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Illési Á, Fejes Z, Pócsi M, Debreceni IB, Hodosi K, Nagy Jr. B, Kappelmayer J, Kőszegi Z, Csanádi Z, Szük T. Technically Challenging Percutaneous Interventions of Chronic Total Occlusions Are Associated with Enhanced Platelet Activation. J Clin Med 2023; 12:6829. [PMID: 37959293 PMCID: PMC10648871 DOI: 10.3390/jcm12216829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/14/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023] Open
Abstract
Percutaneous coronary intervention (PCI) is a frequently performed treatment option for recanalization in patients with chronic total occlusion (CTO). As CTO-PCIs are often complicated and challenging for interventionalists, the stressful and damaging nature of the procedure can be remarkable, thus platelets can be easily activated. Our aim was to investigate the effect of CTO-PCI on platelet activation and the expression of selected circulating microRNAs (miR) of platelet and endothelium origin after CTO-PCI. In this study, 50 subjects after CTO-PCI were enrolled. Blood samples were obtained before PCI, at 2 days and 3-6 months after the procedure to measure the degree of platelet activation and the level of plasma miR-223, miR-181b, and miR-126. Patients were divided based on the characteristics of the intervention. Patients with higher Japanese CTO scores and longer duration of PCI showed significantly elevated platelet P-selectin positivity (p = 0.004 and p = 0.013, respectively) 2 days after the procedure compared to pre-PCI and increased concentration of soluble P-selectin 3-6 months after the intervention (higher Japanese CTO score: p = 0.028 and longer duration of PCI: p = 0.023) compared to baseline values. Shorter total stent length caused a significantly lower miR-181b expression at 3-6 months after the intervention (p = 0.031), while no difference was observed in miR-223 and miR-126. One stent thrombosis occurred during the follow-up period. Although these technically challenging CTO-PCIs may cause enhanced platelet activation right after the intervention and long-term endothelial cell dysfunction, these interventions are not associated with more adverse clinical events.
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Affiliation(s)
- Ádám Illési
- Department of Cardiology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary; (Á.I.); (Z.K.); (Z.C.)
- Doctoral School of Kálmán Laki, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - Zsolt Fejes
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary; (Z.F.); (M.P.); (I.B.D.); (B.N.J.); (J.K.)
| | - Marianna Pócsi
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary; (Z.F.); (M.P.); (I.B.D.); (B.N.J.); (J.K.)
| | - Ildikó Beke Debreceni
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary; (Z.F.); (M.P.); (I.B.D.); (B.N.J.); (J.K.)
| | - Katalin Hodosi
- Institute of Internal Medicine, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary;
| | - Béla Nagy Jr.
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary; (Z.F.); (M.P.); (I.B.D.); (B.N.J.); (J.K.)
| | - János Kappelmayer
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary; (Z.F.); (M.P.); (I.B.D.); (B.N.J.); (J.K.)
| | - Zsolt Kőszegi
- Department of Cardiology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary; (Á.I.); (Z.K.); (Z.C.)
- Doctoral School of Kálmán Laki, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
- András Jósa University Teaching Hospital, 4400 Nyiregyhaza, Hungary
| | - Zoltán Csanádi
- Department of Cardiology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary; (Á.I.); (Z.K.); (Z.C.)
- Doctoral School of Kálmán Laki, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - Tibor Szük
- Department of Cardiology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary; (Á.I.); (Z.K.); (Z.C.)
- Doctoral School of Kálmán Laki, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
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Hussey KK, Hussey JK, Thorpe P, Brittenden J, Bachoo P. The role of subintimal angioplasty in the management of arterial disease of the lower limb: the North-East of Scotland experience. Surgeon 2008; 6:329-334. [PMID: 19110819 DOI: 10.1016/s1479-666x(08)80003-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
INTRODUCTION The management of occlusive femoropopliteal disease continues to evolve and a definitive strategy remains to be defined. We examine the utility ofsubintimal angioplasty (SIA) in our institution. METHODS A retrospective study with predefined end-points, including technical success and primary patency. RESULTS 61 consecutive cases were identified (claudicants n=29 and critical ischaemia n=32). Sixty-four percent of occlusions were greater than 10 cm with poor run-off (60% with two vessels or less). Technical and physiological success was 95% and 79% respectively, with clinical improvement reported by 72%. At a mean follow-up of 20 months twelve-month primary patency (assessed clinically, with ABPI and selective duplex scanning) was 67% (subgroup analysis: claudicants 83%, criticals 53%, p=0.02) and morbidity 8% with no limb loss or procedure related mortality. CONCLUSION SIA is an effective procedure for chronic lower limb ischaemia with acceptable outcome. Our experience correlates well with evidence in the current literature.
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Affiliation(s)
- K K Hussey
- Department of Surgery, Aberdeen Royal Infirmary, UK.
