The association between the triglyceride-glucose index and in-stent restenosis in patients undergoing percutaneous coronary intervention: a systematic review and meta-analysis

BACKGROUND

Insulin resistance (IR) can lead to cellular metabolic disorders, activation of oxidative stress, and endothelial dysfunction, contributing to in-stent restenosis (ISR). The triglyceride-glucose index (TyG index), a new indicator reflecting IR, is extensively researched in the cardiovascular field. This study, through a meta-analysis, aimed to utilize a larger combined sample size and thereby enhance the overall test efficacy to explore the TyG index-ISR relationship.

METHODS

A thorough search was conducted in the PubMed, EMBASE, Web of Science, and Cochrane Library databases to find original papers and their references published between 1990 and January 2024. This search included both prospective and retrospective studies detailing the correlation between the TyG index and ISR in individuals with coronary heart disease (CHD).

OUTCOMES

The five included articles comprised 3,912 participants, and the odds ratio (OR) extracted from each study was combined using the Inverse Variance method. Results showed that, in the context of CHD patients, each incremental unit in the TyG index, when treated as a continuous variable, corresponded to a 42% elevation in ISR risk (95% CI 1.26-1.59, I²=13%, p < 0.005). When analyzing the TyG index categorically, the results revealed a higher ISR risk in the highest TyG index group compared to the lowest group (OR: 1.69, 95% CI 1.32-2.17, I²=0). Additionally, in patients with chronic coronary syndrome (CCS), each unit increase in the TyG index, the risk of ISR in patients increased by 37% (95% CI 1.19-1.57, I²=0%, p < 0.005). This correlation was also observable in acute coronary syndrome (ACS) patients (OR:1.48, 95% CI 1.19-1.85, I²=0, p < 0.005).

CONCLUSIONS

The TyG index, an economical and precise surrogate for IR, is significantly linked with ISR. Furthermore, this correlation is unaffected by the type of coronary heart disease.

Blood biomarkers of progressive atherosclerosis and restenosis after stenting of symptomatic intracranial artery stenosis

In-stent restenosis (ISR) represents a major complication after stenting of intracranial artery stenosis (ICAS). Biomarkers derived from routine blood sampling including C-reactive protein (CRP), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and mean platelet volume (MPV) have been associated with progressive atherosclerosis. We investigated the role of CRP, NLR, PLR and MPV on the development of intracranial ISR and recurrent stroke risk. We retrospectively included all patients who had undergone stenting of symptomatic ICAS at our university hospital between 2005 and 2016. ISR (≥ 50% stenosis) was diagnosed by regular Duplex sonography follow-up studies and confirmed by digital subtraction angiography or computed tomography angiography (mean follow-up duration: 5 years). Laboratory parameters were documented before stenting, at the time of restenosis and at last clinical follow-up. Of 115 patients (mean age: 73 ± 13 years; female: 34%), 38 (33%) developed ISR. The assessed laboratory parameters did not differ between patients with ISR and those without (p > 0.1). While ISR was associated with the occurrence of recurrent ischemic stroke (p = 0.003), CRP, NLR, PLR and MPV were not predictive of such events (p > 0.1). Investigated blood biomarkers of progressive atherosclerosis were not predictive for the occurrence of ISR or recurrent ischemic stroke after ICAS stenting during a 5-year follow-up.

Differentially expressed miR-152, a potential biomarker for in-stent restenosis (ISR) in peripheral blood mononuclear cells (PBMCs) of coronary artery disease (CAD) patients

BACKGROUND AND AIMS

In-stent restenosis (ISR) remains the most daunting challenge of current treatments of coronary artery disease (CAD). MicroRNAs (miRNAs) are prominent regulators of key pathological processes leading to restenosis and used as diagnostic tools in different studies. miR-152 and miR-148a are implicated to contribute in the putative intracellular mechanisms of ISR. The aim of present study is to investigate the potential early-stage diagnostic role of miR-152 and miR-148a expression levels for ISR in peripheral blood mononuclear cells (PBMCs) of patients who underwent stent implantation.

METHODS AND RESULTS

The miRNAs that are supposed to be involved in the ISR were nominated by bioinformatics approach mainly using miRWalk3. Then by quantitative real-time PCR, we determined the relative expression of miR-152 and miR-148a of PBMCs from ISR patients with their age/sex-matched controls.

RESULTS

The presence of ISR significantly coincided with a decrease in the relative expression of miR-152. The area under the curve (AUC) for miR-152 receiver operating characteristic (ROC) curve was 0.717 (95% CI; 0.60-0.83) with a sensitivity of 70% and a specificity of 67%, suggesting that the miRNA expression level might be employed to identify patients at risk of ISR.

CONCLUSIONS

To the best of our knowledge, this is the first work to show that the miR-152 expression level can possibly be applied to predict CAD patients at risk of ISR. The results suggest that the expression levels of miR-152 in PBMCs may serve as a biomarker for ISR. Our finding suggests the importance of miRNA levels in PBMCs as a novel biological tool to detect diseases in their early clinical stages.

Predictive value of inflammatory factors on coronary restenosis after percutaneous coronary intervention in patients with coronary heart disease: A protocol for systematic review and meta-analysis

BACKGROUND

Evidence reveals that inflammatory factors can predict coronary restenosis in patients suffering from coronary heart disease (CHD) after percutaneous coronary intervention (PCI). Perhaps, inflammatory factors are promising biomarkers for the diagnosis of coronary restenosis after PCI. However, the accuracy of inflammatory factors has not been systematically evaluated. Therefore, it is necessary to perform a meta-analysis to certify the diagnostic values of inflammatory factors on coronary restenosis after PCI.

METHODS

China National Knowledge Infrastructure (CNKI), Wanfang, VIP, China Biology Medicine disc (CBM), PubMed, EMBASE, Cochrane Library and Web of Science were searched for relevant studies to explore the potential diagnostic values of inflammatory factors on coronary restenosis after PCI from inception to January 2021. All data were extracted by 2 experienced researchers independently. The risk of bias about the meta-analysis was confirmed by the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). The data extracted were synthesized and heterogeneity was investigated as well. All of the above statistical analyses were carried out with Stata 16.0.

RESULTS

The results of this meta-analysis will be submitted to a peer-reviewed journal for publication.

CONCLUSION

This study clarified confusions about the specificity and sensitivity of inflammatory factors on coronary restenosis after PCI, thus further guiding their promotion and application.

ETHICS AND DISSEMINATION

Ethical approval will not be necessary since this systematic review and meta-analysis will not contain any private information of participants or violate their human rights.

TRIAL REGISTRATION NUMBER

DOI 10.17605/OSF.IO/N28JX.

Predictive value of LncRNA on coronary restenosis after percutaneous coronary intervention in patients with coronary heart disease: A protocol for systematic review and meta-analysis

BACKGROUND

Evidence shows that long-stranded non-coding RNA (LncRNA) can predict coronary artery restenosis in patients suffering from coronary heart disease after percutaneous coronary intervention, suggesting that LncRNA may become a promising biomarker for the diagnosis of coronary artery restenosis after percutaneous coronary intervention. However, its accuracy has not been systematically evaluated. Therefore, it is necessary to perform meta-analysis to certify the diagnostic value of LncRNA on coronary artery restenosis after percutaneous coronary intervention.

METHODS

PubMed, EMBASE, Cochrane Library, and Web of Science were searched for relevant studies to explore the potential diagnostic values of LncRNA on coronary artery restenosis after percutaneous coronary intervention from inception to December 2020. Data were extracted by two experienced researchers independently. The risk of bias about the meta-analysis was confirmed by the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). Data was synthesized and heterogeneity was investigated as well. All of the above statistical analysis was carried out with Stata 14.0.

RESULTS

This study proved the pooled diagnostic performance of LncRNA on coronary artery restenosis after percutaneous coronary intervention.

CONCLUSION

This study clarified confusions about the specificity and sensitivity of LncRNA on coronary artery restenosis after percutaneous coronary intervention, thus further guiding their promotion and application.

ETHICS AND DISSEMINATION

Ethical approval is not required for this study. The systematic review will be published in a peer-reviewed journal, presented at conferences, and shared on social media platforms. This review would be disseminated in a peer-reviewed journal or conference presentations.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/4QT2P.

Platelets in In-stent Restenosis: From Fundamental Role to Possible Prognostic Application

BACKGROUND

Introduction of new generations of stents has decreased the percentage of patients experiencing in-stent restenosis (ISR) following the implantation of stent. However, a large number of patients are still afflicted with this phenomenon, which necessitates further study of ISR pathophysiology.

METHODS

Relevant English literature was searched up to 2018 and retrieved form the PubMed database and Google Scholar search engine. The following keywords were used: "In-stent restenosis", "Platelet", "Chemokine", "Inflammation", "Vascular smooth muscle cell" and "Neointima".

RESULTS

Previous studies have shown that ISR is a pathophysiologic response to damage of the artery wall after its elongation and separation of the atherosclerotic plaque. Development of neointimal hyperplasia (NIH) following this pathophysiologic response is a function of inflammation caused by platelets, monocytes, macrophages, and lymphocytes, as well as rapid migration and proliferation of generally quiescent cells in the median layer of the artery wall.

