Increased restenosis in diabetes mellitus after coronary interventions is due to exaggerated intimal hyperplasia. A serial intravascular ultrasound study

Dynamin-related protein 1 mediates the therapeutic effect of isoliquiritigenin in diabetic intimal hyperplasia via regulation of mitochondrial fission

Phenotypic shift of vascular smooth muscle cells (VSMCs) plays a key role in intimal hyperplasia, especially in patients with diabetes mellitus (DM). This study aimed to investigate the role of dynamin-related protein 1 (DRP1) in mitochondrial fission-mediated VSMC phenotypic shift and to clarify whether DRP1 is the therapeutic target of isoliquiritigenin (ISL). Wire injury of carotid artery or platelet-derived growth factor treatment was performed in DM mice or high-glucose cultured human aortic smooth muscle cells (HASMCs), respectively. The effects of DRP1 silencing on DM-induced intimal hyperplasia were investigated both in vivo and in vitro. Phenotypic shift of HASMCs was evaluated by detection of reactive oxygen species (ROS) generation, cell viability, and related protein expressions. The effects of ISL on DM-induced intimal hyperplasia were evaluated both in vivo and in vitro. DRP1 silencing and ISL treatment attenuated DM-induced intimal hyperplasia with reduced ROS generation, cell viability, and VSMC dedifferentiation. The GTPase domain of DRP1 protein played a critical role in mitochondrial fission in DM-induced VSMC phenotypic shift. Cellular experiments showed that ISL inhibited mitochondrial fission and reduced the GTPase activity of DRP1, which was achieved by the directly binding to K216 of the DRP1 GTPase domain. ISL attenuated mouse intimal hyperplasia by reducing GTPase activity of DRP1 and inhibiting mitochondrial fission in vivo. In conclusion, increased GTPase activity of DRP1 aggregated DM-induced intimal hyperplasia by increasing mitochondrial fission-mediated VSMC phenotypic shift. ISL attenuated mouse intimal hyperplasia by reducing DRP1 GTPase activity and inhibiting mitochondrial fission of VSMCs.

Prevalence, clinical characteristics, and long-term outcomes of new diabetes diagnosis in elderly patients undergoing percutaneous coronary intervention

Previous studies have reported associations between newly diagnosed diabetes and poor outcomes after percutaneous coronary intervention (PCI), but there is limited data focusing on elderly patients (age ≥ 65). This study aimed to analyze the prevalence and clinical implications of newly diagnosed diabetes in elderly patients who underwent PCI. From 2004 to 2021, a total of 2456 elderly patients who underwent invasive PCI at Korea University Guro Hospital were prospectively enrolled and followed up for a median of five years. The primary endpoint was five-year major adverse cardiovascular events (MACE). Cox regression was used to evaluate whether newly diagnosed diabetes impacted on long-term clinical outcomes. Newly diagnosed diabetes was presented in approximately 8.1% to 10.9% of elderly patients who underwent PCI. Those who had a new diagnosis of diabetes had a higher risk of MACE than previously known diabetes (25.28% vs. 19.15%, p = 0.039). After adjusting for significant factors, newly diagnosed diabetes remained an independent predictor of MACE (HR [hazard ratio] 1.64, 95% confidence interval [CI] 1.24-2.17, p < 0.001), cardiac death (HR 2.15, 95% CI 1.29-3.59, p = 0.003) and repeat revascularization (HR 1.52, 95% CI 1.09-2.11, p = 0.013), but not for non-fatal myocardial infarction (HR 1.66, 95% CI 0.94-2.12, p = 0.081). Newly diagnosed diabetes was associated with an increased risk of 5-year MACE compared with non-diabetes and previously diagnosed diabetes in elderly patients underwent PCI. More attention should be given to those elderly newly diagnosed diabetes population.

The Role of TGF-β Signaling in Saphenous Vein Graft Failure after Peripheral Arterial Disease Bypass Surgery

Saphenous vein bypass grafting is an effective technique used to treat peripheral arterial disease (PAD). However, restenosis is the major clinical challenge for the graft vessel among people with PAD postoperation. We hypothesize that there is a common culprit behind arterial occlusion and graft restenosis. To investigate this hypothesis, we found TGF-β, a gene specifically upregulated in PAD arteries, by bioinformatics analysis. TGF-β has a wide range of biological activities and plays an important role in vascular remodeling. We discuss the molecular pathway of TGF-β and elucidate its mechanism in vascular remodeling and intimal hyperplasia, including EMT, extracellular matrix deposition, and fibrosis, which are the important pathways contributing to stenosis. Additionally, we present a case report of a patient with graft restenosis linked to the TGF-β pathway. Finally, we discuss the potential applications of targeting the TGF-β pathway in the clinic to improve the long-term patency of vein grafts.

Long-term outcome and factors associated with restenosis after combination therapy of balloon angioplasty and stenting for symptomatic intracranial stenosis

BACKGROUND

The optimal treatment for intracranial artery stenosis (ICAS) has not been established. We retrospectively examined the initial and long-term outcomes associated with restenosis of a combination therapy of balloon angioplasty and stenting for symptomatic atherosclerotic ICAS.

METHODS

Consecutive patients who underwent balloon angioplasty and/or stenting for ≥ 70% ICAS between 2006 and 2020 were analyzed. Patients within 48 h of stroke onset were excluded. The following procedures were established as standards at our institution: (1) primary balloon angioplasty alone was initially performed; (2) stenting for insufficient dilatation, recoiling, or dissection was conducted; and (3) stenting was considered for restenosis. Intracranial ischemic and hemorrhagic complications within 30 days after treatment were used to evaluate periprocedural safety. Recurrent ischemic events, restenosis and restenosis related factors were used to be evaluate the long-term outcome.

RESULTS

A total of 160 patients were recruited. Initial treatment consisted of balloon angioplasty (n = 101) and stenting (n = 59). Intracranial complications within 30 days after treatment were ischemic in five (3.1%) and hemorrhagic in four patients (2.5%). The incidence of these complication was 3.1% in the stenting group and 2.5% in the balloon angioplasty group. The mean follow-up period was 53.9 months. Restenosis was found in 42 patients (26%). Recurrent ischemic events during follow-up were noted in 14 patients (8.8%), of which six patients had TIA and eight patients had ischemic stroke. Restenosis-associated factors included diabetes, coronary artery disease, percent stenosis after treatment, and balloon angioplasty in logistic univariate analysis. Multivariate Cox regression analysis showed that diabetes (HR: 2.084, CI: 1.039-4.180, p = 0.0386), length of lesion (HR; 1.358, CI: 1.174-1.571, p < 0.0001), and balloon angioplasty (HR: 4.194, CI: 1.083-16.239, p = 0.0379) were independent predictors for restenosis.

CONCLUSION

Combination therapy of balloon angioplasty and stenting for symptomatic ICAS had a low perioperative stroke rate and may improve long-term outcome. Balloon angioplasty, diabetes, and length of lesion were significantly associated with restenosis.

FAK Activation Promotes SMC Dedifferentiation via Increased DNA Methylation in Contractile Genes

Rationale: Vascular smooth muscle cells (SMCs) exhibit remarkable plasticity and can undergo dedifferentiation upon pathological stimuli associated with disease and interventions. Objective: Although epigenetic changes are critical in SMC phenotype switching, a fundamental regulator that governs the epigenetic machineries regulating the fate of SMC phenotype has not been elucidated. Methods and Results: Using SMCs, mouse models, and human atherosclerosis specimens, we found that focal adhesion kinase (FAK) activation elicits SMC dedifferentiation by stabilizing DNA methyltransferase 3A (DNMT3A). FAK in SMCs is activated in the cytoplasm upon serum stimulation in vitro or vessel injury and active FAK prevents DNMT3A from nuclear FAK-mediated degradation. However, pharmacological or genetic FAK catalytic inhibition forced FAK nuclear localization, which reduced DNMT3A protein via enhanced ubiquitination and proteasomal degradation. Reduced DNMT3A protein led to DNA hypomethylation in contractile gene promoters, which increased SMC contractile protein expression. RNA sequencing identified SMC contractile genes as a foremost upregulated group by FAK inhibition from injured femoral artery samples compared to vehicle group. DNMT3A knockdown in injured arteries reduced DNA methylation and enhanced contractile gene expression supports the notion that nuclear FAK-mediated DNMT3A degradation via E3 ligase TRAF6 drives differentiation of SMCs. Furthermore, we observed that SMCs of human atherosclerotic lesions exhibited decreased nuclear FAK, which was associated with increased DNMT3A levels and decreased contractile gene expression. Conclusions: This study reveals that nuclear FAK induced by FAK catalytic inhibition specifically suppresses DNMT3A expression in injured vessels resulting in maintaining SMC differentiation by promoting the contractile gene expression. Thus, FAK inhibitors may provide a new treatment option to block SMC phenotypic switching during vascular remodeling and atherosclerosis.

