In-Hospital and 1-Year Clinical Results from the French Registry Using Polymer-Free Sirolimus-Eluting Stents in Acute Coronary Syndrome and Stable Coronary Artery Disease

Objectives

The aim of this postmarket clinical study was to assess the safety and efficacy of the latest generation polymer-free sirolimus-eluting stents (PF-SES) in an all-comers population comparing outcomes in stable coronary artery disease (CAD) versus acute coronary syndrome (ACS) in France.

Background

The efficacy and safety of the first-generation PF-SES have already been demonstrated by randomized controlled trials and "all-comers" observational studies.

Methods

For this all-comers observational, prospective, multicenter study, 1456 patients were recruited in 22 French centers. The primary endpoint was target lesion revascularization (TLR) rate at 12 months and secondary endpoints included major adverse cardiac events (MACE) and bleeding.

Results

895 patients had stable CAD and 561 had ACS. At 12 months, 2% of patients had a TLR, with similar rates between stable CAD and ACS (1.9% vs 2.2%, p = 0.7). The overall MACE rate was 5.2% with an expected higher rate in patients with ACS as compared to those with stable CAD (7.3% vs 3.9%, p = 0.007). The overall bleeding event rate was 4.5%, with similar rates in stable CAD as compared to ACS patients (3.8% vs 5.6%, p = 0.3). Dual antiplatelet therapy (DAPT) interruptions prior to the recommended duration occurred in 41.7% of patients with no increase in MACE rates as compared to patients who did not prematurely interrupt DAPT (3.9% vs 6.1%, p = 0.073).

Conclusions

The latest generation PF-SES is associated with low clinical event rates in these all-comers patients. There was a high rate of prematurely terminated DAPT, without any effect on MACE at 12 months. This trial is registered with NCT03809715.

Screening coronary artery disease with computed tomography angiogram should limit normal invasive coronary angiogram, regardless of pretest probability

BACKGOUND

Performing functional testing (FT) or a computed tomography angiogram (CCTA) before invasive coronary angiogram (ICA) is recommended for coronary artery disease (CAD). We aimed to evaluate, in a real life setting, the rate of strictly normal ICA following a positive noninvasive test result.

METHODS

We included all patients who underwent an ICA with a prior positive FT or CCTA. Patients were categorized in 5 subgroups, according to pretest probability (PTP) of having a CAD. Main results of ICA were defined as normal ICA, nonobstructive CAD (non-oCAD), and obstructive CAD (oCAD).

RESULTS

For 4,952 patients who underwent ICA following either a positive FT (3276, 66.2%) or CCTA (1676, 33.8%) result, the PTP was (1) low (<15%; n = 968, 19.5%), (2) lower intermediate (15%-35%; n = 1336, 27.0%), (3) higher intermediate (35%-50%; n = 806, 16.3%), (4) high (50%-65%; n = 806, 17.7%), and (5) very high (> 65%; n = 965, 19.5%). ICA showed no CAD (819 patients, 16.5%), non-oCAD (1,193 patients, 24.1%), or oCAD (2940 patients, 59.4%). Without considering the PTP values, CCTA compared to FT showed less frequently normal ICA (7% vs 16.5%), and more frequently CAD (non-oCAD 27.9% vs 22.2%; oCAD 65.1% vs 56.4%) (all P < .0001). When we considered the different PTP values, CCTA always showed lower rates of normal ICA than the FT. In low- and lower intermediate-risk patients, CCTA detected more frequently oCAD compared to FT (P < .001).

CONCLUSIONS

CCTA is a better alternative than FT to limit unnecessary ICA regardless of PTP value, without missing abnormal ICA.

New diagnostic criteria for diabetes and coronary artery disease: insights from an angiographic study

OBJECTIVES

The goal of this research was to study coronary atherosclerosis in patients with type 2 diabetes compared with patients without diabetes according to the new definition of diabetes advocated by the American Diabetes Association in 1997.

BACKGROUND

Patients with diabetes (fasting plasma glucose above 7.0 mM/L) have a higher risk of cardiovascular death. The correlation with the pattern and severity of their coronary atherosclerosis, especially in the new patients with "mild" diabetes (7.0 mM/L < or = fasting plasma glucose < 7.8 mM/L), remains unclear.

