Plaque disruption and thrombus in Ambrose's angiographic coronary lesion types

Cardiovascular imaging following perioperative myocardial infarction/injury

Patients developing perioperative myocardial infarction/injury (PMI) have a high mortality. PMI work-up and therapy remain poorly defined. This prospective multicenter study included high-risk patients undergoing major non-cardiac surgery within a systematic PMI screening and clinical response program. The frequency of cardiovascular imaging during PMI work-up and its yield for possible type 1 myocardial infarction (T1MI) was assessed. Automated PMI detection triggered evaluation by the treating physician/cardiologist, who determined selection/timing of cardiovascular imaging. T1M1 was considered with the presence of a new wall motion abnormality within 30 days in transthoracic echocardiography (TTE), a new scar or ischemia within 90 days in myocardial perfusion imaging (MPI), and Ambrose-Type II or complex lesions within 7 days of PMI in coronary angiography (CA). In patients with PMI, 21% (268/1269) underwent at least one cardiac imaging modality. TTE was used in 13% (163/1269), MPI in 3% (37/1269), and CA in 5% (68/1269). Cardiology consultation was associated with higher use of cardiovascular imaging (27% versus 13%). Signs indicative of T1MI were found in 8% of TTE, 46% of MPI, and 63% of CA. Most patients with PMI did not undergo any cardiovascular imaging within their PMI work-up. If performed, MPI and CA showed high yield for signs indicative of T1MI.Trial registration: https://clinicaltrials.gov/ct2/show/NCT02573532 .

Correlation of plasma soluble suppression of tumorigenicity-2 level with the severity and stability of coronary atherosclerosis

BACKGROUND

Soluble growth stimulation expressed gene 2 (sST2) is the receptor of interleukin (IL)-33. We hypothesized the IL-33/ST2 pathway may be closely related to the progression of coronary atherosclerotic lesions.

METHODS

We analyzed 262 patients, including 63 with stable angina pectoris (SAP), 97 with acute coronary syndrome (ACS), and 102 control subjects. Plasma sST2 levels were determined using ELISA. Gensini scores were calculated. Patients with ACS and SAP were further divided according to the complexity of atherosclerotic lesions (simple/complex). Statistical analysis was performed on all data.

RESULTS

The plasma sST2 levels were significantly higher in patients with coronary artery disease (CAD) than in the control group, and were significantly higher in ACS patients with complex lesions than in those with simple lesions. There were no correlations between plasma sST2 level and both the number of culprit vessels and Gensini score. Multivariate stepwise regression analysis revealed that angiographically detected complex lesions were independently correlated with plasma sST2 level. Logistic regression analyses showed that sST2 was an independent factor of both CAD and the lesion type (simple/complex) of ACS. For the diagnosis of ACS and complex lesions, the area under the receiver operating characteristic curve of sST2 was 0.651.

CONCLUSIONS

The plasma sST2 level was not correlated with the stenosis severity of coronary atherosclerosis. A relationship between the plasma sST2 level and the morphology of complex lesions was found for the first time, especially in ACS patients. It may be a new marker for assessing the stability and complexity of atherosclerotic plaques.

High Plasma Levels of Legumain in Patients with Complex Coronary Lesions

Aim: The degradation of the vascular extracellular matrix is important for atherosclerosis. The cysteine protease legumain was shown to be upregulated in atherosclerotic plaques, especially unstable plaques. However, no study has reported blood legumain levels in patients with coronary artery disease (CAD).

Methods: We investigated plasma legumain and C-reactive protein (CRP) levels in 372 patients undergoing elective coronary angiography.