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Mahemuti A, Meneveau N, Seronde MF, Schiele F, Descotes-Genon V, Ecarnot F, Blonde MC, Mercier M, Racadot E, Bassand JP. Early changes in local hemostasis activation following percutaneous coronary intervention in stable angina patients: a comparison between drug-eluting and bare metal stents. J Thromb Thrombolysis 2008; 28:333-41. [DOI: 10.1007/s11239-008-0266-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2008] [Accepted: 08/12/2008] [Indexed: 11/29/2022]
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Jaumdally RJ, Varma C, Blann AD, MacFadyen RJ, Lip GYH. Platelet Activation in Coronary Artery Disease. Chest 2007; 132:1532-9. [PMID: 17908707 DOI: 10.1378/chest.07-0389] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Platelet activation and aggregation play a key role in coronary artery disease, with antiplatelet therapies leading to improved clinical outcomes. Limited data exist as to whether peripheral venous blood measurements of platelet physical indexes (eg, platelet count, volume, and granularity) and soluble markers of platelet activation (eg, P-selectin [sP-sel] and CD40 ligand [CD40L]) reflect the local (intracardiac) coronary environment. Furthermore, how percutaneous coronary interventions (PCIs) affect levels of peripheral/cardiac platelet indexes is unclear. METHODS Blood samples were sequentially acquired from the coronary os, aortic root, coronary sinus, and the femoral vein, and where relevant, pre-PCI and post-PCI. Eighty-seven patients undergoing coronary angiography were recruited (mean [+/-SD] age, 59.8+/-10.8 years; 54 men [62%]), of whom 36 proceeded to PCI. Platelet physical indexes and plasma sP-sel and CD40L levels were measured (by enzyme-linked immunosorbent assay). RESULTS At baseline, no intracardiac vs peripheral differences were noted in sP sel levels, while CD40L levels were elevated in the aorta compared to the coronary sinus and femoral venous. The mean platelet count (MPC) was similar at all four sites, but within the coronary sinus blood, mean platelet volume (MPV) was significantly lower and mean platelet granularity (MPG) was higher when compared to arterial levels. Though aortic and femoral levels of sP-sel were raised following PCI, transcardiac gradients of plasma sP-sel levels were unaffected. PCI was associated with lower CD40L, MPC, and MPV levels but with a higher MPG level in all sampling sites. CONCLUSIONS sP-sel levels measured peripherally reflect the cardiac environment, unlike CD40L, MPC, MPV, and MPG. PCI leads to further platelet activation (raised sP-sel) despite aggressive antiplatelet therapy.
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Affiliation(s)
- Rumi J Jaumdally
- University Department of Medicine, City Hospital, Haemostasis, Thrombosis, and Vascular Biology Unit, Dudley Rd, Birmingham B18 7QH, UK
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Stone GW, Aronow HD. Long-term care after percutaneous coronary intervention: focus on the role of antiplatelet therapy. Mayo Clin Proc 2006; 81:641-52. [PMID: 16706262 DOI: 10.4065/81.5.641] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Arterial wall injury caused by percutaneous coronary intervention (PCI) triggers transient platelet activation and mural thrombosis; these effects are superimposed on the preexisting platelet hyperreactivity associated with underlying atherothrombosis. Platelet activation has been implicated in the major complications of PCI: acute and subacute thrombosis and restenosis. Antithrombotic and anticoagulant therapy minimizes thrombotic complications after PCI. Aspirin plus a thienopyridine (ticlopidine or clopidogrel) is more effective than aspirin plus heparin and extended warfarin therapy in preventing periprocedural ischemic events and subsequent stent thrombosis and results in less major and minor bleeding. Dual antiplatelet therapy with aspirin and clopidogrel (the preferred thienopyridine because of its superior hematologic safety) is recommended for at least 4 weeks to prevent subacute stent thrombosis with bare-metal stents and 3 to 6 months to prevent late-stent thrombosis with drug-eluting stents. Coronary atherothrombosis is a diffuse vascular disease, and reduction of the risk of future ischemic events requires strategies that extend beyond the focal treatment of stenotic lesions. Optimal long-term care after PCI requires aggressive systemic pharmacotherapy (antiplatelet agents, statins, beta-blockers, and angiotensin-converting enzyme Inhibitors) in conjunction with therapeutic lifestyle changes (smoking cessation, weight reduction, dietary measures, and exercise). In this context, dual antiplatelet therapy (aspirin plus clopidogrel) is recommended for at least 12 months after PCI for prophylaxis of future atherothrombotic events.
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Affiliation(s)
- Gregg W Stone
- Columbia University Medical Center and Cardiovascular Research Foundation, New York, NY 10022, USA.
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Craft JA, Masci PP, Roberts MS, Brighton TA, Garrahy P, Cox S, Marsh NA. Increased platelet-derived microparticles in the coronary circulation of percutaneous transluminal coronary angioplasty patients. Blood Coagul Fibrinolysis 2004; 15:475-82. [PMID: 15311156 DOI: 10.1097/00001721-200408000-00006] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Platelet-derived microparticles that are produced during platelet activation are capable of adhesion and aggregation. Endothelial trauma that occurs during percutaneous transluminal coronary angioplasty (PTCA) may support platelet-derived microparticle adhesion and contribute to development of restenosis. We have previously reported an increase in platelet-derived microparticles in peripheral arterial blood with angioplasty. This finding raised concerns regarding the role of platelet-derived microparticles in restenosis, and therefore the aim of this study was to monitor levels in the coronary circulation. The study population consisted of 19 angioplasty patients. Paired coronary artery and sinus samples were obtained following heparinization, following contrast administration, and subsequent to all vessel manipulation. Platelet-derived microparticles were identified with an anti-CD61 (glycoprotein IIIa) fluorescence-conjugated antibody using flow cytometry. There was a significant decrease in arterial platelet-derived microparticles from heparinization to contrast administration (P = 0.001), followed by a significant increase to the end of angioplasty (P = 0.004). However, there was no significant change throughout the venous samples. These results indicate that the higher level of platelet-derived microparticles after angioplasty in arterial blood remained in the coronary circulation. Interestingly, levels of thrombin-antithrombin complexes did not rise during PTCA. This may have implications for the development of coronary restenosis post-PTCA, although this remains to be determined.
