included. The levels of plasma total oxidative status (TOS) were measured and compared just before and immediately after the procedure in both groups. The clinical and laboratory findings were compatible between the two groups. Although the levels of plasma total oxidative status after coronary angiography were increased in both groups (TF pTOS 20. ± :3; 34 ± 3 vs TR pTOS 18 ± 2; 23 ± 4), this was more pronounced in the transfemoral group as compared with the transradial group (ΔpTOS: 11 ± 4 vs 4 ± 3, p < 0.001) In correlation analysis, TOS levels and white blood cell counts ( r = 0.25, p = 0.042), total cholesterol levels ( r = 0.267, p = 0.041), triglyceride levels ( r = 0.253, p = 0.049), serum creatinine levels ( r = 0.260, p = 0.043) were found to be moderately positively correlated. This study showed that oxidative stress response associated with heart catheterization is more evident in patients undergoing transfemoral coronary angiography versus transradial coronary angiography.

Effects of clopidogrel vs. prasugrel vs. ticagrelor on endothelial function, inflammatory parameters, and platelet function in patients with acute coronary syndrome undergoing coronary artery stenting: a randomized, blinded, parallel study

AIMS

In a randomized, parallel, blinded study, we investigate the impact of clopidogrel, prasugrel, or ticagrelor on peripheral endothelial function in patients undergoing stenting for an acute coronary syndrome.

METHODS AND RESULTS

The primary endpoint of the study was the change in endothelium-dependent flow-mediated dilation (FMD) following stenting. A total of 90 patients (age 62 ± 9 years, 81 males, 22 diabetics, 49 non-ST elevation myocardial infarctions) were enrolled. There were no significant differences among groups in any clinical parameter. Acutely before stenting, all three drugs improved FMD without differences between groups (P = 0.73). Stenting blunted FMD in the clopidogrel and ticagrelor group (both P < 0.01), but not in the prasugrel group. During follow-up, prasugrel was superior to clopidogrel [mean difference 2.13, 95% confidence interval (CI) 0.68-3.58; P = 0.0047] and ticagrelor (mean difference 1.57, 95% CI 0.31-2.83; P = 0.0155), but this difference was limited to patients who received the study therapy 2 h before stenting. Ticagrelor was not significantly superior to clopidogrel (mean difference 0.55, 95% CI -0.73 to 1.82; P = 0.39). No significant differences were seen among groups for low-flow-mediated dilation. Plasma interleukin (IL)-6 (P = 0.02 and P = 0.01, respectively) and platelet aggregation reactivity in response to adenosine diphosphate (P = 0.002 and P = 0.035) were lower in the prasugrel compared to clopidogrel and ticagrelor group.

CONCLUSION

As compared to ticagrelor and clopidogrel, therapy with prasugrel in patients undergoing stenting for an acute coronary syndrome is associated with improved endothelial function, stronger platelet inhibition, and reduced IL-6 levels, all of which may have prognostic implications. This effect was lost in patients who received the study medication immediately after stenting.

EUDRACT-NO

2011-005305-73.

ACRA Perfusion Study

BACKGROUND

Transradial intervention (TRI) may impair digital perfusion with hand dysfunction as a result. However, the effect of TRI on digital perfusion has never been investigated, including the influence of variations of the collateral arterial network and the effect on hand dysfunction.

METHODS AND RESULTS

We investigated the effect of TRI on digital perfusion by laser Doppler perfusion imaging. Laser Doppler perfusion imaging was performed at baseline, during radial access, TR band application, and at discharge. We compared tissue perfusion of the homolateral thumb (access site) with the contralateral thumb (comparator) during radial access as primary outcome. The hand circulation was assessed with angiography. Upper extremity function was evaluated with the validated QuickDASH questionnaire at baseline and follow-up. A significant reduction of tissue perfusion was observed during radial access and TR band application in the homolateral thumb (-32%, -32%, respectively) and contralateral thumb (-34%, -21%, respectively). We detected no perfusion difference between the homolateral and contralateral thumb during radial access (217; interquartile range, 112-364 versus 209; interquartile range, 99-369 arbitrary flux units; P=0.59). Reduced perfusion of the thumb during radial access was not associated with incompleteness of the superficial palmar arch ( P=0.13). Digital perfusion improved at discharge, though it remained below baseline levels (homolateral -11% and contralateral -14%). Hand dysfunction at 18 months was not associated with TRI-induced perfusion reduction ( P=0.54).

CONCLUSIONS

TRI is safe. Digital perfusion is reduced in both hands during radial access and TR band application but is not associated with future loss of hand function and variations of the arterial hand supply.

