Ticagrelor Monotherapy or Dual Antiplatelet Therapy After Drug-Eluting Stent Implantation: Per-Protocol Analysis of the GLOBAL LEADERS Trial

Background

In the GLOBAL LEADERS trial, ticagrelor monotherapy beyond 1 month compared with standard antiplatelet regimens after coronary stent implantation did not improve outcomes at intention‐to‐treat analysis. Considerable differences in treatment adherence between the experimental and control groups may have affected the intention‐to‐treat results. In this reanalysis of the GLOBAL LEADERS trial, we compared the experimental and control treatment strategies in a per‐protocol analysis of patients who did not deviate from the study protocol.

Methods and Results

Baseline and postrandomization information were used to classify whether and when patients were deviating from the study protocol. With logistic regressions, we derived time‐varying inverse probabilities of nondeviation from protocol to reconstruct the trial population without protocol deviation. The primary end point was a composite of all‐cause mortality or nonfatal Q‐wave myocardial infarction at 2 years. At 2‐year follow‐up, 1103 (13.8%) of 7980 patients in the experimental group and 785 (9.8%) of 7988 patients in the control group qualified as protocol deviators. At per‐protocol analysis, the rate ratio for the primary end point was 0.88 (95% CI, 0.75–1.03; P=0.10) on the basis of 274 versus 325 events in the experimental versus control group. The rate ratio for the key safety end point of major bleeding was 1.00 (95% CI, 0.79–1.26; P=0.99). The per‐protocol and intention‐to‐treat effect estimates were overall consistent.

Conclusions

Among patients who complied with the study protocol in the GLOBAL LEADERS trial, ticagrelor plus aspirin for 1 month followed by ticagrelor monotherapy was not superior to 1‐year standard dual antiplatelet therapy followed by aspirin alone at 2 years after coronary stenting.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT01813435.

Long term outcomes of a coordinate care program in patients after myocardial infarction (KOS-MI)

Introduction

Despite significant progress in treatment of myocardial infarction (MI), the annual mortality remains a challenge. Since 2017, The Coordinated Care in Myocardial Infarction Program (KOS-MI) has been introduced in Poland, which guarantees and coordinates patients to achieve complete revascularization, electrotherapy when necessary, cardiac rehabilitation and access to cardiologist for patients after MI.

Purpose

The aim of this study was to assess long term outcomes (3-year follow-up) of patients enrolled in KOS-MI.

Methods

This is a prospective multicenter registry of 1973 consecutive patients with myocardial infarction hospitalized in 4 centers of American Heart of Poland from 11.2017 to 11.2018. Patients which constituted a study group were enrolled in KOS-MI program at discharge. A control group consisted patients who received standard of care. Propensity score matching was utilized for patients baseline characteristic matching and results adjustment. Follow-up was obtained from the National Health Fund registry citizens. Combine endpoint of MACCE consisted of death, MI, stroke and repeated revascularization.

Results

In total 753 patients were enrolled in KOS program and 1173 constituted a control group. More than 90% of patients in both groups underwent PCI. Patients in KOS-MI were mostly men (70% vs. 65%; p<0,05), were younger (65 vs. 68; p<0,05), admitted with STEMI (44,8% vs. 37,5%; p<0,05) with previous history of heart failure (23% vs. 17%; p<0,05). Patients in the control group had more comorbidities: chronic kidney disease (9,8% vs. 4,4%; p<0,05), previous AMI (17,6% vs. 12,6%; p<0,05), prior PCI (15,7% vs. 11%; p<0,05) and atrial fibrillation (11,7% vs. 8,4%; p<0,05). They were more often admitted with NSTEMI (62,5% vs. 55,3%; p<0,05) and acute heart failure (4,7% vs. 2,7%; p<0,05). KOS patients had more often completed revascularization performed (50% vs. 33,4%; p<0,05). Following propensity score matching 576 pairs were matched, and patient baseline characteristic were well balanced in all variables.

In long- term follow-up (mean 2,8±0,27 years) mortality was significantly lower in KOS group (9% vs. 16,3%; p<0,05) and MI similar (10,8% vs. 13,1%; p=0,14). MACCE was higher in the control group (43% vs. 30,2%; p<0,05). Prevalence of hospitalization for HF and repeated revascularization was higher in the control group (14,7% vs. 9,4%; p<0,05 and 27,9% vs. 21%; p<0,05, respectively). After adjustment MACCE remained significantly lower for KOS-MI, whereas there was tendency for lower mortality, hospitalization for HF and repeated revascularizations (Figure 1).

Conclusions

Combination and coordination of unrestricted rehabilitation, complete revascularization, electrotherapy and ambulatory cardiologist care in the KOS-MI program improves long term prognosis in patients after MI.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Ticagrelor Monotherapy Versus Dual-Antiplatelet Therapy After PCI: An Individual Patient-Level Meta-Analysis

OBJECTIVES

The aim of this study was to compare ticagrelor monotherapy with dual-antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with drug-eluting stents.

BACKGROUND

The role of abbreviated DAPT followed by an oral P2Y₁₂ inhibitor after PCI remains uncertain.

METHODS

Two randomized trials, including 14,628 patients undergoing PCI, comparing ticagrelor monotherapy with standard DAPT on centrally adjudicated endpoints were identified, and individual patient data were analyzed using 1-step fixed-effect models. The protocol was registered in PROSPERO (CRD42019143120). The primary outcomes were the composite of Bleeding Academic Research Consortium type 3 or 5 bleeding tested for superiority and, if met, the composite of all-cause death, myocardial infarction, or stroke at 1 year, tested for noninferiority against a margin of 1.25 on a hazard ratio (HR) scale.