Results: CAD was found in 225 patients. Compared with patients without CAD, those with CAD had higher CRP levels (median 0.60 [0.32, 1.53] vs. 0.46 [0.22, 0.89] mg/L, P < 0.001), but no difference was found in legumain levels between patients with and without CAD (median 5.08 [3.87, 6.82] vs. 4.99 [3.84, 6.88] ng/mL). A stepwise increase in CRP was found depending on the number of > 50% stenotic vessels: 0.55 mg/L in 1-vessel, 0.71 mg/L in 2-vessel, and 0.86 mg/L in 3-vessel diseases (P < 0.001). However, legumain did not differ among 1-, 2-, and 3-vessel diseases (5.20, 4.93, and 5.01 ng/mL, respectively). Of 225 patients with CAD, 40 (18%) had complex lesions. No difference was found in CRP levels between patients with CAD with and without complex lesions (0.60 [0.34, 1.53] vs. 0.60 [0.32, 1.51] mg/L). Notably, legumain levels were higher in patients with CAD with complex lesions than without such lesions (6.05 [4.64, 8.64] vs. 4.93 [3.76, 6.52] ng/mL, P < 0.01). In multivariate analysis, legumain levels were not a factor for CAD, but were a factor for complex lesions. The odds ratio for complex lesions was 2.45 (95% CI = 1.26–4.79) for legumain > 5.5 ng/mL.

Conclusion: Plasma legumain levels were associated with the presence of complex coronary lesions.

A Plaque Disruption Index Identifies Patients with Non-STE-Type 1 Myocardial Infarction within 24 Hours of Troponin Positivity

Background

Markers of plaque destabilization and disruption may have a role in identifying non-STE- type 1 Myocardial Infarction in patients presenting with troponin elevation. We hypothesized that a plaque disruption index (PDI) derived from multiple biomarkers and measured within 24 hours from the first detectable troponin in patients with acute non-STE- type 1 MI (NSTEMI-A) will confirm the diagnosis and identify these patients with higher specificity when compared to individual markers and coronary angiography.

Methods

We examined 4 biomarkers of plaque destabilization and disruption: myeloperoxidase (MPO), high-sensitivity interleukin-6, myeloid-related protein 8/14 (MRP8/14) and pregnancy-associated plasma protein-A (PAPP-A) in 83 consecutive patients in 4 groups: stable non-obstructive coronary artery disease (CAD), stable obstructive CAD, NSTEMI-A (enrolled within 24 hours of troponin positivity), and NSTEMI-L (Late presentation NSTEMI, enrolled beyond the 24 hour limit). The PDI was calculated and the patients’ coronary angiograms were reviewed for evidence of plaque disruption. The diagnostic performance of the PDI and angiography were compared.

Results

Compared to other biomarkers, MPO had the highest specificity (83%) for NSTEMI-A diagnosis (P<0.05). The PDI computed from PAPP-A, MRP8/14 and MPO was higher in NSTEMI-A patients compared to the other three groups (p<0.001) and had the highest diagnostic specificity (87%) with 79% sensitivity and 86% accuracy, which were higher compared to those obtained with MPO, but did not reach statistical significance (P>0.05 for all comparisons). The PDI had higher specificity and accuracy for NSTEMI-A diagnosis compared to coronary angiography (P<0.05).

Conclusions

A PDI measured within 24 hour of troponin positivity has potential to identify subjects with acute Non-ST-elevation type 1 MI. Additional evidence using other marker combinations and investigation in a sufficiently large non-selected cohort is warranted to establish the diagnostic accuracy of the PDI and its potential role in differentiating type 1 and type 2 MI in patients presenting with troponin elevation of uncertain etiology.

Role of Oral Anticoagulants in Patients After an Acute Coronary Syndrome

After an acute coronary syndrome, patients continue to be at risk of adverse cardiovascular events despite treatment with the current standard of antithrombotic therapy. The risk may be in part secondary to thrombin, which remains elevated after an acute coronary syndrome event. Several studies have investigated the utility of adding oral anticoagulation to post-acute coronary syndrome medical regimens, with the most promising results coming from the addition of low-dose oral direct anticoagulants. Focusing on optimal dosing strategies and applying therapies to the appropriate populations provide the ability to maximize benefit and minimize risk.