METHODS

A cohort of 466 patients undergoing coronary angiography but free of any previous infarction, coronary intervention and insulin therapy were prospectively recruited. Ninety-three had diabetes (fasting plasma glucose > 7.0 mM/L or hypoglycemic oral treatment). Five angiographic indexes were calculated to describe severity and extent of coronary atherosclerosis.

RESULTS

Overall, patients with diabetes had more diffuse coronary atherosclerosis, a greater prevalence of mild, moderate and severe stenoses and a two-fold higher occlusion rate than patients without diabetes, even after adjustment for age, gender, body mass index, hypertension, lipid parameters, smoking, family history of cardiovascular events and ischemic symptoms. Patients with "mild diabetes" had a coronary atherosclerosis pattern more similar to patients with normal fasting plasma glucose than to patients formerly defined as diabetic according to the World Health Organization criteria, except that they had a higher prevalence of <50% stenoses.

CONCLUSIONS

In patients with type 2 diabetes, those with 7.0 mM/L < or = fasting plasma glucose < 7.7 mM/L have a slightly greater prevalence of mildly severe lesions that may partly explain their higher cardiovascular event rate.

Stimulation of bradykinin B(1) receptors induces vasodilation in conductance and resistance coronary vessels in conscious dogs: comparison with B(2) receptor stimulation

BACKGROUND

Constitutive bradykinin B(1) receptors have been identified in dogs; however, their physiological implications involving the coronary circulation remain to be determined. This study examined, in conscious dogs, the coronary response to des-Arg(9)-bradykinin (a B(1) receptor agonist) and the mechanisms involved.

METHODS AND RESULTS

Eleven dogs were instrumented with a left ventricular micromanometer, a circumflex coronary catheter, a cuff occluder, a Doppler flow probe, and ultrasonic crystals to measure coronary blood flow velocity (CBFv) and coronary diameter (CD). Intracoronary des-Arg(9)-bradykinin (3 to 100 ng/kg) and bradykinin (0.1 to 10 ng/kg) did not modify systemic hemodynamics but dose-dependently increased CBFv and CD. Des-Arg(9)-bradykinin was less potent than bradykinin. Hoe 140 (a B(2) antagonist, 10 microg/kg) abolished the effects of bradykinin but did not influence the effects of des-Arg(9)-bradykinin. When CBFv increase was prevented by the cuff occluder, CD responses to bradykinin and des-Arg(9)-bradykinin were maintained. Intracoronary lisinopril (0. 75 mg) increased the CD response to bradykinin, with only minimal effect on CBFv, and extended the duration of the effect. Lisinopril did not alter des-Arg(9)-bradykinin responses. Intracoronary N(omega)-nitro-L-arginine (2 mg/kg) decreased the CD effect of bradykinin and prevented the CBFv and CD effects of des-Arg(9)-bradykinin. The relaxing effect of des-Arg(9)-bradykinin on isolated coronary rings was prevented by des-Arg(9), [Leu(8)]-bradykinin.

CONCLUSIONS

In the conscious dog, B(1) receptors are present in coronary vessels, and their stimulation produces vasodilation in conductance and resistance vessels, which is mediated essentially by NO but not modulated by angiotensin-converting enzyme. However, the coronary vasodilation induced by B(1) receptor stimulation is not as great as that produced by B(2) receptor stimulation.

[Diabetic coronary disease and risk of myocardial infarction]

The raised incidence of myocardial infarction and sudden death in diabetics was explained over 20 years ago by the increase in prevalence and severity of coronary atherosclerosis. Coronary angiographies of 820 consecutive patients admitted to hospital for coronary artery disease were analysed. One hundred and fifteen of these patients (14%) were diabetic. In 77.4% of diabetics and 72.6% of non-diabetics, coronary angiography showed coronary lesions which were usually distal and three vessel in diabetics. When the three coronary arteries were analysed globally, the percentage of patients with at least one mild stenosis was much higher in diabetics than in non-diabetics (50.6% vs 30.3% respectively, p < 0.001), but there was no statistical difference in the number of severe stenoses or occlusions. The increase in mild stenosis in the diabetic population could indicate an anatomical predisposition to future rupture of a plaque. This result could explain the increased frequency of myocardial infarction and sudden death in diabetes, not necessarily preceded clinically by angina pectoris.

