Prognostic Impact of 9-Month High-Sensitivity C-Reactive Protein Levels on Long-Term Clinical Outcomes and In-Stent Restenosis in Patients at 9 Months after Drug-Eluting Stent Implantation

The role of inflammation in percutaneous coronary intervention, from balloon angioplasty to drug eluting stents

The role of inflammation in percutaneous coronary intervention (PCI) has been investigated in numerous studies. Both pre-PCI and post-PCI inflammatory status have been demonstrated to be linked with patient outcomes. C-reactive protein continues to be the most studied inflammatory biomarker, while a growing number of additional biomarkers, including cytokines and immune cells, are being assessed. As insights are gained into the complexities of the inflammatory response to PCI, it becomes evident that a targeted approach is necessary to ensure optimal patient outcomes. Here, we review the biomarkers that can predict patient outcomes following PCI and specifically how they differ for balloon angioplasty, bare metal stents and drug eluting stents. A specific focus is given to human studies and periprocedural inflammation rather than inflammation associated with myocardial infarction.

High Sensitivity C-reactive Protein in Patients with Coronary Artery in-stent Restenosis: A Case-control Study

Background:

Inflammation plays a pivotal role in the pathogenesis of In-Stent Restenosis (ISR). High sensitivity C-reactive protein (hsCRP) is positively associated with major cardiovascular events.

Aim:

We aimed to investigate the hsCRP inflammatory response to Percutaneous Coronary Intervention (PCI) in Coronary Artery Disease (CAD) patients with coronary ISR vs. patients without ISR.

Methods:

This case-control study included 80 CAD patients previously treated with drug-eluting stent (DES) implantation. Patients had Coronary Angiography (CAG) because of chest pain or equivalent symptoms and were subdivided into 2 groups. Group A (n=40) included CAD patients with ISR. Group B (n=40) included age and gender-matched controls with CAD but without ISR. Serum hsCRP levels were obtained before PCI (baseline) and 8, 16, 24 h post-PCI.

Results:

At baseline (before intervention/CAG), the hsCRP level was increased in the ISR group compared with the No-ISR group (p=0.007). There were 36 (90%) patients in the ISR group who had a high hsCRP (>3 mg/L) compared with 25 (62.5%) patients in the No-ISR group. Also, there was a significant relationship between high hsCRP and the ISR. Patients with ISR had higher frequencies and percentages of elevated CRP than the no-ISR control group. This difference was maintained for all measurements, baseline, after 8, 16, and 24 h (p<0.05). Repeated measures analysis of variance (ANOVA) in the ISR group revealed that mean hsCRP differed significantly between serial measurements (p<0.001). In contrast, in the control group, the mean hsCRP did not differ significantly between the serial measurements (p=0.65).

Most of our patients (n=66, 82.5%) had 1-vessel CAD disease, and the left anterior descending (LAD) coronary artery was significantly affected in 46 patients (57.5%). Management of restenosis was accomplished mainly by stenting by DES in 29 patients (72.5%).

Conclusion:

Patients with ISR had substantially higher pre- and post-PCI hsCRP levels than the no-ISR controls. This difference was maintained up to 24h post-PCI. Conversely, the mean hsCRP did not significantly differ at the follow-up points for the controls without ISR.

The Incidence and Possible Predictors of Coronary Restenosis

Objective. Assess time and possible predictors of restenosis after the implantation of first- and second-generation coronary stents and bare metal stents (BMSs) in patients with stable coronary artery disease after elective coronary stenting.

Materials and Methods. From 2010 to 2014, 3,732 (2,897 males, 60 [53; 68] years old) patients with stable exertional angina of functional class I–III underwent coronary stenting. From 2014 to 2017, 1,487 (1,173 males and 314 females) patients returned. Repeat coronary angiography was performed in 699 patients.