CONCLUSION

After damage to the artery wall, platelets play an essential role in the incidence of NIH by contributing to inflammation and migration of vascular smooth muscle cells and extracellular matrix remodeling, especially via secretion of different chemokines; therefore, developing therapeutic strategies for platelet inhibition in a controlled manner could be the basis of preventive treatments in the near future. In this study, for the first time, we hypothesize that evaluation of platelet activity profile in patients before and after stent implantation may determine the prognosis and likelihood of ISR.

Potential of circulating pro-angiogenic microRNA expressions as biomarkers for rapid angiographic stenotic progression and restenosis risks in coronary artery disease patients underwent percutaneous coronary intervention

BACKGROUND

This study aimed to investigate the correlation of pro-angiogenic microRNA (miRNA) expressions with rapid angiographic stenotic progression (RASP) and restenosis risks in coronary artery disease (CAD) patients underwent percutaneous coronary intervention (PCI) with drug-eluting stents (DES).

METHODS

A total of 286 CAD patients underwent PCI with DES were consecutively recruited in this study. Plasma samples were collected before PCI operation, and 14 pro-angiogenic miRNAs were measured by real-time quantitative reverse transcription-polymerase chain reaction. Rapid angiographic stenotic progression at nontarget lesions and restenosis at stented lesions were evaluated by quantitative coronary angiography at 12 months after PCI operation.

RESULTS

The occurrence rates of RASP and restenosis were 39.5% and 22.4%, respectively. Let-7f, miR-19a, miR-19b-1, miR-92a, miR-126, miR-210, and miR-296 were decreased in RASP patients than non-RASP patients, among which let-7f, miR-19a, miR-126, miR-210, and miR-296 independently correlated with lower RASP occurrence by multivariate analysis, followed by receiver-operating characteristic (ROC) curve exhibited that these five miRNAs showed great value in predicting RASP risk with area under curve (AUC) 0.879 (95% CI: 0.841-0.917). Besides, let-7f, miR-19a, miR-92a, miR-126, miR-130a, and miR-210 were reduced in restenosis patients than non-restenosis patients, among them miR-19a, miR-126, miR-210, and miR-378 independently correlated with lower restenosis occurrence by multivariate analysis, followed by ROC curve disclosed that these four miRNAs had good value in predicting restenosis risk with AUC 0.776 (95% CI: 0.722-0.831).

CONCLUSIONS

Circulating let-7f, miR-19a, miR-126, miR-210, and miR-296 independently correlate with reduced RASP risk, while miR-19a, miR-126, miR-210, and miR-378 independently correlate with decreased restenosis risk in CAD patients underwent PCI with DES.

Clinical analysis of lectin-like oxidized low-density lipoprotein receptor-1 in patients with in-stent restenosis after percutaneous coronary intervention

In-stent restenosis (ISR) is the most common complication associated with percutaneous coronary intervention (PCI). Although some studies have reported an association between lectin-like oxidized low-density lipoprotein receptor-1 (LOX-1) and ISR, not enough clinical validation data are available to support this link. Here, we report our cross-sectional study aimed at exploring the feasibility of LOX-1 as a biomarker for the prognostic diagnosis of patients undergoing PCI.Three groups were included: ISR group, including 99 patients with ISR diagnosed with coronary arteriography (CAG) after PCI; lesion group, comprising 87 patients with coronary artery stenosis (<50%) diagnosed with CAG after PCI; and control group, consisting of 96 volunteers with no coronary artery disease. The levels of LOX-1 were measured in each patient by using an enzyme-linked immunosorbent assay, and their general information as well as laboratory parameters were recorded and followed up during a period of 2 years.LOX-1 levels gradually increased after PCI along with the progression of the lesion in the 3 groups. The levels of LOX-1 were significantly higher in the ISR group than in the other 2 groups (P < .001). LOX-1 levels were correlated with the levels of uric acid (UA) (r = 0.289, P = .007), creatinine (CREA) (r = .316, P = .003), and high-density lipoprotein cholesterol (HDL-C) (r = -0.271, P = .012), whereas no statistically significant correlation was detected with the Gensini score (r = 0.157, P = .141). The sensitivity and specificity of LOX-1 were 81.5% and 55.7%, respectively, with the most optimal threshold (5.04 μg/L). The area under curve (AUC) of the receiver operator characteristic (ROC) curve of LOX-1 was 0.720, and LOX-1 had the highest AUC compared with CREA, UA, and HDL-C, both individually and in combination.A high level of LOX-1 in the early period after PCI has a certain predictive power and diagnostic value for ISR. However, the level of LOX-1 is not related to the Gensini score of coronary artery after PCI, and CREA and UA, which are weakly related to LOX-1, have no obvious synergy in the diagnosis of ISR with LOX-1.

The value of serum visfatin in predicting in-stent restenosis of drug-eluting stents

OBJECTIVE

This study aims to determine the association between serum visfatin level and in-stent restenosis (ISR) after percutaneous coronary intervention (PCI) using drug-eluting stents (DES).

METHODS

A total of 460 patients with stable coronary heart disease who underwent DES placement were included. According to the results of coronary angiography 1year after PCI, 62 patients diagnosed as ISR were enrolled into the ISR group and 398 patients without ISR were recruited into the control group. Baseline clinical data were collected, and serum visfatin level was measured using ELISA method.

RESULTS

The serum visfatin levels before PCI were not different between ISR and control groups (P=0.41). However, visfatin level after PCI in the ISR group was significantly higher than in the control group [(30.2±8.6) ng/ml vs. (22.6±7.9) ng/ml, P<0.01]. In multivariate logistic regression, the independent predictors for ISR included post-procedural visfatin level (odds ratio [OR]: 2.08, 95% confidence interval [CI]: 1.19-3.65), type 2 diabetes (OR: 2.30, 95% CI: 1.10-4.79), reference vessel diameter (OR: 0.79, 95% CI: 0.63-0.98), stent length (OR: 1.52, 95% CI: 1.05-2.21) and stent diameter (OR: 0.67, 95% CI: 0.51-0.88). ROC curve analysis indicated that the area under the curve for post-procedural visfatin in predicting ISR was 0.82 (95% CI: 0.77-0.86), with the optimal cut-off value of 25.9ng/ml showing a sensitivity of 84.0% and a specificity of 69.3%.

CONCLUSION

Increased serum visfatin level after DES placement is independently associated with ISR. Serum visfatin may be useful in the prediction of ISR.

Association between plasma BMP-2 and in-stent restenosis in patients with coronary artery disease

OBJECTIVE

This study aimed to assess the association between plasma bone morphogenetic protein-2 (BMP-2) level and in-stent restenosis in patients with coronary artery disease.

METHODS

A total of 96 patients who underwent percutaneous coronary intervention (PCI) and were followed up after PCI were enrolled in this study. 47 patients diagnosed with in-stent restenosis (ISR) were recruited to ISR group and 49 patients without ISR were recruited to Control group according to the results of coronary angiography (CAG). Baseline characteristic data were collected, and plasma BMP-2 level was evaluated. The results were analyzed using logistic regression.

RESULTS

There were 47 patients in the ISR group and 49 patients in the Control group. Plasma levels of BMP-2 were higher in the ISR group than in the non-ISR group [20.96 (18.44, 27.05) pg/ml vs. 29.53 (25.03, 34.07) pg/ml, P<0.01]. Furthermore, the ISR group had significantly longer stent lengths and lower stent diameters than the Control group (P<0.01 and P<0.01, respectively). In multivariate analysis, BMP-2 level, diabetes, stent length and stent diameter were independently associated with ISR [odds ratio (OR)=1.11, 95% confidence interval (CI)=1.03-1.18, P<0.01; OR=4.75, 95% CI=(1.44-15.61), P=0.01; OR=1.06, 95% CI=(1.02-1.11), P<0.01; and OR=0.15, 95% CI=(0.02-0.95), P=0.04, respectively].

CONCLUSIONS

Increased BMP-2 levels were independently associated with ISR in patients with coronary artery disease. Plasma BMP-2 may be useful in predicting ISR.

High coronary calcium score and post-procedural CK-MB are noninvasive predictors of coronary stent restenosis

Purpose

High coronary calcium score (CCS) and post-procedural cardiac enzyme may be related with poor outcomes in patients with coronary stent implantation.

Methods

A total of 1,072 patients (63.2% male, mean age: 61.7±10.3 years) who underwent coronary multi-detect computed tomography at index procedure and follow-up coronary angiography (CAG) after drug-eluting stent (DES) were divided into two groups: those with and without target lesion revascularization (TLR; >50% reduction in luminal stent diameter or angina symptoms on follow-up CAG). The CCSs for predicting stent revascularization were elucidated.

Results

There were no significant differences between the two groups with regard to risk factors. The initial CCS was significantly higher in the TLR group (1,102.4±743.7 vs 345.8±51.05, P=0.04). After adjustment of significant factors for TLR, only CCS and post-procedural creatine kinase MB form (CK-MB) elevation were significant predictors of coronary artery TLR. Receiver operation curve revealed that >800 in CCS had 69% in sensitivity and 88% in specificity about predicting the TLR.