RESULTS

Bleeding Academic Research Consortium type 3 or 5 bleeding occurred in fewer patients with ticagrelor than DAPT (0.9% vs. 1.7%, respectively; HR: 0.56; 95% confidence interval [CI]: 0.41 to 0.75; p < 0.001). The composite of all-cause death, myocardial infarction, or stroke occurred in 231 patients (3.2%) with ticagrelor and in 254 patients (3.5%) with DAPT (HR: 0.92; 95% CI: 0.76 to 1.10; p < 0.001 for noninferiority). Ticagrelor was associated with lower risk for all-cause (HR: 0.71; 95% CI: 0.52 to 0.96; p = 0.027) and cardiovascular (HR: 0.68; 95% CI: 0.47 to 0.99; p = 0.044) mortality. Rates of myocardial infarction (2.01% vs. 2.05%; p = 0.88), stent thrombosis (0.29% vs. 0.38%; p = 0.32), and stroke (0.47% vs. 0.36%; p = 0.30) were similar.

CONCLUSIONS

Ticagrelor monotherapy was associated with a lower risk for major bleeding compared with standard DAPT, without a concomitant increase in ischemic events.

Neointimal hyperplasia of ultra-thin stents with microcrystalline sirolimus or durable polymer everolimus-eluting stents: 6- and 24-month results of the DESSOLVE III OCT study

AIMS

The DESSOLVE III OCT substudy aimed to compare serially neointimal hyperplasia volume obstruction (%VO) between the thin-strut MiStent with early polymer elimination and nine-month sustained drug release from microcrystalline sirolimus and the durable polymer-coated everolimus-eluting XIENCE stent at six and 24 months after implantation.

METHODS AND RESULTS

The efficacy endpoint was %VO, calculated as abluminal neointimal volume/stent volume. Thirty-six patients (MiStent 16 patients, 16 lesions; XIENCE 20 patients, 22 lesions) underwent serial OCT evaluation at both six and 24 months. At six months, mean abluminal %VO was significantly lower in the MiStent group than in the XIENCE group (14.54±3.70% vs 19.11±6.70%; p=0.011), whereas the difference in %VO between the two groups decreased at 24 months (20.88±5.72% vs 23.50±7.33%; p=0.24). There was no significant difference in percentage malapposed struts and percentage uncovered struts between the two groups at both time points.

CONCLUSIONS

In the serial comparative OCT analysis of the MiStent versus the XIENCE, the MiStent showed a more favourable efficacy for preventing neointimal formation with comparable strut tissue coverage, as compared with the XIENCE at six months, but this difference in %VO decreased at 24 months so that the difference in neointima at 24 months was no longer significant.

Comparison of Investigator-Reported and Clinical Event Committee-Adjudicated Outcome Events in GLASSY

BACKGROUND

Event adjudication by a clinical event committee (CEC) provides a standardized, independent outcome assessment. However, the added value of CEC to investigators reporting remains debated. GLASSY (GLOBAL LEADERS Adjudication Sub-Study) implemented, in a subset of the open-label, investigator-reported (IR) GLOBAL LEADERS trial, an independent adjudication process of reported and unreported potential outcome events (triggers). We describe metrics of GLASSY feasibility and efficiency, diagnostic accuracy of IR events, and their concordance with corresponding CEC-adjudicated events.

METHODS

We report the proportion of myocardial infarction, bleeding, stroke, and stent thrombosis triggers with sufficient evidence for assessment (feasibility) that were adjudicated as outcome events (efficiency), stratified by source (IR or non-IR). Using CEC-adjudicated events as criterion standard, we describe sensitivity, specificity, positive and negative predictive value, and global diagnostic accuracy of IR events. Using Gwet AC coefficient, we examine the concordance between IR- and corresponding CEC-adjudicated triggers. There was sufficient evidence for assessment for 2592 (98.3%) of 2636 triggers.

RESULTS

Overall, the adjudicated end point-to-trigger ratio was high and similar between IR- (88%) and non-IR-reported (87%) triggers. The global diagnostic accuracy and concordance between IR-reported and CEC-adjudicated outcome events was 0.70 (95% CI, 0.65-0.74) and 0.54 (95% CI, 0.45-0.62), respectively, for myocardial infarction; 0.77 (95% CI, 0.75-0.79) and 0.71 (95% CI, 0.68-0.74) for bleeding; 0.70 (95% CI, 0.62-0.79) and 0.59 (95% CI, 0.43-0.74) for stroke; 0.59 (95% CI, 0.52-0.66) and 0.39 (95% CI, 0.25-0.53) for stent thrombosis. For IR bleedings, the concordance with the CEC on type of events was generally weak.

CONCLUSIONS

Implementing CEC adjudication in a pragmatic open-label trial with IR events is feasible and efficient. Our findings of modest global diagnostic accuracy for IR events and generally weak concordance between investigators and CEC support the role for CEC adjudication in such settings. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03231059.

Predicting 2-year all-cause mortality after contemporary PCI: Updating the logistic clinical SYNTAX score

AIMS

We aimed to update the logistic clinical SYNTAX score to predict 2 year all-cause mortality after contemporary percutaneous coronary intervention (PCI).

METHODS AND RESULTS

We analyzed 15,883 patients in the GLOBAL LEADERS study who underwent PCI. The logistic clinical SYNTAX model was updated after imputing missing values by refitting the original model (refitted original model) and fitting an extended new model (new model, with, selection based on the Akaike Information Criterion). External validation was performed in 10,100 patients having PCI at Fu Wai hospital. Chronic obstructive pulmonary disease, prior stroke, current smoker, hemoglobin level, and white blood cell count were identified as additional independent predictors of 2 year all-cause mortality and included into the new model. The c-indexes of the original, refitted original and the new model in the derivation cohort were 0.74 (95% CI 0.72-0.76), 0.75 (95% CI 0.73-0.77), and 0.78 (95% CI 0.76-0.80), respectively. The c-index of the new model was lower in the validation cohort than in the derivation cohort, but still showed improved discriminative ability of the newly developed model (0.72; 95% CI 0.67-0.77) compared to the refitted original model (0.69; 95% CI 0.64-0.74). The models overestimated the observed 2 year all-cause mortality of 1.11% in the Chinese external validation cohort by 0.54 percentage points, indicating the need for calibration of the model to the Chinese patient population.

