Is In-Stent Restenosis After a Successful Coronary Stent Implantation Due to Stable Angina Associated With TG/HDL-C Ratio?

Deteriorative Effect of a Combination of Hypertriglyceridemia and Low High-Density Lipoprotein Cholesterolemia on Target Lesion Revascularization after Everolimus-Eluting Stent Implantation

AIM

This study aimed to investigate the association between a combination of elevated triglyceride (TG) and reduced high-density lipoprotein cholesterol (HDL-C) levels and target lesion revascularization (TLR) following everolimus-eluting stent (EES) implantation. The adverse impact of clinical, lesion, and procedural characteristics on TLR in patients with elevated TG and reduced HDL-C levels was also assessed.

METHODS

We retrospectively collected data on 3,014 lesions from 2,022 consecutive patients, who underwent EES implantation at Koto Memorial Hospital. Atherogenic dyslipidemia (AD) is defined as a combination of non-fasting serum TG ≥ 175 mg/dL and HDL-C ＜40 mg/dL.

RESULTS

AD was observed in 212 lesions in 139 (6.9%) patients. The cumulative incidence of clinically driven TLR was significantly higher in patients with AD than in those without AD (hazard ratio [HR] 2.31, 95% confidence interval [CI] 1.43-3.73, P=0.0006). Subgroup analysis showed that AD increased the risk of TLR with the implantation of small stents (≤ 2.75 mm). Multivariable Cox regression analysis showed that AD was an independent predictor of TLR in the small EES stratum (adjusted HR 3.00, 95% CI 1.53-5.93, P=0.004), whereas the incidence of TLR was similar in the non-small-EES stratum, irrespective of the presence or absence of AD.

CONCLUSIONS

Patients with AD had a higher risk of TLR after EES implantation, and this risk was greater for lesions treated with small stents.

The Triglyceride/High-Density Lipoprotein Cholesterol (TG/HDL-C) Ratio as a Risk Marker for Metabolic Syndrome and Cardiovascular Disease

Atherosclerosis is an immunoinflammatory pathological procedure in which lipid plaques are formed in the vessel walls, partially or completely occluding the lumen, and is accountable for atherosclerotic cardiovascular disease (ASCVD). ACSVD consists of three components: coronary artery disease (CAD), peripheral vascular disease (PAD) and cerebrovascular disease (CCVD). A disturbed lipid metabolism and the subsequent dyslipidemia significantly contribute to the formation of plaques, with low-density lipoprotein cholesterol (LDL-C) being the main responsible factor. Nonetheless, even when LDL-C is well regulated, mainly with statin therapy, a residual risk for CVD still occurs, and it is attributable to the disturbances of other lipid components, namely triglycerides (TG) and high-density lipoprotein cholesterol (HDL-C). Increased plasma TG and decreased HDL-C levels have been associated with metabolic syndrome (MetS) and CVD, and their ratio, TG/HDL-C, has been proposed as a novel biomarker for predicting the risk of both clinical entities. Under these terms, this review will present and discuss the current scientific and clinical data linking the TG/HDL-C ratio with the presence of MetS and CVD, including CAD, PAD and CCVD, in an effort to prove the value of the TG/HDL-C ratio as a valuable predictor for each aspect of CVD.

Treatment effect of metformin combined with atorvastatin in reducing in-stent restenosis after percutaneous coronary intervention in coronary artery disease patients with type 2 diabetic patients

To investigate the effectiveness of metformin and atorvastatin in preventing in-stent restenosis (ISR) on coronary patients with type 2 diabetes mellitus with percutaneous coronary intervention within 8 to 12 months after rapamycin-eluting stent implantation. A total of 1278 consecutive patients implanted with rapamycin-eluting stent from January 2012 to December 2019, who underwent coronary computed tomography or coronary angiography within 8 to 12 months. The patients were categorized into atorvastatin 20 mg, or atorvastatin 20 mg + metformin 1.5/d, or atorvastatin 40 mg + metformin 1.5/d groups. The clinical characteristics of the 3 groups were compared. The correlation between variables and ISR was analyzed. A total of 701 patients participated in the study. The ratio of ISR/nonstenosis (P = .039) and fasting blood sugar (P = .001) differed significantly in the 3 groups. Logistic regression showed that d, L, different therapeutic agents, and dosage groups were independent risk factors of ISR. The longer L and smaller d may increase ISR incidence with 8 to 12 months after percutaneous coronary intervention. Both metformin and atorvastatin are beneficial in reducing stent restenosis by a dose-dependent manner. An increasing dose of atorvastatin and a combination of metformin decreases the incidence of ISR in patients.

