Residual angina pectoris after percutaneous coronary intervention for acute coronary syndrome

Fractional flow reserve (FFR) is an important diagnostic tool to guide decision-making in the cardiac catheterisation laboratory and for evaluation of percutaneous coronary interventions (PCI). Especially the pressure pullback curve at maximal hyperaemia is convincing in demonstrating the exact location and severity of a coronary stenosis. This pressure pullback curve can also demonstrate the presence of diffuse disease. We present a case in which FFR with pressure pullback curve seven days after a PCI, which did not result in complete symptom relief, indicates the presence of diffuse disease. Based on this result the patient was treated medically.     

Impact of obstructive sleep apnea on the occurrence of restenosis after elective percutaneous coronary intervention in ischemic heart disease

Rationale

There is growing evidence that obstructive sleep apnea is associated with coronary artery disease. However, there are no data on the course of coronary stenosis after percutaneous coronary intervention in patients with obstructive sleep apnea.

Objectives

To determine whether sleep apnea is associated with increased late lumen loss and restenosis after percutaneous coronary intervention.

Methods

78 patients with coronary artery disease who underwent elective percutaneous coronary intervention were divided in 2 groups: 43 patients with an apnea hypopnea – Index < 10/h (group I) and 35 pt. with obstructive sleep apnea and an AHI > 10/h (group II). Late lumen loss, a marker of restenosis, was determined using quantitative coronary angiography after 6.9 ± 3.1 months.

Main results

Angiographic restenosis (>50% luminal diameter), was present in 6 (14%) of group I and in 9 (25%) of group II (p = 0.11). Late lumen loss was significant higher in pt. with an AHI > 10/h (0.7 ± 0.69 mm vs. 0.38 ± 0.37 mm, p = 0.01). Among these 35 patients, 21(60%) used their CPAP devices regularly. There was a marginally lower late lumen loss in treated patients, nevertheless, this difference did not reach statistical significance (0.57 ± 0.47 mm vs. 0.99 ± 0.86 mm, p = 0.08). There was no difference in late lumen loss between treated patients and the group I (p = 0.206).

Conclusion

In summary, patients with OSA and coronary artery disease have a higher degree of late lumen loss, which is a marker of restenosis and vessel remodeling after elective percutaneous intervention.     

Cyclic ST-segment elevation after primary percutaneous coronary intervention

Netherlands Heart Journal -     

高龄急性冠脉综合征患者经皮冠状动脉支架治疗的临床观察

目的:评价高龄急性冠脉综合征(acute coronary syndrome,ACS)患者行经皮冠状动脉介入(percutaneous coronary intervention,PCI)治疗的安全性和有效性.方法:对比分析108例高龄ACS患者(≥75岁组)和176例非高龄ACS患者(<75岁组)冠状动脉造 影特征、PCI治疗的情况,即刻手术成功率、住院及随访期间主要心血管事件的发生情况.结果:高龄组与非高龄组比较,冠状动脉病变多为多支病变(72.2%比31.8%,P<001);2组手术即刻成功率无明显差异;2组术后达到心肌梗塞溶检(thrombolysis in myocardial infarction,TIMI)3级血流患者比率无明显差异;高龄组手术操作时间非高龄组长[(68.4±25.4)min比(53.7±21.8)min,P<0.05];高龄组住院期间、随访期间累计总的主要心血管事件发生率明显高于非高龄组.结论:对高龄ACS患者行PCI治疗是比较安全而有效的再灌注手段.     

An initial case of suppressed restenosis with nuclear factor‐kappa B decoy transfection after percutaneous coronary intervention

Background

Nuclear factor‐kappa B (NF‐κB) is well known for playing a pivotal role in restenosis after percutaneous coronary intervention (PCI).

Methods and Results

This is the first report to demonstrate an effect of NF‐κB decoy oligodeoxynucleotides (ODN) to prevent restenosis after PCI after a 4‐year observation using a coronary computed tomography (CT) scan. We showed that the decoy treatment suppressed neointimal formation after stent implantation compared to that in the same artery.

