Pan-Asian adapted ESMO Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with gastric cancer

The European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with gastric cancer (GC), published in late 2022 and the updated ESMO Gastric Cancer Living Guideline published in July 2023, were adapted in August 2023, according to previously established standard methodology, to produce the Pan-Asian adapted (PAGA) ESMO consensus guidelines for the management of Asian patients with GC. The adapted guidelines presented in this manuscript represent the consensus opinions reached by a panel of Asian experts in the treatment of patients with GC representing the oncological societies of China (CSCO), Indonesia (ISHMO), India (ISMPO), Japan (JSMO), Korea (KSMO), Malaysia (MOS), the Philippines (PSMO), Singapore (SSO), Taiwan (TOS) and Thailand (TSCO), coordinated by ESMO and the Japanese Society of Medical Oncology (JSMO). The voting was based on scientific evidence and was independent of the current treatment practices, drug access restrictions and reimbursement decisions in the different Asian regions represented by the 10 oncological societies. The latter are discussed separately in the manuscript. The aim is to provide guidance for the optimisation and harmonisation of the management of patients with GC across the different regions of Asia, drawing on the evidence provided by both Western and Asian trials, whilst respecting the differences in screening practices, molecular profiling and age and stage at presentation. Attention is drawn to the disparity in the drug approvals and reimbursement strategies, between the different regions of Asia.

Impact of electrocardiographic morphology on clinical outcomes in patients with non-ST elevation myocardial infarction receiving coronary angiography and intervention: a retrospective study

Background

The impact of electrocardiography (ECG) morphology on clinical outcomes in patients with non-ST segment elevation myocardial infarction (NSTEMI) receiving percutaneous coronary intervention (PCI) is unknown. This study investigated whether different ST morphologies had different clinical outcomes in patients with NSTEMI receiving PCI.

Methods

This retrospective study analyzed record-linked data of 362 patients who had received PCI for NSTEMI between January 2008 and December 2010. ECG revealed ST depression in 67 patients, inverted T wave in 91 patients, and no significant ST-T changes in 204 patients. The primary endpoint was long-term all-cause mortality. The secondary endpoint was long-term cardiac death and non-fatal major adverse cardiac events.

Results

Compared to those patients whose ECG showed an inverted T wave and non-specific ST-T changes, patients whose ECG showed ST depression had more diabetes mellitus, advanced chronic kidney disease (CKD) and left main artery disease, as well as more in-hospital mortality, cardiac death and pulmonary edema during hospitalization. Patients with ST depression had a significantly higher rate of long-term total mortality and cardiac death. Finally, multiple stepwise Cox regression analysis showed that an advanced Killip score, age, advanced CKD, prior percutaneous transluminal coronary angioplasty and ST depression were independent predictors of the primary endpoint.

Conclusions

Among NSTEMI patients undergoing coronary angiography, those with ST depression had more in-hospital mortality and cardiac death. Long-term follow-up of patients with ST depression consistently reveals poor outcomes.

Paddle Position and Contact Force: An Important Step to Check When Troubleshooting for Refractory Ventricular Fibrillation

Ventricular fibrillation (VF) is a lethal medical emergency that requires immediate defibrillation. VF is resistant when it persists after three or more defibrillator shocks. Successful defibrillation requires depolarisation of a critical mass of myocardium. Several variables, such as the length of time in VF, body type, total energy used, and energy waveform have been reported to be associated with the success rate of defibrillation. Correct paddle position and good contact force to create an adequate current flow through the heart is essential for defibrillation. We report a patient who developed VF because of acute myocardial infarction that was resistant to a total of 13 shocks. The cause of shock-resistant VF was diagnosed by noticing the skin marks caused by the defibrillator paddle that indicated incorrect paddle position and inadequate paddle force. By checking the skin marks, an emergency physician could make a correct diagnosis within a few seconds and save a patient.

EPO-cyclosporine combination therapy reduced brain infarct area in rat after acute ischemic stroke: role of innate immune-inflammatory response, micro-RNAs and MAPK family signaling pathway

This study tested the hypothesis that erythropoietin (EPO) and cyclosporine (CsA) could effectively reduce brain infarct area (BIA) in rat after acute ischemic stroke (AIS) through regulating inflammation, oxidative stress, MAPK family signaling and microRNA (miR-223/miR-30a/miR-383). Adult male Sprague-Dawley rats (n = 48) were equally divided into group 1 (sham control), group 2 (AIS), group 3 [AIS+EPO (5,000 IU/kg at 0.5/24/48 h, subcutaneous)] and group 4 [AIS+CsA (20.0 mg/kg at 0.5/24/48 h, intra-peritoneal)]. By 72 h, histopathology showed that BIA was largest in group 2 and smallest in group 1, and significantly larger in group 4 than group 3 (all P<0.0001). The three microRNAs expressed were higher in group 2 than in the other three groups (all P<0.04); between these three latter groups there were no significant differences. The protein expressions of MAPK family [phosphorylated (p)-ERK1/2, p-p38/p-JNK], inflammatory (iNOS/MMP-9/TNF-α/NF-κB/IL-12/MIP-1α/CD14/CD68/Ly6g), apoptotic (caspase-3/PARP/mitochondrial-Bax), oxidative-stress (NOX-1/NOX-2/oxidized protein) and mitochondrial-damaged (cytosolic cytochrome-C) biomarkers exhibited an identical pattern to BIA findings (all P<0.0001). The cellular expressions of brain edema (AQP4+), inflammation (CD11+/glial-fibrillary-acid protein+), and cellular damage (TUNEL assay/positive Periodic acid-Schiff stain) biomarkers exhibited an identical pattern, whereas the cellular-integrity markers (neuN+/MAP2+/doublecorin+) exhibited an opposite pattern to BIA (all P value <0.001). EPO-CsA therapy markedly reduced BIA mainly by suppressing the innate immune response to inflammation, oxidative stress, microRNAs (miR-223/miR-30a/miR-383) and MAPK family signaling.

Adipose-derived mesenchymal stem cells embedded in platelet-rich fibrin scaffolds promote angiogenesis, preserve heart function, and reduce left ventricular remodeling in rat acute myocardial infarction

OBJECTIVE

This study tested the hypothesis that autologous adipose-derived mesenchymal stem cells (ADMSCs) embedded in platelet-rich fibrin (PRF) can significant promote myocardial regeneration and repair after acute myocardial infarction (AMI).

SUMMARY BACKGROUND

With avoiding the needle-related complications, PRF-embedded autologous ADMSCs graft provides a new effective stem cell-based therapeutic strategy for myocardial repair.

METHODS

Adult male Sprague-Dawley rats were equally divided (n = 8 per group) into group 1 (sham-operated), group 2 (AMI by ligating left coronary artery), group 3 (AMI+ PRF), and group 4 (AMI+PRF-embedded autologous ADMSCs). RPF with or without ADMSCs was patched on infarct area 1h after AMI induction. All animals were sacrificed on day 42 after echocardiography.

RESULTS

Left ventricular (LV) dimension and infarct/fibrotic areas were lowest in group 1, highest in group 2, in group 3 higher than in group 4, whereas LV performance and wall thickness exhibited a reversed pattern in all groups (all p < 0.001). Protein expressions of inflammatory (MMP-9, IL-1β), oxidative, apoptotic (Bax, cleaved PARP), fibrotic (Smad 3, TFG-β), hypertrophic (β-MHC), and heart failure (BNP) biomarkers displayed an identical pattern in infarct/fibrotic areas, whereas the protein expressions of anti-inflammatory (IL-10), anti-apoptotic (Bcl-2), anti-fibrotic (Smad1/5, BMP-2) biomarkers and α-MHC showed an opposite pattern (all p < 0.01). Angiogenic activities (c-Kit+, Sca-1+, CD31+, SDF-1α+, CXCR4+ cells; protein expressions of SDF-1α, CXCR4, VEGF) were highest in group 4 and lowest in group 1 (all p < 0.001).

CONCLUSION

ADMSCs embedded in PRF offered significant benefit in preserving LV function and limiting LV remodeling after AMI.

Phase I study of nanoliposomal irinotecan (PEP02) in advanced solid tumor patients

Purpose

To define the dose-limiting toxicity (DLT), maximum tolerated dose (MTD) and pharmacokinetics (PK) of PEP02, a novel liposome-encapsulated irinotecan, in patients with advanced refractory solid tumors.

Methods

Patients were enrolled in cohorts of one to three to receive escalating dose of PEP02 in a phase I trial. PEP02, from 60 to 180 mg/m², was given as a 90-min intravenous infusion, every 3 weeks.

Results

A total of 11 patients were enrolled into three dose levels: 60 (one patient), 120 (six patients) and 180 mg/m² (four patients). DLT was observed in three patients, one at 120 mg/m² (grade 3 catheter-related infection) and two at 180 mg/m² (grade 4 neutropenia lasting for >3 days in one, grade 4 hematological toxicities and grade 4 diarrhea in the other). MTD was determined as 120 mg/m². Comparing with those after free-form irinotecan in the literature, the dose-normalized PK of SN-38 (the active metabolite) after PEP02 was characterized by lower C_max, prolonged terminal half-life and higher AUC but with significant inter-individual variation. One patient who died of treatment-related toxicity had significantly higher C_max and AUC levels of SN-38 than those of the other three patients at 180 mg/m². Post hoc pharmacogenetic study showed that the patient had a combined heterozygosity genotype of UGT1A1*6/*28. Two patients had objective tumor response.

