Trans-Myocardial Blood Interleukin-6 Levels Relate to Intracoronary Imaging-Defined Features of Plaque Vulnerability and Predict Procedure-Induced Myocardial Infarction

BACKGROUND

Intravascular imaging has defined various vulnerable plaque (VP) phenotypes that predict future clinical events. Atherosclerosis is an inflammatory process and inflammation, measured by systemic biomarkers can also predict events and anti-inflammatory therapy is beneficial. We were interested to assess the relationship between plaque phenotypes and key inflammatory biomarkers, measured close to the coronary.

METHODS

Ninety-two patients scheduled for elective percutaneous coronary intervention (PCI) underwent virtual histology intravascular ultrasound, optical coherence tomography, pressure wire and blood sampling from the guide catheter (GC), coronary sinus (CS) to determine trans-myocardial gradient (TMG = CS-GC) and from peripheral blood. Procedure related troponin release was assessed at 6-hours post-PCI from peripheral venous blood. Biomarker data were analysed and compared with coronary data.

RESULTS

Interleukin (IL)-6 was associated with increased levels of tumour necrosis factor (TNF)-α and C-reactive protein (CRP) and the pre-PCI IL-6 TMG correlated with plaque features of vulnerability: plaque burden - PB (r = 0.253, p = 0.04) and minimal lumen area - MLA (r = -0.438, p = 0.007), although no relationship existed for thin-capped fibroatheroma defined by either imaging modality. Peripheral IL-6 levels had no correlation with post PCI troponin, although the pre-PCI IL-6 TMG was related (r = 0.334, p = 0.006), as was PB (r = 0.27, p = 0.029).

CONCLUSION

IL-6 TMG pre-PCI correlates with plaque burden and MLA that have been shown to predict future clinical events and is correlated with post-PCI troponin release. These associations were not apparent from peripheral blood and suggest that local coronary biomarker signatures may help further define vulnerability and risk.

Periprocedural Myocardial Injury: Pathophysiology, Prognosis, and Prevention

The definition and clinical implications of myocardial infarction occurring in the setting of percutaneous coronary intervention have been the subject of unresolved controversy. The definitions of periprocedural myocardial infarction (PMI) are many and have evolved over recent years. Additionally, the recent advancement of different imaging modalities has provided useful information on a patients' pre-procedural risk of myocardial infarction. Nonetheless, questions on the benefit of different approaches to prevent PMI and their practical implementation remain open. This review aims to address these questions and to provide a current and contemporary perspective.

Coronary plaque tissue characterization in patients with premature coronary artery disease

Premature coronary artery disease (CAD) studies rarely involve coronary plaque characterization. We characterize coronary plaque tissue by radiofrequency intravascular ultrasound (IVUS) in patients with premature CAD. From July 2015 to December 2017, 220 patients from the Department of Cardiology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine with first occurrence of angina or myocardial infarction within 3 months were enrolled. Patients with premature CAD (n = 47, males aged < 55 years, and females aged < 65 years) or later CAD (n = 155) were retrospectively compared for cardiovascular risk factors, laboratory examination findings, coronary angiography data, gray-scale IVUS, and iMap-IVUS. The mean age was 53.53 ± 7.24 vs. 70.48 ± 8.74 years (p < 0.001). The groups were similar for traditional coronary risk factors except homocysteine (18.60 ± 5.15 vs. 17.08 ± 4.27 µmol/L, p = 0.043). After matching for baseline characteristics, LDL cholesterol (LDL-C) was higher for premature CAD than later CAD (2.50 ± 0.96 vs. 2.17 ± 0.80 mmol/L, p = 0.019). Before the matching procedure, the premature CAD group had shorter target lesion length [18.50 (12.60–32.00) vs. 27.90 (18.70–37.40) mm, p = 0.002], less plaque volume [175.59 (96.60–240.50) vs. 214.73 (139.74–330.00) mm³, p = 0.013] than the later CAD group. After the matching procedure, the premature CAD group appeared to be less plaque burden (72.69 ± 9.99 vs. 74.85 ± 9.80%, p = 0.005), and positive remodeling (1.03 ± 0.12 vs. 0.94 ± 0.18, p = 0.034), and lower high risk feature incidence (p = 0.006) than the later CAD group. At the plaque’s minimum lumen, premature CAD had more fibrotic (p < 0.001), less necrotic (p = 0.001) and less calcified areas (p = 0.012). Coronary plaque tissue was more fibrotic with less necrotic and calcified components in premature than in later CAD, and the range and degree of atherosclerosis were significantly lower.

Clinical Predictors of Risk for Decreased Cardiac Tissue Perfusion After Percutaneous Coronary Intervention: A Retrospective Cohort Study

OBJECTIVE

To establish clinical predictors of risk for decreased cardiac tissue perfusion (DCTP) after percutaneous coronary intervention (PCI).

METHODS

Data on demographic, anthropometric, clinical, and procedural variables were collected as explanatory from a database of 1,542 adult patients undergoing PCI. A diagnosis of periprocedural myocardial infarction was used to confirm DCTP. A multivariate logistic regression determined the predictors of DCTP.

RESULTS

The independent predictors of risk for DCTP were age (OR = 1.02, CI 95% = 1.01-1.03, p = .008), multivessel disease (OR = 1.79, CI 95% = 1.30-2.46, p <.001) and intraprocedural lesion complications (OR = 4.56, CI 95% = 3.03-6.87, p <.001).