Neutrophil count as the centerpiece in the joined association networks of inflammatory and cell damage markers, and neuroendocrine stress markers in patients with stable angina pectoris following stenting

Objective

The primary aim of this study was to examine whether markers of cell damage and of the psycho-neuroendocrino-inflammatory/immune (PNI) system could be associated in patients with stable coronary artery disease (CAD) on the next day following percutaneous coronary intervention (PCI).

Materials and methods

Blood samples of 23 patients (18 men and five women, mean age 62.9 ± 10.6 years), were collected immediately before (pre-PCI), immediately after (post-PCI), and on the day following PCI (1d-PCI). Lactoferrin, LL-37 and interleukin-6 (IL-6) were assayed in plasma, in addition to cortisol and chromogranin A (CgA), as well as CK, ASAT and ALAT. Total and differential leukocyte counts were also analysed.

Results

At all the three time points, the monocyte fractions, the monocyte-to-lymphocyte and the neutrophil-to-lymphocyte ratios and CgA levels were elevated. We detected significant peri-procedural changes in the plasma levels of our PNI markers: IL-6 (p<0.05), lactoferrin, LL-37 (both: p <0.0001), CgA, (p<0.05), and cortisol (p<0.01). On the first day after PCI, highly significant associations were found of ASAT with IL-6 and neutrophil count (both: r>0.75, p<0.0001), and of CgA with neutrophil count and monocyte count (both: r>0.79, p<0.0001); furthermore, cortisol was also associated with neutrophil count (r>0.7, p<0.0001).

Conclusions

The findings suggest that myocardial damage could correlate not only with an inflammatory reaction but, via neutrophil count, also with increased level of stress in stable CAD after PCI. Furthermore, 1d-PCI neutrophil count may serve as an easy-to-obtain integrative PNI measure in stable CAD.

Twelve-month outcomes after bioresorbable vascular scaffold implantation in patients with acute coronary syndromes. Data from the European Multicenter GHOST-EU Extended Registry

AIMS

The aim of this study was to report on the midterm outcomes of patients undergoing percutaneous coronary intervention with bioresorbable vascular scaffolds (BVS) for the treatment of acute coronary syndromes (ACS) and compare with those of patients with stable coronary artery disease (sCAD).

METHODS AND RESULTS

One thousand four hundred and seventy-seven (1,477) patients underwent implantation of one or more BVS (Absorb BVS; Abbott Vascular, Santa Clara, CA, USA) at 11 European centres and were included in the GHOST-EU registry. Admissions comprised 47.1% of the patients (951 BVS) with ACS, and 52.8% (1,274 BVS) with sCAD. During a median follow-up of 384 (359-460) days, patient-oriented endpoints (PoCE), including all-cause death, any infarction, any revascularisation, were recorded in 271 patients (12-month incidence in ACS patients: 18.5% vs. 11.6% in the sCAD group, p<0.001). Device-oriented composite endpoints (DoCE), cardiac death, target vessel infarction and target lesion revascularisation, were observed in 98 patients (12-month incidence of 4.2% in the sCAD group, 6.4% in the ACS group; p=0.052). The 12-month incidence of definite scaffold thrombosis was 2.6% in ACS patients and 0.8% in XIENCE patients (p=0.006). In multivariate analysis, ACS was a predictor of DoCE (HR: 2.26 [1.34-3.81], p=0.002), PoCE (HR: 1.71 [1.13-2.58], p=0.011), and stent thrombosis (HR: 2.51 [1.13-5.60], p=0.025). In contrast, the incidence of target lesion revascularisation was not different between groups. There was no difference in the incidence of any of these endpoints among the different clinical presentations (unstable angina, non-ST-elevation infarction and ST-elevation infarction).

CONCLUSIONS

PoCE, DoCE and scaffold thromboses were more frequent in ACS patients, without any difference among different forms of ACS.

The effects of percutaneous transluminal coronary intervention on biomarkers of oxidative stress in the erythrocytes of elderly male patients

OBJECTIVES

Oxidative stress plays a key role in the pathogenesis of coronary artery disease. The aim of this study was to compare the effects of percutaneous transluminal coronary angioplasty (PTCA) and elective coronary angiography (EC) on erythrocytic antioxidant defense in elderly male patients.

METHODS

Twenty-three stable angina pectoris (SAP) patients undergoing PTCA and 18 patients with ischemic symptoms scheduled to undergo diagnostic EC were included in the study. The concentrations of malondialdehyde (MDA) and reduced glutathione (GSH) and the activities of Zn,Cu-superoxide dismutase (SOD-1), catalase (CAT), and cytosolic glutathione peroxidase (GSH-Px) were examined in the erythrocytes before, immediately after and 2 weeks following PTCA or EC.

RESULTS

The MDA concentrations were significantly higher and SOD-1, CAT, and GSH-Px activities were significantly lower in the PTCA group than in the EC group at baseline. Two weeks after treatment, the activities of the enzymes significantly increased in both groups, whereas the MDA concentrations decreased only in the PTCA patients.