In-Hospital Outcomes of Coronary Artery Stenting in Patients With ST-Elevation Myocardial Infarction (STEMI) and Metabolic Syndrome: Insights From the National Inpatient Sample

Background

Metabolic syndrome (MetS) has been recognized as a global health problem. Concurrent MetS diagnosis in patients with ST-elevation myocardial infarction (STEMI) is becoming increasingly common. Given the paucity of studies on the impact of MetS on treatment outcomes in STEMI patients, the purpose of this study was to evaluate in-hospital mortality in STEMI patients with a concurrent MetS diagnosis undergoing a stenting procedure to treat their underlying coronary artery disease.

Method

Patients with or without MetS who underwent coronary stenting following STEMI between 2005 and 2014 were identified from the National Inpatient Sample database. Patients' demographics, comorbidities, and outcomes were compared using a t-test and Pearson's Chi-square test. In addition, 1:1 propensity score matching was performed for age, gender, and race.

Results

Out of 1,938,097 STEMI patients, 5,817 patients with MetS underwent coronary stenting following STEMI and were matched with 5,817 patients with no Mets. MetS group had significantly higher rates of diabetes, hypertension, hyperlipidemia, chronic kidney disease, and obstructive sleep apnea than the no MetS group but lower rates of heart failure and chronic obstructive pulmonary disease. In-hospital mortality following STEMI was significantly lower in patients with MetS (2.5% vs. 7.1%, p<0.001) and remained significant after adjusting for potential confounders (odds ratio (OR) 0.34, 95% confidence interval (95% CI) 0.28-0.42, p<0.0001).

Conclusion

Concurrent diagnosis of MetS among patients undergoing coronary stenting is associated with a decreased in-hospital mortality risk. The impact of specific MetS components on the observed reduction in mortality remains unclear and warrants evaluation in future studies.

Non-Fasting Hypertriglyceridemia as an Independent Risk Factor for Coronary In-Stent Restenosis after Primary Bare Metal Stent Implantation in Patients with Coronary Artery Disease

After a percutaneous coronary intervention (PCI) in patients with coronary artery disease (CAD), in-stent neoatherosclerosis may pose a risk of in-stent restenosis (ISR). To clarify whether non-fasting hypertriglyceridemia contributes to ISR, we examined the relationship between non-fasting hypertriglyceridemia (i.e., triglyceride (TG) level ≥ 200 mg/dL) and ISR after stenting with a bare metal stent (BMS) post-primary PCI in patients with CAD by means of a single-site retrospective analysis. A total of 1,039 patients with CAD were enrolled, and 86 patients (112 lesions) were evaluated for BMS-ISR 3-6 months post-primary PCI. The percentage of patients with non-fasting hypertriglyceridemia was significantly higher in the ISR (+) group than in the ISR (-) group (P < 0.009). The follow-up period and number of patients in the ISR (+) group were significantly smaller than those in the ISR (-) group (P < 0.001). There were no significant between-group differences in the other baseline patient characteristics before the primary PCI or at the time of the follow-up coronary angiography. However, at the follow-up period, the ISR (+) group had significantly lower diastolic blood pressure and high-density lipoprotein cholesterol levels (P = 0.015) and significantly higher TG levels (P = 0.012) than the ISR (-) group. A multiple logistic regression analysis demonstrated that non-fasting hypertriglyceridemia and a follow-up period of ≥ 6 months were independent risk factors for ISR after primary PCI in patients with BMS implantation for stenotic CAD (P = 0.006), with an adjusted odds ratio of 8.232 (1.201-56.410) and 0.006 (95% confidence interval < 0.001-0.045), respectively. Non-fasting hypertriglyceridemia may be an additional independent risk factor for BMS-ISR after primary PCI in patients with CAD.

CYP2C19*2 genetic polymorphism and incidence of in-stent restenosis in patients on clopidogrel: a matched case-control study

OBJECTIVES

The cytochrome P450 2C19*2 (CYP2C19*2) genetic polymorphism is associated with reduced clopidogrel bioactivation, increasing the risk of atherothrombotic complications after percutaneous coronary intervention (PCI). In-stent restenosis (ISR) is a complication that limits the long-term prognosis of PCI. The aim was to investigate the association between presence of the CYP2C19*2 allele and ISR within one-year after PCI in patients prescribed dual antiplatelet therapy with aspirin and clopidogrel.

METHODS

Sixty patients with angiographically-confirmed drug eluting stent (DES)-ISR within 12 months post-PCI when on DAPT with aspirin and clopidogrel were retrospectively identified (Cases). Another 60 patients with no documented ISR post-PCI in the study period (Controls) were case-matched for age, gender, ethnicity, diabetes mellitus and estimated glomerular filtration rate value, and were invited for CYP2C19*2 genotyping. The association between presence of the CYP2C19*2 allele and ISR was analysed using the Fisher's Exact test and binary logistic regression.

RESULTS

Twenty-six (43.3%) cases and 5 (8.3%) controls were carriers of one or two CYP2C19*2 alleles. As to non-carrier status of the CYP2C19*2 allele, 34 (56.7%) cases and 55 (91.7%) controls were identified. The association between CYP2C19*2 carrier status and DES-ISR within one-year post-PCI was statistically significant (p<0.001) in both the univariate and multivariate analysis.