Predictors of outcome in diabetic patients undergoing infrapopliteal endovascular revascularization for chronic limb-threatening ischemia

OBJECTIVE

The incidence of chronic limb-threatening ischemia in diabetic patients is increasing. The factors influencing outcome after infrapopliteal revascularization in these patients are largely unknown. Therefore, this study aims to identify the impact of perioperative glucose control on the long-term outcomes in this patient cohort, and furthermore to identify other factors independently associated with outcome.

METHODS

Consecutive diabetic patients undergoing infrapopliteal endovascular revascularization for chronic limb-threatening ischemia were identified. Patients' demographics, procedural details, daily capillary blood glucose, and hemoglobin A1C levels were collected and analyzed against the study end points using Kaplan-Meier and Cox regression analysis.

RESULTS

A total of 437 infrapopliteal target vessels were successfully crossed in 203 patients. Amputation-free survival by Kaplan-Meier (estimate (standard error)%) was 74 (3.3)% and 63 (3.7)%, primary patency was 61 (4.2)% and 50 (4.9)%, assisted primary patency was 69 (5.2)% and 55 (6.1)%, and secondary patency was 71 (3.8)% and 59 (4.1)% at 1 year and 2 years, respectively. Cox regression analysis showed high perioperative capillary blood glucose levels to be an independent predictor of binary restenosis (hazard ratio [HR], 1.49; 95% confidence interval [CI], 1.31-1.1.78; P = .015). Postprocedural dual-antiplatelet therapy was found to be an independent predictor of amputation-free survival (HR, 1.69; 95% CI, 1.04-2.75; P = .033), and freedom from major adverse limb events (HR: 1.96; 95% CI, 1.16-3.27; P = .023) and baseline estimated glomerular filtration rate was significantly associated with better amputation-free survival (HR, 0.52; 95% CI, 0.31-0.87; P = .014).

CONCLUSIONS

Poor perioperative glycemic control is associated with a higher incidence of restenosis after infrapopliteal revascularization in diabetic patients. Dual antiplatelet therapy is associated with better outcomes in this group.

Anti-Diabetic Effects of Isolated Lipids from Natural Sources through Modulation of Angiogenesis

BACKGROUND

Aberrant angiogenesis plays a fateful role in the development of diabetes and diabetic complications. Lipids, as a diverse group of biomacromolecules, are able to relieve diabetes through the modulation of angiogenesis.

OBJECTIVE

Owing to the present remarkable anti-diabetic effects with no or few side effects of lipids, the aim of this study was to assess the state-of-the-art research on anti-diabetic effects of lipids via the modulation of angiogenesis.

METHODS

To study the effects of lipids in diabetes via modulation of angiogenesis, we have searched the electronic databases including Scopus, PubMed, and Cochrane.

RESULTS

The promising anti-diabetic effects of lipids were reported in several studies. Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) from fish oil (FO) were reported to significantly induce neovasculogenesis in high glucose (HG)-mediated endothelial progenitor cells (EPCs) neovasculogenic dysfunction in type 2 diabetic mice. Linoleic acid, mono-epoxy-tocotrienol-α (MeT3α), and ginsenoside Rg1 facilitate wound closure and vessel formation. N-Palmitoylethanolamine (PEA), α-linolenic acid (ALA), omega-3 (ω3) lipids from flaxseed (FS) oil, ω-3 polyunsaturated fatty acids (PUFA), lipoic acid, taurine, and zeaxanthin (Zx) are effective in diabetic retinopathy via suppression of angiogenesis. Lysophosphatidic acid, alkyl-glycerophosphate, crocin, arjunolic acid, α-lipoic acid, and FS oil are involved in the management of diabetes and its cardiac complications. Furthermore, in two clinical trials, R-(+)-lipoic acid (RLA) in combination with hyperbaric oxygenation therapy (HBOT) for treatment of chronic wound healing in DM patients, as well as supplementation with DHA plus antioxidants along with intravitreal ranibizumab were investigated for its effects on diabetic macular edema.

CONCLUSION

Proof-of-concept studies presented here seem to well shed light on the anti-diabetic effects of lipids via modulation of angiogenesis.

Primary Percutaneous Coronary Intervention in Patients With Type 2 Diabetes With Late/Very Late Stent Thrombosis and de novo Lesions: A Single-Center Observational Cohort Study of Clinical Outcomes and Influencing Factors

Background: This study compared differences in the risk factors and clinical outcomes of primary percutaneous coronary intervention (PCI) in type 2 diabetes mellitus (DM) and non-DM patients with de novo lesions (DNLs) and late or very late stent thrombosis (LST/VLST).

Methods: We used angiography to screen 4,151 patients with acute coronary syndrome for DNL and LST/VLST lesions. Overall, 3,941 patients were included in the analysis and were allocated to the DM (n = 1,286) or non-DM (n = 2,665) group at admission. The primary endpoint was a composite of major adverse cardiovascular events (MACEs), defined as death, myocardial infarction, revascularization, and ischemic stroke, within a median follow-up period of 698 days.

Results: In the group with a total white blood cell count >10 × 10⁹/L (P = 0.004), a neutral granular cell count >7 × 10⁹/L (P = 0.030), and neutrophil–lymphocyte ratio >1.5 (P = 0.041), revascularization was better for DNL than for LST/VLST lesions. Among DM patients with DNLs, each unit increase in age was associated with a 53.6% increase in the risk of MACEs [hazard ratio (HR): 1.536, 95% confidence interval (CI), 1.300–1.815, P < 0.0001]. Older age (≥65 years) was associated with a significantly greater risk of MACEs (P < 0.0001). Furthermore, each standard deviation (SD) increase in the level of peak white blood cell counts was associated with a 50.1% increase in the risk of MACEs (HR, 1.501; 95% CI, 1.208–1.864; P = 0.0002). When stratifying the DM population with DNLs according to the D-dimer baseline and peak levels <0.5 vs. ≥0.5 mg/L, the high D-dimer group at baseline had a 2.066-fold higher risk of MACEs (P < 0.0001), and the high peak level D-dimer group had a 1.877-fold higher risk of MACEs (P = 0.001) compared to the low-level groups. Among DM patients with LST/VLST, each unit increase in age was associated with a 75.9% increase in the risk of MACEs (HR: 1.759, 95% CI, 1.052–2.940, P = 0.032). Furthermore, for each SD increase in the peak D-dimer level, the risk of MACEs increased by 59.7% (HR, 1.597; 95% CI, 1.110–2.295; P = 0.041).

Conclusion: Following successful primary PCI, the measurement of baseline and peak D-dimer values may help identify individuals at high cardiovascular risk. This suggests a potential benefit of lowering D-dimer levels among T2DM patients with DNL. Furthermore, age and the peak D-dimer values may facilitate the risk stratification of T2DM patients with LST/VLST.

The role of intravascular ultrasound in percutaneous coronary intervention of complex coronary lesions

Intravascular ultrasound (IVUS) is a catheter-based coronary imaging technique. It utilises the emission & subsequent detection of reflected high frequency (30-60 MHz) sound waves to create high resolution, cross-sectional images of the coronary artery. IVUS has been the cornerstone of intracoronary imaging for more than two decades. When compared to the invasive coronary angiogram which studies only the silhouette of the contrast-filled artery lumen, IVUS also crucially images the vessel wall. Because of this capability, IVUS has greatly facilitated understanding of the coronary atherosclerosis process. Such insights from IVUS reveal how commonly and extensively plain angiography underestimates the true extent of coronary plaque, the characteristics of plaques prone to rupture and cause acute coronary syndromes (lipid rich, thin cap atheroma), and a realisation of the widespread occurrence of vessel remodelling in response to atherosclerosis. Similarly, IVUS has historically provided salutary mechanistic insights that have guided many of the incremental advances in the techniques of percutaneous coronary intervention (PCI). Examples include mechanisms of in-stent restenosis, and the importance of high-pressure post-dilatation of stents to ensure adequate stent apposition and thereby reduce the occurrence of stent thrombosis. IVUS also greatly facilitates the choice of correct diameter and length of stent to implant. Overall, a compelling body of evidence indicates that use of intravascular ultrasound in PCI helps to achieve optimal technical results and to mitigate the risk of adverse cardiac events. In this review, the role of intravascular ultrasound as an adjunct to PCI in complex coronary lesions is explored. The complex coronary situations discussed are the left main stem, ostial stenoses, bifurcation stenoses, thrombotic lesions, the chronically occluded coronary artery, and calcified coronary artery disease. By thorough review of the available evidence, we establish that the advantages of IVUS guidance are particularly evident in each of these complex CAD subsets. In particular, some consider the use of IVUS to be almost mandatory in left main PCI. A comparison with other intracoronary imaging techniques is also explored.