CONCLUSIONS

The new model of the logistic clinical SYNTAX score better predicts 2 year all-cause mortality after PCI than the original model. The new model could guide clinical decision making by risk stratifying patients undergoing PCI.

PRECISE-DAPT score for bleeding risk prediction in patients on dual or single antiplatelet regimens: insights from the GLOBAL LEADERS and GLASSY

AIMS

The 5-item PRECISE-DAPT, integrating age, haemoglobin, white-blood-cell count, creatinine clearance, and prior bleeding, predicts bleeding risk in patients on dual antiplatelet therapy (DAPT) after stent implantation. We sought to assess whether the bleeding risk prediction offered by the PRECISE-DAPT remains valid among patients receiving ticagrelor monotherapy from 1 month onwards after coronary stenting instead of standard DAPT and having or not having centrally-adjudicated bleeding endpoints.

METHODS AND RESULTS

The PRECISE-DAPT was calculated in 14,928 and 7,134 patients from GLOBAL LEADERS and GLASSY trials, respectively. The ability of the score to predict BARC 3 or 5 bleeding was assessed and compared among patients on ticagrelor monotherapy (experimental strategy) or standard DAPT (reference strategy) from 1 month after drug-eluting stent implantation. Bleeding endpoints were investigator-reported or centrally-adjudicated in GLOBAL LEADERS and GLASSY, respectively.At 2 years, the c-indexes for the score among patients treated with the experimental or reference strategy were 0.67 (95% confidence interval [CI]:0.63-0.71) vs. 0.63 (95% CI:0.59-0.67) in GLOBAL LEADERS (p = 0.27), and 0.67 (95% CI:0.61-0.73) vs. 0.66 (95% CI:0.61-0.72) in GLASSY (p = 0.88). Decision curve analysis showed net benefit using the PRECISE-DAPT to guide bleeding risk assessment under both treatment strategies. Results were consistent between investigator-reported and adjudicated endpoints and using the simplified 4-item PRECISE-DAPT.

CONCLUSIONS

The PRECISE-DAPT offers a prediction model that proved similarly effective to predict clinically-relevant bleeding among patients on ticagrelor monotherapy from 1 month after coronary stenting compared with standard DAPT and appears to be unaffected by the presence or absence of adjudicated bleeding endpoints.

Impact of recruitment and retention on all-cause mortality in a large all-comers randomised controlled trial: insights from the GLOBAL LEADERS trial

OBJECTIVE

Recruitment and retention in trials may bias the results and subsequently complicate their interpretation and validity. The aim of this study is to evaluate the impact of recruitment and retention on all-cause mortality in a large all-comers trial.

METHODS

The recruitment rate in each investigating center of the GLOBAL LEADERS trial was assessed and the 130 centers were subdivided into low and high recruiters according to the median, with all-cause mortality then compared between the two groups. Vital status was obtained from public records in patients with incomplete follow-up.

RESULTS

The trial randomized 15,991 (7.86%) of 203,483 eligible patients with percutaneous coronary intervention during the recruitment period, of whom 15,267 (95.47%) completed follow-up, 23 (0.14%) patients withdrew consent and formally requested to be deleted from the database; 183 (1.14%) withdrew consent but only objected to future data collection; 303 (1.89%) discontinued the study; and 215 (1.34%) were lost to follow-up. Vital status was finally obtained in all but 31 patients (99.81%). Patients from low recruiters had a significantly lower all-cause mortality than high ones (2.26% vs. 3.24%; hazard ratio: 0.69; 95% confidence interval: 0.55-0.87; p = 0.002). There was a significant difference in all-cause mortality among the incomplete follow-up groups (log-rank p < 0.001) with a significantly higher mortality in the 183 patients who withdrew consent than those who completed follow-up (7.38% vs. 2.99%, p = 0.002).

CONCLUSIONS

Recruitment and retention significantly impacted all-cause mortality. Search for vital status through public domains is of paramount importance in the interpretation and validity of large clinical trials.

Safety and efficacy of a sirolimus-eluting coronary stent with ultra-thin strut for treatment of atherosclerotic lesions (TALENT): a prospective multicentre randomised controlled trial

BACKGROUND

Supraflex is a sirolimus-eluting stent with a biodegradable polymer coating and ultra-thin struts. We aimed to compare Supraflex with the standard of care, Xience, an everolimus-eluting stent with a durable polymer coating, regarding clinical outcomes with a randomised trial in an all-comer population.

METHODS

We did a prospective, randomised, single-blind, multicentre study (TALENT) across 23 centres in Europe (the Netherlands, Poland, the UK, Spain, Bulgaria, Hungary, and Italy). Eligible participants were aged 18 years or older, had one or more coronary artery stenosis of 50% or greater in a native coronary artery, saphenous venous graft, or arterial bypass conduit, and had a reference vessel diameter of 2·25-4·50 mm. Patients underwent percutaneous coronary intervention in an all-comer manner. We randomly assigned patients (1:1) to implantation of either a sirolimus-eluting stent with a biodegradable polymer coating and ultra-thin struts (Supraflex) or an everolimus-eluting stent with a durable polymer coating (Xience). Randomisation was done by local investigators by use of a web-based software with random blocks according to centre. The primary endpoint was a non-inferiority comparison of a device-oriented composite endpoint-cardiac death, target-vessel myocardial infarction, or clinically indicated target lesion revascularisation-between groups at 12 months after the procedure, assessed in an intention-to-treat population. On assumption of 1-year composite endpoint prevalence of 8·3%, a margin of 4·0% was defined for non-inferiority of the Supraflex group compared with the Xience group. This trial is registered with ClinicalTrials.gov, number NCT02870140.