Conclusion

High CCS with post-procedural CK-MB might be the useful predictors for TLR after DES implantation.

Clinical and Experimental Analysis of Platelet Micro Particles Inducing Thrombosis after Coronary Stenting

BACKGROUND

A limited number of reports are analyzing the etiology and the mechanism of coronary heart disease by examining the source cells of micro particles (MPs) in coronary heart disease patients with percutaneous coronary intervention (PCI). This study aims to explore the circulating platelet micro particles (PMPs) content variation in the blood stream and the mechanism of MPs-inducing thrombosis in patients operated with coronary stenting, with the intent to analyze the impact of PMPs on thrombosis and in-stent restenosis.

METHODS

3000 patients with coronary heart disease were successfully operated with PCI. Subsequently, 100 patients and 50 healthy subjects were selected and divided into three groups: 1) normal control group (group A, 50 cases) of healthy subjects; 2) stenting + thrombosis group (group B, 50 cases); 3) stenting + non-thrombosis group (group C, 50 cases). Venous blood was drawn from the three groups of subjects to prepare platelet-free plasma, which was subjected to flow cytometry to examine the content of PMPs. In the meantime, the blood samples from the three groups of subjects were induced with 1 x 105 MPs from the patients in the stenting + thrombosis group, and the changes of thrombin-antithrombin (TAT) were observed.

RESULTS

PMPs' red fluorescence from group C was significantly more intense than that in the PMPs from group A, and the difference was statistically significant (p < 0.05). No significant difference was observed when comparing the content of PMPs in group B with the content in group A (p > 0.05). Thrombin in group B was increased significantly compared with thrombin content in group C, and the difference was statistically significant (p < 0.05). The thrombin level difference between group B and group C was not statistically significant (p > 0.05).

CONCLUSIONS

The content of PMPs in the patients with thrombosis after stenting was significantly increased, and the PMPs may induce the generation of thrombin. The PMPs' content variation in the peripheral blood circulation may be used to predict in-stent thrombosis and to evaluate therapeutic efficacy in the clinic.

MicroRNAs as circulating biomarkers in acute coronary syndromes: A review

Coronary artery disease (CAD) and its complications remain the most common cause of death worldwide. Cardiac troponins (cTn) are standard biomarkers used today for diagnosis and risk stratification of myocardial infarction (MI). Increasing efforts are made to develop additional, new biomarkers for more effective and safe rule-in and rule-out of MI patients at the emergency department. During the past decade, microRNAs (miRNAs) have emerged as new, potential diagnostic biomarkers in several diseases, including MI. In this review, we aimed to summarize some of the prominent studies in the field, and discuss the potential value of miRNAs in the diagnosis of MI.

Simvastatin Efficiently Lowers Small LDL-IgG Immune Complex Levels: A Therapeutic Quality beyond the Lipid-Lowering Effect

We investigated a polyethylene glycol non-precipitable low-density lipoprotein (LDL) subfraction targeted by IgG and the influence of statin therapy on plasma levels of these small LDL-IgG-immune complexes (LDL-IgG-IC). LDL-subfractions were isolated from 6 atherosclerotic subjects and 3 healthy individuals utilizing iodixanol density gradient ultracentrifugation. Cholesterol, apoB and malondialdehyde (MDA) levels were determined in each fraction by enzymatic testing, dissociation-enhanced lanthanide fluorescence immunoassay and high-performance liquid chromatography, respectively. The levels of LDL-IgG-IC were quantified densitometrically following lipid electrophoresis, particle size distribution was assessed with dynamic light scattering and size exclusion chromatography. The influence of simvastatin (40 mg/day for three months) on small LDL-IgG-IC levels and their distribution among LDL-subfractions (salt gradient separation) were investigated in 11 patients with confirmed coronary artery disease (CAD). We demonstrate that the investigated LDL-IgG-IC are small particles present in atherosclerotic patients and healthy subjects. In vitro assembly of LDL-IgG-IC resulted in particle density shifts indicating a composition of one single molecule of IgG per LDL particle. Normalization on cholesterol levels revealed MDA values twice as high for LDL-subfractions rich in small LDL-IgG-IC if compared to dominant LDL-subfractions. Reactivity of affinity purified small LDL-IgG-IC to monoclonal antibody OB/04 indicates a high degree of modified apoB and oxidative modification. Simvastatin therapy studied in the CAD patients significantly lowered LDL levels and to an even higher extent, small LDL-IgG-IC levels without affecting their distribution. In conclusion simvastatin lowers levels of small LDL-IgG-IC more effectively than LDL-cholesterol and LDL-apoB levels in atherosclerotic patients. This antiatherogenic effect may additionally contribute to the known beneficial effects of this drug in the treatment of atherosclerosis.

Prognostic Impact of 9-Month High-Sensitivity C-Reactive Protein Levels on Long-Term Clinical Outcomes and In-Stent Restenosis in Patients at 9 Months after Drug-Eluting Stent Implantation

Introduction

The level of 9-month high-sensitivity C-reactive protein (hsCRP) in predicting cardiovascular outcomes is scanty in patients at 9 months after receiving drug-eluting stent (DES) implantations. This study aims to evaluate the relationship between 9-month follow-up hsCRP levels and long-term clinical outcomes in patients at 9 months after receiving DES.

Methods

A total of 1,763 patients who received 9-month follow-up angiography were enrolled and grouped according to hsCRP level 9 months after the DES implantation: group I (718 patients, hsCRP<1.0 mg/L), group II (639 patients, 1.0≦hsCRP≦3.0 mg/L), and group III (406 patients, hsCRP>3.0 mg/L).

Results

Group III patients had a lower cardiovascular event-free survival rate than group I or II patients during a follow-up of 64±45 months (64.5% vs. 71.6% vs. 72.8%, respectively, p = 0.012). Multivariate analysis showed that a follow-up hsCRP level <3.0 mg/L was an independent predictor of a major adverse cardiovascular event (cardiac death, reinfarction, target lesion revascularization, stenting in a new lesion, or coronary bypass surgery). Group III patients had a higher restenosis rate (11.3% vs. 5.8% vs. 6.6%, respectively, p = 0.002) and loss index (0.21±0.32 vs. 0.16±0.24 vs. 0.18±0.28, respectively, p = 0.001) than group I or II patients in 9-month follow-up angiography.

Conclusions

A high 9-month follow-up hsCRP level is an independent predictor of long-term clinical cardiovascular outcomes in patients at 9 months after DES implantation. It is also associated with a higher restenosis rate, larger late loss and loss index at 9 months after DES implantation.

Use of the neutrophil to lymphocyte ratio for prediction of in-stent restenosis in bifurcation lesions

OBJECTIVE

Percutaneous coronary interventions (PCI) are the preferred treatment for coronary artery disease, even though the development of in-stent restenosis (ISR) continues to be an important complication. Neutrophil to lymphocyte ratio (NLR) is indicative of the inflammatory process and can predict the short- and long-term prognosis of cardiovascular diseases. We investigated the relationship between ISR development and neutrophil-lymphocyte ratio (NLR) in bifurcation lesions in stable coronary artery disease (CAD) patients.

PATIENTS AND METHODS

We analyzed the clinical and angiographic data of 181 consecutive stable CAD patients who had undergone successful PCI to the true bifurcation lesion from January 2010-December 2012. Patients were divided into two groups based on the development of ISR (group 1, ISR -; group 2, ISR +).

RESULTS

NLR(after) (p < 0.001) and NLRΔ (p < 0.001) were significantly higher in group 2. NLRΔ was found to be significant independent predictor of ISR in the multivariate logistic regression analysis. A NLRΔ level > 0.58 mg/dL had 81.8% sensitivity and 93.5% specificity for the prediction of ISR, as identified by the ROC curve. A NLR(after) level > 3.43 predicted ISR with 45.5% sensitivity and 95.8% specificity. The comparison of ROC curve analysis demonstrated that NLRΔ was the strongest independent predictor of ISR (p = 0.001).

CONCLUSIONS

As a result, although drug eluting stent implantation is known to be recommended in the bifurcation lesion PCI in worldwide, we want to emphasize the usage of the NLR values in the prediction of ISR. So, we think that NLRΔ levels may be a useful marker for the prediction of ISR in patients who undergo bifurcation PCI.

Hyperglycemia has no effect on development of restenosis after percutaneous transluminal angioplasty (PTA) in a diabetic rabbit model

It is well known that hyperglycemia is a trigger of atherosclerosis in patients with diabetes mellitus. However, the role of hyperglycemia in restenosis remains unclear. In this study, we investigated the effects of hyperglycemia on restenosis. Stenosis was evaluated in two sets of diabetic rabbit models: i) diabetic restenosis versus nondiabetic restenosis and ii) diabetic atherosclerosis versus nondiabetic atherosclerosis. Our results indicated that there was no difference in rates of stenosis between the diabetic and the nondiabetic groups in restenosis rabbit models. However, the incidence of stenosis was significantly higher in the diabetic atherosclerosis group compared with the nondiabetic atherosclerosis group. Similarly, the intima-media thickness and cell proliferation rate were significantly increased in the diabetic atherosclerosis group compared with the nondiabetic atherosclerosis group, but there was no difference between the diabetic restenosis and the nondiabetic restenosis groups. Our results indicate that hyperglycemia is an independent risk factor for atherosclerosis, but it has no evident effect on restenosis. These findings indicate that the processes of atherosclerosis and restenosis may involve different pathological mechanisms.