Abluminus DES+ for the treatment of coronary artery disease in patients with diabetes mellitus

Diabetes mellitus (DM) is a rising global epidemic affecting more than 10% of the world population and predisposes patients to develop highly progressive and complex coronary artery disease. Despite numerous advancements in percutaneous coronary intervention procedural techniques and coronary stent platforms, clinical outcomes in DM patients have improved little compared with non-DM patients. Abluminus DES+, a biodegradable polymer sirolimus-eluting stent deployed with a drug-coated balloon, has been specifically designed to provide adequate coverage for DM patients and reduce adverse clinical outcomes.

Treating diabetic all-comers with contemporary drug-eluting stents: Prespecified comparisons from the BIO-RESORT and the BIONYX randomized trials

BACKGROUND

Patients with diabetes have more extensive coronary disease, resulting in higher risks of adverse clinical events following stenting. In all-comer patients, contemporary DES have shown excellent safety and efficacy, but data on diabetic patients are scarce. Separately for the BIO-RESORT and BIONYX trials, we assessed the 2-year clinical outcomes of diabetic patients, treated with various contemporary drug-eluting stents (DES).

METHODS

We performed two prespecified secondary analyses of two randomized DES trials, which both stratified for diabetes. The main endpoint was target vessel failure (TVF), a composite of cardiac death, target vessel myocardial infarction, or target vessel revascularization. Follow-up was finished before the COVID-19 pandemic.

RESULTS

In BIO-RESORT, 624/3514 (17.8%) had diabetes: 211 received Orsiro sirolimus-eluting stents (SES), 203 Synergy everolimus-eluting stents (EES), and 210 Resolute Integrity zotarolimus-eluting stents (RI-ZES). TVF did not differ between SES (10.2%) and EES (10.0%) versus RI-ZES (12.7%) (SES vs. RI-ZES HR:0.78, 95%-CI [0.44-1.40]; p = 0.40, EES vs. RI-ZES HR:0.79, 95%-CI [0.44-1.40]; p = 0.42). In BIONYX, 510/2488 (20.5%) patients had diabetes: 250 received SES and 260 Resolute Onyx zotarolimus-eluting stents (RO-ZES). There was no difference in TVF between SES (10.7%) versus RO-ZES (12.2%) (HR:0.88, 95%-CI [0.52-1.48]; p = 0.63).

CONCLUSIONS

There was no difference in 2-year clinical outcome among patients with diabetes, who were treated with SES, or EES, versus RI-ZES. In addition there was no difference in clinical outcome in diabetic patients, who were treated with SES versus RO-ZES. These findings may be considered as a signal of safety and efficacy of the studied DES in patients with diabetes.

Restoring the Platelet miR-223 by Calpain Inhibition Alleviates the Neointimal Hyperplasia in Diabetes

Platelet hyperactivity is the hallmark of diabetes, and platelet activation plays a crucial role in diabetic vascular complications. Recent studies have shown that upon activation, platelet-derived miRNAs are incorporated into vascular smooth muscle cells (VSMCs), regulating the phenotypic switch of VSMC. Under diabetes, miRNA deficiency in platelets fails to regulate the VSMC phenotypic switch. Therefore, manipulation of platelet-derived miRNAs expression may provide therapeutic option for diabetic vascular complications. We seek to investigate the effect of calpeptin (calpain inhibitor) on the expression of miRNAs in diabetic platelets, and elucidate the downstream signaling pathway involved in protecting from neointimal formation in diabetic mice with femoral wire injury model. Using human cell and platelet coculture, we demonstrate that diabetic platelet deficient of miR-223 fails to suppress VSMC proliferation, while overexpression of miR-223 in diabetic platelets suppressed the proliferation of VSMC to protect intimal hyperplasia. Mechanistically, miR-223 directly targets the insulin-like growth factor-1 receptor (IGF-1R), which inhibits the phosphorylation of GSK3β and activates the phosphorylation of AMPK, resulting in reduced VSMC dedifferentiation and proliferation. Using a murine model of vascular injury, we show that calpeptin restores the platelet expression of miR-223 in diabetes, and the horizontal transfer of platelet miR-223 into VSMCs inhibits VSMC proliferation in the injured artery by targeting the expression of IGF-1R. Our data present that the platelet-derived miR-223 suppressed VSMC proliferation via the regulation miR-223/IGF-1R/AMPK signaling pathways, and inhibition of calpain alleviates neointimal formation by restoring the expression of miR-223 in diabetic platelet.

Impact of glycemic control status on patients with ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention

Background

The combined effects of diabetes mellitus (DM), admission plasma glucose (APG), and glycated hemoglobin (HbA1c) levels on predicting long-term clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI) are unknown. Therefore, we evaluated their combined effects on long-term clinical outcomes in STEMI patients treated with pPCI.

Methods

In total, 350 consecutive patients with STEMI undergoing pPCI were enrolled. Patients were divided into 3 groups according to DM history and APG and HbA1c levels. The cumulative rates of 24-month all-cause deaths and major adverse cardiac and cerebrovascular events (MACCEs) were calculated.

Results

Both the incidence of all-cause deaths and cumulative rates of MACCEs were significantly the lowest in patients without a DM history and admission HbA1c level < 6.5%. DM patients with poor glycemic control or stress hyperglycemia on admission experienced the highest rates of all-cause deaths, MACCEs, and cardiac deaths. Admission HbA1c levels, Triglyceride (TG) levels, hemoglobin levels, DM history, and admission Killip class > 1 correlated with 24-month all-cause death; HbA1c levels on admission, DM history, APG levels, history of stroke, history of coronary heart disease, and TG levels on admission were significantly associated with MACCEs through the 24-month follow-up. The predictive effects of combining DM and APG and HbA1c levels were such that for STEMI patients undergoing pPCI, DM patients with poor glycemic control or with stress hyperglycemia on admission had worse prognosis than other patients.

Conclusion

Strict control of glycemic status may improve the survival of patients who have both DM and coronary heart diseases.

Long-term impact of diabetes in patients with ST-segment elevation myocardial infarction: Insights from the EXAMINATION randomized trial

BACKGROUND

Long-term outcomes of diabetic patients suffering from ST-segment elevation myocardial infarction (STEMI) and treated with second-generation drug-eluting stent have been scarcely evaluated. The aim of this posthoc subanalysis of the EXAMINATION trial was to compare 5-year outcomes according to the presence of diabetes mellitus.

METHODS

From a total of 1,497 patients included in the trial, 258 were diabetics (n = 137, received everolimus-eluting stent (EES) and n = 121 bare-metal stent (BMS); whereas 1,239 were nondiabetics (n = 613 treated with EES and n = 626 with BMS). Patient-oriented combined endpoint (POCE) defined as all-cause death, any MI or any revascularization, and other clinical parameters were collected up to 5-years. All results were adjusted for various potential confounders.

RESULTS

At 5-years, patients with diabetes showed similar rates of POCE between diabetics treated with EES and those treated with BMS (32.8% vs. 32.2%; p = 0.88). However, rates of TLR were significantly lower in the EES group (4.4% vs. 9.9%; HR 0.52 (0.29-0.94); P = 0.03). In non-diabetics, the use of EES was associated with a significant improvement in all-clinical parameters except for MI rate: POCE: [10.0% vs. 12.6%; HR 0.78(0.62-0.98); P = 0.038], all cause death: [7.0% vs. 12.1%; HR 0.62(0.42-0.90); P = 0.014], and [TLR: 4.2 vs. 6.7; HR 0.60 (0.37-0.98); P = 0.04]. Overall, diabetics showed higher rate of POCE at 5-years (32.6% vs. 21.5% in nondiabetics HR1.45[1.03-2.04];p = 0.03) driven by increased rates of MI and the need for revascularization that occurred in coronary segments remote from target lesions [2.7% vs. 1.1%; HR: 2.27 (1.12-5.23); P = 0.02 and 14% vs. 6.2%; HR: 2.11 (1.38-3.22); P = 0.001, respectively].

CONCLUSIONS

Diabetics had worse clinical outcomes than nondiabetics after STEMI mainly due to atherosclerosis progression. At 5-years, the treatment with EES did not reduce the rate of POCE in diabetics but reduced the need for revascularization compared with BMS.

Approaches to treatment effect heterogeneity in the presence of confounding

The literature on causal effect estimation tends to focus on the population mean estimand, which is less informative as medical treatments are becoming more personalized and there is increasing awareness that subpopulations of individuals may experience a group-specific effect that differs from the population average. In fact, it is possible that there is underlying systematic effect heterogeneity that is obscured by focusing on the population mean estimand. In this context, understanding which covariates contribute to this treatment effect heterogeneity (TEH) and how these covariates determine the differential treatment effect (TE) is an important consideration. Towards such an understanding, this paper briefly reviews three approaches used in making causal inferences and conducts a simulation study to compare these approaches according to their performance in an exploratory evaluation of TEH when the heterogeneous subgroups are not known a priori. Performance metrics include the detection of any heterogeneity, the identification and characterization of heterogeneous subgroups, and unconfounded estimation of the TE within subgroups. The methods are then deployed in a comparative effectiveness evaluation of drug-eluting versus bare-metal stents among 54 099 Medicare beneficiaries in the continental United States admitted to a hospital with acute myocardial infarction in 2008.