FINDINGS

Between Oct 21, 2016, and July 3, 2017, 1435 patients with 1046 lesions were randomly assigned to Supraflex, of whom 720 received the index procedure, and 715 patients with 1030 lesions were assigned to Xience, all receiving the index procedure. At 12 months, the primary endpoint had occurred in 35 patients (4·9 %) in the Supraflex group and in 37 patients (5·3%) in the Xience group (absolute difference -0·3% [one-sided 95% upper confidence bound 1·6%], p_{non-inferiority}<0·0001). Definite or probable stent thrombosis prevalence, a safety indicator, was low in both groups and did not differ between them.

INTERPRETATION

The Supraflex stent was non-inferior to the Xience stent for a device-oriented composite clinical endpoint at 12 months in an all-comer population. Supraflex seems a safe and effective alternative drug-eluting stent to other stents in clinical practice.

FUNDING

European Cardiovascular Research Institute.

Rationale and design of a prospective substudy of clinical endpoint adjudication processes within an investigator-reported randomised controlled trial in patients with coronary artery disease: the GLOBAL LEADERS Adjudication Sub-StudY (GLASSY)

INTRODUCTION

The GLOBAL LEADERS is an open-label, pragmatic and superiority randomised controlled trial designed to challenge the current treatment paradigm of dual antiplatelet therapy (DAPT) for 12 months followed by aspirin monotherapy among patients undergoing percutaneous coronary intervention. By design, all study endpoints are investigator reported (IR) and not subject to formal adjudication by an independent Clinical Event Committee (CEC), which may introduce detection, reporting or ascertainment bias.

METHODS AND ANALYSIS

We designed the GLOBAL LEADERS Adjudication Sub-StudY (GLASSY) to prospectively implement, in a large sample of patients enrolled within the GLOBAL LEADERS trial (7585 of 15 991, 47.5%), an independent adjudication process of reported and unreported potential endpoints, using standardised CEC procedures, in order to assess whether 23-month ticagrelor monotherapy (90 mg twice daily) after 1-month DAPT is non-inferior to a standard regimen of DAPT for 12 months followed by aspirin monotherapy for the primary efficacy endpoint of death, non-fatal myocardial infarction, non-fatal stroke or urgent target vessel revascularisation and superior for the primary safety endpoint of type 3 or 5 bleeding according to the Bleeding Academic Research Consortium criteria.This study will comprehensively assess the comparative safety and efficacy of the two tested antithrombotic strategies on CEC-adjudicated ischaemic and bleeding endpoints and will provide insights into the role of a standardised CEC adjudication process on the interpretation of study findings by quantifying the level of concordance between IR-reported and CEC-adjudicated events.

ETHICS AND DISSEMINATION

GLASSY has been approved by local ethics committee of all study sites and/or by the central ethics committee for the country depending on country-specific regulations. In all cases, they deemed that it was not necessary to obtain further informed consent from individual subjects.

TRIAL REGISTRATION NUMBER

NCT01813435.

Ticagrelor plus aspirin for 1 month, followed by ticagrelor monotherapy for 23 months vs aspirin plus clopidogrel or ticagrelor for 12 months, followed by aspirin monotherapy for 12 months after implantation of a drug-eluting stent: a multicentre, open-label, randomised superiority trial

BACKGROUND

We hypothesised that ticagrelor, in combination with aspirin for 1 month, followed by ticagrelor alone, improves outcomes after percutaneous coronary intervention compared with standard antiplatelet regimens.

METHODS

GLOBAL LEADERS was a randomised, open-label superiority trial at 130 sites in 18 countries. Patients undergoing percutaneous coronary intervention with a biolimus A9-eluting stent for stable coronary artery disease or acute coronary syndromes were randomly assigned (1:1) to 75-100 mg aspirin daily plus 90 mg ticagrelor twice daily for 1 month, followed by 23 months of ticagrelor monotherapy, or standard dual antiplatelet therapy with 75-100 mg aspirin daily plus either 75 mg clopidogrel daily (for patients with stable coronary artery disease) or 90 mg ticagrelor twice daily (for patients with acute coronary syndromes) for 12 months, followed by aspirin monotherapy for 12 months. Randomisation was concealed, stratified by centre and clinical presentation (stable coronary artery disease vs acute coronary syndrome), and blocked, with randomly varied block sizes of two and four. The primary endpoint at 2 years was a composite of all-cause mortality or non-fatal centrally adjudicated new Q-wave myocardial infarction as assessed by a core lab in a blinded manner. The key secondary safety endpoint was site-reported bleeding assessed according to the Bleeding Academic Research Consortium criteria (grade 3 or 5). Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01813435, and is closed to new participants, with follow-up completed.

FINDINGS

Between July 1, 2013, and Nov 9, 2015, 15 968 participants were randomly assigned, 7980 to the experimental group and 7988 to the control group. At 2 years, 304 (3·81%) participants in the experimental group had died or had a non-fatal centrally adjudicated new Q-wave myocardial infarction, compared with 349 (4·37%) participants in the control group (rate ratio 0·87 [95% CI 0·75-1·01]; p=0·073]). There was no evidence for a difference in treatment effects for the primary endpoint across prespecified subgroups of acute coronary syndromes and stable coronary artery disease (p=0·93). Grade 3 or 5 bleeding occurred in 163 participants in the experimental group and 169 in the control group (2·04% vs 2·12%; rate ratio 0·97 [95% CI 0·78-1·20]; p=0·77).

