Feasibility and safety of early initiation of a PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitor in patients with acute myocardial infarction undergoing primary PCI

Background

Recent ESC/EAS Guidelines for the management of dyslipidemia stated that the treatment goal of LDL cholesterol (LDL-C) in very high-risk patients is less than 55mg/dl. PCSK9 inhibitors in addition to strong statins could be a useful strategy for rapid and aggressive lowering of LDL-C. However, the feasibility and safety of early initiation of a PCSK9 inhibitor for AMI patients undergoing primary PCI remain unclear.

Objectives

We examined the effects of early initiation of a PCSK9 inhibitor, evolocumab, on lipid profile and inflammatory markers and its safety in AMI patients undergoing primary PCI.

Methods

This study is a single center, randomized, controlled trial involving 102 patients hospitalized for AMI. The patients were randomly assigned 1:1 to the evolocumab group and the control group. Evolocumab (140 mg) was subcutaneously injected within 24 hours after PCI and then every two weeks. All patients received pitavastatin (2mg/day) in addition to the allocated treatment. The primary endpoints were changes in lipid profile and inflammatory markers from baseline to 4 weeks.

Results

102 patients were enrolled between October 2017 and December 2019. 89 patients were ST-segment elevation myocardial infarction (STEMI), 13 patients were non-STEMI. Primary PCI was successfully performed in all patients. 76 patients were statin-naïve. 2 patients were excluded from analyses because they died severe heart failure in acute phase. Finally, 100 patients (evolocumab; n=51 and control; n=49) were analyzed. Baseline LDL-C was 121.6±30.3 mg/dl in the evolocumab group and 124.7±33.6 mg in the control group. Change in LDL-C from the baseline to 4 weeks was −92.4±32.4 mg/dl (−75%) in the evolocumab group and −44.8±32.1 mg/dl (−33.1%) in the control group (mean difference; 47.6mg/dl, 95% CI; 34.8 to 60.4 mg/dl, p<0.001). LDL-C <70mg/dl at 4 weeks was achieved in 96.0% of the evolocumab group as compared with 26.5% of the control group. Further, in the evolocumab group. LDL <55mg/dl was achieved in 92.1% at 2 weeks and 92.1% at 4 weeks. Regarding inflammatory markers, there were no significant difference in change in high-sensitivity C-reactive protein (p=0.49) and tumor necrosis factor-alpha (p=0.63) between two groups even after adjustment of baseline value. No adverse event associated with evolocumab was observed during this study.

Conclusion

In patients with AMI undergoing primary PCI, early initiation of evolocumab rapidly reduced LDL-C without no adverse event, and achieved LDL-C<55mg/dl in most patients within 2 weeks. Early administration of a PCSK9 inhibitor combined with a strong statin could be a feasible and safe treatment for AMI patients undergoing PCI.

Funding Acknowledgement

Type of funding source: None

Can we predict the insertion torque using the bone density around the implant?

The purpose of this study was to examine the correlation between initial stability and bone density in patients undergoing implant treatment. Twenty-five screw-type dental implants were inserted in 12 patients. All patients underwent multi-detector computed tomography (CT) examination prior to implant insertion. The implant sockets were prepared according to the drilling protocol, and peak insertion torque values were measured. CT values around the implants were measured using preoperatively scanned CT data, which were combined with actual implant positions. Spearman's rank correlation coefficient was used to investigate the correlation between insertion torque values and CT values (in Hounsfield units, HU). Twenty-three implants (8 or 10 mm in length) were inserted in the mandibular molar region and two (10mm length) in the maxillary molar region. The mean CT value of the 8-mm implants was 508.6 ± 187.0 HU and mean insertion torque was 27.2 ± 12.1 N·cm; for the 10-mm implants, these values were 579.6 ± 224.3 HU and 28.1 ± 14.6 N·cm, respectively. Statistical analysis revealed a strong positive correlation between the insertion torque and mean CT values (r=0.699, 8 mm; r=0.771, 10 mm). The results revealed that bone density around the implant is a useful index. This study indicates that preoperative CT may enable the prediction of initial implant stability.

Potassium-benzene interactions on Pt(111) studied by metastable atom electron spectroscopy

Electron emission spectra obtained by thermal collisions of He(∗)(2(3)S) metastable atoms with C(6)H(6)/Pt(111), C(6)H(6)/K/Pt(111), and K/C(6)H(6)/Pt(111) were measured in the temperature range of 50-200 K to elucidate the adsorption/aggregation states, thermal stabilities of pure and binary films, and local electronic properties at the organic-metal interface. For C(6)H(6)/Pt(111), the He(∗)(2(3)S) atoms de-excite on the chemisorbed overlayer predominantly via resonance ionization followed by Auger neutralization and partly via Penning ionization (PI) yielding weak emission just below the Fermi level (E(F)). We assigned this emission to the C(6)H(6) π-derived states delocalized over the Pt 5d bands on the basis of recent density functional calculations. During the layer-by-layer growth, the C(6)H(6)-derived bands via PI reveal a characteristic shift caused by the final-state effect (hole response at the topmost layer). C(6)H(6) molecules chemisorb weakly on the bimetallic Pt(111) (θ(K)=0.1) and physisorb on the K multilayer. In both cases, the sum rule was found to be valid between the K 4s and C(6)H(6)-derived bands. The band intensity versus exposure plot indicates that the C(6)H(6) film grows on the K multilayer by the Volmer-Weber mechanism (island growth), reflecting the weak K-C(6)H(6) interactions. In case of K/C(6)H(6)/Pt(111), the K atoms are trapped on the topmost C(6)H(6) layer at 65 K, forming particlelike clusters. The surface plasmon satellite was identified for the first time and the loss energy increases with increasing cluster size. The K clusters are unstable above ∼100 K due to thermal migration into the C(6)H(6) film. When the cluster coverage is low, the K 4s band extends below and above E(F) of the Pt substrate and the anomaly is discussed in terms of vacuum level bending around the cluster.