Prognostic Value of Hemoglobin A1c Levels in Postmenopausal Diabetic Patients Undergoing Percutaneous Coronary Intervention (PCI) for Acute Coronary Syndrome

Background

The purpose of our study was to analyze the clinical value of glycosylated hemoglobin Alc (HbA1c) levels in postmenopausal women with acute coronary syndrome (ACS) and diabetes following percutaneous coronary intervention (PCI).

Material/Methods

A total of 173 consecutive postmenopausal patients with comorbid diabetes underwent PCI for primary ACS were enrolled in this study. Serum HbA1c levels were measured prior to PCI, and baseline clinical characteristics of all patients were collected. All patients were followed up at regular intervals for major adverse cardiovascular events (MACEs) during the first year after PCI. MACEs included cardiac death, non-fatal myocardial infarction, and target vessel revascularization (TVR).

Results

At the endpoint of this study, 29 (16.8%) patients out of all 173 patients had MACEs. According to the effect of glycemic control (as indicated by HbA1c levels), all patients were stratified into a well-controlled group (HbA1c ≤7.0%, N=72) and a poorly-controlled group (HbA1c >7.0%, N=101). The incidence rate of MACEs and TVR in poorly-controlled diabetics was prominently higher than that in well-controlled diabetics (10.8% vs. 21.8%, p=0.04). In multivariable COX regression analysis, after adjustment for potential confounders, HbA1c ≥7.0% remained an independent risk predictor of MACE (HR, 2.17; 95%CI, 1.13–5.65; p<0.01).

Conclusions

In postmenopausal ACS patients with comorbid diabetes, a high level of HbA1c is associated with a higher MACE rate after PCI, which is mainly driven by a higher rate of TVR.

Genetics, coronary artery disease, and myocardial revascularization: will novel genetic risk scores bring new answers?

Both percutaneous coronary intervention (PCI) and coronary artery bypass graft surgery (CABG) are options for revascularization in multi-vessel coronary artery disease (CAD). However, the best form of revascularization remains controversial. Results from clinical trials (FREEDOM, SYNTAX, NOBLE, EXCEL) have identified factors related to CAD severity such as diabetes and SYNTAX score as indicators that patients may have better outcomes with CABG compared to PCI. Nevertheless, the discovery of other predictors of optimal revascularization therapy is necessary to improve decision-making and personalize the treatment of multi-vessel CAD. Genome-wide association studies have identified numerous previously unknown DNA variants that increase predisposition for CAD. Recently, a composite polygenic risk score has been developed to better assess the relative contribution of multiple SNPs and quantify overall genetic risk for CAD. High polygenic risk score is associated with increased coronary events and greater benefit from statin therapy in large observational studies. This effect is independent from traditional cardiovascular risk factors. At the same time, randomized clinical trials have shown that CAD severity is a determinant of optimal revascularization treatment. It remains unknown whether polygenic risk score is robustly associated with increased CAD severity at presentation, and whether this score can be used to identify patients who will show greater benefit from revascularization with CABG or with PCI.

Lipoxins Protect Against Inflammation in Diabetes-Associated Atherosclerosis

Increasing evidence points to the fact that defects in the resolution of inflammatory pathways predisposes individuals to the development of chronic inflammatory diseases, including diabetic complications such as accelerated atherosclerosis. The resolution of inflammation is dynamically regulated by the production of endogenous modulators of inflammation, including lipoxin A4 (LXA₄). Here, we explored the therapeutic potential of LXA₄ and a synthetic LX analog (Benzo-LXA₄) to modulate diabetic complications in the streptozotocin-induced diabetic ApoE^-/- mouse and in human carotid plaque tissue ex vivo. The development of diabetes-induced aortic plaques and inflammatory responses of aortic tissue, including the expression of vcam-1, mcp-1, il-6, and il-1β, was significantly attenuated by both LXA₄ and Benzo-LXA₄ in diabetic ApoE^-/- mice. Importantly, in mice with established atherosclerosis, treatment with LXs for a 6-week period, initiated 10 weeks after diabetes onset, led to a significant reduction in aortic arch plaque development (19.22 ± 2.01% [diabetic]; 12.67 ± 1.68% [diabetic + LXA₄]; 13.19 ± 1.97% [diabetic + Benzo-LXA₄]). Secretome profiling of human carotid plaque explants treated with LXs indicated changes to proinflammatory cytokine release, including tumor necrosis factor-α and interleukin-1β. LXs also inhibited platelet-derived growth factor-stimulated vascular smooth muscle cell proliferation and transmigration and endothelial cell inflammation. These data suggest that LXs may have therapeutic potential in the context of diabetes-associated vascular complications.

Increased glycated albumin and decreased esRAGE levels in serum are related to negative coronary artery remodeling in patients with type 2 diabetes: an Intravascular ultrasound study

BACKGROUND

Negative coronary artery remodeling is frequent in patients with diabetes, but its mechanism remains unclear. We here evaluated the association of serum levels of glycated albumin (GA) and endogenous secretory receptor for advanced glycation end products (esRAGE) with coronary artery remodeling in type 2 diabetic patients.

METHODS

Serum levels of GA and esRAGE were measured and intravascular ultrasound was performed in 136 consecutive diabetic patients with 143 coronary intermediate lesions. The remodeling index (RI) was calculated as the ratio between external elastic membrane (EEM) area at the lesion site and EEM area at the reference segment. Negative remodeling (NR) was defined as an RI < 0.95 and intermediate or positive remodeling as an RI ≥ 0.95.

RESULTS

Mean plaque burden at the lesion site was 70.96 ± 9.98%, and RI was 0.96 ± 0.18. Negative coronary arterial remodeling existed in 81 (56.6%) lesions. RI correlated closely with serum esRAGE level (r = 0.236, P = 0.005) and was inversely related to serum GA level (r = - 0.240, P = 0.004) and plasma low-density lipoprotein cholesterol (LDL-C) (r = - 0.206, P = 0.014) and total cholesterol levels (r = - 0.183, P = 0.028). Generalized estimating equations logistic regression analysis identified esRAGE (OR 0.037; 95% CI 0.012-0.564, P = 0.021), GA (OR 1.093; 95% CI 1.013-1.179, P = 0.018) and LDL-C (OR 1.479; 95% CI 1.072-2.835, P = 0.023) as independent predictors for negative remodeling.

CONCLUSIONS

In diabetic patients, negative coronary artery remodeling is associated with increased GA and decreased esRAGE levels in serum.

Type-2 diabetes mellitus and cardiovascular disease

The global prevalence of diabetes has risen in adults from 4.7% in 1980 to 8.5% in 2014. 90–95% of adults with diabetes have Type 2 diabetes (T2D). This paper focuses on the diagnosis and treatment of T2D patients who have or are at risk for cardiovascular disease. Hyperglycemia, insulin resistance and excess fatty acids increase oxidative stress, disrupt protein kinase C signaling and increase advanced glycation end-products that result in vascular inflammation, vasoconstriction, thrombosis and atherogenesis. Intensive T2D treatment produces a ≥10% risk reduction in major macrovascular and microvascular events. Glucose-lowering therapies must be individualized. Metformin is an optimal drug for monotherapy. If hemoglobin A1c is not at goal, a sodium-glucose cotransporter-2 inhibitor or a dipeptidyl peptidase-4 inhibitor should be considered for therapy with metformin. Coronary angioplasty/stenting is recommended for diabetic patients with acute myocardial infarctions. Coronary artery bypass grafting is recommended for symptomatic diabetic patients with multivessel disease.

Distal radial arterial hypertrophy after transradial intervention: A serial intravascular ultrasound study

BACKGROUND

Transradial intervention (TRI) may cause damage to the radial artery (RA). We have demonstrated intima-media thickening and luminal narrowing of the distal RA after TRI using intravascular ultrasound (IVUS). This study aimed to determine the predictors of intima-media thickening of RA after TRI in the same patients using serial IVUS.

METHODS AND RESULTS

We enrolled 110 consecutive patients who underwent TRI. IVUS of RA was immediately performed after TRI and repeated 6 months later. Volumetric analyses were performed for the distal RA. The intima-media volume (IMV) increased from 53.56±10.85mm³ to 58.70±13.04mm³ (p=0.0022), whereas the lumen volume (LV) decreased from 146.87±40.53mm³ to 129.64±45.78mm³ (p=0.0018) and vessel volume (VV) decreased from 201.23±44.55mm³ to 188.34±52.25mm³ (p=0.0306). Multiple regression analysis revealed diabetes as the most powerful independent predictor of the percentage change in IMV of the distal RA after TRI. The percentage change in IMV significantly increased in the DM group compared with non-DM group (p<0.001). The percentage change in IMV was significantly positively correlated with HbA1c.