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Affiliation(s)
- Judy A Craft
- School of Life Sciences, Queensland University of Technology, Brisbane, Australia.
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Lee MS, David EM, Makkar RR, Wilentz JR. Molecular and cellular basis of restenosis after percutaneous coronary intervention: the intertwining roles of platelets, leukocytes, and the coagulation-fibrinolysis system. J Pathol 2004; 203:861-70. [PMID: 15258987 DOI: 10.1002/path.1598] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The major limitation of percutaneous coronary intervention (PCI) is restenosis. Restenosis is considered to be an overreaction of the natural healing process after traumatic balloon dilatation. An elaborate web of cellular and molecular responses, including the interaction of platelets, leukocytes, and the coagulation-fibrinolysis system, as well as the secretion of various growth factors and pro-inflammatory cytokines, contributes to neointimal hyperplasia and the development of restenosis. Moreover, platelet and neutrophil activation after stenting appears to be different from that after balloon angioplasty alone. Pharmacotherapy targeting the cell-to-cell interaction between platelets and neutrophils may potentially offer an effective treatment strategy against restenosis after PCI.
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Affiliation(s)
- Michael S Lee
- Cedars-Sinai Medical Center, UCLA School of Medicine, Cardiovascular Intervention Center, Los Angeles, California, USA.
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Welt FGP, Rogers SD, Zhang X, Ehlers R, Chen Z, Nannizzi-Alaimo L, Phillips DR, Simon DI. GP IIb/IIIa inhibition with eptifibatide lowers levels of soluble CD40L and RANTES after percutaneous coronary intervention. Catheter Cardiovasc Interv 2004; 61:185-9. [PMID: 14755809 DOI: 10.1002/ccd.10763] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Platelets are the most abundant blood source of CD40L, a proinflammatory and prothrombotic costimulatory molecule implicated in atherosclerosis. Agonist stimulation results in the secretion of a soluble form of CD40L (sCD40L) and GP IIb/IIIa receptor inhibition blocks secretion of sCD40L in vitro. However, the effect of GP IIb/IIIa inhibition on sCD40L levels in humans is unknown. Plasma sCD40L and inflammatory markers were measured (t = 0, 0.5, 2, and 24 hr post-PCI) in a cohort of patients receiving abciximab (n = 15), eptifibatide (n = 15), or no GP IIb/IIIa inhibitor (n = 15). PCI in the absence of GP IIb/IIIa inhibitor was associated with a small but measurable rise in sCD40L and the platelet-derived chemokine RANTES. In contrast, eptifibatide significantly lowered baseline sCD40L (P = 0.018) and RANTES (P = 0.006) levels. This effect was not observed with abciximab. GP IIb/IIIa inhibition with eptifibatide lowers levels of sCD40L and RANTES post-stenting, possibly conferring anti-inflammatory as well as antithrombotic effects.
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Craft JA, Marsh NA. Increased generation of platelet-derived microparticles following percutaneous transluminal coronary angioplasty. Blood Coagul Fibrinolysis 2003; 14:719-28. [PMID: 14614350 DOI: 10.1097/00001721-200312000-00005] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Platelet-derived microparticles that are produced during platelet activation bind to traumatized endothelium. Such endothelial injury occurs during percutaneous transluminal coronary angioplasty. Approximately 20% of these patients subsequently develop restenosis, although this is improved by treatment with the anti-platelet glycoprotein IIb/IIIa receptor drug abciximab. As platelet activation occurs during angioplasty, it is likely that platelet-derived microparticles may be produced and hence contribute to restenosis. This study population consisted of 113 angioplasty patients, of whom 38 received abciximab. Paired peripheral arterial blood samples were obtained following heparinization and subsequent to all vessel manipulation. Platelet-derived microparticles were identified using an anti-CD61 (glycoprotein IIIa) fluorescence-conjugated antibody and flow cytometry. Baseline clinical characteristics between patient groups were similar. The level of platelet-derived microparticles increased significantly following angioplasty in the group without abciximab (paired t test, P = 0.019). However, there was no significant change in the level of platelet-derived microparticles following angioplasty in patients who received abciximab, despite requiring more complex angioplasty procedures. In this study, we have demonstrated that the level of platelet-derived microparticles increased during percutaneous transluminal coronary angioplasty, with no such increase with abciximab treatment. The increased platelet-derived microparticles may adhere to traumatized endothelium, contributing to re-occlusion of the arteries, but this remains to be determined.
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Affiliation(s)
- Judy A Craft
- School of Life Sciences, Queensland University of Technology, Brisbane, Australia.