Relationship between coronary in-stent restenosis and plasma urotensin II level

AIM

In-stent restonosis is an important limitation for coronary stenting. The cause of in-stent restenosis is neointimal hyperplasia developed from smooth muscle and matrix. We aimed to investigate the association between urotensin II (U-II) and in-stent restenosis after coronary stenting, which causes endothelial and muscle proliferation and accumulation of collagen.

METHODS

Total 153 patient was enrolled to the study who meet criteria for angiographic indication underwent coronary artery angiography. All patients have history undergone for coronary stent implantation 3 to 9 months ago. In-stent restenosis is identified as ≥50% narrowing inside the stent. In-stent restenosis was observed in 73 and remaining of 80 patients revealed no critical lesion in stent on angiographic evaluation. Plasma level measurement of U-II was performed in all subjects.

RESULTS

Urotensin II levels were found to be significantly higher in Group I compared to Group II (1.44±0.74 ng/mL and 1.21±0.59 ng/mL, respectively, P=0.03). In a subgroup analysis, U-II levels were significantly higher in group I than group II in patients treated with bare metal stent (BMS) (1.50±0.76 ng/mL and 1.18±0.56 ng/mL, P=0.016); however, there was not significant change in patients treated with drug-eluted stent (1.26±0.64 ng/mL and 1.27±0.63 ng/mL, P=0.9). Multivariate statistical significance: negative correlation was found between in-stent restenosis and renin-angiotensin-system (RAS) blocker usage (P=0.040) and right coronary artery (RCA) lesion interventions (P=0.018).

CONCLUSION

This study revealed high plasma U-II level might be accepted as a risk factors for in-stent restenosis with BMS. In-stent restenosis is less developed after RCA interventions and taking drug of RAS blockages. Our study findings need to be confirmed in further studies.

Non-alcoholic fatty liver disease and risk of in-stent restenosis after bare metal stenting in native coronary arteries

In-stent restenosis (ISR) remains the most common complication of percutaneous coronary intervention. Due to shared risk factors, it is postulated that non-alcoholic fatty liver disease (NAFLD) patients have an increased risk of ISR. This study aimed to determine the association between NAFLD and ISR in patients after bare metal stenting. This study included a cohort of 210 consecutive patients (150 men and 60 women) undergoing follow-up angiography. The primary end-point was angiographic ISR. Multivariate logistic regression analysis was used to identify independent risk factors for ISR. The cumulative ISR rate during follow-up was analyzed by Kaplan-Meier method. Subgroup analyses were also done for different gender. The ISR rate was 29.5%. Patients with NAFLD had a significantly higher prevalence of ISR than patients without NAFLD (43.3 vs. 16.0%, P < 0.001). In logistic regression analysis, NAFLD was associated with increased ISR, independent of low-density lipoprotein cholesterol, body mass index (adjusted odds ratio: 2.688, 95% confidence intervals: 1.285-5.537, P < 0.001). Male NAFLD patients had a higher prevalence of ISR than patients without NAFLD (48.4 vs. 15.3%, P < 0.001), while the prevalence of ISR in female patients with and without NAFLD were comparable (7.7 vs. 17.0%, P = 0.404). Kaplan-Meier analysis showed a significant association between NAFLD and ISR in all patients (log-rank P = 0.008) and in male subgroup (log-rank P = 0.033), but not in female subgroup (log-rank P = 0.313). This preliminary study suggests that NAFLD could independently associate with a high prevalence of ISR, especially in male patients.

Usefulness of preprocedural serum uric acid level to predict restenosis of bare metal stents

Serum uric acid (SUA) level is known as a significant predictor for cardiovascular diseases, partly through increased inflammatory response and smooth muscle cell proliferation. Inflammation and smooth muscle cells play a crucial role in the pathogenesis of in-stent restenosis (ISR). However, the relation between SUA and ISR has not been studied. The aim of the present study was to investigate the predictive value of preprocedural SUA on the development of ISR in patients who undergo coronary bare-metal stent implantation. Clinical, biochemical, and angiographic data from 708 consecutive patients (mean age 60.3 ± 9.3 years, 71% men) who had undergone bare-metal stent implantation and additional control coronary angiography for stable or unstable angina pectoris were analyzed. Patients were divided into tertiles on the basis of preprocedural SUA levels. Stent restenosis was observed in 54 patients (23%) in the lowest tertile, in 79 (34%) in the middle tertile, and in 109 (46%) in the highest tertile (p <0.001). Using multiple logistic regression analysis, diabetes mellitus, smoking, high-density lipoprotein cholesterol, stent length, C-reactive protein level, and preprocedural SUA level emerged as independent predictors of ISR. On receiver-operating characteristics curve analysis, SUA level >5.5 mg/dl had 75% sensitivity and 71% specificity (area under the curve 0.784, p <0.001) in predicting ISR. In conclusion, higher preprocedural SUA is a powerful and independent predictor of bare-metal stent restenosis in patients with stable and unstable angina pectoris.

[Role of eosinophil granulocytes in the occurrence of restenosis in patients after coronary stenting with drug-eluting stents]

AIM

To study the role of eosinophil granulocytes in the development of restenosis after drug-eluting stent (DES) implantation.

MATERIALS AND METHODS

The blood levels of eosinophils, eosinophil cationic protein (ECP), immunoglobulin E (IgE), and C-reactive protein (CRP) were compared in 170 patients with coronary heart disease (CHD) and stable angina who had undergone recoronarography within the first year after endovascular myocardial revascularization using DES. The blood level of eosinophils was determined by the results obtained employing the FACS Calibur flow cytofluorometer (Becton Dickinson, USA). That of ECP, IgE, and CRP was estimated by enzyme immunoassay by means of an Immulite-100 analyzer (Siemens, Germany). The data were presented as median (25th percentile and 75th percentile).

RESULTS

The blood eosinophil level was 272 (234; 292) cells/μl in patients with restenosis while that was 134 (85; 156) cells/μl in those without restenosis (p = 0.002). The plasma ECP level proved to be greater in the patients who had developed restenosis after DES implantation than in those who had not [17.7 (11.2; 24) and 9 (6.4; 12.9) ng/ml, respectively (p = 0.017). At 6 months after DES implantation, the level of ECP was significantly higher (8.6 (7.3; 9.7) ng/ml) than the baseline level (p = 0.04). Later on, there was an even greater increase in ECP levels. No significant changes were noted in blood ECP levels after bare stent implantation.

CONCLUSION

The findings suggest that there is a relationship between the occurrence of restenosis and the enhanced activity of eosinophil granulocytes in CHD patents after DES implantation.

Relationship of interleukin-6-572C/G promoter polymorphism and serum levels to post-percutaneous coronary intervention restenosis

BACKGROUND

It has been recently reported that inflammatory mechanisms play an important role in in-stent restenosis (ISR) processes. Inflammatory factors after percutaneous coronary intervention (PCI) for dynamic monitoring can probably predict ISR. Functional polymorphisms in the promoter region of genes coding for inflammatory factors might be important for determining the magnitude of the inflammatory response. Thus, in the present study, we aimed to investigate the serial changes in serum interleukin-6 (IL-6) levels before and after PCI and the relationship between the -572C/G polymorphism in the promoter region of the IL-6 gene and ISR. We also discussed genetic polymorphisms in the inflammatory response to PCI.

METHODS

A total of 437 patients who successfully underwent bare metal stent (BMS) implantation with a follow-up angiography were divided into an ISR group (n = 166) and a non-ISR (NISR) group (n = 271). The IL-6 gene promoter polymorphism at position -572 was determined by restricted fragment length polymorphism using the polymerase chain reaction (PCR-RFLP) method. The serum IL-6 levels before and one day, five days and 180 days after PCI were determined by the radioimmunoassay method.