CONCLUSIONS

Serial IVUS of the distal RA revealed a significant increase in IMV and decreases in LV and VV. Diabetes was the most powerful independent predictor of the percentage change in IMV of the distal RA after TRI. The percentage change in IMV was significantly positively correlated with HbA1c.

Genetics of coronary artery disease: should they impact the choice of revascularization?

PURPOSE OF REVIEW

Patients with multivessel coronary artery disease (CAD) may undergo revascularization by either percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG). This review will discuss the use of polygenic risk scores for risk-stratification of patients with multivessel CAD in order to guide the choice of revascularization.

RECENT FINDINGS

A 57-single nucleotide polymorphism (SNP)-polygenic risk score can accurately risk-stratify patients with CAD and identify those who will receive greater benefit from statin therapy. The most recent genomic studies reveal 243 different SNPs are now significantly associated with CAD. Randomized clinical trials comparing PCI vs. CABG (FREEDOM, SYNTAX, NOBLE, EXCEL) have uncovered factors related to CAD severity (diabetes, SYNTAX score) are critical determinants of outcomes after revascularization.

SUMMARY

There is a need to discover predictors of outcomes after PCI vs. CABG to improve clinical decision-making in multivessel CAD. High polygenic risk score is associated with increased CAD severity and better outcomes with statin therapy. Randomized clinical trials indicate CAD severity is associated with better outcomes after CABG compared with PCI. Accordingly, polygenic risk score could also be associated with better outcomes after CABG vs. PCI and used to optimize revascularization for patients with multivessel CAD.

Association of Preexisting Arterial Intimal Hyperplasia with Arteriovenous Fistula Outcomes

BACKGROUND AND OBJECTIVES

Preoperative arterial function is associated with arteriovenous fistula (AVF) development. Because arterial pathology may correlate with its function, preexisting arterial intimal hyperplasia may be associated with AVF development.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Vascular specimens obtained from 125 patients (with minimal 2 mm arterial diameter and 2.5 mm venous diameter) undergoing AVF creation were quantified for arterial intimal hyperplasia, arterial medial fibrosis, arterial microcalcification, and venous intimal hyperplasia. A 6-week postoperative ultrasound quantified AVF diameter, blood flow, and stenosis. Clinical AVF maturation was assessed using a predefined protocol. In a prospective cohort study design, we investigated the association of preexisting arterial intimal hyperplasia with the postoperative AVF diameter, blood flow, stenosis, and clinical maturation failure, after controlling for baseline demographics, comorbidities, and preoperative vein diameter. Additional analyses evaluated whether other vascular pathologies interacted with arterial intimal hyperplasia in affecting AVF outcomes.

RESULTS

The median intimal thickness of the native artery was 22.0 μm (interquartile range, 14.8-37.1 μm). The median postoperative AVF diameter was 4.8 (interquartile range, 3.7-6.8) mm, blood flow was 796 (interquartile range, 413-1036) ml/min, and stenosis was present in 37 out of 98 patients with ultrasound data (38%). AVF nonmaturation occurred in 37 out of 125 patients (30%). Preexisting arterial intimal thickness was not significantly associated with AVF blood flow (-12 ml/min; 95% confidence interval [95% CI], -55 to 30 ml/min), diameter (-0.04 mm; 95% CI, -0.21 to 0.14 mm), stenosis (odds ratio, 0.93; 95% CI, 0.75 to 1.14), or clinical maturation failure (odds ratio, 1.07; 95% CI, 0.90 to 1.28), all per 10 μm increase. There was no significant interaction of preexisting arterial intimal thickness and postoperative AVF outcomes with arterial medial fibrosis, arterial microcalcification, or venous intimal hyperplasia.

CONCLUSIONS

Preexisting arterial intimal hyperplasia is not associated with the 6-week AVF blood flow, diameter or stenosis, or clinical maturation when the preoperative arterial diameter is ≥2 mm.

Statin Therapy and Diabetes Do Not Affect Aneurysm Occlusion or Clinical Outcomes After Pipeline Embolization Device Treatment: A Preliminary Study

BACKGROUND

The effect of statins and diabetes on angiographic and clinical outcomes in aneurysms treated with pipelines has not been adequately reported. Our aim is to assess the effect of concurrent statin medications and diabetes mellitus (DM) on aneurysm occlusion status and outcomes in patients treated with the pipeline embolization device.

METHODS

A retrospective review of our institution's database of aneurysms treated with the pipeline embolization device between 2013 and 2017 was conducted. We collected data about statin therapy status and intensity, and identified patients with a documented history of DM. Our primary outcome was aneurysm obliteration seen on digital subtracted angiography or magnetic resonance angiography at last follow-up.

RESULTS

We identified 151 patients with 182 aneurysms for this cohort, with a median radiographic follow-up time of 7.2 months (6.1-14.5). Thirty-nine patients were taking statins, and 112 patients did not receive statins. Log-rank tests revealed no statistically significant difference in occlusion rates between patients with and without statin therapy (P = 0.30). A history of DM was documented in 11 patients, with 14 aneurysms in total; 140 patients with 168 aneurysms had no history of DM. Similarly, there were no differences in occlusion rates between the diabetic and nondiabetic groups in multivariate analysis (P = 0.24). Only 2 patients showed significant in-stent stenosis on angiographic follow up, and both were diabetic.

CONCLUSIONS

Our analysis did not identify a statistically significant association between statin therapy or DM and higher occlusion rates or better outcomes after pipeline embolization. Diabetic patients may have a theoretic risk of significant in-stent stenosis.

Incidence and Predictors of the In-stent Restenosis after Vertebral Artery Ostium Stenting

BACKGROUND

The incidence and predictors for in-stent restenosis (ISR) was not fully explored. We aim to investigate the incidence and predictors of ISR after stenting at the origin of vertebral artery.

MATERIALS AND METHODS

Two hundred and six patients with 229 stents implantation between July 1, 2005 and July 31, 2015 were included in the study. All patients underwent conventional clinical and angiographic (digital subtraction angiography) follow-up at around 6 months post procedure. ISR was defined as greater than 50% stenosis within or immediately (within 5 mm) adjacent to the stent. Multivariate Cox regression analyses were utilized to investigate the predictors for ISR.

RESULTS

The ISR was found in 30 patients (30/206, 14.6%) with 31 lesions (31/229, 13.5%) with the mean follow-up duration of 11.1-month (range: 3 - 92 months). Stent diameter (hazard ratio 0.504, 95% confidence interval 0.294 - 0.864) was an independent predictor for ISR.

CONCLUSION

ISR rate after Vertebral artery ostium stent placement is acceptable, which was conversely associated with the stent diameter.

PDGF-BB Carried by Endothelial Cell-Derived Extracellular Vesicles Reduces Vascular Smooth Muscle Cell Apoptosis in Diabetes

Endothelial cell-derived extracellular vesicles (CD31EVs) constitute a new entity for therapeutic/prognostic purposes. The roles of CD31EVs as mediators of vascular smooth muscle cell (VSMC) dysfunction in type 2 diabetes (T2D) are investigated herein. We demonstrated that, unlike serum-derived extracellular vesicles in individuals without diabetes, those in individuals with diabetes (D CD31EVs) boosted apoptosis resistance of VSMCs cultured in hyperglycemic condition. Biochemical analysis revealed that this effect relies on changes in the balance between antiapoptotic and proapoptotic signals: increase of bcl-2 and decrease of bak/bax. D CD31EV cargo analysis demonstrated that D CD31EVs are enriched in membrane-bound platelet-derived growth factor-BB (mbPDGF-BB). Thus, we postulated that mbPDGF-BB transfer by D CD31EVs could account for VSMC resistance to apoptosis. By depleting CD31EVs of platelet-derived growth factor-BB (PDGF-BB) or blocking the PDGF receptor β on VSMCs, we demonstrated that mbPDGF-BB contributes to D CD31EV-mediated bak/bax and bcl-2 levels. Moreover, we found that bak expression is under the control of PDGF-BB-mediated microRNA (miR)-296-5p expression. In fact, while PDGF-BB treatment recapitulated D CD31EV-mediated antiapoptotic program and VSMC resistance to apoptosis, PDGF-BB-depleted CD31EVs failed. D CD31EVs also increased VSMC migration and recruitment to neovessels by means of PDGF-BB. Finally, we found that VSMCs, from human atherosclerotic arteries of individuals with T2D, express low bak/bax and high bcl-2 and miR-296-5p levels. This study identifies the mbPDGF-BB in D CD31EVs as a relevant mediator of diabetes-associated VSMC resistance to apoptosis.