Optical coherence tomography features of angiographic complex and smooth lesions in acute coronary syndromes

Plaque rupture (PR) and superimposed thrombosis have been shown as the most frequent underlying substrate in acute coronary syndromes (ACS). Coronary angiography is a luminogram not able to define in vivo features of the culprit plaques. The aim of the study was to use optical coherence tomography (OCT) to investigate the pathology underlying complex (CL) and non-complex angiographic lesions (NCL). We retrospectively enrolled 107 ACS patients admitted to our institution; 83 with non-ST elevation ACS (NSTE-ACS) and 24 with ST-elevation myocardial infarction. Coronary angiography was performed and culprit lesions were classified according to Ambrose criteria into NCL (n = 47) and CL (n = 60). OCT imaging was then performed to better identify plaque morphology; either PR or intact fibrous cap, the presence of superimposed thrombosis, lipid rich plaque, and thin cap fibroatheroma (TCFA). OCT analysis showed that 58 lesions (54.2%) were classified as PR and 48 lesions (44.9%) were associated with thrombi. Lipid rich plaques were identified in 62 lesions (57.9%). PR, intracoronary thrombi, lipid rich plaques and TCFA were more frequent in CL compared with NCL (71.7 vs 31.9%, 63.3 vs 21.3%, 71.7 vs 40.4% and 46.7 vs 21.3% respectively), but PR with superimposed thrombus may be also detected in NCL. OCT demonstrates PR and thrombosis in the majority of ACS patients presenting with CL. However, one-third of NCL show PR by OCT, suggesting that additional intracoronary imaging by OCT may better identify the underlying mechanism of coronary instability than coronary angiography alone.

Coronary and carotid atherosclerosis: how useful is the imaging?

The recent advancement of imaging modalities has made possible visualization of atherosclerosis disease in all phases of its development. Markers of subclinical atherosclerosis or even the most advanced plaque features are acquired by invasive (IVUS, OCT) and non-invasive imaging modalities (US, MRI, CTA). Determining plaques prone to rupture (vulnerable plaques) might help to identify patients at risk for myocardial infarction or stroke. The most accepted features of plaque vulnerability include: thin cap fibroatheroma, large lipid core, intimal spotty calcification, positive remodeling and intraplaque neovascularizations. Today, research is focusing on finding imaging techniques that are less invasive, less radiation and can detect most of the vulnerable plaque features. While, carotid atherosclerosis can be visualized using noninvasive imaging, such as US, MRI and CT, imaging plaque feature in coronary arteries needs invasive imaging modalities. However, atherosclerosis is a systemic disease with plaque development simultaneously in different arteries and data acquisition in carotid arteries can add useful information for prediction of coronary events.

Flow recirculation zone length and shear rate are differentially affected by stenosis severity in human coronary arteries

Flow recirculation zones and shear rate are associated with distinct pathogenic biological pathways relevant to thrombosis and atherogenesis. The interaction between stenosis severity and lesion eccentricity in determining the length of flow recirculation zones and peak shear rate in human coronary arteries in vivo is unclear. Computational fluid dynamic simulations were performed under resting and hyperemic conditions on computer-generated models and three-dimensional (3-D) reconstructions of coronary arteriograms of 25 patients. Boundary conditions for 3-D reconstructions simulations were obtained by direct measurements using a pressure-temperature sensor guidewire. In the computer-generated models, stenosis severity and lesion eccentricity were strongly associated with recirculation zone length and maximum shear rate. In the 3-D reconstructions, eccentricity increased recirculation zone length and shear rate when lesions of the same stenosis severity were compared. However, across the whole population of coronary lesions, eccentricity did not correlate with recirculation zone length or shear rate ( P = not signficant for both), whereas stenosis severity correlated strongly with both parameters ( r = 0.97, P < 0.001, and r = 0.96, P < 0.001, respectively). Nonlinear regression analyses demonstrated that the relationship between stenosis severity and peak shear was exponential, whereas the relationship between stenosis severity and recirculation zone length was sigmoidal, with an apparent threshold effect, demonstrating a steep increase in recirculation zone length between 40% and 60% diameter stenosis. Increasing stenosis severity and lesion eccentricity can both increase flow recirculation and shear rate in human coronary arteries. Flow recirculation is much more sensitive to mild changes in the severity of intermediate stenoses than is peak shear.