Conclusion

Thus, for the first time, we demonstrate the clinical usefulness of the CT scan to reveal the effects of NF‐κB decoy ODN transfer after PCI. Copyright © 2008 John Wiley & Sons, Ltd.     

Neointimal hyperplasia and endothelial function after percutaneous coronary intervention

Percutaneous coronary revascularisation has become much safer and efficacious since its introduction more than 25 years ago. Currently, the need for surgical backup is small and the rate of late complications is lower than 10%. Further improvements are being studied, especially directed towards more biocompatible stents, using pharmacological principles with wider therapeutic windows and enhancing the vascular healing response/reendothelialisation. This article reviews several activities within the ICIN theme group `Vessel Wall''.     

血浆miRNA-1、miRNA-21对冠心病合并糖尿病患者PCI术后支架内再狭窄的影响

目的：观察血浆miRNA-1、miRNA-21在冠心病（CHD）与无冠脉病变患者中含量的差异,探讨其在CHD合并糖尿病（DM）患者的经皮冠状动脉介入治疗（PCI）后发生支架内再狭窄（ISR）与非支架内再狭窄（NISR）患者的含量差异及其对ISR的预测价值。方法：入选CHD支架置入术后患者（CHD组,n=187）、无冠脉病变患者（对照组,n=195）。根据指南,将对照组分为正常对照组（n=150）、单纯DM组（n=45）;将CHD组分为单纯CHD组（n=119）、CHD合并DM组（n=68）,又将CHD组分为ISR组（n=48）及NISR组（n=139）;再将ISR组分为单纯ISR组（n=26）和ISR合并DM组（n=22）。收集各组患者血浆,提取总miRNA,检测miRNA-1、miRNA-21含量并分析各组的含量差异。结果：与对照组比较,CHD组miRNA-1、miRNA-21含量均升高（P<0.05）;与NISR组比较,ISR组miRNA-1、miRNA-21含量均升高（P<0.05）。与单纯CHD组比较,CHD合并DM组ISR发生率明显升高;而且与单纯ISR组比较,ISR合并DM组miRNA-21含量升高（P<0.05）,而单纯ISR组与ISR合并DM组miRNA-1含量无明显差异（P<0.05）。Logistics分析表明,与CHD患者相关危险因素DM、miRNA-1、miRNA-21的OR值分别为2.132,3.066,1.924（P<0.05,P<0.01）;ISR患者相关危险因素DM、miRNA-21的OR值分别为3.091,5.654（P<0.05,P<0.01）;CHD合并DM患者PCI术后发生ISR相关危险因素miRNA-21的OR值为9.148（P<0.01）。ROC曲线评价表明,miRNA-1,miRNA-21与CHD患者发生ISR的AUC分别为0.854,0.857;miRNA 21与CHD合并DM患者发生ISR的AUC为0.783。结论：血浆miRNA-1、miRNA-21对诊断CHD患者支架置入术后ISR发生有重要临床意义,miRNA-21对诊断CHD合并DM患者支架置入术后ISR发生尤其有重要临床意义。     

Genetic impact of TNF-beta on risk factors for coronary atherosclerosis

BACKGROUND: Inflammatory processes are considered to play an important role in the development of coronary atherosclerosis. The proinflammatory cytokine, tumor necrosis factor beta (TNF-beta), is thought to contribute to the pathogenesis of atherosclerosis. STUDY DESIGN: In this clinical study, the influence of genetic variants of TNF-beta (c.7G>A, IVS1+90G>A, C13R, T60N) on major coronary risk factors, including gender, smoking, history of cardiovascular diseases, biochemical data (inflammatory markers, factors of lipid metabolism, coagulation/fibrinolysis balance), and angiographically-proven coronary state, was investigated in 176 European Caucasian probands (130 males, mean age: 51.9 +/- 8.9 y). RESULTS: The most frequent combinations of the polymorphisms investigated were significantly associated with four of the coronary risk factors evaluated: hypertension, body mass index, the common inflammatory marker TNF-alpha (mRNA expression), and fibrinogen (p < 0.05). However, on testing the impact of the genetic background on the incidence of coronary stenosis in this sample of European Caucasians, no significant influence of these polymorphisms (stepwise binary logistic regression analysis) could be proven. These findings emphasise a distinct influence of TNF-beta polymorphisms on important modulators of the development of coronary atherosclerosis, but exclude its genetic background, investigated in this study as an independent coronary risk factor.     