Upregulation of miR-221 and -222 in response to increased extracellular signal-regulated kinases 1/2 activity exacerbates neointimal hyperplasia in diabetes mellitus

BACKGROUND AND AIMS

Diabetes is associated with accelerated arterial intimal thickening that contributes to the increased cardiovascular disease seen in this population. In healthy arteries, intimal thickening is inhibited by elevated levels of the cyclin-dependent kinase inhibitor, p27^Kip1, and intimal thickening is promoted by activation of the mammalian Target of Rapamycin to promote degradation of p27^Kip1 protein. Recently, we reported that two microRNAs, miR-221 and -222, which promote intimal thickening via down-regulation of mRNA encoding p27^Kip1, are elevated in the arteries of diabetic patients. To determine if these miRNAs are critical to the increased intimal thickening under diabetic conditions, we examined the regulation of p27^Kip1in a mouse model of diabetes.

METHODS

Comparisons of p27^Kip1 signaling in NONcNZO10 mice fed a diabetogenic versus control diet were performed using immunochemistry and real-time PCR.

RESULTS

Vascular smooth muscle cells and arteries of diabetic mice exhibited decreased levels of p27^Kip1 that derived from destabilization of p27^Kip1 mRNA in an extracellular signal response kinase-1/2 (ERK-1/2) dependent manner. The activity of ERK-1/2 is increased in the arteries of diabetic mice and promotes an increase in miR-221 and -222. Inhibition of miR-221 and -222 restores normal levels of p27^Kip1 mRNA and protein in the arteries of diabetic mice and reduces intimal thickening following wire injury.

CONCLUSIONS

These data suggest diabetes is accompanied by increases in arterial miR-221 and -222 expression that promotes intimal thickening. Inhibition of the increased miR-221 and -222 may be efficacious in the prevention of the cardiovascular complications of diabetes.

Protective Effect of let-7 miRNA Family in Regulating Inflammation in Diabetes-Associated Atherosclerosis

The let-7 miRNA family plays a key role in modulating inflammatory responses. Vascular smooth muscle cell (SMC) proliferation and endothelial cell (EC) dysfunction are critical in the pathogenesis of atherosclerosis, including in the setting of diabetes. Here we report that let-7 levels are decreased in diabetic human carotid plaques and in a model of diabetes-associated atherosclerosis, the diabetic ApoE^-/- mouse. In vitro platelet-derived growth factor (PDGF)- and tumor necrosis factor-α (TNF-α)-induced vascular SMC and EC activation was associated with reduced let-7 miRNA expression via Lin28b, a negative regulator of let-7 biogenesis. Ectopic overexpression of let-7 in SMCs inhibited inflammatory responses including proliferation, migration, monocyte adhesion, and nuclear factor-κB activation. The therapeutic potential of restoring let-7 levels using a let-7 mimic was tested: in vitro in SMCs using an endogenous anti-inflammatory lipid (lipoxin A₄), ex vivo in murine aortas, and in vivo via tail vein injection in a 24-h murine model. Furthermore, we delivered let-7 mimic to human carotid plaque ex vivo and observed significant changes to the secretome in response to let-7 therapy. Restoration of let-7 expression could provide a new target for an anti-inflammatory approach in diabetic vascular disease.

Risk and timing of clinical events according to diabetic status of patients treated with everolimus-eluting bioresorbable vascular scaffolds versus everolimus-eluting stent: 2-year results from a propensity score matched comparison of ABSORB EXTEND and SPIRIT trials

OBJECTIVES

to compare the occurrence of clinical events in diabetics treated with the Absorb bioresorbable vascular scaffold (Absorb BVS; Abbott Vascular, Santa Clara, CA) versus everolimus-eluting metal stents (EES; XIENCE V; Abbott Vascular, Santa Clara, CA) BACKGROUND: There are limited data dedicated to clinical outcomes of diabetic patients treated with bioresorbable scaffolds (BRS) at 2-year horizon.

METHODS

The present study included 812 patients in the ABSORB EXTEND study in which a total of 215 diabetic patients were treated with Absorb BVS. In addition, 882 diabetic patients treated with EES in pooled data from the SPIRIT clinical program (SPIRIT II, SPIRIT III and SPIRIT IV trials) were used for comparison by applying propensity score matching using 29 different variables. The primary endpoint was ischemia driven major adverse cardiac events (ID-MACE), including cardiac death, myocardial infarction (MI), and ischemia driven target lesion revascularization (ID-TLR).

RESULTS

After 2 years, the ID-MACE rate was 6.5% in the Absorb BVS vs. 8.9% in the Xience group (P = 0.40). There was no difference for MACE components or definite/probable device thrombosis (HR: 1.43 [0.24,8.58]; P = 0.69). The occurrence of MACE was not different for both diabetic status (insulin- and non-insulin-requiring diabetes) in all time points up to the 2-year follow-up for the Absorb and Xience groups.

CONCLUSION

In this largest ever patient-level pooled comparison on the treatment of diabetic patients with BRS out to two years, individuals with diabetes treated with the Absorb BVS had a similar rate of MACE as compared with diabetics treated with the Xience EES. © 2017 Wiley Periodicals, Inc.

Comparison of clinical outcomes after drug-eluting stent implantation in diabetic versus nondiabetic patients in China: A retrospective study

Diabetes mellitus (DM) has been proved to be a predictor of adverse outcomes after percutaneous coronary intervention (PCI). Drug-eluting stents (DESs) could reduce the adverse events in DM patients. In this study, we aimed to analyze the clinical outcome after DES implantation in diabetic versus nondiabetic patients in China. Totally, 200 Chinese DM patients and 400 Chinese non-DM patients were enrolled in this retrospective study. Compared with non-DM patients, DM patients were more likely to have a higher incidence of cardiac death (3.5% vs. 1.0%, P = .048), stent thrombosis (2.5% vs. 0.5%, P = .044), target lesion revascularization (6.0% vs. 1.8%, P = .005), target vessel failure (15.5% vs. 8.0%, P < .001), target lesion failure (14.0% vs. 4.3%, P < .001), myocardial infarction (4.5% vs. 1.5%, P = .030), and major adverse cardiac events (12.5% vs. 5.0%, P = .001) at 2-year follow-up. However, the incidence of target vessel revascularization (7.5% vs. 5.5%, P = .340) was similar between DB and non-DB patients. Patients with DB (hazard ratio [HR] = 2.54, P = .001), older than 80 years (HR = 1.33, P = .027) with hypercholesterolemia (HR = 1.03, P < .001), serum creatinine >177 μmol/L (HR = 3.04, P = .011), a history of cerebral vascular accident (HR = 4.29, P = .010), or a history of myocardial infarction (HR = 31.4, P < .001) were more likely to experience adverse events. In China, DM could also be served as an independent predictor of adverse outcomes after DES implantation. These patients should be reexamined more frequently.

Prospective study of the impact of diabetes mellitus newly diagnosed by glycated hemoglobin on outcomes in patients undergoing percutaneous coronary intervention

BACKGROUND

We sought to determine the prevalence of diabetes mellitus (DM) newly diagnosed by elevated glycated hemoglobin (HbA1c) in patients undergoing percutaneous coronary intervention (PCI) and its association with 1-year clinical outcomes.

METHODS

We prospectively enrolled consecutive patients undergoing PCI (2011-2013). HbA1c levels were assessed during the index hospitalization and newly diagnosed DM was defined as HbA1c≥6.5% in the absence of the previous diagnosis. The primary outcome was MACCE (Major Adverse Cerebro- and Cardiovascular Events) defined as death, stroke, PCI or acute myocardial infarction at 1year.

RESULTS

Diabetes was previously diagnosed in 391 (34%) patients (DM group), 221 (19%) had newly diagnosed DM based on the HbA1c level and 539 (47%) did not have diabetes (Non-DM). In DM group HbA1c was 7.80±1.36% as compared with 7.62±1.30% in patients with newly diagnosed DM (p<0.001). These patients were younger (62.0±11.3years) compared to DM (67.9±10.4years) and non-DM (63.7±13.0) patients, p<0.001. 1-year MACCE rates were 14.8%, 19.5% and 27.96% in the non-DM, newly diagnosed DM and DM groups, respectively (p<0.001). Multivariate analysis showed that compared to non-DM, the adjusted one-year hazard ratios for MACCE were 1.75 and 1.40 in patients with known DM and newly diagnosed DM, respectively (p<0.05 for both).

CONCLUSION

Newly diagnosed DM based on peri-procedural HbA1c is common and associated with increased short and long term risk for adverse outcomes. Our results may warrant routine screening for DM in all patients undergoing PCI.

Impact of Diabetes Mellitus on Intravascular Ultrasound-Guided Provisional Stenting in Coronary Bifurcation Lesions J-REVERSE Sub-Study

OBJECTIVE

To investigate the impact of diabetes mellitus (DM) on provisional coronary bifurcation stenting under the complete guidance of intravascular-ultrasound (IVUS).

BACKGROUND

The efficacy of such intervention has not yet been fully elucidated in the DM patients.