Plasma ghrelin levels are closely associated with severity and morphology of angiographically-detected coronary atherosclerosis in Chineses patients with diabetes mellitus

AIM

Low plasma ghrelin level was found to be associated with diabetes, and ghrelin was shown to inhibit pro-atherogenic changes in experimental models of atherosclerosis. The aim of this study was to investigate the relationship between plasma ghrelin levels and coronary atherosclerotic lesions in Chinese patients with diabetes.

METHODS

Plasma ghrelin levels were measured using an ELISA kit. The severity of coronary artery disease (CAD) was determined via angiography. Composition of atherosclerotic plaques was detected via coronary CT angiography.

RESULTS

A total of 178 patients with diabetes were recruited. Among the patients, 70 were diagnosed with acute coronary syndrome (ACS), 82 with stable angina pectoris (SAP) and 26 without coronary angiographic finding (controls). A negative correlation was found between ghrelin levels and the severity of the CAD, as determined via the Gensini score (r=-0.2434; P=0.0217). In diabetic patients with CAD and a complex lesion, the plasma ghrelin levels were significantly lower than in those with a simple lesion (ACS group: 3.81 ± 0.49 ng/mL vs 4.72 ± 0.50 ng/mL, P<0.0001; SAP group: 4.21 ± 0.52 ng/mL vs 4.76 ± 0.59 ng/mL, P=0.0397). Angiographically-detected complex lesion was an independent factor associated with ghrelin levels (adjusted beta coefficient=-0.67, 95% CI -0.97 to -0.37, P<0.0001).

CONCLUSION

Low plasma ghrelin level is closely related to angiographically-detected severity and the complex lesion morphology in Chinese diabetic patients with CAD.

Periodontal disease: a new factor associated with the presence of multiple complex coronary lesions

BACKGROUND AND AIM

Periodontal disease, including bone loss, is thought to be involved in coronary artery disease. Multiple complex coronary lesions relate to multifocal destabilization of coronary plaques. We investigated whether bone loss could be associated with the presence of multiple complex coronary lesions.

METHODS

This cross-sectional study included 150 patients with recent myocardial infarction (<1 month). Multiple complex coronary lesions were determined at coronary angiography. A panoramic dental X-ray including bone loss >50% was performed. Patients with no or simple complex lesions were compared to patients with multiple complex lesions.

RESULTS

Over 20% of patients had multiple complex coronary lesions. Patients with multiple complex lesion were less likely to be women and more likely to have multivessel disease or elevated C-reactive protein (CRP) than patients with no or single complex lesion. Bone loss >50% tended to be more frequent in patients with multiple complex lesions (p = 0.063). In multivariate analysis, multivessel disease, gender and CRP were associated with multiple complex lesion. Bone loss >50% increased the risk of multiple complex lesion.

CONCLUSION

Bone loss was associated with complex multiple coronary lesions, beyond systemic inflammation. These findings may bear important clinical implications for the prevention and treatment of coronary artery disease.

Eccentric stenosis of the carotid artery associated with ipsilateral cerebrovascular events

BACKGROUND AND PURPOSE

Eccentric stenosis of the coronary artery is associated with plaque disruption and acute coronary syndrome. The purpose of the present study was to determine whether eccentric stenosis of the carotid artery contributes to cerebrovascular events.

MATERIALS AND METHODS

Of 6859 patients with vascular diseases who underwent duplex carotid ultrasonography, we studied 512 internal carotid arteries in 441 patients who had a maximum area stenosis at or more than 70%, which corresponds with approximately 50% or more by the NASCET method. The maximal (A) and minimal wall thicknesses (B) were measured on cross-sectional sonography images, and an eccentricity index was calculated using the following formula: (A - B)/A. Arteries in the lowest quartile of the eccentricity index (<0.69) were defined as having a concentric stenosis, whereas the others were defined as having eccentric stenosis. The underlying clinical characteristics and plaque morphologies, as well as the occurrence of ipsilateral ischemic stroke or transient ischemic attack in the preceding year, were compared between patients with eccentric and concentric stenosis.