Conclusions

PEP02 apparently modified the PK parameters of irinotecan and SN-38 by liposome encapsulation. The MTD of PEP02 monotherapy at 3-week interval is 120 mg/m², which will be the recommended dose for future studies.

Impact of chronic obstructive pulmonary disease on patient with acute myocardial infarction undergoing primary percutaneous coronary intervention

BACKGROUND

This study reported the incidence and prognostic outcome of chronic obstructive lung disease (COPD) patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).

METHODS

Between January 2002 and May 2011, totally 1554 consecutive patients who experienced STEMI undergoing primary PCI were enrolled into the study.

RESULTS

Of the 1554 patients, 124 (9.7%) with diagnosis of COPD and 1430 (90.3%) without COPD were categorized into group 1 and group 2. Although no difference in in-hospital mortality was noted between the two groups (p = 0.726). However, the hospitalization duration was notably longer (p = 0.003), the incidences of recurrent MI and re-hospitalization for congestive heart failure were significantly higher in group 1 than in group 2 (all p < 0.02). Although Kaplan-Meier analysis demonstrated that the incidence of freedom from one-year major adverse clinical outcome (MACO) (defined as recurrent MI, re-admission for congestive heart failure was significantly lower in group 1 than group 2 (p = 0.012), multivariate Cox regression analysis showed COPD was not an independent predictor of MACO-free time after adjusting traditional risk factors.

CONCLUSION

COPD was not an independent predictor of short-term and medium-term MACO in patients with STEMI undergoing primary PCI.

Melatonin treatment improves adipose-derived mesenchymal stem cell therapy for acute lung ischemia-reperfusion injury

This study investigated whether melatonin-treated adipose-derived mesenchymal stem cells (ADMSC) offered superior protection against acute lung ischemia-reperfusion (IR) injury. Adult male Sprague-Dawley rats (n = 30) were randomized equally into five groups: sham controls, lung IR-saline, lung IR-melatonin, lung IR-melatonin-normal ADMSC, and lung IR-melatonin-apoptotic ADMSC. Arterial oxygen saturation was lowest in lung IR-saline; lower in lung IR-melatonin than sham controls, lung IR-melatonin-normal ADMSC, and lung IR-melatonin-apoptotic ADMSC; lower in lung IR-melatonin-normal ADMSC than sham controls and lung IR-melatonin-apoptotic ADMSC; lower in lung IR-melatonin-apoptotic ADMSC than sham controls (P < 0.0001 in each case). Right ventricular systolic blood pressure (RVSBP) showed a reversed pattern among all groups (all P < 0.0001). Changes in histological scoring of lung parenchymal damage and CD68+ cells showed a similar pattern compared with RVSBP in all groups (all P < 0.001). Changes in inflammatory protein expressions such as VCAM-1, ICAM-1, oxidative stress, TNF-α, NF-κB, PDGF, and angiotensin II receptor, and changes in apoptotic protein expressions of cleaved caspase 3 and PARP, and mitochondrial Bax, displayed identical patterns compared with RVSBP in all groups (all P < 0.001). Numbers of antioxidant (GR+, GPx+, NQO-1+) and endothelial cell biomarkers (CD31+ and vWF+) were lower in sham controls, lung IR-saline, and lung IR-melatonin than lung IR-melatonin-normal ADMSC and lung IR-melatonin-apoptotic ADMSC, and lower in lung IR-melatonin-normal ADMSC than lung IR-melatonin-apoptotic ADMSC (P < 0.001 in each case). In conclusion, when the animals were treated with melatonin, the apoptotic ADMSC were superior to normal ADMSC for protection of lung from acute IR injury.

Predictors of bloodstream infection associated with permanently implantable venous port in solid cancer patients

BACKGROUND

The purpose of this study is to characterize the risk factors of bloodstream infection (BSI) associated with the use of permanent implantable venous ports (Port-A) in solid cancer patients.

METHODS

Solid cancer patients implanted with a Port-A were prospectively observed for the occurrence of Port-A-associated BSI (PABSI), defined as BSI without other identifiable infection foci. A PABSI risk score was developed using the Cox proportional hazards model.

RESULTS

A total of 415 patients were registered; 88 PABSI episodes occurred in 58 patients (incidence1.05 per 1000 catheter-days). All but one patient had stage IV cancer. Independent predictors of PABSI occurrence included neutropenia, total parenteral nutrition (TPN), chronic steroid use, invasive procedures, postoperative antibiotics, and preoperative antibiotics. A PABSI risk score with a cut-off value of 0 (sensitivity 88.5%, specificity 64.3%) was defined for stage IV cancer patients as follows: neutropenia, +1.350; TPN, +1.256; chronic steroid use, +1.947; preoperative antibiotics, -0.970; postoperative antibiotics, +0.959; and invasive procedures, +1.098. The median PABSI-free survival was 4.47 months for patients with scores ≥ 0 but not reached for patients with scores <0 (P < 0.0001).

CONCLUSION

The PABSI risk score can assist in identifying high-risk solid cancer patients and may assist in designing future preventive strategies.

Value and level of circulating endothelial progenitor cells, angiogenesis factors and mononuclear cell apoptosis in patients with chronic kidney disease

BACKGROUND

Chronic renal failure on dialysis can reduce the number of circulating endothelial progenitor cells (EPCs), but this biomarker has not been fully investigated in patients with chronic kidney disease (CKD). A link between CKD and increased mononuclear cell apoptosis (MCA) in circulation has been reported but the effect of vascular endothelial growth factor (VEGF) and stromal cell-derived factor (SDF)-1α, two angiogenesis factors, on circulating EPC levels in CKD has not been clarified. This study examined the relationships between the numbers of circulating EPCs and the severity of CKD, degree of MCA and serum levels of VEGF and SDF-1α in CKD patients.

METHODS

The numbers of circulating EPCs (CD31/CD34+, CD62E/CD34+, KDR/CD34+, CXCR4/CD34+) were measured in 166 patients with varying degrees of CKD under regular treatment at an outpatient department and in 30 volunteer control subjects.

RESULTS

CKD patients had significantly lower numbers of EPCs (p < 0.007), higher MCA in circulation and higher serum levels of VEGF and SDF-1 compared with the control subjects (all p < 0.001). Compared with patients with early CKD (stages I-III), patients with late CKD [stage IV-V or end-stage renal disease (ESRD)] had significantly lower numbers of EPCs (CXCR4/CD34+), higher MCA, and elevated serum levels of VEGF and SDF-1α (all p < 0.01). Serum VEGF level but not MCA or SDF-1α was strongly correlated with increased numbers of circulating EPCs. Multivariate analysis showed that ESRD along with lower serum albumin was independently predictive of lower numbers of circulating EPCs (p < 0.04).

CONCLUSION

Circulating EPCs were markedly reduced in CKD patients. ESRD was strongly and independently predictive of decreased numbers of circulating EPCs.

Impact of obesity control on circulating level of endothelial progenitor cells and angiogenesis in response to ischemic stimulation

Background and aim

We tested the hypothesis that obesity reduced circulating number of endothelial progenitor cells (EPCs), angiogenic ability, and blood flow in ischemic tissue that could be reversed after obesity control.

Methods

8-week-old C57BL/6J mice (n = 27) were equally divided into group 1 (fed with 22-week control diet), group 2 (22-week high fat diet), and group 3 (14-week high fat diet, followed by 8-week control diet). Critical limb ischemia (CLI) was induced at week 20 in groups 2 and 3. The animals were sacrificed at the end of 22 weeks.

Results

Heart weight, body weight, abdominal fat weight, serum total cholesterol level, and fasting blood sugar were highest in group 2 (all p < 0.001). The numbers of circulating EPCs (C-kit/CD31+, Sca-1/KDR + and CXCR4/CD34+) were lower in groups 1 and 2 than in group 3 at 18 h after CLI induction (p < 0.03). The numbers of differentiated EPCs (C-kit/CD31+, CXCR4/CD34+ and CD133+) from adipose tissue after 14-day cultivation were also lowest in group 2 (p < 0.001). Protein expressions of VCAM-1, oxidative index, Smad3, and TGF-β were higher, whereas the Smad1/5 and BMP-2, mitochondrial cytochrome-C SDF-1α and CXCR4 were lower in group 2 than in groups 1 and 3 (all p < 0.02). Immunofluorescent staining of CD31+ and vWF + cells, the number of small vessel (<15 μm), and blood flow through Laser Doppler scanning of ischemic area were lower in group 2 compared to groups 1 and 3 on day 14 after CLI induction (all p < 0.001).

Conclusion

Obesity suppressed abilities of angiogenesis and recovery from CLI that were reversed by obesity control.

Comparison of acute versus convalescent stage high-sensitivity C-Reactive protein level in predicting clinical outcome after acute ischemic stroke and impact of erythropoietin

Background and Aim

Currently, no data on the optimal time point after acute ischemic stroke (IS) at which high-sensitivity C-reactive protein (hs-CRP) level is most predictive of unfavorable outcome. We tested the hypothesis that hs-CRP levels during both acute (48 h after IS) and convalescent (21 days after IS) phases are equally important in predicting 90-day clinical outcome after acute IS. We further evaluated the impact of erythropoietin (EPO), an anti-inflammatory agent, on level of hs-CRP after acute IS.