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Soffer D, Moussa I, Harjai KJ, Boura JA, Dixon SR, Grines CL, O'Neill WW, Roubin GS, Moses JW. Impact of angina class on inhibition of platelet aggregation following clopidogrel loading in patients undergoing coronary intervention: do we need more aggressive dosing regimens in unstable angina? Catheter Cardiovasc Interv 2003; 59:21-5. [PMID: 12720236 DOI: 10.1002/ccd.10494] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Pretreatment with thienopyridines has been shown to improve clinical outcomes in patients undergoing percutaneous coronary intervention (PCI). We determine the impact of angina class on inhibition of platelet aggregation (IPA) following clopidogrel loading. Seventy-two patients (mean age, 64 +/- 11 years; 76% male) were pretreated with 450 mg of clopidogrel at least 3 hr prior to PCI. All patients received ASA 325 mg prior to the procedure. Patients were classified into two groups according to angina class: group 1 = stable angina or Braunwald class 1 unstable angina (UA; n = 33); group 2 = Braunwald class 2 or 3 UA (n = 39). IPA was measured prior to PCI, with the Ichor point-of-care platelet analyzer (Helena Laboratories, Beaumont, TX), using 20 microM of ADP. Group 2 patients were more likely to have prior MI (54% vs. 27%; P = 0.023), prior CABG (33% vs. 5%; P = 0.046), and received IV heparin (64% vs. 27%; P = 0.0018). Mean IPA was significantly lower in group 2 compared to group 1 (19% +/- 22% vs. 32% +/- 22%; P = 0.004). In multivariate analysis, higher angina class was independently associated with lower IPA (P = 0.018). Patients with UA undergoing PCI have a lower IPA following clopidogrel loading with 450 mg. This may indicate the possibility of clopidogrel resistance in such patients.
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Affiliation(s)
- Daniel Soffer
- Division of Cardiology, William Beaumont Hospital, Royal Oak, Michigan 48073, USA.
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Mckenzie M, Malinin A, Bell C, Dzhanashvili A, Horowitz E, Oshrine B, Atar D, Serebruany V. Blood Coagul Fibrinolysis 2003; 14:249-253. [DOI: 10.1097/00001721-200304000-00005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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McKenzie ME, Malinin AI, Bell CR, Dzhanashvili A, Horowitz ED, Oshrine BR, Atar D, Serebruany VL. Aspirin inhibits surface glycoprotein IIb/IIIa, P-selectin, CD63, and CD107a receptor expression on human platelets. Blood Coagul Fibrinolysis 2003; 14:249-53. [PMID: 12695747 DOI: 10.1097/01.mbc.0000046182.72384.ab] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Platelet inhibition after aspirin therapy reduces the risk for the development of acute coronary syndromes. However, the mechanism by which aspirin affect platelets other than by prostaglandin blockade is unclear. We sought to determine the in vitro effects of aspirin on the surface expression of nine platelet receptors using whole blood flow cytometry. Blood from 24 healthy volunteers was incubated for 30 min with 1.8 and 7.2 mg/l phosphate-buffered saline-diluted acetylsalicylic acid in the presence or absence of apyrase. Platelet serotonin release, and the surface expression of platelet receptors with or without apyrase were determined using the following monoclonal antibodies: anit-CD41 [glycoprotein (GP)IIb/IIIa], CD42b (GPIb), CD62p (P-selectin), CD51/CD61 (vitronectin receptor), CD31 [platelet/endothelial cellular adhesion molecule-1 (PECAM-1)], CD107a [lysosomal associated membrane protein (LAMP)-1], CD107b (LAMP-2), CD63 (LIMP or LAMP-3), and CD151 (PETA-3). Samples were then immediately fixed with 2% paraformaldehyde, and run on the flow cytometer within 48 h. Aspirin does not affect serotonin release from human platelets. Dose-dependent inhibition of GPIIb/IIIa, P-selectin, CD63, and CD107a receptor expression was observed in the aspirin-treated whole-blood samples. Apyrase potentiates the effects of aspirin, and independently inhibits PECAM-1. In addition to the known effect of irreversibly inhibiting platelet cyclooxygenase-1, thereby blocking thromboxane A(2) synthesis, it appears that aspirin exhibits direct effects on selective major platelet receptors.
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Affiliation(s)
- Marcus E McKenzie
- Center for Thrombosis Reseasrch, Sinai Hospital of Baltimore, Johns Hopkins University, 2401 West Belvedere Avenue, Baltimore, MD 21215, USA
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Kamishirado H, Inoue T, Mizoguchi K, Uchida T, Nakata T, Sakuma M, Takayanagi K, Morooka S. Randomized comparison of cilostazol versus ticlopidine hydrochloride for antiplatelet therapy after coronary stent implantation for prevention of late restenosis. Am Heart J 2002; 144:303-8. [PMID: 12177649 DOI: 10.1067/mhj.2002.122874] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Cilostazol is a newly developed antiplatelet drug that has been widely applied for clinical use. Its antiplatelet action appears to be mainly related to inhibition of intracellular phosphodiesterase activity. Recently, cilostazol has been used for antiplatelet therapy after coronary stent implantation. However, its evaluation has not been established yet. METHODS This prospective randomized trial was designed to investigate the efficacy of cilostazol for the prevention of late restenosis and acute or subacute stent thrombosis in comparison with ticlopidine hydrochloride. One hundred thirty consecutive patients, scheduled for elective coronary stenting, were randomly assigned to receive oral aspirin (81 mg/day) plus ticlopidine hydrochloride therapy (200 mg/day; group I) or aspirin plus cilostazol therapy (200 mg/day; group II). These medications were started at least 2 days before coronary intervention and continued until follow-up coronary angiography was performed 6 months later. RESULTS Subacute stent thrombosis was observed in 2 patients of group I but in no patients of group II. Major cardiac events were similarly present in both groups. Elevated transaminase levels were observed more frequently in group I than in group II (P <.05). Each of the quantitative coronary angiography variables before and immediately after coronary stenting were similar in both groups. At follow-up angiography, however, late lumen loss (0.69 +/- 0.79 mm vs 0.28 +/- 0.40 mm; P <.01) and loss index (0.42 +/- 0.56 vs 0.16 +/- 0.27; P <.01) were smaller in group II than in group I. Restenosis rate (13% vs 31%; P <.05) and target lesion revascularization rate (7% vs 21%; P <.05) were both lower in group II than in group I. CONCLUSION Aspirin plus cilostazol therapy may be an effective regimen for prevention of not only stent thrombosis but also restenosis.