CONCLUSIONS

The results confirm that an advanced state of atherosclerosis is related to greater levels of oxidative stress. The study indicates that both procedures may induce antioxidant defenses; however, PTCA exclusively induces a long-term reduction in lipid peroxidation.

Prasugrel Results in Higher Decrease in High-Sensitivity C-Reactive Protein Level in Patients Undergoing Percutaneous Coronary Intervention Comparing to Clopidogrel

OBJECTIVES

A growing body of clinical and laboratory evidence indicates that inflammation plays a crucial role in atherosclerosis. In the present study, we compared the effects of clopidogrel and prasugrel on high-sensitivity C-reactive protein (hs-CRP) in patients undergoing percutaneous coronary intervention (PCI).

METHODS

The present randomized, double-blind clinical trial included 120 patients who underwent PCI. Eligible patients were randomly assigned 2:1 to one of the two groups: 80 patients in the first group received clopidogrel (Plavix^®; loading dose and maintenance dose of 300 and 75 mg daily, respectively) and 40 patients in the second group received prasugrel (Effient^®; loading dose and maintenance dose of 60 and 10 mg, respectively) for 12 weeks. The hs-CRP levels between baseline and 12th week were compared.

RESULTS

Of the 120 patients, 69 patients (57.5%) were male. Pretreatment hs-CRP level was statistically comparable in clopidogrel (median, 15.10 mg/dL; interquartile range [IQR], 9.62–23.75 mg/dL) and prasugrel groups (median, 18 mg/dL; IQR, 14.25–22 mg/dL; P = 0.06). Patients taking clopidogrel showed a significant reduction in hs-CRP level compared with the baseline values (P < 0.001). Prasugrel administration also resulted in a significant reduction in hs-CRP level (P < 0.001). A significant 73% overall reduction in the hs-CRP level was seen with prasugrel compared with 39% overall reduction in hs-CRP level with clopidogrel (P = 0.002).

CONCLUSION

Prasugrel seems to be superior to clopidogrel in the reduction of hs-CRP in patients undergoing PCI.

Endothelial NO-Synthase Gene-Enhanced Progenitor Cell Therapy for Pulmonary Arterial Hypertension: The PHACeT Trial

RATIONALE

Pulmonary arterial hypertension (PAH) remains a progressive and eventually lethal disease characterized by increased pulmonary vascular resistance because of loss of functional lung microvasculature, primarily at the distal (intracinar) arteriolar level. Cell-based therapies offer the potential to repair and regenerate the lung microcirculation and have shown promise in preclinical evaluation in experimental models of PAH.

OBJECTIVE

The Pulmonary Hypertension and Angiogenic Cell Therapy (PHACeT) trial was a phase 1, dose-escalating clinical study of the tolerability of culture-derived endothelial progenitor cells, transiently transfected with endothelial nitric oxide synthase, in patients with PAH refractory to PAH-specific therapies.

METHODS AND RESULTS

Seven to 50 million endothelial nitric oxide synthase-transfected endothelial progenitor cells, divided into 3 doses on consecutive days, were delivered into the right atrium via a multiport pulmonary artery catheter during continuous hemodynamic monitoring in an intensive care unit setting. Seven patients (5 women) received treatment from December 2006 to March 2010. Cell infusion was well tolerated, with no evidence of short-term hemodynamic deterioration; rather, there was a trend toward improvement in total pulmonary resistance during the 3-day delivery period. However, there was 1 serious adverse event (death) which occurred immediately after discharge in a patient with severe, end stage disease. Although there were no sustained hemodynamic improvements at 3 months, 6-minute walk distance was significantly increased at 1, 3, and 6 months.

CONCLUSION

Delivery of endothelial progenitor cells overexpressing endothelial nitric oxide synthase was tolerated hemodynamically in patients with PAH. Furthermore, there was evidence of short-term hemodynamic improvement, associated with long-term benefits in functional and quality of life assessments. However, future studies are needed to further establish the efficacy of this therapy.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00469027.

Cardiac catheterization: consequences for the endothelium and potential for nanomedicine

Cardiac catheterization results in interactions between the catheter and surfaces and the artery lumen, which is lined by the endothelium. These interactions can range from minor rubbing to severe mechanical injury. Further, in the case of radial access, even atraumatic interactions have consequences ranging from clinical complications, such as radial spasm and radial occlusion, to lasting endothelial cell dysfunction. These consequences may be underappreciated; however, endothelial cells play a central role in maintaining vascular homeostasis via nitric oxide production. Existing treatment paradigms do not address endothelial dysfunction or damage and, thus, novel therapeutic approaches are needed. Nanomedicine, in particular, offers great potential in the form of targeted drug delivery, via functionalized coatings or nanocarriers, aimed at increased nitric oxide bioavailability or reduced inflammation.