RESULTS

Patient characteristics and plaque morphology were similar between the 2 groups. Cerebrovascular events occurred more frequently ipsilaterally to the artery with eccentric stenosis (13.5%) than to the artery with concentric stenosis (5.5%; P = .013); the difference was more evident when cerebrovascular events of presumed carotid arterial origin were assessed (P = .005). After adjusting for risk factors and plaque morphology, eccentric stenosis was independently related to the presence of recent cerebrovascular events (odds ratio = 2.76; 95% confidence interval = 1.19-6.40).

CONCLUSIONS

In patients with an area carotid stenosis of 70% or more, eccentric plaque was associated with a significantly increased incidence of ipsilateral cerebrovascular events compared with patients with concentric stenosis.

Predictors and prognosis for complex coronary lesions in patients with acute myocardial infarction: data from RICO survey

BACKGROUND

We aimed to investigate the determinants and outcomes of multiple complex lesions (MCLs) on coronary angiography in patients with an acute myocardial infarction.

METHODS

One thousand one hundred fifty-two consecutive nonselected myocardial infarction patients who underwent coronary angiography within 24 hours after admission were analyzed. A complex lesion was defined by the presence of thrombus, ulceration, irregular plaque, and flow impairment. Patients with < or = 1 complex lesion were considered with single complex lesion (SCL), and patients with > 1 complex lesions with MCLs.

RESULTS

Multiple complex lesions were identified in 360 patients (31%). Patients from the MCL group were older and had a higher rate of cardiovascular risk factors but were less likely to be smokers when compared with the SCL group. Patients with MCLs were more likely to have altered left ventricular ejection fraction and multivessel disease and showed a trend toward an increased median time delay to revascularization (360 vs 285 minutes; P = .070). Moreover, the C-reactive protein (CRP) plasma levels increased with the number of CLs. By multivariate analysis, multivessel disease and CRP level were associated with the presence of MCLs. When compared with the SCL group, patients with MCLs had a higher risk of inhospital cardiogenic shock (18% vs 11%; P = .005) and 30-day mortality (11% vs 6%; P = .002). At 1-year follow-up, the presence of MCLs was an independent predictive factor of death.

CONCLUSIONS

This study shows that the presence of MCLs is associated with worse outcomes and that risk factors such as CRP are able to identify patients at a high risk for MCLs.

Intravascular imaging of atherosclerotic human coronaries in a porcine model: a feasibility study

OBJECTIVES

To perform intravascular imaging of atherosclerotic human coronary conduits in an animal model under conditions of flow and cardiac motion that approximate those encountered in vivo.

BACKGROUND

Given the lack of animal models of vulnerable plaque, a model which would allow imaging of human disease and simulate coronary motion and blood flow could advance the development of emerging technologies to detect vulnerable plaques.

METHODS

Human coronary segments from adult cadaver hearts were prepared as xenografts. In anesthetized Yorkshire pigs (45-50 kg) the chest was opened and the exposed aorta and right atrium were cannulated and attached in an end-to-end fashion to the human coronary xenograft, forming an aorto-atrial conduit. The xenograft was fixed to the anterior wall of the heart to simulate motion. Angiography and intravascular ultrasound (IVUS) of each graft were performed.

RESULTS

Twelve human coronary grafts (10 from right coronary segments) were prepared and implanted successfully in seven animals. All animals tolerated the procedure. The average graft length was 39 +/- 2.3 mm. Blood flow rates distal to the graft were >100 ml/min in nine grafts. IVUS was performed in all 12 grafts and documented expansion of arterial (6.9%) and luminal (9.3%) dimensions during the cardiac cycle (P < 0.001 for both). There was a wide range of coronary atherosclerotic pathology within the grafts, including intimal thickening, fibrocalcific plaque, and deep lipid pools.