RESULTS

ISR patients showed higher IL-6 serum levels than NISR patients before PCI ((324.42 ± 28.14) ng/L vs. (283.22 ± 47.30) ng/L, P < 0.001), and one day post-PCI IL-6 serum levels in the ISR group also showed a significantly higher level than in the NISR group (P < 0.001). Increased IL-6 after PCI persisted at a statistically significant level throughout the study in ISR patients, whereas IL-6 levels had normalized five days after the procedure in NISR patients. One day post-PCI serum IL-6 level was the most accurate marker for diagnosis of ISR, the area under the ROC curve being 0.927 (95%CI 0.878 - 0.977). The cut-off value for IL-6 to predict ISR was over 355.50 ng/L, with a sensitivity of 0.968 and a specificity of 0.865. There were no significant differences in frequencies of -572 genotype and allele between the two groups (P > 0.05). One day post-PCI IL-6 serum levels in patients with the G allele was significantly higher than in patients without the G allele ((366.99 ± 49.37) ng/L vs. (347.20 ± 55.30) ng/L, P < 0.05). In the ISR group, one day post-PCI serum levels of IL-6 in patients with the G allele was also significantly higher than that in patients without the G allele ((405.67 ± 26.56) ng/L vs. (375.69 ± 38.81) ng/L, P < 0.05). Multivariate Logistic regression analysis revealed positive correlations between male gender, one day post-PCI serum levels of IL-6, the pre-PCI degree of stenosis, the length of the target lesion stenosis, and restenosis; and there were negative correlations between the stent diameter, the diameter of the reference vessel before stent implantation and restenosis.

CONCLUSIONS

IL-6 is an early post-PCI inflammatory cytokine, and one day post-PCI serum IL-6 level is an independent risk factor for restenosis. The frequencies of IL-6 gene -572 genotype and allele are not different between patients with and without ISR in a Chinese Tianjin Han population, but carrying the IL-6 -572G allele is likely to increase an individual's susceptibility to ISR by promoting serum IL-6 levels.

Usefulness of the neutrophil-to-lymphocyte ratio to predict bare-metal stent restenosis

Inflammation plays a crucial role in the pathogenesis of in-stent restenosis (ISR). Neutrophil-to-lymphocyte ratio (NLR) provides a simple method for assessment of inflammatory status and prognosis in patients with coronary artery disease. The aim of the present study was to investigate the predictive value of preprocedural NLR on development of ISR in patients undergoing coronary stent implantation. We retrospectively analyzed clinical, hematologic, and angiographic data of 624 patients (mean age 60.5 ± 10.2 years, 71.8% men) who had undergone coronary stent implantation and a further control coronary angiography owing to stable or unstable angina pectoris. Patients were divided into 3 tertiles based on preprocedural NLR. Restenosis occurred in 21 patients (10.1%) in the lowest tertile, in 62 (29.8%) in the middle tertile, and in 107 (51.4%) in the highest NLR tertile (p <0.001). Serum C-reactive protein levels were also significantly higher in patients in tertile 3 than in those in tertiles 1 and 2 (p <0.001). Using multiple logistic regression analysis, smoking, diabetes mellitus, stent length, preprocedural NLR, and C-reactive protein levels emerged as independent predictors of ISR. In receiver operating characteristics curve analysis, NLR >2.73 had 80% sensitivity and 75% specificity in predicting ISR. In conclusion, high preprocedural NLR is a powerful and independent predictor of bare-metal stent restenosis in patients with stable and unstable angina pectoris.

Association between polymorphisms of eNOS and GPx-1 genes, activity of free-radical processes and in-stent restenosis

Our aim was to examine correlations between polymorphisms in five antioxidant enzymes genes, activity of free-radical processes, and the risk of restenosis after coronary artery stenting with bare metal stents (BMS). A total of 101 male patients who underwent intracoronary stenting using BMS and coronary angiography follow-up of 6 months were enrolled in: group with in-stent restenosis (n = 44) and without restenosis (n = 57). The content of lipoperoxides and malondialdehyde (MDA) in Low-density lipoprotein (LDL), activity of superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPx) in erythrocytes, and genotypes polymorphisms of the CAT gene (-262C/T), paraoxonase-1 (PON-1) gene (163T/A and 575A/G), endothelial nitric oxide synthase (eNOS) gene (298G/T (rs#1799983) and -786T/C), GPx-1 gene (599C/T (rs#1050450)), and glutathione-S-transferase (GSTP) gene (313A/G) were determined. In carriers of the minor allele of 599C/T polymorphism of the GPx-1 gene, activity of GPx in erythrocytes was lower by 17 % than in wild allele homozygotes, while the content of lipoperoxides in LDL was higher by 74 %. T-allele of 599C/T polymorphism of the GPx-1 gene (OR = 2.9; 95 % CI: 1.23-6.82) and T-allele of 298G/T polymorphism of the eNOS gene (OR = 2.79; 95 % CI: 1.17-6.66) were associated with the risk of in-stent restenosis. Minor alleles of polymorphisms 298G/T of the eNOS gene and 599C/T of the GPx-1 gene are associated with an increased risk of in-stent restenosis. Minor allele of the GPx-1 gene 599C/T polymorphism leads to a decrease of the GPx activity and increase of the activity of free-radical processes.

Decreased expression of vitamin D receptors in neointimal lesions following coronary artery angioplasty in atherosclerotic swine

Background

Inflammatory cytokines, such as TNF-α, play a key role in the pathogenesis of occlusive vascular diseases. Activation of vitamin D receptors (VDR) elicits both growth-inhibitory and anti-inflammatory effects. Here, we investigated the expression of TNF-α and VDR in post-angioplasty coronary artery neointimal lesions of hypercholesterolemic swine and examined the effect of vitamin D deficiency on the development of coronary restenosis. We also examined the effect of calcitriol on cell proliferation and effect of TNF-α on VDR activity and expression in porcine coronary artery smooth muscle cells (PCASMCs) in-vitro.

Methodology/Principal Findings

Expression of VDR and TNF-α and the effect of vitamin D deficiency in post-angioplasty coronary arteries were analyzed by immunohistochemistry and histomorphometry. Cell proliferation was examined by thymidine and BrdU incorporation assays in cultured PCASMCs. Effect of TNF-α-stimulation on the activity and expression of VDR was analyzed by luciferase assay, immunoblotting and immunocytochemistry. In-vivo, morphometric analysis of the tissues revealed typical lesions with significant neointimal proliferation. Histological evaluation showed expression of smooth muscle α-actin and significantly increased expression of TNF-α in neointimal lesions. Interestingly, there was significantly decreased expression of VDR in PCASMCs of neointimal region compared to normal media. Indeed, post-balloon angioplasty restenosis was significantly higher in vitamin D-deficient hypercholesterolemic swine compared to vitamin D-sufficient group. In-vitro, calcitriol inhibited both serum- and PDGF-BB-induced proliferation in PCASMCs and TNF-α-stimulation significantly decreased the expression and activity of VDR in PCASMCs.

Conclusions/Significance

These data suggest that significant downregulation of VDR in proliferating smooth muscle cells in neointimal lesions could be due to atherogenic cytokines, including TNF-α. Vitamin D deficiency potentiates the development of coronary restenosis. Calcitriol has anti-proliferative properties in PCASMCs and these actions are mediated through VDR. This could be a potential mechanism for uncontrolled growth of neointimal cells in injured arteries leading to restenosis.

The impact of preprocedural hemoglobin A1c on the efficacy of sirolimus-eluting and paclitaxel-eluting stents

Several reports have shown contrary results regarding the efficacy of sirolimus-eluting stents (SES) and paclitaxel-eluting stents (PES) in diabetic patients. The association between hemoglobin A1c (A1c) before coronary intervention and the midterm clinical outcomes of patients treated with these stents is unclear. The enrolled population was 415 patients with diabetes or impaired glucose tolerance (IGT) who underwent follow-up angiography after being implanted with a SES (n = 282) or PES (n = 133). The enrolled population was classified into the optimal glycemic control group (n = 213) and suboptimal glycemic control group (n = 202), and the predictors of restenosis were examined in each group. In the optimal glycemic control group, the use of PES was an independent predictor of restenosis [odds ratio (OR) 9.98, 95% confidence interval (CI) 3.08-38.9, p < 0.0001]; on the other hand, the use of SES was a positive independent predictor of restenosis prevention (OR 0.10, 95% CI 0.03-0.32, p < 0.0001). In the suboptimal glycemic control group, neither stent was predictive of restenosis. In a subanalysis, preprocedural A1c (≥7.0%) was found to be an independent predictor of restenosis in the SES group (OR 3.61, 95% CI 1.14-12.8, p = 0.03), but not the PES group. Postprocedural A1c (≥7.0%) was not an independent predictor of restenosis in either stent group. This study showed that the superiority of SES compared to PES was attenuated in the suboptimal glycemic control group. Preprocedural A1c (≥7.0%) was found to be an independent predictor of restenosis in the SES group, but not in the PES group.

The predictive value of inflammatory activity and markers of the adipo-insular axis on restenosis in patients with type 2 diabetes

AIMS

Patients with type 2 diabetes (T2DM) have a high restenosis rate after percutaneous coronary intervention (PCI). This study investigated whether markers of inflammation and the adipo-insular axis associated with T2DM and poor metabolic control were able to predict restenosis after PCI in T2DM patients.

METHODS AND RESULTS

The predictive value of traditional and non-traditional risk markers, including IL-1β, IL-6, TNF-α, hsCRP, interferon gamma, leptin, IGF-I, insulin, proinsulin and NT-proBNP, was investigated in 82 patients with T2DM. A re-angiography 6 months after the index percutaneous coronary intervention (PCI) revealed that 43% of the patients had a restenosis. In a multiple regression analysis, the only independent predictors of restenosis were fasting glucose before the PCI and previous myocardial infarction (odds ratio [OR] 1.44, 95% confidence interval [CI] 1.07-1.92; p = 0.015 and OR 8.00, 95% CI 2.49-25.67; p ≤ 0.001, respectively). None of the other markers remained as significant predictors.