The prevention of contrast-induced nephropathy by simultaneous hemofiltration during coronary angiographic procedures: a comparison with periprocedural hemofiltration

BACKGROUND

Periprocedural (6 h pre- and 24 h post-angiography) hemofiltration appears to effectively prevent contrast-induced nephropathy (CIN) in chronic kidney disease (CKD) patients undergoing coronary angiography. However, this procedure over-uses medical resources, and the cessation of hemofiltration during coronary angiography results in persistent renal injury. In comparison, simultaneous hemofiltration performed only during coronary angiography requires fewer medical resources and can provide instantaneous protection against CIN.

METHODS

Sixty-eight CKD patients (serum creatinine, 2.51±1.15 mg/dL) undergoing coronary angiography were randomized in a 1:2 ratio to receive either periprocedural (n=23) or simultaneous (n=45) hemofiltration. The expected CIN rate was similar for the two groups (41.3% versus 40.0%, p=0.769).

RESULTS

On day 3 after contrast exposure, four and seven patients in the periprocedural and simultaneous groups, respectively experienced CIN (17.4% versus 15.6%, p=0.846). On days 5-30, seven and three patients in the periprocedural and simultaneous groups, respectively experienced CIN (30.4% versus 6.7%, p=0.009). The serum creatinine levels of patients in the periprocedural group transiently decreased on day 1 and persistently increased during days 5-30 compared with the simultaneous group. This difference between the two groups in terms of creatinine levels over time was statistically significant (F statistic=6.830; p=0.001, by ANCOVA). The cost of hemofiltration was doubled in the periprocedural group ($1066±83 versus $504±40, p<0.001).

CONCLUSIONS

Simultaneous hemofiltration provide equal early (day 3) and better late-stage (days 5-30) renal protection against CIN at a significantly lower cost compared with periprocedural hemofiltration.

Effects of clopidogrel, prasugrel and ticagrelor on endothelial function, inflammatory and oxidative stress parameters and platelet function in patients undergoing coronary artery stenting for an acute coronary syndrome. A randomised, prospective, controlled study

INTRODUCTION

Particularly in the setting of acute coronary syndromes, the interplay between vascular and platelet function has been postulated to have direct clinical implications. The present trial is designed to test the effect of clopidogrel, prasugrel and ticagrelor on multiple parameters of vascular function, platelet aggregation, oxidative and inflammatory stress before and up to 4 weeks after coronary artery stenting.

METHODS AND ANALYSIS

The study is designed as a three-arm, parallel design, randomised, investigator-blinded study. Patients with unstable angina or non-ST elevation myocardial infarction undergoing coronary intervention with a drug-eluting stent will be randomised to receive 600 mg clopidogrel, 60 mg prasugrel or 180 mg ticagrelor followed by oral therapy with the same drug. The primary endpoint of the trial is the impact of antiplatelet treatments on endothelial function as assessed by flow-mediated dilation at 1 day, 1 week and 1 month in patients who have undergone stenting. Secondary endpoints include the impact of study medications on parameters of macrovascular and microvascular function, platelet reactivity, oxidative and inflammatory stress. The study recruitment is currently ongoing and, after an interim analysis which was performed at 50% of the initially planned population, it is planned to continue until July 2015.

ETHICS AND DISSEMINATION

The protocol was approved by the local ethics committee. The trial will provide important pathophysiological insight on the relationship between platelet aggregation and endothelial function, two parameters that have been shown to influence patients' prognosis.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT01700322; EudraCT-Nr.: 2011-005305-73. Current V.1.3, from 24 February 2014.

Cardiac release and kinetics of cytokines after elective bare metal coronary stenting

The study was designed to assess the cardiac release kinetics of the cytokines interleukin-1ß (IL-1ß), interleukin-6 (IL-6) and tumor-necrosis-factor-α (TNF-α) in patients with significant stenosis of the ramus interventricularis anterior. Ten patients were treated by bare metal stent implantation, 11 patients who underwent a diagnostic coronary angiography without intervention served as a control group. Cytokines paired blood samples were withdrawn from the coronary sinus and a peripheral vein immediately before and 1, 2, 6 h after the intervention. Myocardial ischemia was monitored by means of cardiac lactate metabolism and 12-lead electrocardiogram. After coronary intervention IL-6 gradually increased from a common baseline level of 1.34 ± 1.56 pg/ml to a maximum of 10.58 ± 5.7 pg/ml in the peripheral vein and 15.81 ± 6.98 pg/ml in the coronary sinus within 6 h with persistent higher levels in the coronary sinus indicating coronary IL-6 release. After 12 h the peripheral venous concentration of IL-6 returned to baseline levels. Neither in the study group for IL-1ß and TNF-α nor in the control group for any cytokine level significant changes were found. Myocardial ischemia was excluded in all patients. Uncomplicated percutaneous coronary intervention (PCI) was followed by a significant cardiac IL-6 release due to endothelial injury and not to myocardial ischemia.