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Affiliation(s)
- Hirotoshi Kamishirado
- Department of Cardiology, Koshigaya Hospital, Dokkyo University School of Medicine, Saitama, Japan
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McKenzie ME, Bell CR, Horowitz ED, Oshrine BR, Atar D, Serebruany VL. Effects of in vitro exposure of alcohol on surface receptor expression of human platelets. Clin Physiol Funct Imaging 2002; 22:153-6. [PMID: 12005158 DOI: 10.1046/j.1365-2281.2002.00411.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Platelet inhibition after moderate alcohol consumption in patients with ischaemic heart disease may contribute to reducing the risk for developing acute coronary syndromes. However, the mechanism by which ethanol affects platelets is not clarified. We sought to determine the in vitro effects of alcohol on the surface expression of human platelet receptors using whole blood flow cytometry. Blood samples from 10 healthy volunteers were incubated for 30 min with 25 and 50 mmol l(-1) of phosphate buffered saline diluted grain ethanol, concentrations often used in in vitro studies. The surface expression of platelet receptors was determined by flow cytometry after fixation with 2% paraformaldehyde using the following monoclonal antibodies: CD 41 (GP IIb/IIIa), CD 42b (GP Ib), CD 62p (P-selectin), CD 51/CD 61 (vitronectin receptor), CD 31 (PECAM-1), CD 107a (LAMP-1), CD 107b (LAMP-2), CD 63 (LIMP, LAMP-3) and CD 151 (PETA-3). Dose-dependent inhibition of GP IIb/IIIa, P-selectin, CD 63 and CD 107a receptor expression was observed in the ethanol-treated whole blood samples. This study for the first time establishes a direct effect of ethanol on selective major platelet receptors. Beneficial cardiovascular properties of moderate alcohol consumption may be explained by ethanol's antiplatelet action.
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Serebruany VL, Cummings CC, Malinin AI, Steinhubl SR, Gurbel PA. Uniform platelet activation exists before coronary stent implantation despite aspirin therapy. Am Heart J 2001; 142:611-6. [PMID: 11579350 DOI: 10.1067/mhj.2001.116478] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Platelets play an important role in the natural history of coronary artery disease. Enhanced platelet aggregation and receptor expression unquestionably occur after coronary stent implantation; however, the functional characteristics of platelets before stenting have not been fully elucidated. METHODS Platelets were assessed before intervention by platelet-rich plasma aggregation (PA) with 5 mmol adenosine diphosphate (ADP) and 1 mg/mL collagen; whole blood aggregation (WBA) by 1 mg/mL collagen; shear-induced closure time (CT); contractile force (CF); and expression of 9 surface receptors by flow cytometry in 126 patients undergoing elective coronary artery stent placement. All patients received aspirin for at least 7 days. The data were compared with those from 64 healthy volunteers. RESULTS Each test revealed sustained platelet activation in patients undergoing coronary stenting compared with control values. These differences were significant for collagen-induced PA (P =.031); CF (P =.0001); expression of glycoprotein (GP) IIb/IIIa (P =.0001); P-selectin (P =.0008); platelet/endothelial cell adhesion molecule (PECAM)-1 (P =.0001); CD107a (P =.0001); CD107b (P =.0004); and CD63 (P =.009). CONCLUSION Platelets are indeed activated before coronary stenting despite antecedent therapy with aspirin.
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Affiliation(s)
- V L Serebruany
- Center for Thrombosis Research, Sinai Hospital, Baltimore, MD 21215, USA.
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Christov A, Kostuk WJ, Jablonsky G, Lucas A. Fluorescence spectroscopic analysis of circulating platelet activation during coronary angioplasty. Lasers Surg Med 2001; 28:414-26. [PMID: 11413553 DOI: 10.1002/lsm.1069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND AND OBJECTIVE Platelet activation during percutaneous transluminal coronary angioplasty (PTCA) initiates thrombus formation and plaque regrowth at sites of arterial injury, limiting procedure efficacy. We have developed a simple assay for circulating platelet activation based on fluorescence analysis of membrane fluidity and intracellular calcium concentration and light scattering analysis of platelet aggregation. STUDY DESIGN/MATERIALS AND METHODS Platelet activation state was measured in 45 patients undergoing angioplasty, before and after treatment with platelet inhibitors. RESULTS PTCA alone produced a decrease in pyrene dimer formation (P0.0083) and an increase in light scattering at 650 nm (P0.0128). Treatment with ADP and GPIIb/IIIa receptor antagonists reduced PTCA induced changes in pyrene dimer formation. An unexpected decrease in pyrene dimer formation (P0.05) was detected when the GPIIb/IIIa receptor antagonist was given together with an ADP receptor antagonist. CONCLUSIONS 1) Analysis of membrane fluidity provides a sensitive marker for platelet activation state. 2) Reduced membrane fluidity after combined platelet inhibitor treatments suggests reduced antiplatelet efficacy.