CONCLUSION

This human-to-porcine coronary xenograft model allows intravascular imaging of human coronary pathology under conditions of blood flow and motion, and may be used to develop technologies aimed at identifying high-risk plaques.

Elevated plasma levels of oxidized low-density lipoprotein relate to the presence of angiographically detected complex and thrombotic coronary artery lesion morphology in patients with unstable angina

BACKGROUND

Increased levels of oxidized low-density lipoprotein (ox-LDL) are related to plaque instability, so the aim of the present study was to investigate whether there is a relationship between angiographic coronary plaque morphology in patients with unstable angina pectoris (UAP) and the level of ox-LDL.

METHODS AND RESULTS

Plasma ox-LDL levels were measured in 149 patients with UAP and in 88 control subjects, using a highly sensitive enzyme-linked immunosorbent assay method. Angiographic morphology of the culprit lesion was classified as either simple or complex based on the Ambrose classification. Plasma ox-LDL levels in patients with Braunwald class III were significantly higher than in patients with class I (p<0.0001) or in control subjects (p<0.0001). In each of the 3 Braunwald classes, plasma ox-LDL levels in patients with a complex lesion were significantly higher than in patients with a simple lesion. Multivariate logistic regression analysis revealed that ox-LDL level and Braunwald class III were independent factors associated with angiographically detected complex lesions.

CONCLUSION

In each Braunwald class of UAP, elevated plasma levels of ox-LDL closely relate to the presence of angiographically detected complex and thrombotic lesion morphology.

Update on coronary angioscopy: review of a 20-year experience and potential application for detection of vulnerable plaque

Predicting the occurrence of future acute coronary syndromes remains an important challenge of contemporary cardiology. It is thought that detecting the individual vulnerable plaques in patients can be an important step to preventing myocardial infarction and sudden cardiac death. Coronary angioscopy can provide detailed information of the luminal surface of plaque, such as color, thrombus, or disruption, and is one of a few possibly useful imaging modalities for identifying vulnerable plaques. During its 20-year history, coronary angioscopy has been used as a diagnostic tool or to guide coronary angioplasty, and has contributed to our understanding of the pathophysiology of coronary artery disease. Yellow plaques seen during angioscopy seem to have many characteristics of high risk or vulnerable plaques, most consistent with the thin-cap fibroatheroma. Moreover, differences in yellow color have been reported to reflect differences in the structure or composition of plaques. Development of quantitative methods to assess plaque color and histopathologic correlations in conjunction with prospective natural history studies may lead to advances in vulnerable plaque detection by coronary angioscopy. Although current angioscopic devices are limited by the need to displace the column of blood in order to see the vessel wall, and by the lack of quantitative colorimetric methods, advances in technology may lead to new device versions that could be practical for expanded clinical use.

Distal Protection Improved Reperfusion and Reduced Left Ventricular Dysfunction in Patients With Acute Myocardial Infarction Who Had Angioscopically Defined Ruptured Plaque

Background— Distal protection, in the Saphenous Vein Graft Angioplasty Free of Emboli (SAFER) trial, is demonstrated to prevent distal embolism in the percutaneous coronary intervention of saphenous vein graft. However, in the Enhanced Myocardial Efficacy and Recovery by Aspiration of Liberated Debris (EMERALD) trial, it was not effective in the percutaneous coronary intervention of native coronary arteries in patients with acute myocardial infarction (AMI). We hypothesized that its effectiveness would be determined by lesion characteristics. Therefore, we classified the type of culprit lesion by angioscopy and examined its influence on the effectiveness of distal protection, comparing patients with AMI treated with and without distal protection.

