Lower level of low-density lipoprotein cholesterol by statin prevents progression of coronary restenosis after successful stenting in acute myocardial infarction

Low-Density Lipoprotein Cholesterol Levels Are Associated With Subsequent Stented-Territory Ischemic Stroke After Carotid Artery Stenting: A Single Center Retrospective Study

Objective

The role of low-density lipoprotein cholesterol (LDL-C) after carotid artery stenting (CAS) is not well known with respect to stented-territory infarction (STI) and in-stent restenosis (ISR). We hypothesized that LDL-C levels after CAS might be independently associated with STI and ISR.

Methods

We conducted a retrospective study for patients with significant extracranial carotid stenosis who were subjected to CAS between September 2013 and May 2021. LDL-C levels were measured after 6 and 12 months following CAS. The association between STI and ISR, and LDL-C was explored using Cox proportional-hazard model.

Results

Of 244 patients enrolled, STI and ISR were observed in 11 (4.5%) and 10 (4.1%) patients, respectively. In multivariable analysis, higher white blood cell count (hazard ratio [HR], 1.408 per 10³/mm³; 95% confidence interval [CI], 1.085-1.828; p=0.010), higher LDL-C levels after 12 months (HR, 1.037 per 1 mg/dL; 95% CI, 1.011-1.063; p=0.005), and ISR (HR, 13.526; 95% CI, 3.405-53.725; p<0.001) were independent predictors of STI. Diabetes (HR, 4.746; 95% CI, 1.026-21.948; p=0.046), smaller stent diameter (HR, 0.725 per 1 mm; 95% CI, 0.537-0.980; p=0.036), and higher LDL-C levels after 12 months (HR, 1.031 per 1 mg/dL; 95% CI, 1.007-1.055; p=0.011) were independent predictors of ISR.

Conclusion

We showed that LDL-C levels after 12 months independently predict STI and ISR after CAS. It is necessary to investigate the optimal target LDL-C level for STI prevention through well designed research in the future.

Do statins have a role in reduction/prevention of post-PCI restenosis?

The pathophysiology of post-PCI restenosis involves neointimal formation that consists of three phases: thrombosis (within 24 h), recruitment (3-8 days), and proliferation, which starts on day 8 of PCI. Various factors suggested to be predictors/risks for restenosis include C-reactive protein (CRP), inflammatory mediators (cytokines and adhesion molecules), oxygen radicals, advanced glycation end products (AGEs) and their receptors (RAGE), and soluble RAGE (sRAGE). The earlier noted factors produce thrombogenesis, vascular smooth muscle cell proliferation, and extracellular matrix formation. Statins have pleiotropic effects. Besides lowering serum cholesterol, they have various other biological effects including antiinflammatory, antithrombotic, CRP-lowering, antioxidant, antimitotic, and inhibition of smooth muscle cell proliferation. They inhibit matrix metalloproteinase and cyclooxygenase-2, lower AGEs, decrease expression of RAGE and increase levels of serum sRAGE. They also increase the synthesis of nitric oxide (NO) by increasing endothelial NO synthase expression and activity. Preprocedural statin therapy is known to reduce peri- and post-PCI myonecrosis and reduce the need for repeat revascularization. There is evidence that statin-eluting stents inhibit in-stent restenosis in animal models. It is concluded that because of the above attributes of statins, they are suitable candidates for reduction of post-PCI restenosis and post-PCI myonecrosis. The future directions for the use of statins in reduction of post-PCI restenosis and myonecrosis have been discussed.

Impact of glycemic control on the clinical outcome in diabetic patients with percutaneous coronary intervention--from the FU-registry

BACKGROUND

It is not yet clear whether glycemic control affects the clinical outcome of percutaneous coronary intervention (PCI) in diabetic patients.