Methods

Totally 160 patients were prospectively randomized to receive either EPO therapy (group 1, n = 80) (5,000 IU each time, subcutaneously) at 48 h and 72 h after acute IS, or placebo (group 2, n = 80). Serum level of hs-CRP was determined using ELISA at 48 h and on day 21 after IS and once in 60 healthy volunteers.

Results

Serum level of hs-CRP was substantially higher in all patients with IS than in healthy controls at 48 h and day 21 after IS (all p < 0.001). Levels of hs-CRP did not differ between group 1 and 2 at 48 h and day 21 after IS (all p > 0.5). Multivariate analysis showed that hs-CRP levels (at 48 h and day 21) were independently predictive of 90-day major adverse neurological event (MANE) (defined as recurrent stroke, NIHSS≥8, or death) (all p < 0.03), whereas EPO therapy was independently predictive of reduced 90-day MANE (all p < 0.02).

Conclusion

EPO therapy which was independently predictive of freedom from 90-day MANE did not alter the crucial role of hs-CRP levels measured at 48 h and 21-day in predicting unfavorable clinical outcome after IS.

Major adverse upper gastrointestinal events in patients with ST-segment elevation myocardial infarction undergoing primary coronary intervention and dual antiplatelet therapy

The aim of this study was to investigate the incidence of composite short-term and long-term major adverse upper gastrointestinal (UGI) events (MAUGIEs; defined as gastric ulcer, duodenal ulcer, gastroduodenal ulcer, or UGI bleeding) in patients with acute ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention and routinely received dual-antiplatelet therapy. From May 2002 to September 2010, a total of 1,368 consecutive patients who experienced ST-segment elevation myocardial infarction and underwent primary percutaneous coronary intervention were prospectively enrolled in the study. The incidence of in-hospital UGI bleeding complications and composite MAUGIEs was 8.9% and 9.9%, respectively. The in-hospital mortality rate was significantly higher in patients with in-hospital MAUGIEs than in those without (p <0.001). Multivariate analysis showed that age, advanced Killip score (≥3), and respiratory failure were the strongest independent predictors of in-hospital composite MAUGIEs (all p <0.003). The cumulative composite of MAUGIEs after uneventful discharge in patients without adverse UGI events who continuously received dual-antiplatelet therapy for 3 to 12 months, followed by aspirin therapy, was 10.4% during long-term (mean 4.0 years) follow-up. In conclusion, the results of this study show a remarkably high incidence of composite short-term and long-term MAUGIEs in patients with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention and received routine dual-antiplatelet therapy. Age, advanced Killip score, and respiratory failure were significantly and independently predictive of in-hospital composite MAUGIEs.

Myocardium-derived conditioned medium improves left ventricular function in rodent acute myocardial infarction

BACKGROUND

We investigated whether myocardium-derived conditioned medium (MDCM) is effective in preserving left ventricular (LV) function in a rat acute myocardial infarction (AMI) model.

METHODS

Adult male Sprague-Dawley (SD) rats (n = 36) randomized to receive either left coronary artery ligation (AMI induction) or thoracotomy only (sham procedure) were grouped as follows (n = 6 per group): Group I, II, and III were sham-controls treated by fresh medium, normal rat MDCM, and infarct-related MDCM, respectively. Group IV, V, and VI were AMI rats treated by fresh medium, normal MDCM, and infarct-related MDCM, respectively. Either 75 μL MDCM or fresh medium was administered into infarct myocardium, followed by intravenous injection (3 mL) at postoperative 1, 12, and 24 h.

RESULTS

In vitro studies showed higher phosphorylated MMP-2 and MMP-9, but lower α-smooth muscle actin and collagen expressions in neonatal cardiac fibroblasts treated with MDCM compared with those in the cardiac fibroblasts treated with fresh medium (all p < 0.05). Sirius-red staining showed larger collagen deposition area in LV myocardium in Group IV than in other groups (all p < 0.05). Stromal cell-derived factor-1α and CXCR4 protein expressions were higher in Group VI than in other groups (all p < 0.05). The number of von Willebrand factor- and BrdU-positive cells and small vessels in LV myocardium as well as 90-day LV ejection fraction were higher, whereas oxidative stress was lower in Group VI than in Group IV and Group V (all p < 0.05).

CONCLUSION

MDCM therapy reduced cardiac fibrosis and oxidative stress, enhanced angiogenesis, and preserved 90-day LV function in a rat AMI model.

Role of stromal cell-derived factor-1alpha, level and value of circulating interleukin-10 and endothelial progenitor cells in patients with acute myocardial infarction undergoing primary coronary angioplasty

BACKGROUND

The relationships among the circulating levels of endothelial progenitor cells (EPC), stromal cell-derived factor (SDF)-1alpha, interleukin (IL)-10 and outcome were examined in patients with ST-segment elevation acute myocardial infarction (ST-se AMI) undergoing primary coronary angioplasty.

METHODS AND RESULTS

Circulating levels of IL-10, SDF-1alpha, and EPCs [defined by staining markers: CD31/CD34 (E(1)) and KDR/CD34 (E(2))] were examined by ELISA and flow cytometry, respectively. The IL-10 level was higher, whereas the circulating level of EPCs (E(1-2)) was lower (all P<0.05) in AMI patients than in normal subjects. Additionally, the SDF-1alpha level was significantly and independently predictive of an increased level of circulating EPCs (E(1-2)) (P<0.0001). Furthermore, patients with a high SDF-1alpha level (>1,500 pg/ml) had lower left ventricular performance, higher Killip score (defined as >or=3), and increased 30-day mortality than those with low SDF-1alpha level (<or=1,500 pg/ml) (all P<0.007). Moreover, high circulating levels of E(2) and IL-10 were the most significant independent predictors of increased 30-day major adverse clinical outcome (MACO) (defined as advanced Killip score >or=3 or 30-day mortality) (P<0.01).

CONCLUSIONS

The serum SDF-1alpha level is independently predictive of an increased level of circulating EPCs (E(1-2)). E(2) and IL-10 are major independent predictors of 30-day MACO in ST-se AMI patients undergoing primary coronary angioplasty.

Clinical profile and outcome of first acute myocardial infarction with ischemic mitral regurgitation

BACKGROUND

Ischemic mitral regurgitation indicates a poor prognosis after acute myocardial infarction (AMI). This study addresses the clinical characteristics and contribution of ischemic mitral regurgitation to the midterm survival rate of patients following first AMI in our institution.

METHODS

Between January 2000 and December 2002, patients who underwent 2-dimensional color Doppler echocardiographic quantitation of ischemic mitral regurgitation within 30 days after first myocardial infarction (MI) were analyzed.

RESULTS

During the study period, 519 patients were enrolled (mean age 62.7 +/- 12 years, 76% men). The population was divided into 2 groups based on the degree of mitral regurgitation (MR). Group A included 440 subjects with no MR (n = 41), trivial MR (n = 188), and mild MR (n = 211). Group B included 79 subjects with moderate MR (n = 64), and severe MR (n = 15). Group B patients were more likely to be older (p < 0.05), women (p < 0.01), and nonsmokers (p < 0.01). Group B had a higher prevalence of inferior wall MI (p < 0.01) and lateral wall MI (p < 0.01). After 6 months of follow-up, 57 deaths had occurred (42 in Group A and 15 in Group B). Group B had a lower survival rate than Group A 180 days post-AMI (19% vs. 9.79%, p < 0.01).

CONCLUSIONS

Post-AMI patients with significant ischemic mitral regurgitation were more likely to be older, female, and nonsmokers. There was a positive association between the severity of ischemic mitral regurgitation and inferior MI and lateral wall MI. The severity of ischemic mitral regurgitation showed a significant inverse relationship with the mid-term post-MI survival rate.

Association between circulating level of CD40 ligand and angiographic morphologic features indicating high-burden thrombus formation in patients with acute myocardial infarction undergoing primary coronary intervention

BACKGROUND

This study tested the hypothesis that in the acute phase of myocardial infarction (MI), the circulating level of soluble CD40 ligand (sCD40L), an index of platelet activation, is predictive of angiographic morphologic features that indicate high-burden thrombus formation (HBTF) in the infarct-related artery (IRA).

METHODS AND RESULTS

This prospective study included 162 consecutive patients: 64 with HBTF and 98 with low-burden thrombus formation (LBTF). All patients had a Killip's classification<or=3 ST-segment elevation acute myocardial infarction (AMI) of onset<12 h who were undergoing primary percutaneous coronary intervention (PCI). Blood samples for measurement of the circulating levels of sCD4L and high-sensitivity C-reactive protein (hs-CRP) and white blood cell (WBC) count were collected before PCI. The circulating levels of sCD40L and hs-CRP, and the WBC count were also evaluated in 20 normal control subjects. Blood was aspirated by export suction catheter from the intracoronary artery (ICA) in 49 HBTF patients. The WBC count, and the circulating levels of hs-CRP and sCD40L were significantly higher in the HBTF and LBTF groups than in the normal control subjects (all p<0.005). Additionally, the circulating levels of sCD40L and the WBC count were substantially higher in the HBTF than in the LBTF patients (all p<0.001). Furthermore, in HBTF patients the ICA had a significantly higher sCD40L level and WBC count compared with the values for the systemic circulation (all p<0.001). Multiple statistical analyses identified increased circulating level of sCD40L as the most independent predictor of HBTF in the IRA (p<0.0001).

CONCLUSIONS

The sCD40L level is the most independent predictor of angiographic morphologic features that indicate HBTF in the acute phase of MI.