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Affiliation(s)
- A Christov
- Vascular Biology Group, John P. Robarts Research Institute, University of Western Ontario, London, Ontario N6A 5K8, Canada
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17
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Nielsen TG, Hesse B, Boehme MW, Schroeder TV. Intraoperative endothelial damage is associated with increased risk of stenoses in infrainguinal vein grafts. Eur J Vasc Endovasc Surg 2001; 21:513-9. [PMID: 11397025 DOI: 10.1053/ejvs.2001.1377] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Saphenous vein injury is believed to predispose to vein graft stenoses. The aims of this study were to assess the endothelial injury associated with infrainguinal vein bypass surgery by serial measurements of serum thrombomodulin concentration as well as by platelet scintigraphy, and to relate these findings with the postoperative development of stenoses. METHODS In 35 patients undergoing vein bypass surgery serum thrombomodulin concentration was measured pre- and postoperatively. Autologous 111-indium labelled platelets were administered into the common femoral artery immediately after restoration of flow in the graft and scintigraphic images were obtained 4 and/or 24 h later. RESULTS Serum thrombomodulin increased markedly from median 17 ng/ml preoperatively to 32 ng/ml 1 day after surgery (p =0.00002). Platelet scintigraphy revealed a total of 62 focal activity accumulations, the majority being located in the anastomotic regions. Among the 30 patients with grafts remaining patent at 30 days stenoses occurred in nine (16%) of 55 regions with scintigraphic platelet accumulations as compared to only four (4%) of 94 regions without platelet accumulations (p =0.03). CONCLUSIONS The very high predictive value of a negative platelet scintigraphy (96%) strongly suggests that localised perioperative endothelial injury is an important pathogenetic factor in the development of vein graft stenoses.
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Affiliation(s)
- T G Nielsen
- Department of NuclearDepartment of Vascular Surgery Medicine and Clinical Physiology, Rigshospitalet, Copenhagen, Denmark
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Inoue T, Sohma R, Miyazaki T, Iwasaki Y, Yaguchi I, Morooka S. Comparison of activation process of platelets and neutrophils after coronary stent implantation versus balloon angioplasty for stable angina pectoris. Am J Cardiol 2000; 86:1057-62. [PMID: 11074199 DOI: 10.1016/s0002-9149(00)01159-0] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The pathophysiologic features of stent-induced cellular responses of platelets and leukocytes have not been established. This study was designed to clinically investigate the activation of platelets and neutrophils after coronary stenting and to identify its effects on the long-term results of coronary stents. Forty-eight consecutive patients with left anterior descending coronary artery disease indicating coronary intervention were randomly assigned to either a balloon angioplasty group or a coronary stent group. Flow cytometric analysis demonstrated that the transcardiac gradient (the value of coronary sinus blood minus the value of peripheral blood) of platelet surface expression of CD62P (p < 0.001) and CD63 (p < 0.01) increased immediately after coronary stenting, but increased less significantly immediately after balloon angioplasty (CD62P, p < 0.01; CD63, p < 0.05). These increases were persistently observed after coronary stenting but transiently after balloon angioplasty alone during a 48-hour observation period after the procedures. The gradient for neutrophil surface expression of CD11b increased, and that of CD62 L decreased 48 hours after coronary stenting (CD11b, p < 0.001; CD62 L, p < 0.05), but these changes showed less significance 48 hours after balloon angioplasty alone (CD11b, p < 0.05; CD62 L, p = NS). The gradients 48 hours after the procedures for both CD62P (r = 0.39, p < 0.05) and CD11b (r = 0.44, p < 0.01) were independently correlated with the late loss in the stent group, whereas the correlation was seen only for CD11b (r = 0.38, p < 0.05) in the balloon angioplasty group. Both platelet and neutrophil activation was greater after coronary stenting than after balloon angioplasty. Cellular interactions between platelets and neutrophils may be related to the progression of neointimal proliferation leading to restenosis after coronary stent implantation.
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Affiliation(s)
- T Inoue
- Department of Cardiology, Koshigaya Hospital and Institute for Medical Science, Dokkyo University School of Medicine, Koshigaya City, Saitama, Japan
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Chakhtoura EY, Shamoon FE, Haft JI, Obiedzinski GR, Cohen AJ, Watson RM. Comparison of platelet activation in unstable and stable angina pectoris and correlation with coronary angiographic findings. Am J Cardiol 2000; 86:835-9. [PMID: 11024397 DOI: 10.1016/s0002-9149(00)01102-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We sought to investigate the relation between platelet activation and the angiographic evidence of ruptured plaque in patients presenting with unstable and stable angina pectoris. We prospectively enrolled 25 consecutive patients (5 women and 20 men, mean age 62 +/- 3 years), 17 with unstable angina and 8 with stable angina. Systemic venous blood samples were collected within 4 to 6 hours of admission for flow cytometry analysis. Activation-dependent epitope CD63 and glycoprotein IIb/IIIa on the platelet membrane were assayed. Fibrinogen levels were also measured. All patients with unstable angina underwent cardiac catheterization and had angiographic evidence of ruptured plaque. Of the patients with stable angina, 5 underwent coronary angiography with smooth noncomplex lesions and 3 had negative technetium-99m sestamibi stress tests. Patients with unstable angina were characterized by 39% higher levels of fibrinogen than patients with stable angina (423 +/- 304 vs 304 +/- 51 mg/dl, p = 0.004). The percentage of platelets positive for the activation-dependent epitope CD63 was 5 times higher in patients with unstable than stable angina (14.6 +/- 5.6% vs 2.75 +/- 1.6%, p = 0.0026). They also had a 15% higher expression of their glycoprotein IIb/IIIa (517 +/- 79 vs 449 +/- 50 mean fluorescence intensity, p = 0.038). Thus, this study establishes a direct relation between the morphology of ruptured plaque and platelet activation in patients with unstable angina. This may allow for further risk stratification. Patients with unstable complex lesions had a fivefold higher expression of the platelet activation epitope CD63 than patients with stable angina. Furthermore, they had 15% more glycoprotein IIb/IIIa aggregation sites expressed on their platelet membrane, thus indicating an intense thrombogenic potential.