METHODS

A total of 100 DM and 139 non-DM patients in a prospective multi-center registry of IVUS-guided bifurcation stenting were compared in angiographic results at 9 months. Vessel and luminal changes during the intervention were analyzed using the IVUS. Vascular healing at the follow-up was also investigated in 23 lesions in each group using optical coherence tomography (OCT).

RESULTS

No difference was detected regarding baseline reference vessel diameter and minimum lumen diameter in proximal main vessel (MV), distal MV, and side branch (SB). The rate of everolimus-eluting stent use (78.4% vs. 78.3%), final kissing inflation (60.1% vs. 49.0%), and conversion to 2-stent strategy (2.9% vs. 2.8%) were also similar. In the DM group, late loss was greater in proximal MV (DM 0.23 ± 0.29 vs. non-DM 0.16 ± 0.24 mm, P < 0.05) and SB (0.04 ± 0.49 vs. -0.08 ± 0.35 mm, P < 0.05). Smaller vessel area restricted stent expansion in the proximal MV (6.18 ± 1.67 vs. 6.72 ± 2.07 mm² , P < 0.05). More inhomogeneous neointimal coverage (unevenness score, 1.90 ± 0.33 vs. 1.72 ± 0.29, P < 0.05) and more frequent thrombus attachment (26% vs. 4%, P < 0.05) were documented in the proximal MV at 9-month follow-up OCT.

CONCLUSIONS

Despite IVUS optimization for coronary bifurcation, DM is potentially associated with smaller luminal gain, higher late-loss, and inhomogeneous vascular healing with frequent thrombus attachment in the proximal MV.

Cutting Balloon Angioplasty for the Treatment of In-Stent Restenosis in Diabetics: A Matched Comparison of 6 Months' Outcome With Conventional Balloon Angioplasty

Ranging from 24% to 55%, angiographic in-stent restenosis (ISR) rates in diabetics are higher than the 17% to 28% rates observed in nondiabetics. There are controversies regarding optimal treatment for ISR. Recently, cutting balloon angioplasty (CBA) emerged as a tool in management. The authors assessed the hypothesis that CBA has advantages over conventional percutaneous transluminal balloon angioplasty (PTCA) in treatment of ISR in diabetics. CBA or PTCA was applied to 165 diabetics (267 ISR lesions) in their institution. With a computer algorithm, an attempt was made to match each lesion in the CBA group with a corresponding lesion in the PTCA group. The lesion pairs should match with respect to the patients' age and gender, type of target vessel and stent, reference vessel diameter, and baseline minimal lumen diameter (MLD). Following the matching process, 55 ISR lesion pairs were identified. Baseline patient characteristics were similar among the groups (p=NS). There was no difference in the in-hospital major adverse cardiac events (MACE) between the groups, whereas MACE at follow up was significantly lower in the CBA group compared to the PTCA group (CBA, 20.0% vs PTCA, 43.6%, p<0.05). The recurrent ISR rate was significantly lower in the CBA group compared to the PTCA group (CBA, 27.3% vs PTCA, 49.1%; p<0.05). Also, a diffuse pattern of recurrence was more common in lesions treated with PTCA, whereas a focal pattern of recur- rence was more common in the CBA group. The minimal luminal diameter at follow-up, the acute gain, and net gain were significantly higher in the group of lesions treated with CBA than in the PTCA group. In addition, a significantly higher late loss and loss index at follow-up were observed in the PTCA group compared to the CBA group. CBA has advantages over PTCA in treatment of diabetic patients with ISR, with better immediate and follow-up angiographic outcomes, and better follow-up clinical outcome.

Comparison of 12-month clinical outcomes in diabetic and nondiabetic patients with chronic total occlusion lesions: a multicenter study

Supplemental Digital Content is available in the text.

This study aimed to compare 1-year clinical outcomes in diabetic and nondiabetic patients with chronic total occlusion (CTO) lesions.

Nitric oxide differentially affects proteasome activator 28 after arterial injury in type 1 and type 2 diabetic rats

BACKGROUND

Diabetic patients display aggressive restenosis after vascular interventions, likely because of proproliferative influences of hyperglycemia and hyperinsulinemia. We have shown that nitric oxide (NO) inhibits neointimal hyperplasia in type 2, but not in type 1, diabetic rats. Here, we examined proteasome activator 28 (PA28) after arterial injury in different diabetic environments, with or without NO. We hypothesize that NO differentially affects PA28 levels based on metabolic environment.

MATERIALS AND METHODS

Vascular smooth muscle cell (VSMC) lysates from male, nondiabetic Lean Zucker (LZ) and Zucker Diabetic Fatty (ZDF) rats were assayed for 26S proteasome activity with or without PA28 and S-nitroso-N-acetylpenicillamine. LZ and ZDF VSMCs were treated with (Z)-1-[N-(2-aminoethyl)-N-(2-ammonioethyl)amino]diazen-1-ium-1,2-diolate for 24 h. Balloon-injured carotid arteries from LZ, streptozotocin-injected LZ (STZ, type 1), and ZDF (type 2) rats treated with disodium 1-[2-(carboxylato)pyrrolidin-1-iyl]diazen-1-ium-1,2-diolate were harvested at 3 or 14 d. PA28α was assessed by Western blotting and immunofluorescent staining.

RESULTS

S-nitroso-N-acetylpenicillamine reversed PA28-stimulated increases in 26S proteasome activity in LZ and ZDF VSMCs. Increased (Z)-1-[N-(2-aminoethyl)-N-(2-ammonioethyl)amino]diazen-1-ium-1,2-diolate lowered PA28α in LZ VSMCs but increased PA28α in ZDF VSMCs. At 3 d after injury, disodium 1-[2-(carboxylato)pyrrolidin-1-iyl]diazen-1-ium-1,2-diolate potentiated injury-induced PA28α decreases in LZ, STZ, and ZDF rats, suggesting VSMCs, depleted at this early time point, are major sources of PA28α. At 14 d after injury, total PA28α staining returned to baseline. However, although intimal and medial PA28α staining increased in injured STZ rats, adventitial PA28α staining increased in injured ZDF rats.

CONCLUSIONS

PA28 dysregulation may explain the differential ability of NO to inhibit neointimal hyperplasia in type 1 versus type 2 diabetes.

Influence of Clinically Relevant Mechanical Forces on Vascular Smooth Muscle Cells Under Chronic High Glucose: An In Vitro Dynamic Disease Model

BACKGROUND

In this study, we subjected vascular smooth muscle cells (VSMC) to acute and chronic high glucose conditions under physiologically relevant levels of cyclic strain and low wall shear forces to compare phenotypic modulation and thus conceptualize a dynamic-disease test model which captures cellular response more accurately in comparison with static cultures.

METHODS

P2-P6 rat aortic smooth muscle cells were seeded on type I collagen-coated silicone membranes and subjected to 0-7% cyclic strain at 1 Hz and 0.3 dynes/cm(2) shear stress from flow for 24 hr under acute (25 mM d-glucose, 84 hr) and chronic high glucose conditions (25 mM d-glucose, 3-4 weeks). Samples were analyzed for cell proliferation, percent apoptosis, cellular hypertrophy, and expression levels of smooth muscle contractile state-associated markers with 0.05 level of significance.

RESULTS

Concomitant application of cyclic strain and flow shear resulted in an overall increase in proliferation of VSMCs under both acute and chronic high glucose conditions as compared with normal glucose control (P < 0.0001). Application of both cyclic strain and cyclic strain shear resulted in a significant increase in percent apoptosis with chronic high glucose treatment in comparison with both normal glucose controls (P < 0.0001) and acute high glucose (P < 0.0001). Cellular hypertrophy as estimated by measuring cell area and aspect ratio revealed a significantly altered morphology due to concomitant loading under chronic high glucose conditions with significantly higher cell area (P < 0.0001) and lower aspect ratio (P < 0.0001) indicative of a relatively rounded morphology as compared with normal glucose controls. Western blot analysis demonstrated reduced expression of SM α-actin (P < 0.0001), calponin (P < 0.0001), and SM22α (P = 0.0008) for concomitant loading under chronic high glucose treatment as compared with normal glucose controls.

CONCLUSIONS

Concomitant application of cyclic strain and low wall shear stress resulted in greater phenotypic modulation of VSMCs due to chronic high glucose treatment as compared with normal glucose controls, thus implicating cellular-response differences which may impact progression of in-stent restenosis in diabetic patients with poorly controlled hyperglycemia. Similarity of VSMC response from our study to existing preclinical models of diabetes and reports of altered phenotype of VSMCs isolated from diabetic patients substantiate the relevance of our dynamic disease test model.