The double-faced metabolic and inflammatory effects of standard drug therapy in patients after percutaneous treatment with drug-eluting stent

OBJECTIVE

The inflammatory responses after percutaneous coronary intervention (PCI) with drug-eluting stent (DES) remain poorly understood; therefore, this study aims to investigate the changes of metabolic parameters and systematic inflammatory status of circulating mononuclear cells (MNC) in patients after percutaneous treatment with DES implantation.

METHODS AND RESULTS

Twenty-seven patients with acute coronary syndrome who would undergo PCI with DES implantation were consecutively recruited and treated with standard drug therapy from the start of hospitalization. Metabolic parameters including total cholesterol, triglycerides, high-density lipoprotein, low-density lipoprotein improved significantly after 12 weeks of standard medication, whereas the plasma levels of interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), macrophage migration inhibitory factor (MIF), and matrix metalloproteinase-9 (MMP-9) increased (P=0.012, 0.035, 0.062 and 0.112, respectively, compared to the baseline). The NF-κB DNA binding activity in MNC increased significantly compared to the baseline (P=0.015), whereas IκB-β and PPAR-γ were significantly suppressed (P=0.046 and 0.002, respectively). There were strong correlations among the changes of metabolic parameters and the changes of proinflammatory factors; however, none of them is statistically significant.

CONCLUSIONS

Standard drug therapy can improve the metabolic parameters but fail to restrain the proinflammatory state after PCI with DES implantation. Longer term endpoint-based studies are still needed for further exploration of the relationship between inflammatory factors and clinical cardiovascular events in the era of DES.

Proteomic Analysis of the Systemic Response to Radiographic Contrast Media

Introduction

Radiographic contrast media (RCM) have numerous effects on the hemostatic system, inflammatory pathways, and vascular endothelium. Given the increasing number of high-risk patients undergoing radiographic procedures, more information regarding the systemic effects of RCM is needed.

Methods

Blood samples prior to baseline, 4 and 24 h following elective coronary angiography in 10 patients, were subjected to matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. Data are presented as the ratio of the protein mass at 4 (iTRAQ4) and 24 h (iTRAQ24) compared to baseline. A ratio >1.0 and a ratio <1.0 indicate production and consumption, respectively, relative to baseline.

Results

In this sample, we identified 102 proteins with a confidence interval of ≥90%. Six proteins were identified at each time point in all patients. Of the proteins identified, apolipoprotein A-I, apolipoprotein A-II, complement C3, fibrinogen beta chain, immunoglobulin α, and prothrombin revealed an iTRAQ ratio <1.0 at 4 h when compared to baseline (all with p value <0.05) and a trend toward baseline levels at 24 h.

Conclusions

Systemic administration of RCM results in a variety of alterations to the proteome. Of interest, there is activation of the thrombotic and inflammatory pathways as well as an interaction with lipoprotein metabolism. These changes are most pronounced at 4 h but may persist through 24 h and may be of clinical relevance in patients at risk for thrombotic- and inflammatory-mediated consequences of atherosclerosis.

Persistent high fever and systemic inflammation induced by percutaneous coronary intervention-related periaortitis

After coronary catheterization, fever sometimes occurs, usually transiently. We report a very rare case that suggests persistent high fever and systemic inflammation might be caused by periaortitis induced by coronary catheterization including percutaneous coronary intervention.

Inflammatory markers: linking unstable plaques to coronary event, an interventional perspective

Abundant data links inflammatory mechanisms to atheromatous plaque destabilization leading to plaque rupture and coronary events. The discovery of inflammatory cells and inflammatory mediators within atherosclerotic plaques prone to rupture led to a series of studies demonstrating an association between various markers of inflammation and future coronary events. Inflammatory markers have also been used in patients undergoing coronary angioplasty in an attempt to predict restenosis and risk for post-procedural coronary events. This review article provides an overview on the potential use of inflammatory markers in the context of coronary interventions.

C-reactive protein elevation and rapid angiographic progression of nonculprit lesion in patients with non-ST-segment elevation acute coronary syndrome

BACKGROUND

In non-ST-segment elevation acute coronary syndromes (NSTE-ACS), the relation of the level of high-sensitivity C-reactive protein (CRP) to the progression of atherosclerosis remains unclear.