INTERPRETATION

Ticagrelor in combination with aspirin for 1 month followed by ticagrelor alone for 23 months was not superior to 12 months of standard dual antiplatelet therapy followed by 12 months of aspirin alone in the prevention of all-cause mortality or new Q-wave myocardial infarction 2 years after percutaneous coronary intervention.

FUNDING

AstraZeneca, Biosensors, and The Medicines Company.

Ranolazine in patients with incomplete revascularisation after percutaneous coronary intervention (RIVER-PCI): a multicentre, randomised, double-blind, placebo-controlled trial

BACKGROUND

Incomplete revascularisation is common after percutaneous coronary intervention and is associated with increased mortality and adverse cardiovascular events. We aimed to assess whether adjunctive anti-ischaemic pharmacotherapy with ranolazine would improve the prognosis of patients with incomplete revascularisation after percutaneous coronary intervention.

METHODS

We performed this multicentre, randomised, parallel-group, double-blind, placebo-controlled, event-driven trial at 245 centres in 15 countries in Europe, Israel, Russia, and the USA. Patients (aged ≥18 years) with a history of chronic angina with incomplete revascularisation after percutaneous coronary intervention (defined as one or more lesions with ≥50% diameter stenosis in a coronary artery ≥2 mm diameter) were randomly assigned (1:1), via an interactive web-based block randomisation system (block sizes of ten), to receive either twice-daily oral ranolazine 1000 mg or matching placebo. Randomisation was stratified by diabetes history (presence vs absence) and acute coronary syndrome presentation (acute coronary syndrome vs non-acute coronary syndrome). Study investigators, including all research teams, and patients were masked to treatment allocation. The primary endpoint was time to first occurrence of ischaemia-driven revascularisation or ischaemia-driven hospitalisation without revascularisation. Analysis was by intention to treat. This study is registered at ClinicalTrials.gov, number NCT01442038.

FINDINGS

Between Nov 3, 2011, and May 27, 2013, we randomly assigned 2651 patients to receive ranolazine (n=1332) or placebo (n=1319); 2604 (98%) patients comprised the full analysis set. After a median follow-up of 643 days (IQR 575-758), the composite primary endpoint occurred in 345 (26%) patients assigned to ranolazine and 364 (28%) patients assigned to placebo (hazard ratio 0·95, 95% CI 0·82-1·10; p=0·48). Incidence of ischaemia-driven revascularisation and ischaemia-driven hospitalisation did not differ significantly between groups. 189 (14%) patients in the ranolazine group and 137 (11%) patients in the placebo group discontinued study drug because of an adverse event (p=0·04).

INTERPRETATION

Ranolazine did not reduce the composite rate of ischaemia-driven revascularisation or hospitalisation without revascularisation in patients with a history of chronic angina who had incomplete revascularisation after percutaneous coronary intervention. Further studies are warranted to establish whether other treatment could be effective in improving the prognosis of high-risk patients in this population.

FUNDING

Gilead Sciences, Menarini.

[Myocardial infarction due to left main occlusion in a patient with Leriche's syndrome]

We present the case of a 55 year-old male admitted to Malopolskie Centrum Sercowo-Naczyniowe PAKS in Chrzanów with diagnosis of anterior wall myocardial infarction (STEMI). We decided to treat the patient invasively because of presence of chest pain, persistent ST elevation and signs of haemodinamical instability. As it revealed later patient needed combination of PCI of left main/left anterior descending artery with PTA of iliac artery.

Novel biodegradable polymer-coated, paclitaxel-eluting stent inhibits neointimal formation in porcine coronary arteries

BACKGROUND

Biodegradable polymer-coated stents may have positive effects on arterial healing, and reduce the need for prolonged antiplatelet therapy.

AIM

To assess the vascular effects of the biodegradable polymer proposed as a stent coating, as well as to evaluate inhibition of intimal hyperplasia by Biodegradable Polymer-Coated Paclitaxel-Eluting Stents (BP-PES, LUC-Chopin, Balton) in porcine coronary arteries.

METHODS

A total of 19 stents were implanted into the coronary arteries of 13 pigs: seven bare metal stents (BMS), six biodegradable polymer-coated stents (PCS) and six BP-PES. Animals were followed up for 28 days. Additionally, 11 BP-PES were implanted in four pigs which were followed for 90 days. Twenty eight and 90 days after stent implantation, the control coronary angiography was performed. Subsequently, the animals were sacrificed, their hearts were extracted and the coronary arteries were isolated for further histopathological analysis.

RESULTS

After 28 days, BP-PES stents effectively limited neointimal hyperplasia in comparison to the control group (LL = 0.48 +/- 0.06 for BMS vs 0.87 +/- 0.16 for PCS vs 0.15 +/- 0.05 mm for BP-PES; p < 0.05). However, at three months, a 'catch-up' effect in neointimal formation was observed. Histopathology demonstrated favourable safety, with complete endothelialisation and inflammation significantly decreased between one and three months.

CONCLUSIONS

It seems that the biodegradable polymer-coated, paclitaxel-eluting stent examined in the present study is both safe and feasible. This supports the first such study in humans being conducted.

Comparison of thin-strut cobalt-chromium stents and stainless steel stents in a porcine model of neointimal hyperplasia

BACKGROUND

The high radial force and durability of cobalt-chromium alloy enable the construction of low-profile stents with thin struts, which improves their elasticity and may play a key role in reducing the incidence of neointimal hyperplasia as well as allow faster endothelialization. The aim of this study was to compare cobalt-chromium (CoCr) and stainless steel (SS) coronary stents in a pig model of neointimal hyperplasia.