Intensity of C-reactive protein immunohistochemical staining of atherosclerotic plaque macrophages and extracellular tissue of patients with angina pectoris undergoing directional coronary atherectomy

BACKGROUND

An elevated C-reactive protein (CRP) level plays a crucial role in cell biology of atherosclerosis and unstable plaque formation. However, direct evidence of CRP involvement in atherosclerotic plaque development and vulnerability is still limited. We hypothesized that CRP is present in the vulnerable plaques and that CRP staining intensity is stronger in vulnerable plaques compared to stable plaques.

METHODS

Directional coronary atherectomy (DCA) was performed on 58 patients with stable angina (group 1) and 40 patients with unstable angina (group 2). White blood cell (WBC) counts were measured prior to DCA. Immunohistochemical staining (IHCS) was performed to localize CRP in the atheroma. Staining intensity in macrophages and extracellular tissue was graded as: 0, no staining; 1+, < 30%; 2+, 30%-60%; 3+, > 60%.

RESULTS

The IHCS demonstrated that CRP staining - 1+ intensity in macrophages and extracellular tissue were significantly higher in group 1 than in group 2 patients (all p values < 0.0001). However, IHCS demonstrated that CRP staining a 2+ intensity in macrophages and extracellular tissue were significantly higher in group 2 than in group 1 patients (all p values < 0.0001). By multiple analysis, only stable angina was independently associated with CRP staining : 1+ intensity in both macrophages and extracellular tissue (p < 0.0001), whereas unstable angina and WBC counts were independent predictors of CRP staining > or = 2+ intensity in both macrophages and extracellular tissue (p < 0.0001).

CONCLUSION

CRP was frequently found in atherosclerotic plaques of patients with unstable angina. This analytical finding suggests that CRP directly mediates an inflammatory process in the atherosclerotic plaque.

Association of Interleukin-10 Level With Increased 30-Day Mortality in Patients With ST-Segment Elevation Acute Myocardial Infarction Undergoing Primary Coronary Intervention

BACKGROUND

The prognostic value of interleukin (IL)-10 in patients with ST-segment elevation acute myocardial infarction (ST-se AMI) is currently unclear. The purpose of this study was to test whether the serum IL-10 level can predict 30-day mortality in patients with ST-se AMI undergoing primary percutaneous coronary intervention (PCI).

METHODS AND RESULTS

The study design was a prospective cohort study of 250 consecutive patients with ST-se AMI of onset <12 h who were undergoing primary PCI. Blood samples for serum IL-10 levels were collected in the catheterization laboratory following vascular puncture. The serum IL-10 level was also evaluated in 20 healthy and 30 at-risk control subjects. The mean serum level of IL-10 was significantly higher in the AMI patients than in either group of controls (all values of p<0.0001). Patients with a high serum IL-10 level (> or = 30 pg/ml) had a significantly lower left ventricular ejection fraction (LVEF) (defined as <50%), significantly higher incidence of cardiogenic shock, higher white blood cell (WBC) count, more advanced congestive heart failure (defined as New York Heart Association function classification of > or = 3), and increased 30-day mortality than those patients with a low serum IL-10 level (<30 pg/ml) (all values of p<0.0001). Multiple stepwise logistic regression analysis demonstrated that a high serum IL-10 level, together with low LVEF, high WBC count and unsuccessful reperfusion, was independently predictive of increased 30-day mortality (all values of p<0.005).

CONCLUSION

In patients with ST-se AMI, the serum IL-10 level is a major independent predictor of 30-day mortality and should be used for early risk stratification following acute myocardial infarction.

Level and Value of Interleukin-18 in Patients With Acute Myocardial Infarction Undergoing Primary Coronary Angioplasty

BACKGROUND

The prognostic value of interleukin (IL)-18 in patients with ST-segment elevation acute myocardial infarction (STEMI) is currently unclear. Thus, the purpose of this study was to test whether the circulating IL-18 level can predict prognosis in patients with STEMI undergoing primary percutaneous coronary intervention (PCI).

METHODS AND RESULTS

A prospective cohort study was conducted with 267 consecutive patients with STEMI of onset <12 h who were undergoing primary PCI. Blood samples for plasma IL-18 level were collected in the catheterization laboratory following vascular puncture. The plasma IL-18 level was also evaluated in 25 healthy and 30 at-risk control subjects. The plasma level of IL-18 was significantly higher in acute myocardial infarction (AMI) patients than in both groups of control subjects (all p<0.0001). Patients with high plasma IL-18 level (> or =560 pg/ml) had significantly higher peak creatine kinase-MB levels, higher incidence of cardiogenic shock upon presentation, significantly lower left ventricular ejection fraction (LVEF), lower successful reperfusion and significantly higher incidence of 30-day composite major adverse clinical events (MACE) (advanced congestive heart failure > or = class 3 or 30-day mortality) than those patients with low plasma IL-18 level (<560 pg/ml) (all p<0.0001). Multiple stepwise logistic regression analysis demonstrated that high plasma IL-18 level (> or =560 pg/ml) along with low LVEF (<50%) and cardiogenic shock were the most independent predictors of 30-day MACE (p<0.0001).

CONCLUSIONS

In patients with STEMI, plasma IL-18 level is a major independent inflammatory predictor of 30-day MACE. Evaluation of circulating IL-18 might improve the prediction of unfavorable clinical outcomes following AMI.

An open, multi-centre, phase II clinical trial to evaluate the efficacy and safety of paclitaxel, UFT, and leucovorin in patients with advanced gastric cancer

The aim of the study was to evaluate the response rate and safety of weekly paclitaxel (Taxol((R))) combination chemotherapy with UFT (tegafur, an oral 5-fluorouracil prodrug, and uracil at a 1 : 4 molar ratio) and leucovorin (LV) in patients with advanced gastric cancer. Patients with histologically confirmed, locally advanced or recurrent/metastatic gastric cancer were studied. Paclitaxel 1-h infusion at a dose of 100 mg m(-2) on days 1 and 8 and oral UFT 300 mg m(-2) day(-1) plus LV 90 mg day(-1) were given starting from day 1 for 14 days, followed by a 7-day period without treatment. Treatment was repeated every 21 days. From February 2003 to October 2004, 55 patients were enrolled. The median age was 62 years (range: 32-82). Among the 48 patients evaluated for tumour response, two achieved a complete response and 22 a partial response, with an overall response rate of 50% (95% confidence interval: 35-65%). All 55 patients were evaluated for survival and toxicities. Median time to progression and overall survival were 4.4 and 9.8 months, respectively. Major grade 3-4 toxicities were neutropenia in 25 patients (45%) and diarrhoea in eight patients (15%). Although treatment was discontinued owing to treatment-related toxicities in nine patients (16%), there was no treatment-related mortality. Weekly paclitaxel plus oral UFT/LV is effective, convenient, and well tolerated in treating patients with advanced gastric cancer.

Concentration of soluble P-selectin and white blood cell counts in infarct coronary arteries in patients with acute myocardial infarction differ from the systemic circulation

BACKGROUND

Previously, researchers have suggested that Soluble (s) P-selectin mediates the accumulation of leukocytes which in turn promotes fibril deposition. Soluble P-selectin and white blood cell (WBC) counts have been shown to be increased in the systemic circulation after acute myocardial infarction (AMI). However, whether the infarct coronary artery (ICA) and systemic circulation differs with respect to the concentration of sP-selectin and WBC counts following AMI remain unknown. In this study, we investigated whether the concentration of sP-selectin and WBC counts differed between the ICA and the systemic circulation after AMI.

METHODS

Blood samples for circulating sP-selectin and WBC counts were immediately obtained after vascular puncture in 72 patients with AMI of < 12 h undergoing primary percutaneous coronary intervention (PCI). Additionally, blood samples for ICA sP-selectin and WBC counts were obtained via Export Suction Catheter during PCI. For comparison, blood samples for sP-selectin and WBC counts were obtained once in 30 healthy subjects.

RESULTS

The results demonstrated that the circulating sP-selectin [64.7 +/- 18.1 (ng/ml) vs. 29.5 +/- 6.3 (ng/ml), p < 0.0001] and WBC counts [12.1 +/- 3.6 (x 10(3)/ml) vs. 5.0 +/- 1.0 (x 10(3)/ml), p < 0.0001] were significantly higher in our patients than in healthy subjects. Furthermore, the sP-selectin [72.7 +/- 23.3 (ng/ml) vs. 64.7 +/- 18.1 (ng/ml), p < 0.0001] and the WBC counts [16.2 +/- 3.8 (x 10(3/)ml) vs. 12.1 +/- 3.6 (x 10(3)/ml), p < 0.0001] were markedly higher in the ICA than in the systemic circulation for the patients.

CONCLUSIONS

The plasma level of sP-selectin and WBC counts were more elevated in the ICA than in the systemic circulation of patients with AMI undergoing primary PCI. These findings strengthen the role of sequestration of WBC and sP-selectin in the ICA as crucial in thrombus formation.

Impact of clopidogrel on suppression of circulating levels of soluble CD40 ligand in patients with unstable angina undergoing coronary stenting

This study investigated whether a regimen that comprised a loading dose of 300 mg of clopidogrel followed by 75 mg/day could significantly suppress circulating levels of soluble CD40 ligand (sCD40L) in patients who had unstable angina and underwent coronary stenting. Study results showed that the clopidogrel loading dose substantially decreased the circulating level of sCD40L at 24 hours after stenting (p <0.0001). Combined with aspirin, 75 mg/day of clopidogrel continuously decreased sCD40L levels after coronary stenting.