The Value of Pre- and Post-Stenting Fractional Flow Reserve for Predicting Mid-Term Stent Restenosis Following Percutaneous Coronary Intervention (PCI)

Measuring fractional flow reserve (FFR) in percutaneous coronary intervention (PCI) has predictive value for PCI outcome. We decided to examine the utility of pre- and post-stenting FFR as a predictor of 6-month stent restenosis as well as MACE (major adverse cardiac events). Pre- and post-stenting FFR values were measured for 60 PCI patients. Within 6 months after stenting, all patients were followed for assessment of cardiac MACE including myocardial infarction, unstable angina, or positive exercise test. Stent restenosis was also assessed. Cut-off values for pre- and post-stenting FFR measurements were considered respectively as 0.65 and 0.92. Stent restenosis was detected in 4 patients (6.6%). All 4 patients (100%) with restenosis had pre-stenting FFR of < 0.65, while only 26 of 56 patients without restenosis (46.4%) had pre-stenting FFR value of < 0.65 (P = 0.039). Mean pre-stenting FFR in patients with restenosis was significantly lower than in those without restenosis (0.25 ± 0.01 vs. 0.53 ± 0.03, P = 0.022). Although stent restenosis was higher in patients with post-stenting FFR of < 0.92 (2 cases, 9.5%) than in those with FFR value of ≥ 0.92 (2 cases, 5.1%), the difference was not statistically (P = 0.510). Pre-stenting FFR, the use of longer stents, and history of diabetes mellitus can predict stent restenosis, but the value of post-stenting FFR for predicting restenosis was not explicit.

Treatment strategies for coronary in-stent restenosis: systematic review and hierarchical Bayesian network meta-analysis of 24 randomised trials and 4880 patients

STUDY QUESTION

What is the most safe and effective interventional treatment for coronary in-stent restenosis?

METHODS

In a hierarchical Bayesian network meta-analysis, PubMed, Embase, Scopus, Cochrane Library, Web of Science, ScienceDirect, and major scientific websites were screened up to 10 August 2015. Randomised controlled trials of patients with any type of coronary in-stent restenosis (either of bare metal stents or drug eluting stents; and either first or recurrent instances) were included. Trials including multiple treatments at the same time in the same group or comparing variants of the same intervention were excluded. Primary endpoints were target lesion revascularisation and late lumen loss, both at six to 12 months. The main analysis was complemented by network subanalyses, standard pairwise comparisons, and subgroup and sensitivity analyses.

STUDY ANSWER AND LIMITATIONS

Twenty four trials (4880 patients), including seven interventional treatments, were identified. Compared with plain balloons, bare metal stents, brachytherapy, rotational atherectomy, and cutting balloons, drug coated balloons and drug eluting stents were associated with a reduced risk of target lesion revascularisation and major adverse cardiac events, and with reduced late lumen loss. Treatment ranking indicated that drug eluting stents had the highest probability (61.4%) of being the most effective for target lesion vascularisation; drug coated balloons were similarly indicated as the most effective treatment for late lumen loss (probability 70.3%). The comparative efficacy of drug coated balloons and drug eluting stents was similar for target lesion revascularisation (summary odds ratio 1.10, 95% credible interval 0.59 to 2.01) and late lumen loss reduction (mean difference in minimum lumen diameter 0.04 mm, 95% credible interval -0.20 to 0.10). Risks of death, myocardial infarction, and stent thrombosis were comparable across all treatments, but these analyses were limited by a low number of events. Trials had heterogeneity regarding investigation periods, baseline characteristics, and endpoint reporting, with a lack of information at long term follow-up. Direct and indirect evidence was also inconsistent for the comparison between drug eluting stents and drug coated balloons.

WHAT THIS STUDY ADDS

Compared with other currently available interventional treatments for coronary in-stent restenosis, drug coated balloons and drug eluting stents are associated with superior clinical and angiographic outcomes, with a similar comparative efficacy.

FUNDING, COMPETING INTERESTS, DATA SHARING

This study received no external funding. The authors declare no competing interests. No additional data available.

Long-term outcomes of rotational atherectomy in coronary bifurcation lesions

The aim of the present study was to determine the long-term outcomes of bifurcation lesions following a rotational atherectomy (ROTA). In this retrospective study, patients that had undergone a ROTA of the bifurcation coronary lesions in Juntendo University Hospital (Tokyo, Japan) were enrolled between January 2007 and December 2009, and received follow-up for a median duration of 48 months (range, 12-84 months). A total of 337 patients were enrolled. Each patient was treated with an average of 1.2±0.4 ROTA burrs (mean size, 2.9±0.3 mm). Baseline lesion length, reference diameter, minimal lumen diameter (MLD) and percentage of diameter stenosis (%DS) prior to the procedure were comparable between the DM and non-DM patients. Furthermore, MLD, %DS and acute gain following the procedure were similar between the two groups. At follow-up, DM patients exhibited a significantly decreased MLD (1.97±0.92 vs. 2.26±0.73 mm; P=0.0038), increased %DS (27.9±21.3 vs. 20.2±13.3%; P=0.022) and late loss (0.70±0.45 vs. 0.42±0.36 mm; P=0.0047) compared with the non-DM patients. Follow-up examinations (mean duration, 52.2±19.4 months) revealed that the DM patients experienced significantly higher rates of target lesion revascularization (TLR) [28 (15.7%) vs. 8 (5.0%); P=0.0011], target lesion (TL) restenosis [46 (25.8%) vs. 20 (12.6%); P=0.0019] and major adverse cardiac events (MACE) [36 (20.2%) vs. 19 (12.0%), P=0.039] compared with the non-DM patients. Although the usage of ROTA and drug-eluting stent evidently improved long-term outcomes in patients with bifurcation lesions, DM remained an independent risk factor for TLR, TL restenosis and MACE. Therefore, the management of DM in bifurcation lesions treated with ROTA requires increased investigation in future clinical practice.

Microparticle levels after arterial injury and NO therapy in diabetes

BACKGROUND

Little is known about how arterial injury, nitric oxide (NO), or the diabetic milieu impact microparticle (MP) levels in the vasculature. We hypothesized that MP levels would increase following local arterial injury, and that NO would modify MP levels differently based on the metabolic environment.

MATERIALS AND METHODS

Type 1 diabetes was induced in male Lean Zucker (LZ) rats with streptozotocin, and type 2 diabetes was induced in male Zucker diabetic fatty rats through diet. Lean Zucker rats served as nondiabetic controls. The rat carotid balloon injury was performed ± NO (n > 4/group). Blood was obtained at intervals from baseline to 14 d after injury and analyzed for platelet MP (PMP), leukocyte MP (LMP), and endothelial MP (EMP) using fluorescence-activated cell sorting (FACS) analysis.

RESULTS

At baseline, type 1 diabetic rats had the highest EMP levels (P < 0.05). After arterial injury, type 1 and type 2 diabetic rats had a transient increase in EMP levels (P < 0.05) before decreasing below baseline levels. Both LMP and PMP levels generally declined after injury in all three animal models but were the lowest in both type 1 and type 2 diabetic rats. NO therapy had little impact on MP levels in nondiabetic and type 1 diabetic rats after injury. Conversely, NO caused a dramatic increase in EMP, LMP, and PMP levels in type 2 diabetic animals at early time points after injury (P < 0.05).

CONCLUSIONS

These data demonstrate that the diabetic milieu impacts MP levels at baseline, after arterial injury and with NO treatment.

Comparison of 2-year outcomes of repeated second-generation drug-eluting stent implantation for focal-type versus nonfocal-type in-stent restenosis

BACKGROUND

Second-generation drug-eluting stents (DES) have been used widely to treat DES in-stent restenosis (ISR), which remains a clinical challenge. Knowledge of the outcomes of repeated second-generation DES implantation for focal versus nonfocal-type ISR is still missing.

METHODS

In the current study, 254 patients with DES-ISR were divided into focal or nonfocal groups according to their ISR angiographic types. All patients with ISR lesions included in the current study received second-generation DES. Treatment modalities for both groups were similar without any systematic bias toward either group. The primary endpoint of the study was the occurrence of major adverse cardiac events (MACEs) over a 2-year follow-up period. MACEs were defined as cardiac death, myocardial infarction, and target lesion revascularization.

RESULTS

The nonfocal-type group showed significantly greater incidence of MACEs than the focal-type group (38.3 vs. 24.1%; P=0.03), in which the occurrence of target lesion revascularization was more pronounced (32.3 vs. 18.4%; P=0.02). However, this group showed a higher incidence of type B2/C lesions (69.5 vs. 41.4%; P<0.01), with longer lesion length, and received significantly more and longer reimplanted stents than the focal-type group. Cox regression analysis indicated that nonfocal-type ISR was an independent predictor of MACEs (odds ratio 2.134, 95% confidence interval 1.173-3.884; P=0.014) after adjusting for all significant variables.

CONCLUSION

In the current study, second-generation DES is more effective in the treatment of focal-type DES-ISR than nonfocal-type ISR in terms of the occurrence of MACEs. Nonfocal-type ISR is an independent predictor of MACEs after the treatment of DES-ISR with second-generation DES.