MATERIAL/METHODS

Eighteen stents were implanted into the coronary arteries of nine pigs. Control coronarography was performed 28 days after stent implantation. The animals were then sacrificed, their hearts explanted, and the coronary arteries isolated for further histopathological analysis.

RESULTS

Quantitative coronary angiography and histomorphometric analysis revealed no statistically significant difference between the two groups of stents. However, there was a trend toward greater late lumen loss (p=0.09) and neointimal area in the CoCr stents (p=0.08). The qualitative histopathology of the CoCr stents revealed findings typical of bare metal stents reviewed in the literature and approved for use in clinical practice. No signs of stent thrombosis, necrosis, or fibrin deposits were observed nor signs of excessive inflammatory reaction. Endothelialization was complete within 28 days.

CONCLUSIONS

Despite thinner struts, CoCr stents have no advantage over stainless steel stents in terms of neointimal hyperplasia inhibition. However, their positive safety results together with their high radial strength, low profile, and excellent elasticity can ensure their usage, especially in lesions of complex morphology.

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.

[Primary percutaneous coronary intervention complicated by left anterior descending artery perforation - a case report]

A case of a 72-year-old man with anterior wall myocardial infarction and PCI procedure complicated by coronary artery perforation, is presented. Life-threatening complication was successfully treated percutaneously with graft-stent implantation, and the patient was discharged home five days later in a good condition. Control coronary angiography after 3 months was scheduled.

[Percutaneous closure of a congenital coronary artery fistula with the use of graftstent - a case report]

The congenital coronary fistula is a rare anomaly revealed sometimes during diagnostic procedures. Although it is rarely symptomatic many authors consider elective procedure of closure, because of relatively low risk of procedure. This case demonstrate the percutaneous closure of a congenital coronary artery fistula using graftstent.

Lack of benefit from percutaneous intervention of persistently occluded infarct arteries after the acute phase of myocardial infarction is time independent: insights from Occluded Artery Trial

AIMS

The Occluded Artery Trial (OAT) (n = 2201) showed no benefit for routine percutaneous intervention (PCI) (n = 1101) over medical therapy (MED) (n = 1100) on the combined endpoint of death, myocardial infarction (MI), and class IV heart failure (congestive heart failure) in stable post-MI patients with late occluded infarct-related arteries (IRAs). We evaluated the potential for selective benefit with PCI over MED for patients enrolled early in OAT.

METHODS AND RESULTS

We explored outcomes with PCI over MED in patients randomized to the </=3 calendar days and </=7 calendar days post-MI time windows. Earlier, times to randomization in OAT were associated with higher rates of the combined endpoint (adjusted HR 1.04/day: 99% CI 1.01-1.06; P < 0.001). The 48-month event rates for </=3 days, </=7 days post-MI enrolled patients were similar for PCI vs. MED for the combined and individual endpoints. There was no interaction between time to randomization defined as a continuous (P = 0.55) or categorical variable with a cut-point of 3 days (P = 0.98) or 7 days (P = 0.64) post-MI and treatment effect.

CONCLUSION

Consistent with overall OAT findings, patients enrolled in the </=3 day and </=7 day post-MI time windows derived no benefit with PCI over MED with no interaction between time to randomization and treatment effect. Our findings do not support routine PCI of the occluded IRA in trial-eligible patients even in the earliest 24-72 h time window.

Prospective registry evaluating safety and efficacy of cobalt-chromium stent implantation in patients with de novo coronary lesions

BACKGROUND

Cobalt-chromium (Co-Cr) stents are a new type of endovascular prostheses characterised by better mechanical properties than traditional stainless steel stents.

AIM

To assess the safety and efficacy of percutaneous coronary interventions (PCI) using the new Co-Cr Kos stent (Balton, Poland).

METHODS

A total of 59 patients with coronary artery diseases (76% men, aged 60+/-9 years, diabetes - 16.9%, smoking - 62.7%, 11.8% - acute myocardial infarction) underwent PCI for de novo lesions in native coronary vessels. The patients were followed for 6 months for the occurrence of cardiac events. Quantitative coronary angiography was performed at baseline and after 6 months.

RESULTS

In total, we implanted 62 stents in 59 coronary arteries. The mean diameter of the stents was 3.18+/-0.18 mm, and length - 14.62+/-2.12 mm. During a one-month follow-up period no cardiac events were noted. During a 6-month follow-up no death or new myocardial infarction were recorded. Control angiography was done in 55 (92%) subjects. Repeated target vessel revascularisation due to recurrent angina or in-stent restenosis was required in 10 (17%) patients; however, off-line core evaluation found significant re-narrowing in implanted stents (>50% diameter stenosis) only in 6 cases (10.9%). The mean late vessel lumen loss was 0.55+/-0.6 mm and stenosis 25.2+/-17.9%.

CONCLUSIONS

Implantation of the new Co-Cr Kos stent during PCI is safe and effective.

Local paclitaxel delivery as a treatment of persistent, recurrent in-stent restenosis -- safety assessment

INTRODUCTION

In-stent restenosis still remains a serious clinical problem. Local intramural drug delivery (LDD -- Local Drug Delivery) seems to be an interesting alternative to drug-eluting stents (DES).

AIM

The aim of the study was to assess the safety and effectiveness of local intramural paclitaxel administration in the treatment of recurrent in-stent restenosis (ISR).