METHODS AND RESULTS

This study compared the effects of glycemic control on the clinical outcome in 2 groups of patients with diabetes mellitus (DM) who underwent PCI: a poor-glycemic-control group, who showed greater than 6.9% HbA(1c) at the time of PCI (Pre-HbA(1c)) (`≥6.9 group', n=334 patients) and a good-glycemic-control group, who showed less than <6.9% at Pre-HbA(1c) (`<6.9 group', n=212 patients). The patients in the ≥6.9 group were further divided into 2 groups for further comparisons: a `DM control group' and a `Poor control group'. At follow-up (300 days), the incidence of major adverse cardiac event (MACE) was significantly (P<0.05) lower in the <6.9 group (18.4% vs. 26.2%). However, there was no difference in MACE between the DM control group and the Poor control group. In a multivariate analysis, there was no relationship between the incidence of MACE and Pre-HbA(1c), Pre-HbA(1c)≥6.9% or the HbA(1c) difference (Pre-HbA(1c)-HbA(1c) at follow-up).

CONCLUSIONS

Clinical outcomes in the <6.9 group were superior to those in the ≥6.9 group as pre-PCI glycemic control affected the baseline characteristics. The results suggested that glycemic control started at PCI was not associated with an improvement in the clinical outcome at follow-up.

Lipid Control before CABG and Its Association with In-Hospital Mortality

BACKGROUND

Controlling risk factors such as dyslipidemia in patients with coronary artery disease, including candidates for coronary artery bypass grafting (CABG), is of great importance and has serious effects on CABG morbidity and mortality. The aim of this study was to evaluate lipid serum levels, comprising TG, LDL, and HDL, before CABG and their relation with in-hospital outcome.

METHODS

The clinical profiles of 3,593 patients in the hospital cardiac surgery databank who underwent isolated CABG between April 2006 and April 2008 were reviewed. Three components of lipid profile, including TG, LDL, and HDL serum levels, were checked at the time of hospitalization in all the patients. Lipid control was evaluated according to the published guidelines.

RESULTS

The mean LDL, HDL, and TG serum levels were 103.4±48.5, 40.9±16, and 168±87 mg/dl, respectively. Additionally, 487 (13.6%) patients had entire TG, LDL, and HDL serum levels within the acceptable range and in 668 (18.6%) patients, all of these components were within the uncontrolled range. After adjustment for confounders, in-hospital mortality in patients with uncontrolled TG, LDL, and HDL was higher than patients with controlled TG, LDL, and HDL (p value=0.042, OR=1.399, 95% CI =1.012-1.934).

CONCLUSION

The high prevalence of uncontrolled lipids in our patient population is alarming. Regular and frequent pre- and post-operative visits to monitor and modify patient risk factors, including dyslipidemia, seem necessary. An increase in statin dosage or adjunctive therapy with other lipid lowering agents may be helpful. Attempts to maintain all lipids within the controlled range may have beneficial effects on hospital outcome.

Lipoprotein(a) and other serum lipid subfractions influencing primary patency after infrainguinal percutaneous transluminal angioplasty

PURPOSE

To evaluate the influence of serum lipid subfraction concentrations on arterial patency after percutaneous transluminal angioplasty (PTA) in patients with infrainguinal peripheral artery occlusive disease (PAOD).

METHODS

From January 2007 to June 2008, a prospective study was conducted involving 39 patients (29 men; mean age 68.6+/-10.0 years) with infrainguinal PAOD in 41 limbs who had preprocedural lipid assessment and underwent successful PTA (<30% residual stenosis). Patient demographics, Fontaine clinical stage classification, Texas University Classification of ulcers, coexisting medical conditions, endovascular procedures, and lipid profiles were collected in a database. Follow-up included clinical and duplex ultrasound evaluation at discharge and at 1, 3, 6, and 12 months. To analyze any correlation between various lipid subfractions and the loss of primary patency (Cox proportional hazards modeling), the patients were dichotomized into high and low groups according to these thresholds: LDL-C >100 mg/dL, HDL-C <40 mg/dL, Lp(a) >30 mg/dL, and an Apo(B)/Apo(A) ratio >0.8 mg/dL.