Re-Elevation of High-Sensitivity C-Reactive Protein but not the von Willebrand Factor After Withdrawing Atorvastatin Therapy in Patients With Unstable Angina Undergoing Coronary Artery Stenting A Kinetic Study

Statins are known to reduce high-sensitivity C-reactive protein (hs-CRP) concentrations and improve endothelial function. However, whether statin withdrawal causes re-elevated concentrations of hs-CRP and von Willebrand Factor (vWF) (a marker of endothelial damage) remains unknown. We hypothesized that the concentrations of hs-CRP and vWF are substantially increased in patients with unstable angina pectoris (UAP) and noticeably decreased following coronary stenting along with atorvastatin therapy. However, re-elevations of these biomarker concentrations occurred once again after withdrawing atorvastatin therapy. We serially examined the plasma concentrations of hs-CRP and vWF in 51 patients with UAP before (day 0) and after (days 21, 90, 180, 270) performing coronary artery stenting. The concentrations of these 2 biomarkers were also measured in 30 healthy control subjects. Patients were treated with atorvastatin (40 mg/day orally) for 180 days, after which the therapy was withdrawn. The hs-CRP and vWF concentrations were significantly higher in the patients than in the healthy control subjects before the procedure (both P values < 0.001). The hs-CRP concentration decreased significantly on day 21 (P < 0.001), and further to a substantially lower level on day 180 (P < 0.0001). However, the hs-CRP level significantly increased again on day 270, as compared with that on day 180 (P < 0.001). The vWF plasma concentration decreased gradually to a significantly lower level on day 180. The concentration of this biomarker did not differ between days 180 and 270. In conclusion, although hs-CRP concentrations decreased markedly following combined stenting and atorvastatin therapy, re-elevation after atorvastatin therapy was withdrawn in UAP patients undergoing coronary stenting was not observed. Conversely, restoration of endothelial function was slow and persistent in these patients.

Platelet Activation in Patients With Chronic Nonvalvular Atrial Fibrillation

Increased platelet activity plays a key role in atherothrombotic events. Persistent platelet activity has been reported in patients with atrial fibrillation (AF) following myocardial infarction and in the chronic phase after ischemic stroke. However, platelet activity in patients with AF remains clear. This study investigated platelet reactivity (expressed by CD62p) in patients with chronic nonvalvular (NV) AF. Expression of CD62p was measured by flow cytometry in 62 consecutive patients with chronic NVAF (defined as sustained AF > 6 months) and no previous embolic events. The CD62p expression was also evaluated in 20 healthy subjects. Expression of CD62p was not different between AF patients and healthy subjects (P = 0.970). Additionally, CD62p expression did not differ between patients with and patients without the following atherosclerotic risk factors: hypertension, current smoking, and hypercholesterolemia (all P values > 0.1). Furthermore, CD62p expression did not differ between patients taking and not taking the following medications: warfarin, a statin, or an angiotensin converting enzyme inhibitor/angiotensin II receptor blocker (all P values > 0.2). However, diabetes mellitus (DM) was strongly associated with increased CD62p expression (P < 0.0001). Multiple linear regression analysis demonstrated that only DM independently predicted increased CD62p expression (r2 = 0.509, regression coefficient = 3.044, P < 0.0001). In conclusion, compared to healthy subjects, CD62p expression was not significantly enhanced in chronic NVAF patients. However, CD62p expression was substantially elevated in diabetic patients with chronic NVAF.

Impact of PercuSurge Device Conjugative With Intracoronary Administration of Nitroprusside on No-Reflow Phenomenon Following Primary Percutaneous Coronary Intervention

BACKGROUND

The present study tested the hypothesis that when administered in conjunction with a PercuSurge device for treatment of acute myocardial infarction (AMI), intracoronary (IC) administration of nitroprusside (NTP) is safe and superior to IC administration of NTP alone or nitroglycerin (NTG) for reversing slow-flow or no-reflow, both of which occur frequently during primary percutaneous coronary intervention (PCI).

METHODS AND RESULTS

Sixty-two patients with ST-segment elevation AMI of <12 h duration undergoing primary PCI were enrolled. When the final Thrombolysis In Myocardial Infarction (TIMI) flow was normal (TIMI-3), NTG 200 microg was administered first, followed by (5 min later) NTP 100 microg via an intra-guiding catheter. When final TIMI flow was <or=2, NTG 200 mug was given, followed by NTP 100 microg via an export suction catheter advanced into the infract-related artery (IRA). Primary endpoint was epicardial blood flow (TIMI-flow), corrected TIMI frame counts, or microvascular circulation [myocardial blush (MB) grade]. Analytical results indicated that the final TIMI-3 flow was significantly higher in patients receiving NTP than in those receiving NTG therapy (100% vs 88.7%, p=0.023). As compared with NTG, NTP therapy significantly improved final MB grade (p<0.0001) and corrected TIMI flame count time (p<0.0001). Subgroup analysis demonstrated that final MB grade (p<0.001) and corrected TIMI flame count time (p<0.01) were significantly higher in patients (n=33) with than in patients (n=29) without the PercuSurge. No significant NTP related adverse events occurred, apart from insignificant transient hypotension.

CONCLUSION

IC administration of NTP is safe and superior to NTG for improving final epicardial blood flow and microvascular circulation in patients with AMI undergoing primary PCI. Combination therapy of PercuSurge device and NTP provided an additional benefit to NTP alone for improving microvascular circulation.

Serial changes in platelet activation in patients with unstable angina following coronary stenting: evaluation of the effects of clopidogrel loading dose in inhibiting platelet activation

BACKGROUND

Platelet activation is crucial in the development of acute or subacute stent thrombosis following implantation. This study investigated whether a conventional regimen comprising a loading dose of 300 mg of clopidogrel, followed by daily doses of 75 mg, could significantly suppress platelet activation in patients with unstable angina (UA) undergoing coronary stenting.

METHODS AND RESULTS

Platelet activation (expressed by CD62p) was serially examined using flow cytometry in 42 consecutive patients with UA who underwent coronary stenting. CD62p expression was also evaluated in 30 normal control subjects. CD62p expression was markedly higher pre-procedure in the study patients than in the normal control subjects (5.2+/-4.0% vs 1.4+/-0.6%, p<0.0001). CD62p expression in the study patients remained significantly higher at 24 h after the procedure than in the control subjects (3.8+/-2.1% vs 1.4+/-0.6%, p<0.001). Additionally, only 26% of CD62p expression (5.2% vs 3.8%, p=0.026) in the study patients was suppressed at 24 h after the procedure. However, more than 60% of CD62p expression (5.2% vs 2.0%, p<0.0001) was suppressed on day 7 after the procedure.

CONCLUSION

Less than one-third of CD62p expression was suppressed at 24 h by the conventional loading dose (300 mg) of clopidogrel in patients with UA following coronary stenting. This finding indicates the need to evaluate whether an increased loading dose of clopidogrel would be a more efficacious and safe regimen for patients in this clinical setting.

Serum concentrations of high-sensitivity C-reactive protein predict progressively obstructive lesions rather than late restenosis in patients with unstable angina undergoing coronary artery stenting

BACKGROUND

The present study tested the hypothesis that high-sensitivity C-reactive protein (hs-CRP) concentrations might show significant serial changes in patients with unstable angina (UAP), and that elevation of hs-CRP might indicate a progressively obstructive lesion, rather than late restenosis in such patients undergoing coronary stenting.

METHODS AND RESULTS

Serum concentrations of hs-CRP in 168 patients with UAP undergoing coronary stenting for a new obstructive lesion were prospectively measured (pre-procedure, and on days 21, 90, and 180 post-procedure). The hs-CRP concentrations were also evaluated in 30 at-risk controls and 50 healthy volunteers. Moderately obstructive lesions of non-culprit vessels (defined as > or =50-69% stenosis) that were not treated by coronary angioplasty were found in 107 (63.7%) patients. The hs-CRP concentration was significantly higher at pre-procedure in the study patients than in the controls and healthy volunteers (all p-values <0.0001) and markedly declined after the procedure (p<0.0001). Pre-procedure (p=0.799) and post-procedure hs-CRP concentrations (all p-values >0.1) did not differ between restenotic and non-restenotic patients. However, at pre-procedure or on day 180, the concentration of hs-CRP was independently associated with progressively obstructive lesions of non-culprit vessels that required coronary angioplasty (both p-values <0.05).

CONCLUSION

The hs-CRP concentration was significantly higher at pre-procedure and declined substantially thereafter in patients with UAP following coronary stenting. There was no evidence of a positive association between an elevated hs-CRP concentration and late restenosis. However, both the pre-procedure and day 180 concentrations of hs-CRP were strongly associated with the progression of moderately obstructive lesions in non-culprit vessels.

Levels and value of soluble P-selectin following acute myocardial infarction: evaluating the link between soluble P-selectin levels and recruitment of circulating white blood cells and the marker for the rapid diagnosis of chest pain

BACKGROUND

Platelet activation that results from coronary plaque rupture is important in the pathogenesis of acute myocardial infarction (AMI). Soluble p-selectin (sP-selectin) is crucial in modulating leukocyte adhesion to both platelets and endothelial cells during inflammatory response and thrombus formation. We hypothesized that sP-selectin, an index of both platelet activation and acute inflammation, rapidly increases and modulates the recruitment of circulating white blood cells (WBC) in patients following AMI.