METHODS AND RESULTS

The study group comprised 153 patients with NSTE-ACS who underwent percutaneous coronary interventions (PCI) and follow-up (mean interval, 7 months) coronary angiography. Rapid progression was defined as > or =10% diameter reduction of a preexisting stenosis > or =50%, > or =30% diameter reduction of a stenosis <50%, development of a new stenosis > or =30% in a previously normal segment, or progression of any stenosis to total occlusion. Progressors had higher CRP levels on admission and at 48 h after PCI, a higher level of low-density lipoprotein cholesterol at follow-up, a higher rate of multiple complex lesions, and a lower frequency of statin use at follow-up than nonprogressors. Multivariate analysis showed that admission CRP elevation (CRP level on admission > or =0.166 mg/dl, median value; odds ratio (OR) 2.92, p=0.010), post-PCI CRP elevation (CRP level 48 h after PCI > or =1.586 mg/dl, median value; OR 2.67, p=0.022), and multiple complex lesions (OR 2.66, p=0.017) were independent predictors of rapid progression of nonculprit lesions.

CONCLUSIONS

Enhanced inflammatory response to PCI, as well as baseline inflammatory activity as reflected by CRP level, may be involved in the progression of atherosclerosis in NSTE-ACS.

Comparison of C-reactive protein levels in patients who do and do not develop atrial fibrillation during electrophysiologic study

C-reactive protein (CRP) was increased in patients with atrial fibrillation (AF). The aim of this study was to evaluate CRP after inducing AF in 39 patients undergoing electrophysiologic study (EPS). After a diagnostic EPS, programmed atrial stimulation with 3 extra stimuli from the right atrium was performed in all patients. CRP was measured before and 6 and 24 hours after the procedure. Patients in whom AF was induced were monitored for 24 hours. AF was induced in 18 of 39 patients. Twenty-one patients without a tachyarrhythmia constituted the control group. Groups were similar with regard to age, gender, incidences of hypertension and diabetes, and history of coronary artery disease. On average, AF lasted 4.8 hours, and spontaneous conversion to sinus rhythm was observed in all patients. There were no statistically significant differences with respect to baseline and 6-hour CRP values between groups. However, mean CRP at 24 hours was significantly higher in patients with AF compared with controls (10 +/- 11 and 3.9 +/- 4.2 mg/L; p = 0.04). In conclusion, induction of AF during EPS led to increased CRP. This finding suggested that increased CRP may be the consequence of AF.

Effects of Unfractionated Heparin and Glycoprotein IIb/IIIa Antagonists Versus Bivalirdin on Myeloperoxidase Release From Neutrophils

OBJECTIVES The objective of this study was to determine whether adjunctive therapy during percutaneous coronary intervention (PCI) affects markers of systemic inflammation or platelet activation. Despite different mechanisms of action, direct-thrombin inhibition with bivalirudin during PCI provided similar protection from periprocedural and chronic ischemic complications as compared with unfractionated heparin (UFH) plus planned use of GPIIb/IIIa antagonists in the REPLACE-2 and ACUITY trials.

METHODS AND RESULTS

Patients undergoing nonurgent PCI of a native coronary artery were randomized to receive adjunctive therapy with bivalirudin or UFH+eptifibatide. Interleukin (IL)-6 and C-reactive protein (CRP) transiently increased in both groups after PCI. In the UFH+eptifibatide, but not the bivalirudin group, myeloperoxidase (MPO) levels were elevated 2.3-fold above baseline (P=0.004) immediately after PCI. In an in vitro assay, heparin and to a lesser extent enoxaparin, but not bivalirudin or eptifibatide, stimulated MPO release from and binding to neutrophils and neutrophil activation. A mouse model of endoluminal femoral artery denudation was used to investigate further the importance of MPO in the context of arterial injury.

CONCLUSIONS

Adjuvant therapy during PCI may have undesired effects on neutrophil activation, MPO release, and systemic inflammation.

Increase in interleukin-6 following arterial injury is related to insulin resistance, the -174G-->C polymorphism and complex plaque morphology