Results. A total of 644 first-generation stents, 5,321 second-generation stents, and 473 BMSs were implanted. During the control coronary angiography, contrasting was repeated for 193 first-generation stents, 899 second-generation stents, and 77 BMSs. Restenosis (stenosis of 50 % or more in the previously stented segment) was detected in 28 (14 % of angiographic control) first-generation drug-eluting stents, 94 (10 %) second-generation drug-eluting stents, and 21 (27 %) BMSs. Patients with BMS restenosis returned significantly earlier than patients with restenosis of the first- and second-generation drug-eluting stents (11 [6, 27] months vs. 32 [11; 48]) months and 24 [12; 42] months, respectively; p<0.05). The initial and repeat levels of high-sensitivity C-reactive protein (hs-CRP) were higher in patients with restenosis (2.2 [1.2, 5.0] mg / L vs. 2.1 [1.0, 4.6] mg / L, respectively; p> 0.05) than in patients without restenosis (2.0 [0.9, 4.2] mg / L vs. 1.9 [0.7, 3.5] mg / L respectively, p>0.05). Blood levels of hs-CRP ≥2 mg / L according to receiver operating characteristic curve (ROC) analysis at return visit were used as a predictor to identify restenosis of stents with a diameter <3 mm and a length >25 mm – area under the curve (AUC) 0.67 (95 % confidence interval (CI) 0.51–0.84), p <0.05, odds ratio 3.7 (95 % CI 1.1–12.1), p<0.05. Stent type had a significant effect on the time to restenosis in the survival analysis (p<0.0005).

Conclusion. The time from coronary stenting to the return visit of patients presenting with restenosis after the implantation of first- and second-generation drug-eluting stents is consistent; median time of the return visit of patients with restenosis of the first-generation stents was 2–3 years after coronary stenting. Blood levels of hs-CRP ≥2 mg / L at the return visit is a predictor of restenosis of stents with a diameter <3 mm and a length >25 mm.

Comprehensive analysis of predictive factors for rapid angiographic stenotic progression and restenosis risk in coronary artery disease patients underwent percutaneous coronary intervention with drug-eluting stents implantation

BACKGROUND

This study aimed to explore the correlation of baseline, procedural, and postprocedure characteristics with the risk of rapid angiographic stenotic progression (RASP) and restenosis in coronary artery disease (CAD) patients after percutaneous coronary intervention (PCI) with drug-eluting stents implantation.

METHODS

Two hundred fourteen CAD patients underwent PCI with drug-eluting stents implantation were consecutively enrolled. Baseline, procedural, and postprocedure characteristics of patients were collected for analysis. Coronary angiography was performed to evaluate coronary stenosis before PCI and at 12 months after PCI. RASP of nontarget lesions and restenosis of stent-implanted target lesions were then assessed.

RESULTS

37.8% CAD patients occurred RASP at 12 months after PCI and compared to non-RASP group, RASP group presented with increased diabetes mellitus (DM) complication, higher concentration of serum uric acid (SUA), cardiac troponin I, N-terminal probrain natriuretic peptide, and high sensitive C-reactive protein (hs-CRP) as well as elevated occurrence of multivessel artery lesions. In addition, DM, SUA, hs-CRP, and multivessel artery lesions independently predicted high RASP risk. For restenosis, 21.0% patients occurred restenosis at 12 months after PCI, and patients in restenosis group presented with increased hypertension and DM occurrence, higher concentrations of SUA, LDL-C, and hs-CRP, as well as longer target lesion and length of stent in surgery compared to nonrestenosis group. Also, DM, SUA, LDL-C, hs-CRP, and length of target lesion independently predicted increased restenosis risk.

CONCLUSION

Diabetes mellitus, SUA, and hs-CRP are potential predictive factors for increased risk of both RASP and restenosis in CAD patients underwent PCI and drug-eluting stents implantation.

Clinical impact of high-sensitivity C-reactive protein during follow-up on long-term adverse clinical outcomes in patients with coronary artery disease treated with percutaneous coronary intervention

INTRODUCTION

C-reactive protein (CRP) is an established marker for vascular inflammation and predictor of adverse cardiovascular events, but the prognostic value of preprocedural CRP in coronary artery disease (CAD) patients who have undergone percutaneous coronary intervention (PCI) remains controversial. Furthermore, the impact of CRP levels during follow-up in CAD patients after PCI on long-term adverse clinical outcomes is uncertain. We evaluated the association between high-sensitivity (hs)-CRP values at follow-up angiography and long-term clinical outcomes in CAD patients after coronary intervention.