METHODS

We conducted a prospective cohort study of 142 consecutive patients with ST-segment elevated AMI of onset < 12 h who were undergoing primary percutaneous coronary intervention. Blood samples for plasma levels of sP-selectin were obtained in the catheterization laboratory before coronary angiography was performed. The plasma levels of sP-selectin were also measured in 30 risk control subjects and 20 healthy control subjects.

RESULTS

The plasma level of sP-selectin and the circulating WBC count were significantly higher in patients with AMI than in either the risk control or healthy subjects (all of p values < 0.0001). Additionally, repeated measures of ANOVA demonstrated that there were no significant differences in plasma levels of sP-selectin (p > 0.10) in three intervals from the start of chest pain to blood sample collection (< 180 min, > or = 180 < 360, and > or = 360 < 720) following AMI. Correlation analysis demonstrated that the increase in the plasma level of sP-selectin was significantly related to the circulating WBC count (r = 0.248, p = 0.003).

CONCLUSIONS

sP-selectin was markedly elevated in an early phase of AMI. sP-selectin may be involved in modulating the recruitment of circulating WBC during AMI. These findings raise the need for a prospective investigation of sP-selectin as a potential reliable clinical tool for rapidly diagnosing AMI.

Atrial Pacemaker Complex Preserved Radiofrequency Maze Procedure Reducing the Incidence of Sick Sinus Syndrome in Patients With Atrial Fibrillation

BACKGROUND

The Cox maze III procedure can effectively restore sinus rhythm in most patients with permanent atrial fibrillation (AF). However, previous studies have shown that the maze procedure results in significant sinus node dysfunction, and, consequently, a considerable number of patients required postoperative pacemaker implantation.

HYPOTHESIS

This study investigates the hypothesis that the modification of the Cox III maze procedure, to avoid injuring the sinus node and the atrial physiologic pacemaker complex, will reduce the incidence of sick sinus syndrome following surgery.

METHODS AND RESULTS

This study investigated 71 patients with permanent AF and mitral valve disease who were undergoing concomitant open-heart surgery. Most atrial incisions in the Cox maze III procedure were replaced with radiofrequency ablation, and the intercaval counterablation was moved posterolaterally to avoid injury to the sinus node and atrial pacemaker complex. At a mean (+/- SD) follow-up time of 46.5 +/- 24 months, 59 patients (83.1%) regained sinus rhythm without receiving antiarrhythmic drug therapy or undergoing electrical cardioversion. The transmitral atrial wave was observed in 44 patients (62%), and the transtricuspid atrial wave was also observed in 53 patients (74.6%). Late sinus node dysfunction developed in only two patients (2.8%), who received permanent pacemaker implantation.

CONCLUSION

This modified radiofrequency maze procedure produces few patients with sick sinus syndrome and effectively restores sinus rhythm and atrial transport function in most patients with permanent AF undergoing concomitant open-heart surgery.

Circulating levels of soluble P-selectin in patients in the early and recent phases of myocardial infarction

BACKGROUND

Circulating soluble P-selectin (sP-selectin), a biomarker of platelet activation is substantially increased in patients with acute myocardial infarction (AMI). However, the circulating level of sP-selectin in patients in the early (onset of AMI > 12 h but < 7 d) or recent (onset of AMI > 8 d but < 21 d) phase after AMI remains unclear. The purpose of this study was to prospectively evaluate whether the circulating level of sP-selectin remains elevated in these two consecutive phases after an AMI.

METHODS

Blood samples were collected in the catherization room before coronary angiography to assess the circulating level of sP-selectin. A total of 53 consecutive patients, 34 with early MI (group 1) and 19 with recent MI (group 2), who had had no prior thrombolytic therapy were included. Circulating levels of sP-selectin were also measured in 30 risk control (stable angina) subjects undergoing elective percutaneous coronary intervention and in 20 healthy subjects who comprised the healthy control group.

RESULTS

The circulating level of sP-selectin did not differ between patients with early AMI and those with recent MI (p = 0.632). However, the plasma level of sP-selectin was significantly higher in group 1 and 2 patients than in the risk control and healthy control subjects (all p values < 0.0001).

CONCLUSIONS

Circulating sP-selectin was elevated in patients 12 hours to 7 days after AMI and the elevation was maintained until 21 days after AMI. Therefore, investigation of longer utilization of anti-platelet and anti-inflammatory agents for patients following AMI might be worthwhile.

Percutaneous Transluminal Mitral Valvuloplasty Reduces Circulating Soluble CD40 Ligand in Rheumatic Mitral Stenosis

BACKGROUND

Recent data suggest that the pathogenesis of vascular inflammation and thrombosis involves CD40 ligand (CD40L), which is mostly derived from platelets. Previous studies have demonstrated that platelet activation occurs in peripheral blood of patients with rheumatic mitral stenosis (MS). However, in patients with MS, the plasma level of soluble CD40L has never been investigated.

METHODS AND RESULTS

Seventeen patients with symptomatic MS undergoing percutaneous transluminal mitral valvuloplasty were studied (group 1, 11 patients in permanent atrial fibrillation and 6 patients in sinus rhythm). Solid-phase, sandwich enzyme-linked immunosorbent assay determined the plasma levels of soluble CD40L in the femoral vein and artery, and right and left atria before valvuloplasty, and those in the peripheral venous blood obtained 10 min after valvuloplasty, and at the 4-week follow-up after valvuloplasty. The Doppler pressure half-time method was used to calculate the mitral valve area. Additionally, plasma concentrations of soluble CD40L in the peripheral venous blood obtained from 17 control patients were measured (including nine healthy volunteers in sinus rhythm [group 2] and eight patients in permanent lone atrial fibrillation [group 3]). Plasma levels of soluble CD40L were significantly elevated in group 1 patients (437.6 +/- 370.2 pg/mL) [mean +/- SD] compared with group 2 (203.8 +/- 218.0 pg/mL) and group 3 patients (173.5 +/- 105.0 pg/mL) [p < 0.05]. The area of mitral valve increased significantly after valvuloplasty (1.10 +/- 0.20 cm(2) vs 1.47 +/- 0.29 cm(2), p < 0.0001). The mean left atrial pressure fell significantly and immediately after valvuloplasty (22.8 +/- 4.9 mm Hg vs 17.6 +/- 5.5 mm Hg, p = 0.0004). The peripheral venous plasma levels of soluble CD40L obtained before valvuloplasty significantly fell after valvuloplasty (before, 437.6 +/- 370.2 pg/mL; vs 10 min after, 215.4 +/- 113.9 pg/mL; vs 4 weeks after, 217.5 +/- 111.9 pg/mL; p < 0.02).

CONCLUSIONS

Patients with moderate-to-severe MS had higher venous plasma levels of soluble CD40L than healthy volunteers or patients with lone atrial fibrillation. Additionally, the elevated venous plasma levels of soluble CD40L fell significantly following valvuloplasty.

Phase II study of weekly vinorelbine and 24-h infusion of high-dose 5-fluorouracil plus leucovorin as first-line treatment of advanced breast cancer

We prospectively investigated the efficacy and safety of combining weekly vinorelbine (VNB) with weekly 24-h infusion of high-dose 5-fluorouracil (5-FU) and leucovorin (LV) in the treatment of patients with advanced breast cancer (ABC). Vinorelbine 25 mg m⁻² 30-min intravenous infusion, and high-dose 5-FU 2600 mg m⁻² plus LV 300 mg m⁻² 24-h intravenous infusion (HDFL regimen) were given on days 1 and 8 every 3 weeks. Between June 1999 and April 2003, 40 patients with histologically confirmed recurrent or metastatic breast cancer were enrolled with a median age of 49 years (range: 36–68). A total of 25 patients had recurrent ABC, and 15 patients had primary metastatic diseases. The overall response rate for the intent-to-treat group was 70.0% (95% CI: 54–84%) with eight complete responses and 20 partial responses. All 40 patients were evaluated for survival and toxicities. Among a total of 316 cycles of VNB–HDFL given (average: 7.9: range: 4–14 cycles per patient), the main toxicity was Gr3/4 leucopenia and Gr3/4 neutropenia in 57 (18.0%) and 120 (38.0%) cycles, respectively. Gr1/2 infection and Gr1/2 stomatitis were noted in five (1.6%) and 59 (18.7%) cycles, respectively. None of the patients developed Gr3/4 stomatitis or Gr3/4 infection. Gr2/3 and Gr1 hand–foot syndrome was noted in two (5.0%) and 23 (57.5%) patients, respectively. Gr1 sensory neuropathy developed in three patients. The median time to progression was 8.0 months (range: 3–25.5 months), and the median overall survival was 25.0 months with a follow-up of 5.5 to 45+ months. This VNB–HDFL regimen is a highly active yet well-tolerated first-line treatment for ABC.

Levels and values of serum high-sensitivity C-reactive protein within 6 hours after the onset of acute myocardial infarction

BACKGROUND

C-reactive protein (CRP), which has been suggested to directly enhance inflammation in plaques, is rapidly synthesized and secreted in the liver 6 h after an acute inflammatory stimulus. Therefore, serum levels of CRP within 6 h after the onset of acute myocardial infarction (AMI) merely reflect a chronic and persistent inflammatory process and are not due to acute myocardial damage. We hypothesized that the serum CRP level, which would abnormally elevate thereafter, is followed by a plaque rupture in the clinical setting of AMI.