METHODS

Five patients were enrolled in the study (3 men, mean age 50+/-7 years) with at least a second episode of ISR within the same stent. Percutaneous coronary angioplasty was performed on a total of 11 vessel segments. Remedy delivery catheters (Boston Scientific) were used for balloon angioplasty. Inflation pressure was calibrated to obtain a balloon/vessel lumen ratio of 1.1:1. Then the pressure was lowered to 3 atmospheres and 100 microg of paclitaxel diluted in 2 ml of 0.9% NaCl was given over 60 seconds under the pressure of 2-3 atmospheres. This dose was used for each 10 mm of lesions. Control coronary angiography was performed six months after the procedure.

RESULTS

In all patients effective target vessel revascularisation was achieved. No adverse events were observed in the periprocedural period or during the 6-month follow-up period. Control angiography revealed ISR in three segments (27.2%) and in-stent late lumen loss of 0.21+/-0.93 mm.

CONCLUSIONS

Local intramural paclitaxel delivery is a safe and effective method of ISR treatment. The optimal paclitaxel dose should be established in further studies.

The new Polish stent Chopin. Assessment of safety and efficacy in the treatment of de-novo coronary lesions using percutaneous angioplasty

AIM

The aim of the present study was to assess the safety and efficacy of percutaneous coronary interventions (PCI) using the new Polish stent "Chopin" (Balton, Poland).

METHODS

The study consisted of experimental and clinical parts. In the experimental phase, the new stent was implanted into 5 pigs and control coronary angiography as well as intracoronary ultrasonography (ICUS) were performed 30 days later. In the clinical phase, 101 patients (57% of males, mean age 55.6+/-10 years) with symptomatic coronary artery disease (CAD) with "de novo" coronary lesions (including 12% of patients with unstable angina and 19% with acute myocardial infarction [MI]) underwent stent implantation. The patients were followed for 6 months for the occurrence of cardiac events. Quantitative coronary angiography was performed at baseline and after 6 months.

RESULTS

In total, we attempted to implant 107 stents, which resulted in the successful deployment of 106 stents to 105 coronary arteries. The mean diameter of the stents was 3.2+/-0.3 mm, and length - 15.4+/-2 mm. During a one month follow-up period no cardiac events were noted. During a 6-month follow-up no death or new MI were recorded. Repeated target vessel revascularisation due to recurrent angina and in-stent restenosis was required in 15 (15.5%) patients. Control coronary angiography was performed in 97 (96%) patients. Of 101 stents, angiographic restenosis (narrowing of dilated lesion by >50% of vessel lumen) was documented in 18.8% of cases. The mean late vessel lumen loss was 0.77+/-0.6 mm, and stenosis - 29.1+/-20%. The restenosis rate was significantly higher in patients with unstable angina rather than in those with stable angina or acute MI.

CONCLUSIONS

Implantation of the new Polish stent "Chopin" during PCI is safe and effective.

[The role of tumor necrosis factor (TNF-alpha) in control of metabolism]

Tumor necrosis factor is multifunctional cytokine involved in various cell functions, such as differentiation, mitosis, angiogenesis, inflammation and immune controls. TNF-alpha plays also an important role in the control of metabolism. Its action on adipocytes includes increasing secretion of triglicerydes and inhibiting insulin action, controlling expression of some genes and modulating free fatty acid and leptin secretion. The review of the current literature on the TNF-alpha role in metabolism is presented in this paper.

[Nitric oxide in physiology and pathology of metabolism]

Adipose tissue generates many bioactive substances, which may exert autocrine, paracrine and endocrine effects. Recent studies have revealed, that one of these substances is nitric oxide. There are observed increased expressions of synthases NO (eNOS and iNOS) in adipose tissue in obesity. It seems that these increased expression NOS is reflected by increased serum concentration of NO in obese subjects. The review of the current literature on role of nitric oxide in physiology and pathology metabolism is presented in this paper.

Serum concentrations of nitric oxide, tumor necrosis factor (TNF)-alpha and TNF soluble receptors in women with overweight and obesity

The aims of the present study was to examine how overweight and obesity affect serum concentrations nitric oxide (NO) metabolites and to determine whether there is association between serum concentrations tumor necrosis factor (TNF)-alpha and TNF soluble receptors (sTNF-R) in subjects with overweight and obesity. The study groups involved 154 women: 102 obese (81 obese with body mass index [BMI] 30 to 40 kg/m2 and 21 obese with BMI > 40 kg/m2), 24 overweight patients, and 28 lean controls. Serum concentrations of NO metabolites and of TNF-alpha and its soluble receptors (sTNF-R1, sTNFR-2) were measured by enzyme-linked immunosorbent assay (ELISA) kits. Serum concentration of insulin was measured by radioimmunoassay (RIA). Plasma glucose, cholesterol, high-density lipoprotein (HDL)-cholesterol, and triglicerydes were determined by enzymatic procedure. Body composition was determined by impedance analysis using Bodystat (Douglas, British Isles). Serum concentrations of NO in the overweight group (35.1 +/- 12.1 micromol/L) and the obese groups with BMI 30 to 40 kg/m2 (32.8 +/- 9.3 micromol/L) and with BMI greater than 40 kg/m2 (33.3 +/- 8.5 micromol/L) were significantly higher when compared to controls (28.2 +/- 8.1 micromol/L): P < .05; P < .01, and P < .01, respectively. There was no difference in levels of NO between the overweight group and both obese groups. Serum concentration of TNF-alpha was also significantly higher in the group with overweight (6.5 +/- 3.1 pg/mL), in the obese group with BMI 30 to 40 kg/m2 (6.8 +/- 3.1 pg/mL), and in the obese group with BMI greater than 40 kg/m2 (7.4 +/- 2.6 pg/mL) when compared to controls (2.9 +/- 2.2 pg/mL): P < .00005; P < .00005, and P < .0000001, respectively. However, serum concentrations of sTNF-R1 and -R2 did not differ significantly between the overweight group, both obese groups, and controls. In conclusion, we observed increased serum concentrations of TNF-alpha and NO in overweight and obese women. It seems that there is an association between serum concentrations of TNF-alpha and NO; however, this relationship depends on the degree of obesity.