CONCLUSION

Fasting glucose prior to the PCI was an independent predictor of restenosis in patients with T2DM while analyses of a variety of markers related to inflammation and the adipo-insular axis did not add any further information.

Long-term reduction of mortality in the 4-year follow up of tirofiban therapy in elective percutaneous coronary interventions (TOPSTAR) trial

BACKGROUND

TOPSTAR was a randomized, placebo-controlled trial studying the effects of adding the glycoprotein IIb/IIIa inhibitor tirofiban to conventional treatment with aspirin and clopidogrel in patients undergoing elective percutaneous coronary interventions (PCI). TOPSTAR demonstrated a lower periprocedural troponin release and a reduced 6-month mortality risk following PCI. The present study analyzed the corresponding long-term effects.

METHODS

All 96 patients who were initially included were followed for a minimum of 4 years (median follow-up time, 4.3 years). The prespecified endpoints were: 1) all-cause mortality and 2) the combined endpoint of all-cause death, myocardial infarction and target vessel revascularization by intention-to-treat analysis in patients randomly assigned to elective PCI. Survival analyses were carried out using Kaplan-Meier analysis and Cox proportional hazard regression.

RESULTS

After 4 years of follow up, no differences were observed between the two groups with respect to medical therapy, NYHA classification and number of reinterventions and target vessel revascularizations. All-cause mortality was still higher in the placebo group (10.9%; 5/46) compared with the tirofiban group (0%; 0/50; Kaplan-Meier log rank = 0.017). The combined endpoint occurred in 21.7% (10/46) in the placebo group versus 8.0% (4/50) in the tirofiban group (Kaplan-Meier log rank = 0.056).

CONCLUSIONS

The reduced 6-month mortality risk after elective PCI in the TOPSTAR trial persisted after 4 years of follow up. Even in this relatively small study, periprocedural effective platelet inhibition had a sustained impact on long-term mortality risk.

The evolving role of inflammatory biomarkers in risk assessment after stent implantation

The main adverse reactions to coronary stents are in-stent restenosis (ISR) and stent thrombosis. Along with procedural factors, individual susceptibility to these events plays an important role. In particular, inflammatory status, as assessed by C-reactive protein levels, predicts the risk of ISR after bare-metal stent implantation, although it does not predict the risk of stent thrombosis. Conversely, C-reactive protein levels fail to predict the risk of ISR after drug-eluting stent (DES) implantation, although they appear to predict the risk of stent thrombosis. Of note, DES have abated ISR rates occurring in the classical 1-year window, but new concern is emerging regarding late restenosis and thrombosis. The pathogenesis of these late events seems to be related to delayed healing and allergic reactions to polymers, a process in which eosinophils seem to play an important role by enhancing restenosis and thrombosis. The identification of high-risk individuals based on biomarker assessment may be important for the management of patients receiving stent implantation. In this report, we review the evolving role of inflammatory biomarkers in predicting the risk of ISR and stent thrombosis.

Role of plasma C-reactive protein in predicting in-stent restenosis in patients with stable angina after coronary stenting

BACKGROUND

The role of plasma high sensitivity C-reactive protein (hs-CRP) in in-stent restenosis (ISR) remains controversial. We investigated plasma hs-CRP level at both admission and follow-up in patients with stable angina (SA) after successful coronary stenting in order to clarify the predictive value of hs-CRP for ISR.

METHODS

We summarized 303 consecutive chronic SA patients with coronary drug-eluting stent (DES) implantation. The ISR was analyzed by quantitative coronary analysis (QCA) at a mean follow-up of 8 months, and the patients were divided into two groups according to the detected ISR as ISR group (n = 48) and non-ISR group (n = 255). Plasma hs-CRP was examined at both admission and 8-month follow-up in all patients, standard medication continued throughout the investigation period.

RESULTS

QCA presented that 48 patients (15.8%) suffered from ISR at follow-up. The basic clinical characteristics were similar between the two groups, while plasma hs-CRP was higher in ISR group than that in non-ISR group at both admission and follow-up, P < 0.001 respectively. Multivariate regression analysis indicated that plasma hs-CRP level at either admission or follow-up could independently predict ISR occurrence (OR = 5.581, 95%CI 2.532-12.302, P < 0.001 and OR = 6.299, 95%CI 2.722-14.577, P < 0.001, respectively).

CONCLUSIONS

Our data indicate that plasma hs-CRP level may independently predict ISR at both admission and follow-up in SA patients with coronary DES implantation, which implies that a chronic, sustained systemic inflammatory response might be involved in ISR pathogenesis.

Baseline C-reactive protein serum levels and in-stent restenosis pattern after m-TOR inhibitors drug-eluting stent implantation

BACKGROUND

A diffuse pattern of in-stent restenosis (ISR) has been shown to have a worse prognosis when compared to a focal pattern. It is still unknown whether baseline C-reactive protein (CRP) levels predict ISR pattern.

METHODS

Our database was searched retrospectively for patients presenting with ISR after m-TOR inhibitor drug-eluting stent (DES) implantation from January 2007 to December 2009. Angiographic restenosis patterns were evaluated according to the simplified Mehran classification and patients were allocated either to the diffuse or focal pattern group. Predictors of restenosis pattern were assessed among clinical, angiographic, procedural and laboratory data, including baseline high-sensitivity CRP, recorded at the time of the first percutaneous intervention.

RESULTS

72 patients (age, 65 ± 9 years; male sex, 64%) found to have ISR after DES implantation were enrolled. 34 patients presented with a focal pattern, whereas 38 patients presented with a diffuse pattern. At multivariate analysis, CRP levels were the only independent predictor of a diffuse ISR pattern [odds ratio, 2.5; 95% confidence interval, 1.4-4.3; p = 0.001)]. Rising CRP tertiles were associated with an increased rate of diffuse pattern (13% versus 26% versus 61%; p for trend = 0.0001).

CONCLUSION

Baseline CRP serum levels are associated with a diffuse ISR pattern after m-TOR inhibitor DES implantation. These findings suggest that baseline inflammatory reactivity may contribute to aggressive restenosis occurring despite drug elution.

Serum concentration of insulin-like growth factor-I, but not tumor necrosis factor-alpha, measured twelve months after stenting of the infarct-related artery, is associated with in-stent restenosis

Percutaneous coronary intervention (PCI) has revolutionized the management of and outcomes in patients with ST-segment elevation myocardial infarction (STEMI). The role of insulin-like growth factor-I (IGF-I) and tumor necrosis factor-alpha (TNF-alpha) in restenosis has been intensively studied. We aimed to investigate the power of serum IGF-I and TNF-alpha concentrations to predict restenosis in patients who had previously undergone PCI for STEMI. Thirty-seven patients were enrolled in the study. Twelve months prior to the study they underwent successful PCI with stent placement for STEMI. The patients were divided into two groups: group 1 - patients with in-stent restenosis in the infarct-related artery (N=9); group 2 - patients without in-stent restenosis in the infarct-related artery (N=28). Baseline profile was similar in both groups. The mean diameter and length of placed stents were similar in both groups. Smaller minimal lumen diameter (MLD) and greater lumen loss (LL) were observed in group 1. Median IGF-I concentrations were substantially higher in patients with ISR compared to those without ISR (170 ng/mL vs 115 ng/mL, p=0.004). Strikingly, median TNF-alpha levels were lower in group 1 (2.4 pg/mL vs 4.1 pg/mL, p=0.05). Correlation analysis showed that serum IGF-I levels were significantly associated with diameter stenosis (R=0.29 p=0.05), LL (R=0.37 p=0.02), MLD (R= -0.38 p=0.03), and stent length (R=0.30 p=0.05). The cut-off value to predict restenosis for IGF-I was less than 158 ng/mL (sensitivity 55 percent, specificity 93 percent, positive predictive value 71 percent, negative predictive value 87 percent). IGF-I detected twelve months after stent placement during the acute phase of AMI may be a late determinant of restenosis. High concentrations of IGF-I could play a permissive role in the progression of NIH and subsequently restenosis. It seems that as far as TNF-alpha is concerned, diagnostic value remains inconclusive.

[Correlation of adiponectin, monocyte chemoattractant protein-1, and endothelial function to vascular remodeling in coronary in-stent restenosis]

OBJECTIVE

To investigate the correlation between vascular remodeling index (RI) and serum adiponectin, plasma monocyte chemoattractant protein-1 (MCP-1), endothelial function and evaluate the mechanism of coronary in-stent restenosis.

METHODS

RI 6 months after percutaneous coronary intervention (PCI), serum adiponectin, plasma MCP-1 and flow-mediated dilation (FMD) before and 3 days,6 months after PCI were measured in 30 patients with and 30 without coronary in-stent restenosis.