METHODS AND RESULTS

CRP was prospectively measured by high-sensitivity CRP assay (hs-CRP) in 157 consecutive patients (106 patients within 6 h, and 51 patients >/= 6 h but < 12 h after the onset of AMI) with ST-segment elevation AMI undergoing primary percutaneous coronary intervention (PCI). Serum levels of hs-CRP were also measured in 30 patients with stable angina undergoing elective PCI and in 30 healthy control subjects. The serum level of hs-CRP was significantly higher in patients with an onset of AMI < 6 h than in patients with angina pectoris (2.7 +/- 2.3 mg/L vs 1.4 +/- 0.7 mg/L, p < 0.0001 [mean +/- SD]) and in healthy subjects (2.7 +/- 2.3 mg/L vs 1.0 +/- 0.6 mg/L, p < 0.0001). There were no significant differences in serum levels of hs-CRP in patients with an onset of AMI </= 3 h than in those patients with an onset of AMI > 3 h but < 6 h (2.7 +/- 2.5 mg/L vs 2.7 +/- 2.2 mg/L, p = 0.87). However, the serum level of hs-CRP was significantly higher in patients with an onset >/= 6 h than in patients with an onset < 6 h (14.1 +/- 16.5 mg/L vs 2.7 +/- 2.3 mg/L, p < 0.0001).

CONCLUSIONS

Serum levels of hs-CRP were significantly higher in patients with an onset of AMI < 6 h than in healthy subjects and in patients with angina pectoris undergoing PCI. The inflammatory process has been proved as one of the mechanisms causing plaque rupture. Elevated serum hs-CRP levels in patients with AMI < 6 h may portend vulnerable plaque rupture.

Levels and Values of Inflammatory Markers in Patients With Angina Pectoris

Inflammation plays an important pathogenic role in the initiation and progression of atherosclerotic plaque lesions. C-reactive protein (CRP), which directly participates in plaque inflammation, induces vascular cell adhesion molecule-1 (VCAM-1) expression in endothelial cells. However, the levels and values of high-sensitivity (hs)-CRP, white blood cell (WBC) count, and VCAM-1 in both stable and unstable angina pectoris (AP) have not been fully investigated. This study examines the levels and values of these inflammatory markers in patients with stable or unstable AP. From March 2003 to December 2003, a prospective cohort study was conducted in 128 consecutive patients, including unstable AP patients (class I: n = 59; combined class II and III: n = 16) and stable AP patients (n = 53) undergoing elective coronary stenting. Blood samples for hs-CRP, WBC count, and VCAM-1 were obtained in the catheterization laboratory before coronary angiography. The circulating levels of hs-CRP and VCAM-1 were also evaluated in 40 healthy volunteers. The circulating levels of these three inflammatory markers were substantially higher in patients than in healthy volunteers (all P values < 0.0001). Additionally, circulating levels of hs-CRP and the WBC count were significantly higher in patients with unstable AP than in patients with stable AP (all P value < 0.0001). However, only those patients with class II and III unstable AP had significantly higher circulating levels of VCAM-1 than patients with stable AP (P < 0.0001). On the other hand, the circulating levels of VCAM-1 did not differ between patients with class I unstable AP and patients with stable AP (P = 0.782). Multiple stepwise logistic regression analysis showed that only hs-CRP level was independently associated with unstable AP (P = 0.0002). In conclusion, circulating levels of hs-CRP, WBC count, and VCAM-1 were significantly increased in patients with AP. The circulating level of hs-CRP was strongly associated with the clinical setting of unstable AP.

Phase II study of weekly oxaliplatin and 24-h infusion of high-dose 5-fluorouracil and folinic acid in the treatment of advanced gastric cancer

To investigate the efficacy and safety of combining weekly oxaliplatin with weekly 24-h infusion of high-dose 5-fluorouracil (5-FU) and folinic acid (FA) in treatment of patients with advanced gastric cancer. Patients with histologically confirmed, locally advanced or recurrent/metastatic gastric cancer were studied. Oxaliplatin 65 mg m⁻² 2-h intravenous infusion, and 5-FU 2600 mg m⁻² plus FA 300 mg m⁻² 24-h intravenous infusion, were given on days 1 and 8, repeated every 3 weeks. Between January 2001 through January 2002, 55 patients were enrolled. The median age was 64 years (range: 22–75). In all, 52 patients (94.5%) had recurrent or metastatic disease and three patients had locally advanced disease. Among 50 patients evaluable for tumour response, 28 patients achieved partial response, with an overall response rate of 56% (95% confidence interval (CI): 41.8–70.3%). All 55 patients were evaluated for survival and toxicities. Median time to progression and overall survival were 5.2 and 10.0 months, respectively, during median follow-up time of 24.0 months. Major grades 3–4 toxicities were neutropenia in 23 cycles (7.1%) and thrombocytopenia in 16 cycles (5.0%). Treatment was discontinued for treatment-related toxicities in nine patients (16.4%), of whom eight were due to oxaliplatin-related neurotoxicity. One patient (1.8%) died of neutropenic sepsis. This oxaliplatin-containing regimen is effective in the treatment of advanced gastric cancer. Except for neurotoxicity that often develops after prolonged use of oxaliplatin, the regimen is well tolerated.

Comparison of Baseline Characteristics, Clinical Features, Angiographic Results, and Early Outcomes in Men vs Women With Acute Myocardial Infarction Undergoing Primary Coronary Intervention

BACKGROUND

Women have had a higher early mortality rate than men after acute myocardial infarction (AMI) in the prethrombolytic and thrombolytic eras. Primary percutaneous coronary intervention (PCI) has been shown to significantly improve survival of patients with AMI, and to be superior to thrombolytic therapy in terms of immediate restoration of normal flow in the infarct-related artery and reduction of recurrent ischemic events. However, the effect of primary PCI on early outcomes of women vs men remains unknown. Therefore, we examined whether there was any difference in term of 30-day mortality between women and men after primary PCI.

METHODS AND RESULTS

Between May 1993 and April 2002, primary PCI was performed in 1,032 consecutive patients (15.3% women and 84.7% men) with AMI. The overall successful reperfusion (final Thrombolysis in Myocardial Infarction grade 3 flow) and 30-day morality rates were 84.0% and 8.5%, respectively. The rate of successful reperfusion did not differ between women and men (84.8% vs 83.9%, p = 0.77). However, mortality at 30 days was significantly higher in women than in men (14.6% vs 7.4%, p = 0.003). In comparison with men, women were older; had significantly higher incidences of hypertension, diabetes mellitus, complete atrioventricular block, and right ventricular infarction; and had longer times of reperfusion (all p values < 0.05). During hospitalization, advanced congestive heart failure (New York Heart Association class 3 or greater), free wall rupture, and major bleeding complications were more likely to occur in women than in men (all p values < 0.05). Compared with men, the unadjusted odds ratio for 30-day death among women was 2.12 (95% confidence interval [CI], 1.27 to 3.53). After adjusting for age, the odds ratio was substantially reduced to 1.66 (95% CI, 0.98 to 2.79). Further adjustment for age and other variables further reduced the odds ratio to 1.06 (95% CI, 0.53 to 2.14).

CONCLUSIONS

A gender gap of 30-day mortality existed between women and men with AMI that could not be altered by primary PCI. However, this gap was only an apparent one, and was not truly related to gender alone. In comparison with men, women were older, had significantly higher incidences of comorbidities and major untoward clinical events, and had longer times of reperfusion, which could help explain why the 30-day mortality rate was higher in women than in men.

The Potential Impact of Primary Percutaneous Coronary Intervention on Ventricular Septal Rupture Complicating Acute Myocardial Infarction

BACKGROUND

Recent data suggest that the risk of acquired ventricular septal defect (VSD), a complication of acute myocardial infarction (AMI), could be reduced using thrombolytic therapy. There are, however, still no available data regarding the potential impact of primary percutaneous coronary intervention (PCI) on AMI-related VSD in a clinical setting. The purposes of this study were to delineate the incidence and the potential risk factors of AMI-related VSD in the Chinese population, and to determine whether primary PCI could reduce such risk.

METHODS AND RESULTS

From May 1993 through March 2003, a total of 1,321 patients with AMI (for < 12 h) underwent primary PCI in our hospital. Of these 1,321 patients, 3 patients (0.23%) developed VSD after undergoing a primary PCI, with a mean (+/- SD) time of occurrence of 25.3 +/- 12.2 h. During the same period, a total of 616 consecutive, unselected patients with early AMI [ie, > 12 h and < or = 7 days] or recent myocardial infarction (MI) [ie, > or = 8 days and < 30 days] who had not received thrombolytic therapy underwent elective PCI. Of these 616 patients, 18 (2.9%) had VSD either on presentation or during hospitalization, with a mean time of occurrence of 71.1 +/- 64.2 h. Clinical variables were utilized to statistically analyze the potential risk factors. Univariate analysis demonstrated that the enrollment variables strongly related to this complication were advanced age, hypertension, nonsmokers, anterior infarction, female gender, and lower body mass index (BMI) [all p < 0.005]. Using multiple stepwise logistic regression analysis, the only variables independently related to VSD were advanced age, female gender, anterior infarction, and low BMI (all p < 0.05). The in-hospital mortality rate was significantly higher in patients with this complication than in patients without this complication (47.6% vs 8.0%; p < 0.0001). The incidence of this complication was significantly lower in patients with AMI who underwent primary PCI than in those with early or recent MI who underwent elective PCI (3.0% vs 0.23%, respectively; p = 0.0001).