[Sibutramine administration in polycystic ovary syndrome treatment]

Obesity is considered important factor contributing development of PCOS. Insulin resistance, low level of serum SHBG and activation of pituitary-adrenal axis plays a major role in pathogenesis and symptoms of PCOS. The achievement of weight loss is an important factor in treatment of PCOS, but difficulties with adherences to the dietary regiment discourage physicians to use this method. In our paper we would like to show the effectiveness of such treatment and pay attention to possibilities of drug facilities in dietary approach in treatment of PCOS coexisting with obesity.

[Evaluation of gastric motility in obesity]

There are conflicting information about differences of gastric emptying rate between lean and obese subjects and lack of information concerning antral motility in both groups. It has been suggested that obesity is associated with an altered rate of gastric emptying, but the results of earlier studies examining gastric emptying rates in obesity have proved inconsistent.

AIM

The purpose of this study was to compare gastric emptying rate and antral motility in obese and lean subjects.

MATERIALS AND METHODS

Gastric antral motility and gastric emptying were measured after consumption of sweet omelette in 2 groups of patients: 10 obese (BMI mean = 33.18) and 10 lean subjects (BMI mean = 22.16) using a scintigraphic technique. Lag phase was assessed by physiologic and mathematic approach. Gastric area was calculated using a computer programme (Diacam-Siemens).

RESULTS

There was no difference in gastric emptying profiles; the mean gastric contents after 2 hours of assessment in obese and lean groups was 69% and 71.6%, respectively. Gastric antral motility parameters such as contraction amplitude and frequency, relaxation and contraction time were not differing between the groups. Only in the 90th minute of the assessment a significant difference in contraction time was found. There were also no differences in gastric area and duration of lag phase. No significant correlation between height, BMI, gastric area and body area was found in both groups.

CONCLUSIONS

There are no differences in the rate of gastric emptying and gastric antral motility between lean and obese subjects. No correlation between BMI, height, body area and gastric area was found. This findings deny the common opinion suggesting that obese people have bigger stomach which empties more rapidly than in lean subjects.

[The influence of three-months weight reducing treatment on eating behavior in obese women]

The effectiveness of weight reducing treatment and maintaining of reduced weight depends in great extend on changing patient's food preferences and it can be achieved through nutritional education and through patients self-esteem. Estimation of changes in eating behaviour in obese women during 3 months of weight reducing treatment carried by doctors, dietician and psychotherapist. 3 months of weight reducing treatment resulted in weight loss of 9.1%. Percentage of animal fats in the meals was significantly reduced and the percentage of complex carbohydrates (fruit and vegetables) and low-fat protein products was increased. The change of a diet structure was accompanied by a symptomatic decrease of preferences of simple carbohydrates and animal fats as well as protein products. 3 months of weight reducing group treatment resulted not only in a reduction of weight but also in modification of eating behaviour. The beneficial change of food preferences which influenced the composition of the consumed meals seems to be good predictor of a long-term effect of the treatment. The most favourable results of the weight reducing treatment can be obtained by group therapy using eating education and psychotherapy.

[Effect of chitosan in complex management of obesity]

The aim of the present study was to verify the effect of chitosan as a possible adjuvant in the complex management of obesity.

METHOD

Fifty obese women (22-59 years, BMI > 30) participated in the study. A six months program consisted of 2-hour meetings with a physician, psychologist and dietitian, in a group of about 20 persons, every two weeks. Low calorie diet (1000 kcal/day), physical activity and behaviour modification were recommended. Supplementation with chitosan was evaluated in a randomized, placebo-controlled, double-blind study. In the chitosan group, participants received ChitininN (Primex Ingredients ASA, Avaldsnes, Norway) i.e. 750 mg pure chitosan per tablet, two tablets three times daily before each main meal. The placebo group received identical placebo tablets.

RESULTS

Significantly higher body weight loss was noted in the chitosan-supplemented group (15.9 kg) than in the placebo group (10.9 kg) Also a greater decrease of systolic and diastolic blood pressure was observed in the chitosan group. There was no difference between the groups in the decrease of LDL and total cholesterol. No adverse effects were noted but the number of drop-outs was higher in the placebo group than in the chitosan group.

CONCLUSION

Chitosan can be used as a valuable and safe adjuvant in long-term dietary treatment of obesity. Chitosan seems to accentuate the reduction of blood pressure associated with weight reduction.

Serum concentrations of TNF-alpha and soluble TNF-alpha receptors in obesity

OBJECTIVE

To study whether weight reducing treatment modulates serum concentration of TNF-alpha and two soluble TNF-alpha receptors in obese subjects.

SUBJECTS AND MEASUREMENTS

Serum concentrations of TNF-alpha and two soluble receptors (sTNF-R1, sTNF-R2), plasma glucose, insulin, total cholesterol, HDL-cholesterol and triglicerides were measured in 27 obese subjects (age 48 +/- 12y, body mass index (BMI): 36 +/- 6 kg/m2) before and after 3 months weight reducing treatment consisted of a diet & 1,000 kcal/day and physical exercises.

RESULTS

The mean loss of weight during 3 months' treatment was 9.3 +/- 3.3 kg. The serum concentration of TNF-alpha decreased after weight loss and at the same time both of the receptors (sTNF-R1,sTNF-R2) increased significantly.

CONCLUSION

The observed decrease of the serum concentration of TNF-alpha and the increase in both TNF soluble receptors after weight reducing treatment in obese subjects, may be a counter-regulation preventing further weight loss.