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20
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Mizuno O, Hojo Y, Ikeda U, Katsuki T, Fukazawa H, Kurosaki K, Fujikawa H, Shimada K. Assessment of coagulation and platelet activation in coronary sinus blood induced by transcatheter coronary intervention for narrowing of the left anterior descending coronary artery. Am J Cardiol 2000; 85:154-60. [PMID: 10955369 DOI: 10.1016/s0002-9149(99)00651-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Influences of recently developed methods for coronary intervention on hemostasis in the coronary circulation are unclear. The objective of this study was to investigate changes in coagulation and platelet activation in the coronary circulation induced by percutaneous transluminal coronary angioplasty (PTCA). We studied 35 patients with coronary heart disease who underwent elective PTCA to isolated stenotic narrowing of left coronary arteries. Seven patients received only PTCA, 12 underwent percutaneous transluminal rotational atherectomy (PTRA), and 16 underwent stent implantation. Blood samples were drawn from the coronary sinus immediately before and after as well as 4 and 24 hours after PTCA. Plasma levels of tissue factor (TF), thrombin-antithrombin III complex, plasminogen activator inhibitor (PAI)-1, tissue plasminogen activator (t-PA), beta-thromboglobulin, and platelet factor 4 were measured by enzyme-linked immunosorbent assay. In all patients, TF levels in the coronary sinus blood showed significant increases 4 and 24 hours after PTCA and thrombin-antithrombin III complex levels showed significant increases 24 hours after PTCA. PAI-1 showed significant increases 24 hours after PTCA and t-PA showed significant increases 4 and 24 hours after PTCA. Changes in levels of these markers by PTCA were similar among the 3 groups. In PTRA, levels of beta-thromboglobulin and platelet factor 4, markers of platelet activation, increased immediately after the procedure and returned to baseline levels after 4 hours. PTCA induced increases in blood coagulation and fibrinolysis in the coronary circulation. PTRA caused a marked but transient activation of platelets. These changes may contribute to acute complications during the procedure.
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Affiliation(s)
- O Mizuno
- Department of Cardiology, Jichi Medical School, Tochigi, Japan
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Inoue T, Sohma R, Morooka S. Cilostazol inhibits the expression of activation-dependent membrane surface glycoprotein on the surface of platelets stimulated in vitro. Thromb Res 1999; 93:137-43. [PMID: 10030830 DOI: 10.1016/s0049-3848(98)00172-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cilostazol is a newly developed antiplatelet drug that has been widely applied for clinical use. Its antiplatelet action appears to be mainly related to inhibition of intracellular phosphodiesterase activity. Our study was designed to investigate inhibitory effects of cilostazol on the expression of activation-dependent platelet membrane surface glycoproteins. We performed flow cytometric analysis using monoclonal antibodies, PAC-1 (antibody against activation dependent epitope of GPIIb/IIIa), anti-CD62P (P-selectin), and anti-CD63. In vitro ADP stimulation of platelets taken from seven healthy volunteers produced significant increases in the mean channel fluorescence intensities (MFI) for PAC-1 (148% increase) and CD62P (43% increase) but did not increase in that for CD63. The enhanced MFI for CD62P was suppressed to the control level by pretreatment with 1 microM (88% suppression), 3 microM (94% suppression), and 10 microM (95% suppression) of cilostazol. However, that of PAC-1 was suppressed to a lesser degree (12, 16, and 21% suppressions, respectively). Cilostazol may inhibit P-selectin release from alpha-granule, rather than activation-dependent conformational change of GPIIb/IIIa in platelets. Cilostazol inhibits cellular interaction among platelets, leukocytes, and vascular endothelial cells mediated by P-selectin.
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Affiliation(s)
- T Inoue
- Department of Cardiology, Koshigaya Hospital, Dokkyo University School of Medicine, Koshigaya City, Saitama, Japan.