In vitro differences of stress concentrations for internal and external hex implant-abutment connections: a short communication

The aim of this study was to clarify the difference in the stress distribution patterns between implants with external-hex or internal-hex connection systems using in vitro models. Three 13 mm fixtures with external-hex and internal-hex connections were installed into an acrylic bone analogue. One piece abutments of 7 mm height was connected. Strain gauges were attached to the abutment surface, and the cervical and fixture tip areas of the bone analogue surface. Vertical and horizontal load applied was 30 N. Data were normalized for each model by obtaining values relative to the sum of the three values. Almost the same force distribution pattern was found under vertical load in both systems. Fixtures with external-hex showed an increase in strain at the cervical area under horizontal load, while in internal-hex fixtures the strain was at the fixture tip area. Within limitations of our model study, it was suggested that fixtures with internal-hex showed widely spread force distribution down to the fixture tip compared with external hex ones.

Efficacy of a posterior implant support for extra shortened dental arches: a biomechanical model analysis

The purpose of this study was to test the efficacy of utilizing implants underneath distal free-end denture bases to establish a stable occlusal support for extreme shortened dental arches (ESDA). The authors constructed a two-dimensional finite element model of the ESDA where only lower anterior teeth remain. Posterior occlusal support was provided by a fixed partial denture with an osseointegrated implant (IFPD), fixed cantilever partial denture (CFPD), or a removable partial denture with or without an implant underneath (IRPD and RPD). A dentate mandible model was the control. When muscle vectors simulating clenching force were applied, stress levels on the temporal bone surface area under each configuration were compared, to evaluate the efficacy in establishing the occlusal support. The largest stress increase in temporal bone was found in the ESDA situation followed by the RPD. The least amount of stress increase was found with the IFPD followed by IRPD when the implant was placed in the molar region. The stress increase with IRPD was about 20-45% of the amount with RPD. Our results suggest that IFPD provides most favourable and stable occlusal support, however, IRPD with a single posterior implant also provide stable occlusal support with reducing the stress levels in the temporomandibular joint.

Biomechanical study of temporomandibular joint on its form and function. Part I: Condyle morphology in frontal section

In this study the mechanisms controlling the biomechanical relationship between form and function in the temporomanidbular joints were investigated using two-dimensional finite element analysis and optimization theory. Factors investigated included morphology and occlusion, the latter being an important attribute of this system. Results indicate that change in frontal condyle head morphology was closely related to the occlusion condition.

Development of a mandibular tracking device with six degrees of freedom using optoelectronic system

The purpose of this study was to develop a prototype handy mandibular tracking device with six degrees of freedom using the optoelectronic kinematic data acquisition system and to evaluate its accuracy. The system consisted of the light-weight sensor part mounted on the mandibular incisor portion and two 2-D PSD cameras positioned in front of the patient. On the sensor part, three light emitting diodes (LEDs) were attached in triangular form. Displacements of the sensor part were detected by two cameras, transformed into electric signals, and sampled by A/D converter in a desktop computer. Since the overall accuracy of this system was about 0.03 mm in the displacement and 0.06 degrees in the rotation angles, this system was proven to be capable for the wide range of clinical application.

[Teeth arrangement of anterior artificial teeth. 1. Age and teeth exposure]

In selecting and arranging anterior artificial teeth for edentulous patients, it is necessary to consider their sex, personality, age and other factors. The relation of upper and lower lip lines to incisal edge has been one of the standards for the selection and the arrangement of anterior artificial teeth. The purpose of this report was to establish and to evaluate decision bases for the selection and arrangement. We recorded and measured the exposure rate of anterior natural teeth (48 men, 46 women) during function, such as smile, pronunciation, by means of the image analysis. Following results were obtained. 1. As the age of patients increased, upper anterior teeth appeared less than lower's. 2. Differences in exposure ratio between upper and lower teeth were found more remarkable in smiling rather than in pronunciation.

[Clinical application of T-scan System. 1. Sensitivity and reproducibility and its application]

Analyzing occlusal contacts is significant for establishing the occlusal scheme as well as for the diagnosis on dysfunction of stomatognathic system. We tested a new occlusal contact analyzing device (T-Scan: Tekscan Inc. Boston, U.S.A.) for its sensitivity and reproducibility in relation to its clinical application. Following results were obtained. 1) As the modeling of dental arch of this system was not always correct, much care should be needed for identifying the contact location. 2) The minimum amount of load needed for displaying each five step occlusal force increased linear fashion (step 1: 250 g and step 5: 1750 g) when the sensor was vertically pressed on the intersection of force sensitive line. The minimum amount of force changed with the loading condition such as area and direction. Distortion of the sensor could lead the measurement error. 3) Since the time measurement data by this system were shorter than actual length of time and were measured over about 250 g load, light and early occlusal contacts could not be detected.