Methods and Results— Consecutive patients with AMI treated without distal protection (n=110) from July 2000 to July 2002 and those treated with distal protection (n=81) from July 2002 to July 2004 were included. Patients in each group were subdivided according to whether or not they had angioscopically defined ruptured plaque at culprit lesion. Among those groups, incidence of no-reflow phenomenon, ST-segment resolution, myocardial blush grade, and left ventricular ejection fraction at 6 months were compared. Aspirated samples by distal protection were semiquantitatively and histologically analyzed and compared between patients with and without ruptured plaque. No-reflow phenomenon was most frequently ( P <0.05) observed in patients with ruptured plaque treated without distal protection. ST-segment resolution (68±15% versus 40±21%, P <0.001), myocardial blush grade (2.6±0.5 versus 1.8±0.3, P <0.001), and left ventricular ejection fraction (47.2±6.7% versus 41.0±9.7%, P <0.01) were improved by distal protection among patients with ruptured plaque but not among patients without ruptured plaque. Aspirated samples >1 mm were detected more frequently (97.3% versus 78.5%, P <0.05) in patients with ruptured plaque than those without ruptured plaque. Histologically, aspirated samples contained plaque debris (95.3% versus 31.1%, P <0.05) more frequently in patients with ruptured plaque than in those without ruptured plaque.

Conclusions— Distal protection reduced microcirculation damage and left ventricular dysfunction in patients with AMI who had angioscopically defined ruptured plaque. Distal embolization of plaque debris was detected more frequently in patients with ruptured plaque. These results suggest that microcirculation damage and left ventricular dysfunction are increased mainly by distal embolization of plaque debris rather than of thrombus.

T helper cell related interleukins and the angiographic morphology in unstable angina

Angiographically visible complex lesions, associated with disrupted plaques and intraluminal thrombus, are more common in unstable angina (UA). The aim of our study was to evaluate the relationship between the complex lesions and the T helper cells related Interleukins (IL). We analyzed the concentrations of IL-10, IL-12, IL-18 using ELISA and that of hsCRP using Latex particle enhanced Immunoturbidimetry in 50 patients of UA. Thirty-one of these patients had complex lesions and 19 had simple lesions as visible during coronary angiography. We further compared them with 30 control subjects having no evidence of coronary artery diseases. The levels of IL-12 in patients having complex lesions tended to be higher than in those having simple lesions and levels of IL-10 tended to be lower in the former than the latter, but the differences were not statistically significant. The patients with complex lesions showed significantly higher concentrations of IL-18 as compared to those having simple lesions. Furthermore, IL-18 was found to be independent predictor for the complex lesion morphology in UA patients. These findings suggest that disrupted plaques and intraluminal thrombus, angiographically visible as complex lesions are associated with increased concentrations of T helper 1 cell related interleukins, mainly IL-18, and IL-18 being a possible bio-marker for risk stratification in UA.

Distal protection with a filter device during coronary stenting in patients with stable and unstable angina

BACKGROUND

Filter protection after percutaneous coronary intervention (PCI) is now available to prevent distal embolization. The aims of this study were (1) to evaluate the microembolization phenomenon during procedures of stent implantation in native coronary arteries of patients with stable and unstable angina, (2) to assess the amount and characteristics of the debris captured by the Angioguard, and (3) to investigate the relation between clinical and angiographic variables and pathological data.

METHODS AND RESULTS

Elective coronary stenting with the use of a protective filter was attempted in 39 consecutive coronary artery lesions with >60% stenosis (mean, 67.6+/-8.79%). Debris was present in 75.6% of the filters. Particle size ranged from 47.16 to 2503.48 microm (mean, 518.83+/-319.61 microm) in the major axis. Particles >300 microm were found in 24 of 28 filters with debris (85.7%), and particles >1000 microm were present in 10 of 28 filters (35.7%). Patients with unstable angina had greater particles (mean maximum longitudinal diameter, 1098.33+/-714.3 microm) than those with stable angina (412.91+/-453 microm; P<0.001). The presence of unstable angina (OR, 65; CI, 1.2 to 3420; P=0.03) and age >67 years (OR, 42; CI, 1 to 1698; P=0.04) were found to be the only independent predictors of embolic particle size.

CONCLUSIONS

By limiting embolization, protective devices may prevent a number of potentially unfavorable events, thereby improving outcome. Our data support the use of these devices, especially in lesions with higher embolic potential, such as those occurring in older patients and in those with unstable angina.