Interleukin-6 (IL-6) is associated with many disease states in humans. We prospectively sought to determine whether IL-6 levels increased following percutaneous coronary intervention (PCI) in the absence of myonecrosis. Additionally, we systematically assessed other clinical and anatomic factors associated with IL-6 levels in a population of patients with coronary atherosclerosis undergoing PCI. Blood samples were collected from 117 patients at baseline, 8 and 16 h following PCI. Samples were assayed for IL-6, creatine kinase-myocardial band (CK-MB), troponin-I (Tn-I), high sensitivity C-reactive protein, glucose, haemoglobin A1c, and a lipid profile. Genotyping of the -174G-->C polymorphism of the IL-6 gene was performed. IL-6 levels increased following PCI among the study group (slope = 0.4 pg/mL/h, P = 0.001). IL-6 levels increased to a similar degree in the absence of myonecrosis. Patients with the XC genotype (either having the GC or the CC allele) had higher IL-6-values at baseline compared to GG genotype patients (4.9 +/- 6.4 vs. 2.6 +/- 1.8 pg/mL, P = 0.02). Multivariable predictors of detectable baseline IL-6 levels included XC genotype (odds ratio [OR]: 4.14, 95% CI 1.58-10.82, P = 0.004), ACC/AHA type C lesion classification (OR: 4.08, 95% CI 1.54-10.84, P = 0.005), elevated baseline Tn-I (OR: 3.31, 95% CI 1.16-9.43, P = 0.025), diabetes (OR: 3.00, 95% CI 1.11-8.09, P = 0.030), and waist circumference (OR: 1.49, 95% CI 1.08-2.06, P = 0.015). Predictors of peak IL-6 following PCI included the XC genotype (estimate 1.4, 95% CI 1.06-1.87, P = 0.019), homeostasis model assessment (estimate 0.99, 95% 0.982-0.999, P = 0.042) and baseline Tn-I > upper limit of normal (estimate 0.7, 95% CI 0.50-0.96, P = 0.039). Lastly, IL-6 increased following PCI even in the absence of myonecrosis as measured by Tn-I elevation. IL-6 levels are also related to the -174G-->C polymorphism, arterial injury, lesion complexity, and insulin resistance.

Impact of percutaneous coronary intervention on the levels of interleukin-6 and C-reactive protein in the coronary circulation of subjects with coronary artery disease

Many clinical studies have evaluated the inflammatory response (mainly interleukin [IL]-6 and C-reactive protein [CRP]) after percutaneous coronary intervention (PCI) in patients with coronary artery disease (CAD). The aim of this study was to verify the source of possible elevation of IL-6 and CRP after PCI using coronary sinus sampling. We studied 87 subjects who underwent coronary angiography for diagnostic, therapeutic, or follow-up purposes. Blood samples were taken by the PCI team during the catheterization study from the coronary sinus. We measured coronary IL-6 levels by sandwich enzyme-linked immunosorbent assay, and high-sensitivity CRP levels were measured by latex immunonephelometry. The subjects were then classified according to their coronary angiographic findings into non-CAD (no evidence of significant organic CAD), mild CAD (1 vessel narrowed), and severe CAD (>or=2 vessels narrowed) groups. PCI (including stent deployment) was performed in 16 patients with CAD. The mean coronary IL-6 value was higher in the severe than in the mild CAD group (3.67 +/- 2.48 vs 2.3 +/- 1.15 pg/ml, p = 0.027). The mean coronary IL-6 value was higher in the subjects who underwent PCI than in those who did not (2.9 +/- 1.23 vs 1.87 +/- 0.9 pg/ml, p = 0.037), and the same was found regarding CRP (1.244 +/- 0.72 vs 0.498 +/- 0.51 mg/L, p = 0.032). The coronary IL-6 values correlated positively with the coronary CRP values (r = 0.374, p = 0.017). In conclusion, the increase in coronary IL-6 and CRP levels after PCI in patients with CAD might be attributed to their release from the coronary atheroma secondary to the direct mechanical effect applied on the atheroma itself by balloon inflation and stent deployment.

Elevated levels of C-reactive protein are associated with impaired coronary collateral development

BACKGROUND

In vitro studies have shown that C-reactive protein (CRP) attenuates nitric oxide production and inhibits angiogenesis, which may result in impaired collateral development. The aim of this study was to investigate the association between high sensitivity CRP (hsCRP) levels and the extent of coronary collaterals.

MATERIALS AND METHODS

We investigated the association between hsCRP levels and the extent of coronary collaterals according to the Rentrop classification in a cohort of 185 patients who had high-grade coronary stenosis or occlusion on their angiograms.

RESULTS

Mean age was 62 years and 80% were males. Subjects with a higher grade of collaterals were significantly less likely to have diabetes mellitus (OR; 0.48, 95% and CI; 0.28, 0.83) or acute coronary syndrome (OR; 0.58, 95% and CI; 0.33, 0.99), but they were more likely to have higher number of vessels with significant stenosis (OR; 1.41, 95% and CI; 1.03, 1.93) and to have received statins (OR; 1.84, 1.09, 3.13). The mean hsCRP values reduced significantly as the Rentrop grades increased (trend, P = 0.0006). After adjusting for age, gender, statin use, clinical presentation with acute coronary syndrome, diabetes mellitus and the number of vessels with significant stenosis, each 10-unit increase in hsCRP values corresponded to a 31% reduced odds of having a higher collateral score (OR; 0.69, 95% and CI; 0.53, 0.90).

CONCLUSIONS

Our findings indicate that elevated hsCRP levels are associated with a significant impairment in coronary collateralization. These data suggest a previously unrecognized mechanism through which inflammation may worsen cardiovascular outcomes.