Optimal duration of dual antiplatelet therapy after percutaneous coronary intervention or after acute coronary syndrome

To prevent recurrent ischaemic events, dual antiplatelet therapy (DAPT) is the standard of care after percutaneous coronary intervention and in the treatment of acute coronary syndrome. Recent evidence supports an adjusted DAPT duration in selected patients.The current paper aims to encourage cardiologists to actively search for patients benefiting from either shorter or prolonged duration DAPT and proposes an algorithm to identify patients who are likely to benefit from such an alternative strategy.Individualised DAPT duration should be considered in high-risk anatomic and/or clinical subgroups or in patients at increased haemorrhagic risk with low ischaemic risk. Both thrombotic and haemorrhagic risk should be assessed in all patients. In patients undergoing percutaneous coronary intervention, the interventional cardiologist could advise on the minimal duration of DAPT. However, in contrast to the minimum duration of DAPT for stent thrombosis prevention, longer duration DAPT is aimed at prevention of spontaneous myocardial infarction, and not at stent thrombosis, and thus the key to success is to treat the patient’s overall thrombotic risk.The advice on the duration of DAPT must be documented in the patient’s records and communicated with the treating physician and general practitioner. DAPT duration should be reassessed at least on a yearly basis.     

P2Y12 blocker monotherapy after percutaneous coronary intervention

For secondary prevention of coronary artery disease (CAD) antiplatelet therapy is essential. For patients undergoing a percutaneous coronary intervention (PCI) temporary dual antiplatelet platelet therapy (DAPT: aspirin combined with a P2Y12 blocker) is mandatory, but leads to more bleeding than single antiplatelet therapy with aspirin. Therefore, to reduce bleeding after a PCI the duration of DAPT is usually kept as short as clinically acceptable; thereafter aspirin monotherapy is administered. Another option to reduce bleeding is to discontinue aspirin at the time of DAPT cessation and thereafter to administer P2Y12 blocker monotherapy. To date, five randomised trials have been published comparing DAPT with P2Y12 blocker monotherapy in 32,181 stented patients. Also two meta-analyses addressing this novel therapy have been presented. P2Y12 blocker monotherapy showed a 50–60% reduction in major bleeding when compared to DAPT without a significant increase in ischaemic outcomes, including stent thrombosis. This survey reviews the findings in the current literature concerning P2Y12 blocker monotherapy after PCI.     

IABP在急性心肌梗死介入治疗中的应用进展

主动脉内球囊反搏术(intra aortic balloon counterpulsation,IABP)目前已被广泛的应用于心血管领域,尤其在急性心肌梗死介入治疗中的应用进展最快,它主要通过反搏球囊的充放气,增加主动脉内舒张压,增加冠状动脉供血,降低收缩压,减少左心室后负荷.主动脉内球囊反搏术的临床应用,明显增加了冠状动脉介入治疗的安全性,使越来越多的高危复杂冠心病,特别是急性心肌梗死(acute myocardial infarction,AMI)患者,得到有效的介入性诊治,降低了患者的住院死亡率,改善了患者的长期预后.     

Effect of statins on coronary blood flow after percutaneous coronary intervention in patients with stable coronary artery disease

Aims

Statins have favourable effects on the vascular system. However, few data are available regarding the effect of these drugs on patients undergoing percutaneous coronary intervention (PCI). We sought to determine the impact of prior statin use on coronary blood flow after PCI in patients with stable coronary artery disease (CAD) by using the corrected thrombolysis in myocardial infarction (TIMI) frame count (CTFC).