Increased incidence of moderate stenosis among patients with diabetes: substrate for myocardial infarction?

Persons with diabetes are at higher risk for myocardial infarction and sudden death than are persons without diabetes. It has been demonstrated that the artery that occludes during acute myocardial infarction generally had less than 75% stenosis on a previous angiogram. The extent of coronary artery stenosis was analyzed for 820 consecutively examined patients who underwent coronary angiography at our institution. The patients were categorized according to the presence or absence of diabetes mellitus. The severity of stenosis was taken into consideration. Patients with diabetes had moderate (50% to 75% narrowing) stenosis much more frequently than patients without diabetes (50.6 versus 30.3%, p < 0.001). Moreover diabetes mellitus was an independent risk factor for moderate stenosis. The lesions were more frequently located on distal arteries, more frequently had a pattern of three-vessel disease, and had a trend toward more diffuse disease than described 25 years ago. This greater amount of moderate stenosis may be considered a substrate for future acute plaque rupture. It may explain the high prevalence of acute myocardial infarction and sudden death among patients with diabetes without an increase in the incidence of angina pectoris.

Chronic inhibition of NO synthase enhances the production of prostacyclin in coronary arteries through upregulation of the cyclooxygenase type 1 isoform

We previously reported that chronic inhibition of NO synthase (NOS) in dogs leads to an upregulation of the cyclooxygenase (COX) pathway in the endothelium of the coronary artery after stimulation by bradykinin (BK) in vitro. The present experiments were designed to identify the nature of the COX isoform involved in this phenomenon. Rings of circumflex (LCX) and left anterior descending (LAD) coronary arteries were isolated from six control dogs and six dogs treated with the NOS-inhibitor, N omega-nitro-L-arginine (L-NNA, 30 mg/kg/d, i.v., during 7 days). Concentration-response curves to BK in U46619-contracted rings from LCX coronary arteries were constructed in the presence and absence of another NOS inhibitor (NG-monomethyl-L-arginine, L-NMMA), of selective inhibitors of the inducible isoform of COX (NS-398 and L-745,337) and of a non selective inhibitor of the inducible and constitutive isoforms of COX (indomethacin). Finally, measurements of 6-keto-prostaglandin F1 alpha, the stable metabolite of prostacyclin, were performed in the incubation medium by enzymo-immuno-assay on rings of isolated LAD coronary arteries in the presence and absence of the same inhibitors of COX, before and after stimulation by BK. In rings taken from control dogs, BK evoked a concentration-dependent relaxation (Emax: 115 +/- 10%; EC50: 8 +/- 4 nM). In the presence of L-NMMA, the concentration-relaxation curve to BK was significantly shifted to the right (Emax: 77 +/- 8%; EC50: 43 +/- 22 nM, P < 0.05). Addition of NS-398, L-745,337 and indomethacin to L-NMMA did not further modify the concentration-relaxation curve to BK. After chronic inhibition of NOS, the concentration-relaxation curve to BK was similar to that observed in rings taken from control dogs in the presence of L-NMMA (Emax: 75 +/- 5%; EC50: 69 +/- 36 nM). Addition of L-NMMA, alone or in combination with NS-398 or L-745,337 did not significantly modify this concentration-relaxation curve to BK. In contrast, the L-NMMA-indomethacin combination blunted the BK-induced relaxation of the coronary artery (Emax: 28 +/- 10%, P < 0.01). Basal release of prostacyclin was not different in rings taken from control and L-NNA treated dogs (56 +/- 16 vs 58 +/- 15 pg.mm-2). BK significantly increased this release but the increment was twofold greater in rings taken from L-NNA treated dogs than in rings taken from control dogs (P < 0.05). In rings taken from control and L-NNA treated dogs, the BK-stimulated production of prostacyclin observed in the presence of the solvent was not significantly modified by L-NMMA or the L-NMMA-L-745,337 combination. In contrast, the L-NMMA-indomethacin combination as well as endothelium removal completely suppressed the BK-stimulated production of prostacyclin. These findings demonstrate that in dogs submitted to chronic inhibition of NO synthesis (1) the residual relaxation to BK of canine isolated coronary arteries is mainly due to production of prostacyclin of endothelial origin, and (2) the enhancement of prostacyclin production by these vessels is mainly due to an upregulation of the endothelial constitutive isoform of COX.