CONCLUSION AND IMPLICATIONS FOR NURSING PRACTICE

These results increase the level of evidence of risk for DCTP by refining its risk factors and can support nurses' clinical judgment.

Protective effect of nicorandil on myocardial injury following percutaneous coronary intervention in older patients with stable coronary artery disease: Secondary analysis of a randomized, controlled trial (RINC)

Background

Our previous study examined an effect of remote ischemic preconditioning (RIPC) or intravenous nicorandil on reduction of periprocedural myocardial injury (pMI) following percutaneous coronary intervention (PCI) in patients with stable coronary artery disease (CAD). We further investigated the effect of RIPC or nicorandil on pMI in older patients.

Methods

Patients with stable CAD who planned to undergo PCI were assigned to a 1:1:1 ratio to control, intravenous nicorandil, or upper-limb RIPC groups. This substudy analyzed patients aged >65 years (n = 282) from the principal cohort. The primary outcome was the incidence of pMI following PCI. We defined pMI as an elevated level of high-sensitive cardiac troponin T or creatine kinase myocardial band 12 or 24 hours after PCI.

Results

We found that pMI following PCI was significantly reduced in the nicorandil group compared with the control group (37.2% vs. 53.7%, multiplicity-adjusted p = 0.046), but not in the RIPC group compared with the control group (43.0% vs. 53.7%, multiplicity-adjusted p = 0.245). The adjusted odds ratios (95% confidence interval) for pMI in the RIPC and nicorandil groups versus the control group were 0.63 (0.34 to 1.16) and 0.51 (0.27 to 0.96), respectively.

Conclusion

Intravenous nicorandil significantly reduces pMI following PCI in a subgroup of older patients with stable CAD. Phase 3 trials are required to validate our results.

Trial registration

UMIN Clinical Trials Registry UMIN000005607.

Postoperative Assessment of Myocardial Function and Microcirculation in Patients with Acute Coronary Syndrome by Myocardial Contrast Echocardiography

BACKGROUND Postoperative myocardial function and microcirculation of acute coronary syndrome (ACS) was assessed by myocardial contrast echocardiography (MCE). MATERIAL AND METHODS Eighty-nine ACS patients treated with percutaneous coronary intervention (PCI) were detected by MCE and two-dimensional ultrasonography before and a month later after PCI respectively. Their myocardial perfusion was evaluated by myocardial contrast score (MSC) and contrast score index (CSI); cross-sectional area of microvessel (A), average myocardial microvascular impairment (β), and myocardial blood flow (MBF) were analyzed by cardiac ultrasound quantitative analysis (CUSQ), and fractional flow reserve (FFR) change was observed. Left ventricular ejection fraction (LVEF), left ventricular end-diastolic dimension (LVEDD), and left ventricular end-systolic dimension (LVESD) were observed; the index of microcirculatory resistance (IMR), FFR, and coronary flow reserve (CFR) were detected to evaluate coronary microcirculation. RESULTS None of the 89 patients experienced no-reflow. Patients with normal myocardial perfusion mostly had normal or slightly decreased ventricular wall motion after PCI. A month after the operation, there was an increase in A, β, MBF, LVEF, E/A, IMR, FFR, and CFR (all P<0.05), while LVEDD, LVESD, diastolic gallop A peak, E/Ea, E/Ea×S, and Tei decreased (all P<0.05). LVEF and IMR were in positive correlations with A. LVEF, IMR, FFR and CFR were positively correlated with b and MBF (both r>0, P<0.05), while E/Ea×Sa and Tei were negatively correlated with b and MBF (r<0, P<0.05). CONCLUSIONS MCE can safely assess post-PCI myocardial function and microcirculation of ASC.

Coronary plaque morphology on multi-modality imagining and periprocedural myocardial infarction after percutaneous coronary intervention

Percutaneous coronary intervention (PCI) may be complicated by periprocedural myocardial infarction (PMI) as manifested by elevated cardiac biomarkers such as creatine kinase (CK)-MB or troponin T. The occurrence of PMI has been shown to be associated with worse short- and long-term clinical outcome. However, recent studies suggest that PMI defined by biomarker levels alone is a marker of atherosclerosis burden and procedural complexity but in most cases does not have independent prognostic significance. Diagnostic multi-modality imaging such as intravascular ultrasound, optical coherence tomography, coronary angioscopy, near-infrared spectroscopy, multidetector computed tomography, and magnetic resonance imaging can be used to closely investigate the atherosclerotic lesion in order to detect morphological markers of unstable and vulnerable plaques in the patients undergoing PCI. With the improvement of technical aspects of multimodality coronary imaging, clinical practice and research are increasingly shifting toward defining the clinical implication of plaque morphology and patients outcomes. There were numerous published data regarding the relationship between pre-PCI lesion subsets on multi-modality imaging and post-PCI biomarker levels. In this review, we discuss the relationship between coronary plaque morphology estimated by invasive or noninvasive coronary imaging and the occurrence of PMI. Furthermore, this review underlies that the value of the multimodality coronary imaging approach will become the gold standard for invasive or noninvasive prediction of PMI in clinical practice.

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Periprocedural myocardial infarction (PMI) has been shown to be associated with worse short- and long-term clinical outcome.

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Clinical practice and research are increasingly shifting toward the plaque morphology and patients outcomes.

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This review discusses the relationship between plaque morphology estimated by coronary imaging and the occurrence of PMI.

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This review underlies the value of the multimodality coronary imaging approach for prediction of PMI in clinical practice.