CONCLUSION

Primary PCI had a striking impact on reducing the incidence of VSD after AMI compared to elective PCI in patients who did not receive thrombolytic therapy. Advanced age, female gender, anterior infarction, and low BMI had potentially increased the risk of this catastrophic complication after AMI in this Chinese population.

Effect of Adjunctive Tirofiban Therapy on Angiographic and Clinical Outcomes in Patients With ST-segment Elevated Acute Myocardial Infarction Undergoing Primary Stenting

The benefit of primary percutaneous coronary intervention is limited by a 5% to 20% incidence of suboptimal epicardial coronary blood (< or = TIMI-2 flow). Recently, data has demonstrated that when administered in conjunction with primary stenting for the treatment of acute myocardial infarction (AMI), abciximab improves the success rate of the stenting procedure and provides additional clinical benefits. But data on a combination of tirofiban and primary stenting for treatment of ST-segment elevated (ST-se) AMI is unknown. Between May 1999 and September 2000, primary stenting without adjunctive tirofiban therapy was performed in 136 consecutive patients (control group) with ST-se AMI. Between January 2001 and May 2002, we routinely administered tirofiban to 133 consecutive patients (study group) with ST-se AMI before they underwent primary stenting. The angiographic and clinical outcomes of both groups were compared in a chronologically consecutive manner. The overall mortality rate was significantly higher in patients with failed (< or = TIMI-2 flow) than in patients with successful (TIMI-3) reperfusion (20.0% vs 3.5%, P < 0.0001). Univariate analysis demonstrated that there were no significant differences in the successful reperfusion (85.7% vs 84.6%, P = 0.84) or 30-day combined end points - death, recurrent ischemia or reinfarction (8.3% vs 11.0%, P = 0.59) between study and control group patients. Clinical variables were used to statistically analyze potential risk factors for unsuccessful reperfusion (< or = TIMI-2 flow) in the study group patients. Multiple stepwise logistic regression analysis demonstrated that the reference lumen diameter (RLD) of the infarct-related artery (IRA) > or = 3.5 mm (P = 0.0004) and the lesion length of the obstruction > or = 20.0 mm (P = 0.018) were the significant independent predictors of failed normalized coronary blood flow. There were no significant differences in the restenotic rate of IRA (29.2% vs 30.8%, P = 0.9) or mortality rate (1.6% vs 1.6%, P = 1.0) at six-month follow-up. In conclusion, our study demonstrates that primary stenting with adjunctive tirofiban therapy in ST-se AMI did not provide additional benefits in short-term and intermediate-term angiographic and clinical outcomes compared to conventional primary stenting.

Clinical features and outcome of coronary artery aneurysm in patients with acute myocardial infarction undergoing a primary percutaneous coronary intervention

BACKGROUND

While coronary artery aneurysm is an uncommon anatomic disorder and has various forms, its clinical features and outcome and its impact on thrombus formation and the no-reflow phenomenon in the clinical setting of acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (p-PCI) have not been discussed. The purpose of this study was to evaluate whether this anatomic disorder predisposes to a high burden of thrombus formation, and subsequently leads to the no-reflow phenomenon and untoward clinical outcome in patients with AMI undergoing p-PCI.

METHODS AND RESULTS

In our hospital, emergency p-PCI was performed in 924 consecutive patients with AMI between May 1993 and July 2001. Of these 924 patients, 24 patients (2.6%) who had an infarct-related artery (IRA) with aneurysmal dilatation were retrospectively registered and constituted the patient population of this study. Angiographic findings demonstrated that the ectasia type (defined as diffuse dilatation of 50% or more of the length of the IRA) was found most frequently (70%), followed by the fusiform type (20%; defined as a spindle-shaped dilatation in the IRA) and the saccular type (10%; defined as a localized spherical-shaped dilatation in the IRA). The right coronary artery was the most frequently involved vessel (54.2%), followed by the left anterior descending (25.0%) and the left circumflex arteries (20.8%). Coronary angiography revealed that all of these aneurysmal IRA filled with heavy thrombus (indicated as high-burden thrombus formation). The no-reflow phenomenon (defined as <or=TIMI-2 flow) and distal embolization after p-PCI were found in 62.5 and 70.8% of the IRA, respectively. The incidence of cardiogenic shock and the 30-day mortality rate were 25 and 8.3%, respectively. The survival rate was 90.9% (20/22) during a mean follow-up of 19 +/- 30 months.

CONCLUSIONS

While aneurysmal dilatation of an IRA is an uncommon angiographic finding in the clinical setting of AMI, it is frequently associated with high-burden thrombus formation and has a significantly lower incidence of successful reperfusion. However, the long-term survival of these patients is excellent.

Acute myocardial infarction with simultaneous ST-segment elevation in the precordial and inferior leads: evaluation of anatomic lesions and clinical implications

BACKGROUND

Simultaneous ST-segment elevation in the precordial and inferior leads is a rare ECG finding in patients with acute myocardial infarction (AMI) and its clinical implications rarely have been reported. The purpose of this study was to evaluate the clinical features of this distinctive ECG manifestation and its impact on clinical outcome.

METHODS AND RESULTS

Between May 1993 and July 2001 in our hospital, direct percutaneous coronary intervention (dPCI) was performed in 924 patients with AMI. Of these 924 consecutive patients, 37 patients (4.0%) who had simultaneous ST-segment elevation (> or = 1 mm) in the precordial and inferior leads were retrospectively analyzed. Eight of these 37 patients who had a wrapped left anterior descending artery (LADA) occlusion were placed into group 1 (ie, wrapped LADA). Twenty-nine of the 37 patients who had anatomic lesions other than a wrapped LADA in the coronary arteries were placed into group 2 (ie, "nonwrapped" LADA). Group 2 patients had significantly higher incidences of cardiogenic shock (58.6% vs 0%, respectively; p = 0.004), pulmonary edema (43.8% vs 0%, respectively; p = 0.02), and sustained sudden cardiac death due to malignant ventricular tachyarrhythmias (44.8% vs 0%, respectively; p = 0.03) than did group 1 patients. Group 1 patients usually had ST-segment elevations of < 2 mm the inferior leads. However, group 2 patients always had ST-segment elevations of > or = 2 mm in the inferior leads. Univariate analysis demonstrated that the mean (+/- SD) ST-segment elevation in the inferior leads was significantly higher in group 2 patients than in group 1 patients (11.08 +/- 4.18 vs 2.95 +/- 0.92 mm, respectively; p = 0.0001). Coronary angiography demonstrated that the incidence of multivessel disease (93.1% vs 37.5%, respectively; p = 0.002) and the incidence of severe obstructive two-vessel disease (ie, stenosis of > 85%) [93.1% vs 0%, respectively; p = 0.0001] were significantly higher in group 2 than in group 1 patients. Although there was no significant difference in the rate of unsuccessful reperfusion (24% vs 13%, respectively; p = 0.38) between group 2 and group 1 patients, the 30-day mortality rate was significantly higher in group 2 patients than in group 1 patients (48.3% vs 0%, respectively; p = 0.015).

CONCLUSIONS

AMI with ECG manifestation of simultaneous ST-segment elevation in precordial and inferior leads can be caused by either a wrapped LADA occlusion or a nonwrapped LADA occlusion. While patients with wrapped LADA occlusions usually have favorable clinical outcomes, patients with nonwrapped LADA occlusions usually have serious clinical presentations and unfavorable clinical outcomes. Specific clinical and ECG features identifying high-risk patients in this clinical setting would be extremely important for early, aggressive, and appropriate management.

The feasibility and safety of early discharge for low risk patients with acute myocardial infarction after successful direct percutaneous coronary intervention

There is a lack of consensus among cardiologists regarding the length of time patients should be hospitalized after an uncomplicated acute myocardial infarction (AMI) and successful direct percutaneous coronary intervention (d-PCI). The purpose of this study was to evaluate the feasibility and safety of early discharge (discharge <4 days after the procedure) for low risk patients with AMI who underwent successful d-PCI. From May 1996 through December 2001, d-PCI was performed in 898 consecutive patients with AMI. Of these 898 patients, 463 (51.6%) were stratified to be at low risk. Lower risk was defined as: (1) Killip classification < or = 2 on admission; (2) the infarct-related artery achieved normal blood flow without recurrent ischemia or reinfarction in the first 24 hours; (3) no mechanical or electrical complications after d-PCI. (4) no acute renal failure, acute stroke, or major bleeding complication; (5) no advanced congestive heart failure (defined as > or = New York Heart Association functional class 3); and (6) no sepsis. Patients who were discharged <4 days after undergoing the procedure were enrolled in group 1 (n = 266). Patients who were discharged > or = 4 days after undergoing the procedure were enrolled in group 2 (n = 197). Univariate analysis demonstrated that group 2 patients had a significantly longer hospital stay (P = 0.0001) than group 1 patients. At the first 30-day follow-up examination, there were no significant differences in the combined major cardiac events (death, recurrent isehemia, reinfarction, revascularization. or advanced congestive heart failure) between the group 1 and group 2 patients (1.50% vs 1.52%, P = 0.92). There were also no significant differences in the combined major noncardiac complications (acute stroke, acute renal failure, bleeding complications requiring blood transfusion, vascular sequelae, or sepsis) between the group 1 and group 2 patients (1.13% vs 0.51%. P = 0.89). Early discharge was feasible in a majority of the patients who experienced AMI and were at lower risk 24 hours after successful d-PCI. Thus, the patients had a shortened hospital stay and no increased risk.