RESULTS

Mean follow-up was 7.5 months (range 3-12). After 1, 3, and 6 months, the primary patency rates by Kaplan-Meier analysis were 94.9%, 73.7%, and 64.1%, respectively. Restenosis at 6 months was significantly related to female gender (HR 95.9, 95% CI 6.8 to 1352.5, p = 0.001), HDL-C <40 mg/dL (HR 86.9, 95% CI 6.4 to 1183.1, p = 0.001), LDL-C >100 mg/dL (HR 9.6, 95% CI 1.6 to 57.4, p = 0.013), and Lp(a) >30 mg/dL (HR 6.1, 95% CI 1.4 to 26.3, p = 0.016).

CONCLUSION

Our results suggest that Lp(a), LDL-C, and HDL-C are independent risk factors for restenosis after infrainguinal PTA.

Predictors of in-stent restenosis and patient outcome after percutaneous coronary intervention in patients with diabetes mellitus

Diabetics have a significantly higher incidence of major adverse cardiac events (MACEs) and in-stent restenosis (ISR) than nondiabetics after percutaneous coronary intervention (PCI). Predictors of MACEs and ISR are uncertain in diabetics. In recent studies, microalbuminuria and proliferative retinopathy have been believed to relate to progressive coronary atherosclerosis. We retrospectively studied 191 consecutive patients (mean age 65 +/- 9 years) with diabetes who underwent PCI to determine predictors of ISR and MACEs (defined as cumulative incidence of myocardial infarction, revascularization, or death from cardiovascular cause), with special reference to microalbuminuria and proliferative retinopathy. Of 191 patients, 106 (56%) had a follow-up coronary angiogram at 16 +/- 2 months. Of these 106 patients, 66 (62%) developed ISR. In the multivariate model, microalbuminuria or proliferative retinopathy did not achieve significant association with ISR. Serum high-density lipoprotein cholesterol levels were significantly associated with a lower incidence of ISR (odds ratio [OR] 0.928, 95% confidence interval [CI] 0.876 to 0.983, p = 0.011) and MACEs (OR 0.96, 95% CI 0.931 to 1.000, p = 0.048). Use of drug-eluting stents also had a negative association with ISR (OR 0.171, 95% CI 0.05 to 0.585, p = 0.004). Renal insufficiency was associated with higher MACEs (OR 3.19, 95% CI 1.45 to 7.031, p = 0.0039). In conclusion, serum high-density lipoprotein cholesterol levels were inversely associated with ISR or MACEs.

Statin therapy: not just used to lower cholesterol?

3-Hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, also known as statins, are the cornerstones of treatment of hyperlipidemia. They are widely used drugs that have well-documented, advantageous effects on cholesterol and atherosclerosis. The pleiotropic activities of statins can lead to newer applications. This review describes some of the available evidence supporting the use of statins for the treatment of acute coronary syndrome, as adjuncts to percutaneous coronary intervention, and for the prevention of sepsis. It also briefly discusses the rationale behind the potential development of statin-eluting stents.

Successful intensive lipid-lowering therapy using atorvastatin stabilizes coronary artery plaque as assessed by multi-detector row computed tomography

A 35-year-old male was diagnosed as angina pectoris and showed severe stenosis with soft plaque in the proximal segment of the left anterior descending (LAD) coronary artery as detected by multi-detector row computed tomography (MDCT). Although percutaneous coronary stent implantation to the LAD lesion was performed, soft plaque remained in the proximal lesion of the stent. Atorvastatin increased the coronary plaque density at the 6-month follow-up MDCT examination, and the low-density lipoprotein cholesterol level fell from 141 to 63 mg/dl after 6 months. This case may indicate that assessment of the shape or composition of coronary plaque by MDCT is a useful strategy for judging the effects of intensive lipid-lowering therapy using statin.