METHODS

We prospectively enrolled 3507 consecutive CAD patients who underwent first PCI between 1997 and 2011 at our institution. We identified 2509 patients (71.5%) who underwent follow-up angiography (6-8 months after PCI). Of those, 1605 patients (45.8%) who had data available for hs-CRP at follow-up angiography were stratified into three groups according to tertiles of hs-CRP level at the time of follow-up angiography. The primary endpoint was composite of all-cause death and non-fatal acute coronary syndrome (ACS).

RESULTS

Median follow-up was 1716 days. The cumulative incidence of all-cause death and ACS differed significantly among groups (log-rank, p=0.0002). Multivariate Cox regression analysis showed that a higher hs-CRP level at follow-up angiography was associated with a greater risk of all-cause death and ACS [adjusted hazard ratio (HR) for all-cause death and ACS 2.14, 95% confidence interval (CI) 1.43-3.27, p=0.0002.

CONCLUSION

Elevated hs-CRP levels during follow-up were significantly associated with higher frequencies of adverse long-term clinical outcomes in patients with CAD after PCI.

Impact of hyperuricemia on clinical outcomes after percutaneous coronary intervention for in-stent restenosis

Background

There have been limited data on the impact of hyperuricemia on long-term clinical outcomes after percutaneous coronary intervention (PCI) for in-stent restenosis (ISR).

Methods

From January 2009 to July 2015, 317 patients who underwent repeat PCI for ISR were divided into two groups: patients with normal serum uric acid (UA) levels (normal UA group) and patients with higher serum UA levels (higher UA group). The higher UA group included patients with serum UA levels > 6.8 mg/dL or patients who were taking anti-hyperuricemic medication.

Results

During a median follow-up period of 1088 days, the cumulative incidence rates of major adverse event (MAE), including a composite of all-cause death, non-fatal myocardial infarction, and any revascularization, were similar between the two groups (higher UA 36.4% vs. normal UA 29.9%, p = 0.389, log-rank p = 0.367). Follow-up angiographic data showed similar outcomes of late lumen loss (0.8 ± 0.9 mm vs. 0.8 ± 1.1 mm, p = 0.895) and binary restenosis rate (28.1% vs. 34.7%, p = 0.622). Multivariate Cox regression analysis indicated higher levels of low-density lipoprotein cholesterol (hazard ratio [HR] 1.011, 95% confidence interval [CI] 1.003–1.019, p = 0.006) and lower left ventricular ejection fraction (HR 0.972, 95% CI 0.948–0.996, p = 0.022), but not UA levels, to be the independent risk predictors of MAE.

Conclusion

Hyperuricemia is not associated with poor clinical outcomes after repeat PCI for ISR lesions.

Electronic supplementary material

The online version of this article (10.1186/s12872-018-0840-2) contains supplementary material, which is available to authorized users.

Preprocedural C-Reactive Protein Predicts Outcomes after Primary Percutaneous Coronary Intervention in Patients with ST-elevation Myocardial Infarction a systematic meta-analysis

Risk assessment in patients with acute coronary syndromes (ACS) is critical in order to provide adequate treatment. We performed a systematic meta-analysis to assess the predictive role of serum C-reactive protein (CRP) in patients with ST-segment elevation myocardial infarction (STEMI), treated with primary percutaneous coronary intervention (PPCI). We included 7 studies, out of 1,033 studies, with a total of 6,993 patients with STEMI undergoing PPCI, which were divided in the high or low CRP group, according to the validated cut-off values provided by the corresponding CRP assay. High CRP values were associated with increased in-hospital and follow-up all-cause mortality, in-hospital and follow-up major adverse cardiac events (MACE), and recurrent myocardial infarction (MI). The pre-procedural CRP predicted in-hospital target vessel revascularization (TVR), but was not associated with acute/subacute and follow-up in-stent restenosis (ISR), and follow-up TVR. Thus, pre-procedural serum CRP could be a valuable predictor of global cardiovascular risk, rather than a predictor of stent-related complications in patients with STEMI undergoing PPCI. This biomarker might have the potential to improve the management of these high-risk patients.