CONCLUSIONS

The proportion of patients who were carriers of one or two CYP2C19*2 alleles who presented with DES-ISR within one-year post-PCI while on clopidogrel was significantly higher compared to patients with no documented ISR.

Association between type D personality and in-stent restenosis in patients treated with percutaneous coronary intervention: A mediation analysis of dietary patterns

OBJECTIVE

Type D personality is a psychosocial risk factor for cardiovascular events and in-stent restenosis (ISR), but the mechanisms involved are not well understood. This study aimed to evaluate the effects of dietary patterns on the association between Type D personality and ISR in patients with coronary artery disease treated with percutaneous coronary intervention (PCI).

METHODS

This cross-sectional study comprised a total of 230 post-PCI patients who were assessed for Type D personality, depression, dietary patterns, physical activity and medication adherence via self-administered questionnaires. ISR was assessed by coronary angiography.

RESULTS

Type D personality (odds ratio [OR], 3.35; 95% confidence interval [CI], 1.05-10.71, p=0.042), low fruit intake (OR, 0.30; 95% CI, 0.12-0.68, p=0.008) and low vegetable intake (OR, 0.48, 95% CI, 0.27-0.91, p=0.021) were independent risk factors for ISR after adjustment for psychosocial, lifestyle and cardiovascular risk factors. Mediation analyses revealed that Type D personality had a significant direct effect on the development of ISR (p<0.05). In addition, nutrients in fruits and vegetables, including vitamin C, vitamin E and fiber, were important mediators of the relationship between Type D personality and ISR (p<0.05), the percentage of total indirect effect was 24.65%.

CONCLUSIONS

These findings suggested that the low intake of fruit and vegetables in Type D patients can predict ISR. The healthy dietary interventions to supply vitamin C, vitamin E and fiber may help to improve the prognosis in post-PCI patients with Type D personality.

The association between genetic polymorphisms of the interleukin-10, tumor necrosis factor-alpha, and annexin A5 gene loci and restenosis after percutaneous coronary angioplasty and stenting

BACKGROUND

Advances in the technology for percutaneous coronary angioplasty, such as coated stents, have reduced its complications, but restenosis remains an important clinical problem. The factors associated with an increased risk of restenosis include diabetes mellitus and multiple coronary artery disease. It is also possible that genetic factors play a role in restenosis although there are little data on this. We have investigated the association of three genetic markers of genes involved in inflammation leading to restenosis.

MATERIALS AND METHODS

In this case-control study, 306 unrelated Iranian patients who were thought to have restenosis on clinical grounds were investigated. Based on the results of angiography, 104 patients were found to have >50% stenosis within an implanted stent, and these were allocated to the in-stent restenosis (ISR) group; 202 patients with no in-stent stenosis or stenosis ≤50% were allocated to the non-ISR (NISR) group. Demographic data were collected from medical records. Biochemical parameters were measured using routine methods. Genotypes of the interleukin-10 (IL-10), annexin A5 (AnxA5), and tumor necrosis factor-alpha (TNFα) loci were determined using real-time polymerase chain reaction and a high-resolution melting assay.

RESULTS

Fasting blood glucose, serum triglycerides, and serum high-sensitivity C-reactive protein (hs-CRP) concentrations were higher in the ISR group than in the NISR group (P < 0.05), and a history of diabetes mellitus was significantly related to the presence of restenosis (P < 0.001). There were no significant differences in the frequency of the genetic polymorphisms of IL-10, AnxA5, and TNFα genes and the presence of ISR.

CONCLUSION

After adjustment for clinical variables, the genetic polymorphisms at the IL-10, TNFα, and ANXA5 gene loci do not appear to be risk factors for >50% ISR in our population. However, our data suggested a significant association between diabetes mellitus, serum hs-CRP, stent type, and restenosis.

Association Between TG-to-HDL-C Ratio and In-Stent Stenosis Under Optical Coherence Tomography Guidance

We determined the relevance between the TG-to-HDL-C ratio and stent restenosis. Ninety-nine patients with in-stent stenosis (ISR) who were admitted to An Zhen Hospital in Beijing between April 2014 and June 2017 were selected. At the same time, 122 patients with coronary stenosis <50% were selected. All patients were tested for TG, HDL-C, and TG/HDL-C ratio. Optical coherence tomography (OCT) can assess microscopic status in all ISR patients. The proportion of male and Diabetic patients were significantly higher for ISR. There were differences in the prevalence of cigarette smokers among the different tissue types, among which the layered tissue type accounted for the highest proportion. In logistic regression analysis the study showed that male, diabetes mellitus, and the TG/HDL-C ratio are risk factors for ISR. The ISR ROC was 0.725 based on the TG/HDL-C ratio diagnosis. It is related to the degree of coronary stenosis and effective in diagnosing in-stent stenosis in ISR.