Angiographically confirmed coronary heart disease and periodontal disease in middle-aged males

BACKGROUND

The aim of this study was to investigate whether an association could be demonstrated between coronary heart disease (CHD) and chronic periodontitis in a population of middle-aged males in Northern Ireland.

METHODS

A case-control design was used. Cases were men aged over 40 years with angiographically proven CHD. Controls were age-matched males, with no evidence of CHD, randomly drawn from the same locality as the cases. Each subject had a clinical periodontal examination and completed a detailed sociodemographic questionnaire. High sensitivity C-reactive protein (CRP) was measured in serum by immunoturbidimetry.

RESULTS

There were 92 cases (mean age 56.7 years; SD = 6.3) and 79 controls (mean age 58.2 years; SD = 6.7). The CHD cases had an average of three teeth less than the controls (P <0.0001). A higher proportion of sites examined in cases than controls had plaque (P = 0.004), bleeding on probing (P = 0.013), and probing depths of > or = 4 mm (P = 0.006) or > or = 6 mm (P = 0.03). Subjects with > or = 4 mm pocketing in more than 20% of their interproximal sites and those with deep pocketing (> or = 6 mm) were classified as having poor periodontal status. A total of 35 cases (38%), compared to only 13 controls (16%), had a poor periodontal status (P = 0.0017). Men with a poor periodontal condition had higher levels of CRP (median 2.19 mg/l) than those with good periodontal health (median 1.42 mg/l), P = 0.007. After adjusting for smoking, academic achievement, alcohol consumption, unemployment, ability to maintain body weight, regular exercise, ability to relax daily, having a hobby or pastime, plaque, and CRP, logistic regression analysis showed that poor periodontal status was significantly associated with CHD, with an adjusted odds ratio of 3.06 and 95% confidence intervals of 1.02 to 9.17, P = 0.046.

CONCLUSIONS

There was an association between coronary heart disease and poor periodontal status in the middle-aged males investigated. This association was independent of diabetes and all other cardiovascular risk factors investigated.

The novel role of C-reactive protein in cardiovascular disease: risk marker or pathogen

C-reactive protein (CRP) is a non-specific biomarker of inflammation. Recent research has shown that inflammation is an important step in the genesis of atherosclerosis, and is involved in the development of unstable plaques. Measurement of serum levels of CRP using a high sensitivity assay (hsCRP) can demonstrate subclinical inflammatory states, which may reflect vascular inflammation. Clinical studies have shown that elevated hsCRP levels in healthy populations predict vascular events such as myocardial infarction (MI) and stroke as well as the development of diabetes. In patients with acute coronary syndromes, higher hsCRP levels are associated with adverse outcomes and subsequent vascular events. There is data to suggest that aspirin, angiotensin converting enzyme (ACE) inhibitors and HMG Co-A reductase inhibitors (statins), which all reduce vascular event rates, also reduce serum levels of hsCRP and therefore hsCRP levels may potentially guide therapy. As well as having a critical role in risk prediction, recent evidence has emerged implicating CRP directly in atherogenesis. CRP has been found in human atherosclerotic plaque and CRP has been shown to cause endothelial cell dysfunction, oxidant stress and intimal hypertrophy in experimental models. We review the postulated roles of CRP in atherogenesis and prediction of vascular events, as well as discussing current recommendations for CRP testing in patients.

Inflammatory markers predict late cardiac events in patients who are exhausted after percutaneous coronary intervention

Chronic inflammation is one of the main underlying mechanisms in the development of coronary artery disease (CAD). We investigated the prognostic value of inflammatory markers for cardiac events occurring more than 6 months after percutaneous coronary intervention (PCI), i.e. late cardiac events, furthermore we investigated the temporal stability of these markers. Exhausted patients (234) recently treated by successful PCI were studied. Serum samples collected about 6 weeks after PCI (baseline), 6 and 18 months after baseline were analyzed for CRP, IL-6, tumour necrosis factor (TNF-alpha), IL-10, IL-1ra, IL-8 and neopterin. In the mean cardiac follow-up of 24 months, 25 late cardiac events occurred. Cox proportional hazards analysis was used to determine the prognostic value. Elevated concentrations of IL-6 at baseline and 6 months later increased the risk of late cardiac events (RR 3.9, CI 1.7-9.0, p 0.00 and RR 3.6, CI 1.6-8.5, p 0.00). Elevated concentrations of CRP and IL-10 at baseline also increased the risk of late cardiac events (RR 2.5, CI 1.1-5.7, p 0.04 and RR 2.5, CI 1.1-5.6, p 0.03) as did IL-1 receptor antagonist at 6 months (RR 2.6, CI 1.1-6.1, p 0.04). Temporal stability was high for most markers, but highest for IL-6. These results support the assumption that chronic inflammation is a pathophysiological mechanism in the development of CAD.