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Mickelson JK, Ali MN, Kleiman NS, Lakkis NM, Chow TW, Hughes BJ, Smith CW. Chimeric 7E3 Fab (ReoPro) decreases detectable CD11b on neutrophils from patients undergoing coronary angioplasty. J Am Coll Cardiol 1999; 33:97-106. [PMID: 9935015 DOI: 10.1016/s0735-1097(98)00532-4] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The purpose of this study was to monitor the effects of chimeric 7E3 Fab (ReoPro) on leukocyte and platelet activation and interaction during coronary angioplasty. BACKGROUND Increased expression of CD11b on monocytes and neutrophils promotes their adhesion to endothelial cells, extracellular matrix and smooth muscle cells. Thrombin-activated platelets adhere via P-selectin to monocytes and neutrophils. These cell interactions may affect the outcome of coronary angioplasty. METHODS During coronary angioplasty, venous blood was obtained for flow cytometric detection of leukocyte CD11b; platelet CD41a, CD61a and CD62P; the percentage of leukocytes with adherent platelets and the intensity of bound platelet fluorescence. RESULTS Leukocyte CD11b expression increased after angioplasty in control patients (neutrophils 171+/-25 to 255+/-31 mean fluorescence intensity [MFI, mean+/-SEM], n=25, p < 0.0001; monocytes 200+/-40 to 248+/-36 MFI, n=17, p < 0.05) and decreased in the patients selected to receive chimeric 7E3 Fab (neutrophils 146+/-30 to 82+/-22 MFI, n=25, p < 0.0001; monocytes 256+/- 53 to 160+/-38 MFI, n= 17, p < 0.05). Neutrophil CD11b decreased after in vitro incubation of whole blood with chimeric 7E3 Fab (n=5, p=0.01), but fMLP-induced increases in CD11b were not prevented. The CD11b expression was unchanged and increased with fMLP stimulation after in vitro incubation of isolated neutrophils with chimeric 7E3 Fab. Direct-labeled chimeric 7E3 Fab was not detected bound to neutrophils in whole blood or isolated cells using flow cytometric techniques. Adhesion of isolated neutrophils to protein-coated glass was not prevented by in vitro incubation with chimeric 7E3 Fab. Platelet activation increased after angioplasty in control patients (CD62P 8.9+/-0.8 to 12.3+/-1.2 MFI, n=25, p < 0.05; CD41a 382+/-25 to 454+/-26 MFI, n=25, p < 0.05, CD61a 436+/-52 to 529+/-58 MFI, n=11, p < 0.05); it did not increase in the patients selected to receive chimeric 7E3 Fab (CD62P 13.2+/-1.0 to 9.0+/-0.9 MFI, n=25, p < 0.05; CD61a 398+/-32 to 410+/-38 MFI, n=7, p=NS). Leukocytes with adherent platelets tended to increase in the control group of patients and decrease after the procedure in patients selected to receive chimeric 7E3 Fab; individual and procedure-related variability were marked. CONCLUSIONS Despite standard aspirin and heparin therapy, leukocyte and platelet activation with platelet adherence to leukocytes occurs after coronary angioplasty. Although chimeric 7E3 Fab does not bind to leukocytes directly, it influences CD11b expression in whole blood. Modulation of platelet and leukocyte activation and interaction by chimeric 7E3 Fab may contribute to an improved outcome after coronary angioplasty.
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Affiliation(s)
- J K Mickelson
- Department of Medicine, Baylor College of Medicine, Veterans Administration Medical Center, Houston, Texas 77030, USA
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Watkins MW, Luetmer PA, Schneider DJ, Witmer WT, Vaitkus PT, Sobel BE. Determinants of rebound thrombin activity after cessation of heparin in patients undergoing coronary interventions. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1998; 44:257-64. [PMID: 9676792 DOI: 10.1002/(sici)1097-0304(199807)44:3<257::aid-ccd2>3.0.co;2-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
This study was designed to characterize hemostatic activation (using fibrinopeptide A (FPA), a marker of thrombin activity, and beta-thromboglobulin (BTG), a marker of platelet activation) sequentially in the coronary and peripheral circulation in patients during percutaneous coronary intervention (PCI) and several hours after PCI and discontinuation of heparin therapy. Heparin administered during PCI is known to nonuniformly suppress thrombin activity in the coronary. Persistent elevations of FPA in coronary sinus (CS) blood during PCI have been associated with subsequent ischemic events. As a related consideration, rebound thrombin activity has been demonstrated in peripheral blood samples several hours after cessation of heparin therapy in patients with acute coronary syndromes. Accordingly, we hypothesized that increased thrombin activity occurs in the coronary circulation after PCI and is induced by cessation of intravenous heparin to facilitate vascular sheath removal. Such a rebound prothrombotic effect, may contribute to suboptimal outcomes after PCI. In 21 patients undergoing PCI, heparin-bonded catheters were employed to obtain sequential CS and femoral vein (FV) blood samples for measurement in the coronary and peripheral circulation of plasma FPA, a marker of thrombin activity in vivo, and BTG released by platelets during degranulation. Following heparin administration samples were obtained immediately prior to (base) and during (start and end) PCI. Late samples were obtained several hours after PCI (284 +/- 46 min, mean +/- SD) following the cessation of heparin and prior to planned vascular sheath removal. Mean FPA concentration in CS blood was low at baseline (3.82 +/- 2.09 ng/ml) and did not increase during PCI. Mean FPA concentration in CS blood increased significantly several hours after cessation of heparin (3.42 +/- 2.36 vs. 7.82 +/- 9.98, end vs. late, P < 0.001). In contrast, mean FPA concentration in FV blood was highest at baseline following vascular sheath insertion, decreased during PCI (69%, P < 0.05, base vs. end), and trended upward after PCI and cessation of heparin. Mean FPA values were higher at all times in FV compared with CS blood samples and were not concordant after PCI. Elevation of coronary circulation FPA after PCI was maximal in patients with myocardial infarction within 7 days (13.7 +/- 12.4 vs. 5.6 +/- 7.9 ng/ml, P = 0.08), but was not influenced by heparin treatment prior to PCI, a history of unstable angina, or coronary stent placement during PCI (9 of 21 patients). BTG values showed less variation than did FPA values, and cessation of heparin after PCI was not associated with an increase in BTG in CS or FV blood samples. An increase in thrombin activity occurs in the coronary circulation after PCI following discontinuation of heparin. The extent of increased thrombin activity was greatest in patients with recent myocardial infarction and was not exacerbated by coronary stent placement during PCI. This phenomenon may contribute to the important minority of ischemic complications early after PCI.
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Affiliation(s)
- M W Watkins
- Cardiology Unit, Fletcher Allen Health Care, University of Vermont College of Medicine, Burlington 05401, USA
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