RESULTS

Compared with patients without restenosis and those with restenosis before PCI, the patients with coronary in-stent restenosis showed significantly increased plasma MCP-1 3 days and 6 months after PCI (P<0.05) and reduced RI 6 months after PCI, serum adiponectin and FMD 3 days and 6 months after PCI (P<0.05). RI was positively correlated to serum adiponectin and FMD and inversely to MCP-1.

CONCLUSION

The occurrence of coronary in-stent restenosis is the result of the interrelations between multiple factors.

[Association between plasma adiponectin level and in-stent restenosis after coronary stenting]

OBJECTIVE

The purpose of the present study was to identify the relationship between the plasma level of adiponectin and in-stent restenosis of patients with coronary heart disease after coronary stenting.

METHOD

The study population comprised 119 individuals (92 men) who underwent stent implantation, including 65 subjects without in-stent restenosis (group A) and 54 patients with in-stent restenosis (group B). The level of plasma adiponectin was measured using ELISA. Coronary angiography was performed immediately before and after implanting stent and 9 - 12 months later.

RESULTS

Baseline characteristics including drug use after PCI were similar between the groups. The rate of implanting bare metal stent is 8 (12.31%) and 6 (11.11%), TAXUS drug-eluting stent is 11 (16.92%) and 10 (18.52%) and CYPHER drug-eluting stent is 46 (70.77%) and 38 (70.37%) respectively (all P > 0.05). Plasma level of adiponectin in patient of group A was significantly higher than that in group B [(15.16 +/- 5.02) mg/L vs. (10.01 +/- 4.93) mg/L, P < 0.05]. The quantitative coronary angiography (QCA) showed that lesion length was similar between groups [(15.82 +/- 6.67) mm vs. (13.40 +/- 4.20) mm, P > 0.05], minimum lumen diameter (MLD) and stenosis rate were also similar before and after implanting stent (P > 0.05) and acute gain was (1.48 +/- 0.65) mm vs. (1.19 +/- 0.37) mm (P > 0.05). MLD was higher in group A than that in group B [(2.55 +/- 0.53) mm vs. (0.57 +/- 0.60) mm, P < 0.01] at 9 - 12 months follow up. Restenosis rate [(24.2 +/- 11.2)% vs.(81.0 +/- 19.1)%, P < 0.01] and late lumen loss [(0.50 +/- 0.34) mm vs. (1.60 +/- 0.54) mm, P < 0.01] were lower in group A than in group B.

CONCLUSIONS

The lower plasma adiponectin level might be associated with in-stent restenosis after coronary stenting.

[Stromal progenitor cells and blood leukocytes after implantation of drug-eluting stents]

Aim of the study was to assess participation in development of restenosis of circulating in blood progenitor cells of stromal line of differentiation and polymorphonuclear granulocytes. We compared levels of osteonectin positive progenitor cells, neutrophils, eosinophils, and basophils in blood of patients with ischemic heart disease (IHD) in whom according to data of angiographic study after endovascular myocardial revascularization with the help of stents with drug coating (Cypher, Cordis Corp, USA) restenosis was detected (n=15), in patients without restenosis (n=23), and in healthy persons (n=17). Levels of stromal progenitor cells and polymorphonuclear granulocytes in blood were measured with the help of methods of flow cytometry. In groups of patients with IHD with and without restenosis number of osteonectin positive cells in blood was higher than in healthy subjects (2.4+/-0.7 and 2.5+/-0.9 vs 1.5+/-0.5 cells/ microL, respectively, p=0.004) without significant differences between groups (p=0.59). These 2 groups of patients did not differ by numbers of leukocytes, neutrophils, and basophils in blood. At the same time we found that in patients with restenosis number of eosinophils in blood was significantly greater than in the group of patients without restenosis (262+/-68 vs 124+/-67 cells/ microL, respectively p<0.001). Moreover in patients with level of eosinophils exceeding 170 cells/ microL rate of development of restenosis was 74% against 5% in patients with number of eosinophils less than 170 cells/ microL (p<0.001). Thus level of stromal progenitor cells in blood of patients with IHD was higher than in healthy persons and remained equally high in groups with and without restenosis. Number of blood eosinophilic leukocytes in patients who had been subjected to coronary stenting in whom later restenosis developed was significantly higher than in patients without restenosis. The data obtained indicate at the presence of link between development of in - stent restenosis and elevated content of eosinophilic granulocytes in blood of patients with IHD.

[Effect of the anti-inflammatory peptide preparation ingramon on the blood levels of acute-phase proteins and chemokines in patients after coronary stenting]

AIM

To study the effect of the anti-inflammatory peptide preparation ingramon on the peripheral blood levels of inflammatory markers in patients with exercise-induced stable angina after coronary stenting (CS).

SUBJECTS AND METHODS

The investigation enrolled 64 patients with stable angina who had undergone coronary bypass surgery, of them 34 patients received ingramon in addition to standard therapy. The blood levels of high-sensitive C-reactive protein (hs-CRP), fibrinogen, the chemokines MCP-1, IL-8, IP-10, and MID were measured before and 1, 2, and 7 days and 1, 3, and 6 months after surgery. Twenty patients who had gone coronarography (CG) only were examined as a control group.

RESULTS

In the post CS patients receiving only standard therapy, the levels of hs-CRP and fibrinogen were much higher on days 1, 2, and 7 after surgery than in the CG patients. On day 1 following CS, the increment in hs-CRP correlated with the length of implanted stents. During ingramon therapy, the content of hs-CRP and fibrinogen was considerably lower on days 1, 2, and 7 after CS than in the control group; this trend persisted a month after surgery; there was also a reduction in MCP-1 levels within the first 24 hours after initiation of therapy. The levels of the chemokines IP-10, MIG, and IL-8 were significantly unchanged. CONCLUSION. When added to standard therapy, ingramon exerts a positive effect against risk factors for coronary heart disease (CHD) and its events. Further investigations are required to define the impact of ingramon therapy on prognosis in patients with CHD.

Mean platelet volume as a predictor of cardiovascular risk: a systematic review and meta-analysis

AIM

To determine whether an association exists between mean platelet volume (MPV) and acute myocardial infarction (AMI) and other cardiovascular events. Platelet activity is a major culprit in atherothrombotic events. MPV, which is widely available in clinical practice, is a potentially useful biomarker of platelet activity in the setting of cardiovascular disease.

METHODS AND RESULTS

We performed a systematic review and meta-analysis investigating the association between MPV and AMI, all-cause mortality following myocardial infarction, and restenosis following coronary angioplasty. Results were pooled using random-effects modeling. Pooled results from 16 cross-sectional studies involving 2809 patients investigating the association of MPV and AMI indicated that MPV was significantly higher in those with AMI than those without AMI [mean difference 0.92 fL, 95% confidence interval (CI) 0.67-1.16, P < 0.001). In subgroup analyses, significant differences in MPV existed between subjects with AMI, subjects with stable coronary disease (P < 0.001), and stable controls (P < 0.001), but not vs. those with unstable angina (P = 0.24). Pooled results from three cohort studies involving 3184 patients evaluating the risk of death following AMI demonstrated that an elevated MPV increased the odds of death as compared with a normal MPV (11.5% vs. 7.1%, odds ratio 1.65, 95% CI 1.12-2.52, P = 0.012). Pooled results from five cohort studies involving 430 patients who underwent coronary angioplasty revealed that MPV was significantly higher in patients who developed restenosis than in those who did not develop restenosis (mean difference 0.98 fL, 95% CI 0.74-1.21, P < 0.001).

CONCLUSIONS

Elevated MPV is associated with AMI, mortality following myocardial infarction, and restenosis following coronary angioplasty. These data suggest that MPV is a potentially useful prognostic biomarker in patients with cardiovascular disease. Whether the relationship is causal, and whether MPV should influence practice or guide therapy, remains unknown.

Impact of C-reactive protein on in-stent restenosis: a meta-analysis

We sought to evaluate the impact of C-reactive protein (CRP) levels on in-stent restenosis after percutaneous coronary intervention.The plasma level of CRP is considered a risk predictor for cardiovascular diseases. However, the relationship between CRP and in-stent restenosis has been a matter of controversy. Meta-analysis reduces variability and better evaluates the correlation.We performed a systemic search for literature published in March 2008 and earlier, using MEDLINE(R), the Cochrane clinical trials database, and EMBASE(R). We also scanned relevant reference lists and hand-searched all review articles or abstracts from conference reports on this topic. Of the 245 studies that we initially searched, we chose 9 prospective observational studies (1,062 patients).Overall, CRP concentration was higher in patients who experienced in-stent restenosis. The weighted mean difference in CRP levels between the patients with in-stent restenosis and those without was 1.67, and the Z-score for overall effect was 2.12 (P=0.03). Our subgroup analysis that compared patients with stable and unstable angina showed a weighted mean difference in the CRP levels of 2.22 between the patients with and without in-stent restenosis, and the Z-score for overall effect was 2.23 (P=0.03) in 5 studies of unstable-angina patients. There was no significance in 4 studies of stable-angina patients.In spite of significant heterogeneity across the studies, our meta-analysis suggests that preprocedurally elevated levels of CRP are associated with greater in-stent restenosis after stenting and that this impact appears more prominent in unstable-angina patients.