Methods

A total of 80 consecutive eligible patients (mean age: 60 ± 7 years, 65?% male) with the diagnosis of stable CAD who were hospitalised for elective PCI were retrospectively enrolled in our study. The study population was divided into two groups according to statin use at least 6 months before PCI. Group 1 comprised of 51 patients (67?% male; mean age: 58 ± 4 years) taking statins and group 2 comprised of 29 patients (62?% male; mean age: 60 ± 3 years) not taking statins. PCI was applied to de novo type A lesions. CTFC was calculated for the treated vessels at baseline and after PCI.

Results

The two groups had similar characteristics in terms of age, sex, concomitant medications, lesion characteristics, pre-procedural CTFC, lipid parameters, and risk factors for CAD. Post-PCI CTFC (16 ± 3 vs. 22 ± 5, p = 0.01) and hs-CRP (2.1 ± 0.7 mg/l vs. 6.1 ± 2 mg/l, p = 0.01) in patients receiving statins before PCI were significantly lower than in patients without statin therapy. Multiple logistic regression analysis showed that statin pre-treatment (OR 2.5, 95?% CI 1.2 to 3.8, p < 0.001) and hs-CRP level (OR 1.8, 95?% CI 1.2 to 2.4, p = 0.001) were independent predictors of post-PCI CTFC.

Conclusions

In patients with stable CAD undergoing PCI, receipt of long-term statin therapy was associated with improvement in epicardial perfusion after PCI.

     

Genetic risk factors for melanoma

The genetic basis of melanoma is complex and has both inherited and acquired components. Different genomic approaches have been used to identify a number of inherited risk factors, which can be stratified by penetrance and prevalence. Rare high-penetrance factors are expressed in familial clustering of melanoma and include mutations in CDKN2A (encoding p16^INK4a and p14^ARF) and CDK4. These genes are involved in cell-cycle arrest and melanocyte senescence and are nearly invariably targeted by somatic mutations during melanoma progression. Low-penetrance factors are common in the general population and include single-nucleotide polymorphisms in or near MC1R, ASIP, TYR and TYRP1. These genes are major determinants of hair and skin pigmentation, but their role in melanoma development remains unclear. This review describes the efforts that have led to the current understanding of melanoma susceptibility as the result of complex gene–gene and gene–environment interactions. Despite the significant advances, the majority of familial cases remain unaccounted for.     

Genetic determinants of risk factors for cardiovascular disease in a population from rural Brazil

We investigate the heritability of and pleiotropic relationships among triglycerides and cholesterol lipoproteins that have long been considered traditional risk factors for cardiovascular disease. Quantitative lipid and lipoprotein phenotypes were determined for a cross-sectional sample of a community in Jequitinhonha valley in northern Minas Gerais state, Brazil. The sample consisted primarily of subsistence farmers. Two hundred sixty-nine individuals (128 males and 141 females), ages 18-88 years, were sampled. Eighty-eight percent (n = 252) of the individuals belonged to a single pedigree, which was highly informative for genetic analysis. Data on anthropometrics, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), total cholesterol, and triglycerides were available for each study participant. Extended pedigrees were constructed using the pedigree-based data management software PedSys. Univariate and bivariate variance-components analyses, adjusted by sex and age, were performed using the SOLAR software package. Heritability estimates of lipids and lipoproteins ranged from 29% to 45% (p < 0.008). The highest heritability estimated was for HDL-C (h2 = 44.8%, p < 0.0001), and this was the only trait that exhibited a significant household effect (c2 = 25%). Strong positive genetic correlations were found between triglycerides and very low density lipoprotein (VLDL) (rhog = 0.998) and between total cholesterol and LDL-C (rhog = 0.948). Significant genetic correlations were also found between triglycerides and LDL-C, between total cholesterol and VLDL, and between total cholesterol and LDL-C and VLDL, and finally between LDL and VLDL. There was a significant negative environmental correlation between triglycerides and HDL-C (rhoe = -0.406).