Effect of quinapril on in-stent restenosis and relation to plasma apoptosis signaling molecules

Angiotensin-converting enzyme inhibitors have been reported to inhibit in-stent restenosis. To assess the effect of angiotensin-converting enzyme inhibition on in-stent restenosis and its relation to apoptosis, 86 patients with chronic coronary artery disease who required stent implantation in the left anterior descending coronary artery or a major diagonal branch were studied. Patients were randomized to receive quinapril 40 mg/day orally (n = 43) or a placebo (n = 43). Drug therapy was initiated 1 week before initial stenting and continued for 6 months. Plasma levels of the apoptotic signaling molecules soluble Fas and soluble Fas ligand obtained from blood drawn from the left anterior descending coronary artery were measured just before initial stenting and 6 months later, at the time of repeat coronary angiography. In-stent restenosis was present in 9.3% of patients in the quinapril group and 25.6% of patients in the placebo group (p = 0.047). Mean late luminal loss was 0.56 +/- 0.51 mm in the quinapril group and 0.95 +/- 0.95 mm in the placebo group (p = 0.003). There were no significant differences in plasma soluble Fas or soluble Fas ligand levels at baseline. At 6 months, the change in plasma soluble Fas level was significantly higher in the quinapril group (0.72 +/- 1.24 ng/ml) than in the placebo group (0.28 +/- 0.72 ng/ml) (p = 0.024). The change in plasma soluble Fas ligand levels at 6 months was significantly higher in the quinapril group (7.43 +/- 12.2 pg/ml) than in the placebo group (0.06 +/- 6.8 pg/ml) (p = 0.002). In conclusion, the angiotensin-converting enzyme inhibitor quinapril inhibits in-stent restenosis by stimulating apoptosis after percutaneous intervention.

Platelet-derived chemokine RANTES may be a sign of restenosis after percutaneous coronary intervention in patients with stable angina pectoris

Inflammation plays a pathogenic role in the development of restenosis after percutaneous coronary intervention (PCI). We measured and compared the ratio of elevated levels of regulated on activation normally T-cell expressed and secreted (RANTES), monocytic chemotactic peptide-1 (MCP-1), soluble (s) P-selectin and sL-selectin after PCI. Plasma levels of chemokines and soluble markers were measured before, 1, 3 and 7 days after PCI in 52 patients (43 males and nine females, aged 63 +/- 10 years) who underwent PCI and who had repeated angiograms at a 6-month follow-up. Restenosis occurred in 16 (31%) patients. A significant and time-dependent increase in sL-selectin was observed in the restenosis group. However, there were no significant differences in MCP-1 levels with or without restenosis. sP-selectin levels in the restenosis group exhibited a transient elevation at 3 days after PCI. RANTES levels were no different at baseline between patients with or without restenosis. However, a significant and time-dependent decrease in RANTES levels were observed in the non-restenosis group, and patients with restenosis compared with patients without restenosis had a statistically significant ratio of elevated levels of RANTES. These findings suggest that restenosis development after PCI in patients with effort angina pectoris may involve leukocyte activation at an early period after PCI. In addition, platelet-derived chemokine RANTES may be a sign of restenosis after PCI in patients with stable angina pectoris.

Predictors of target lesion revascularization in patients undergoing lower extremity percutaneous interventions

BACKGROUND

Predictors of target lesion revascularization (TLR) have not been well defined in patients undergoing peripheral percutaneous interventions (PPI). In this study we analyze predictors of TLR in a consecutive cohort of patients from two medical centers.

METHODS

Data were extracted from a prospectively collected peripheral vascular registry. Of 105 consecutive patients (175 vessels) undergoing PPI, follow up was achieved in 104 patients (172 vessels) at 8.06 +/- 4.51 months. Univariate analysis was performed between the groups with (n = 19, vessels = 25) and without (n = 85, vessels = 147) TLR. Logistic regression analysis was utilized to model for the predictors of TLR.

RESULTS

TLR occurred in 14% of vessels treated at 8.06 +/- 4.51 months. By univariate analysis, vessels with TLR on follow up had longer treated segments (167.0 +/- 139.16 mm vs. 98.49 +/- 113.33 mm; p = 0.027), more severe lesions (91.96 +/- 12.56% vs. 85.51 +/- 14.43%; p = 0.037) and were younger (63.0 +/- 10.1 years vs. 69.1 +/- 11.1 years; p = 0.032). Also, there was a trend toward a higher hs-CRP (11.35 +/- 17.85 vs. 7.45 +/- 9.57 mg/L) and more total occlusions (44.0% vs. 22.6%) in the TLR group, but these did not reach statistical significance. Logistic regression analysis with backward elimination including all these variables showed that younger age (p = 0.007), female gender (p = 0.033) and treated vessel length (p = 0.028) were the only independent predictors of TLR.

CONCLUSIONS

Younger age, female gender and longer treated vessel length are independent predictors of TLR in patients undergoing PPI. The cost-effectiveness in treating these patients with PPI versus surgery needs to be defined in future studies.

Plasma levels of C-reactive protein and interleukin-10 predict late coronary in-stent restenosis 6 months after elective stenting

BACKGROUND

In-stent restenosis (ISR) is one of the major limitations of percutaneous coronary intervention (PCI).

AIM

To evaluate the relationship between the levels of hs-CRP, IL-6, IL-10 and intimal hyperplasia six months after coronary bare metal stent (BMS) implantation.

METHODS

The study population consisted of 73 consecutive patients who underwent bare metal stent implantation into narrowed coronary segments. A total of 74 stents were implanted. Angiographic study after six months, together with evaluation of serum level of IL-6 (pg/ml), IL-10 (pg/ml), hs-CRP (microg/ml), fasting insulin (microIU/ml) and glucose (mg%) was performed. Insulin sensitivity was calculated using the HOMA-IR formula. The QCA analysis of stented segments was performed at baseline, after intervention and at six-month follow-up.

RESULTS

Restenosis at six months occurred in 10 patients (13.7%). The mean % diameter stenosis at follow-up was 27.8 +/- 19% and late loss was 0.81 +/- 0.6 mm. We found a correlation between late loss and serum hs-CRP, IL-6 and IL-10 concentration. There was no correlation between the lipid profiles, insulin levels and HOMA-IR and re-narrowing of the stented segments. Patients with restenosis were characterised by significantly higher serum concentration of CRP (2.04 +/- 3.4 vs. 10.38 +/- 6.7 microg/ml, p = 0.0036), IL-6 (14.98 +/- 8.3 vs. 5.70 +/- 5.5 pg/ml, p = 00062), and fasting glucose (184.0 +/- 50.5 vs. 107.5 +/- 40.4 mg%, p = 0.0051), as well as lower IL-10 levels (1.25 +/- 0.6 vs. 4.85 +/- 4.9 pg/ml, p = 0.0000). The ROC analysis indicated that CRP (> 2.86 microg/ml), IL-6 (> 6.24 pg/ml) and IL-10 (< 1.7 pg/ml) values predicted the restenosis with reasonable accuracy. A multiple logistic regression model identified CRP and IL-10 levels as independent predictors of restenosis.

CONCLUSION

We demonstrated that elevated inflammatory markers 6 months after PCI are associated with late angiographic in-stent restenosis.

Glycaemic control and restenosis after percutaneous coronary interventions in patients with diabetes mellitus: a report from the Insulin Diabetes Angioplasty study

OBJECTIVE

We investigated the impact of glucose control on target lesion restenosis after PCI in patients with type 2 diabetes.

METHODS

Ninety-three consecutive patients with type 2 diabetes accepted for PCI were randomised to intensified glucose control based on insulin (I-group; n=44) or to continue ongoing glucose-lowering treatment (C-group; n=49).The treatment target was a FBG of 5-7 mmol/L and HbA1c <6.5%. Information on target lesion restenosis after six months was available in 82 patients.

RESULTS

At baseline HbA1c and FBG did not differ between the I- and C-groups, respectively (HbA1c: 6.5 vs. 6.5%; p=1.0 and FBG: 7.0 vs. 7.3 mmol/L; p=0.3). After six months there was no significant change in HbA1c or FBG in either group (change in HbA1c: -0.2 vs.-0.1%; p=0.3 and in FBG: +0.2 vs. -0.3 mmol/L; p=0.3 in the I- and C-groups, respectively). Target lesion restenosis at six months did not differ, I vs. C = 41 and 44% (p=0.8). Independent predictors for restenosis were previous myocardial infarction (OR 8.0, 95% CI 2.5-25.7; p=<0.001) and FBG at baseline (OR for an increase by 1 mmol/L = 1.4, 95% CI 1.1-1.9; p=0.015).

CONCLUSIONS

Restenosis was predicted by baseline FBG suggesting that it would be of interest to target glucose normalisation in future trials. Intensified insulin treatment did not influence the rate of restenosis indicating that the main focus should be on lowering glucose rather than the tool to normalise glucose.