Elective Coronary Stent Implantation Research Articles

Increased frequency of CYP2C19 loss-of-function alleles in clopidogrel-treated patients with recurrent cerebral ischemia.

Clopidogrel is used as secondary prevention after cerebral ischaemia. Previous, mainly Asian, studies have shown that genetic variations in CYP2C19 are associated with an increased risk of recurrent stroke in clopidogrel-treated patients. Evidence on the impact of this drug-gene interaction in European neurology patients is currently limited. The aim of this study is to compare the prevalence of CYP2C19 loss-of-function (LoF) alleles in a population with recurrent cerebral ischaemia to two reference groups from the same region. CYP2C19-genotyping (*2 and *3) was performed in clopidogrel-treated patients who presented with a recurrent ischaemic stroke/transient ischaemic attack (TIA). Genotype distributions were compared with two reference groups; a cohort of consecutive patients who underwent elective coronary stent implantation and a cohort of healthy Dutch volunteers. In total, 188 cases with a recurrent ischaemic event were identified, of whom 38 (20.2%) experienced an early recurrent event (24 hours to 90 days after the previous event). Among the total case group, 43.6% of the patients carried at least one CYP2C19 LoF allele, compared with 27.6% and 24.7% in respectively the cardiology and the healthy volunteers reference groups (P < .001 for both comparisons). Among the cases with an early recurrent event, 55.3% of patients were carriers of at least one CYP2C19 LoF allele (P < .0001). In this clopidogrel-treated population with recurrent cerebral ischaemia, the frequency of CYP2C19 LoF alleles was significantly higher than in reference groups, especially in early recurrent events. This study adds to the growing body of evidence that genotype-guided antiplatelet therapy could improve patient outcomes.

Cilostazol combined with P2Y12 receptor inhibitors: A substitute antiplatelet regimen for aspirin-intolerant patients undergoing percutaneous coronary stent implantation.

BackgroundCilostazol combined with P2Y12 receptor inhibitor has been used as a substitute regimen for aspirin‐intolerant patients undergoing percutaneous coronary stent implantation on a small scale. Its exact impact on platelet functions and clinical benefits of aspirin‐intolerant patients is unknown.HypothesisCilostazol combined with P2Y12 receptor inhibitors could be used as a substitute antiplatelet regimen for aspirin‐intolerant patients undergoing percutaneous coronary stent implantation.MethodsIn this multicenter prospective cohort trial, patients undergoing elective percutaneous coronary stent implantation were assigned to the cilostazol group (cilostazol plus P2Y12 receptor inhibitors), based on aspirin intolerance criteria, or the aspirin group (aspirin plus P2Y12 receptor inhibitors). Platelet PAC‐1, CD62p, and vasodilator‐stimulated phosphoprotein phosphorylation (VASP‐P) were detected by flow cytometry. The primary endpoints were major adverse cardiovascular and cerebrovascular events (MACCE) including all‐cause death, acute myocardial infarction, emerging arrhythmia, nonfatal stroke, and heart failure. The secondary endpoints were the Bleeding Academic Research Consortium (BARC) bleeding events.ResultsOne hundred and fifty‐four aspirin‐intolerant percutaneous coronary stent implantation patients and 154 matched aspirin‐tolerant patients from a total of 2059 percutaneous coronary stent implantation patients were enrolled. The relative activation level of PAC‐1, CD62p, and platelet reaction index reflected by the VASP‐P test were similar in the two groups (p > .05). After 12 months of follow‐up, the incidence of all‐cause death was 1.9% in the cilostazol group and 1.3% in the aspirin group (risk ratio [RR], 1.500; 95% confidence interval [CI], 0.254–8.852; p = 1.000); the incidence of acute myocardial infarction was 0.6% in the cilostazol group and 1.3% in the aspirin group (RR, 0.500; 95% CI, 0.046–5.457; p = 1.000). No significant difference was seen in other MACCE events, or in any types of BARC bleeding events.ConclusionsCilostazol combined with P2Y12 inhibitors was not inferior to aspirin‐based standard therapy and could be used as a reasonable substitute antiplatelet regimen for aspirin‐intolerant patients undergoing percutaneous coronary stent implantation, but again with limitations, which required a larger sample and longer follow‐up to confirm its efficacy.

Association between high on-treatment platelet reactivity to clopidogrel and hepatosteatosis in patients undergoing elective stent implantation.

The present study is an investigation of the association between high on-treatment platelet reactivity to clopidogrel (HTPRC) and hepatosteatosis in patients who had elective stent implantation due to coronary artery disease. A total of 190 consecutive patients who underwent an elective coronary stent implantation due to coronary artery disease were prospectively enrolled in the study. Eligible patients were given a 300 mg loading dose of clopidogrel before percutaneous coronary intervention. All of the patients underwent an ultrasound assessment for fatty liver. The patients were divided into 2 groups according to the detection of HTPRC: patients with HTPRC and patients without HTPRC. HTPRC was present in 54.2% (103 of 190 patients) of the total study population. The age and body mass index data were similar between the 2 groups. In all, 111 (58.6%) patients had hepatosteatosis. The HTPRC ratio was statistically higher in female patients (p=0.032). Hepatosteatosis was significantly greater in patients with HTPRC (p<0.001); 84 (81.6%) patients with HTPRC had hepatosteatosis (p=0.001). There was also a statistically significant association between the hepatosteatosis grade and HTPRC (p<0.001). The percentage of HTPRC was greater in patients with ≥grade 2 hepatosteatosis than grade 1 (p<0.001). Logistic regression analysis indicated that hepatosteatosis (odds ratio: 9.403, 95% confidence interval: 4.519-19.566; p<0.001), fasting blood glucose, and hypertension were independent predictors of HTPRC. To the best of our knowledge, this is the first study to demonstrate a relationship between hepatosteatosis and HTPRC.

Impact of CYP2C19 genotype and platelet function on clinical outcome in coronary atherosclerotic heart diseases patients received clopidogrel post percutaneous coronary intervention

Objective: To analyze association of CYP2C19 genotype and platelet function phenotype and their impact on clinical outcomes including bleeding events of coronary artery disease(CAD) patients received clopidogrel post percutaneous coronary intervention(PCI). Methods: Coronary atherosclerotic heart diseases patients underwent elective PCI and coronary stent implantation in Fuwai hospital were prospectively enrolled during May 2012 to April 2013. Patients were assigned into groups by genotype of CYP2C19 (extensive metabolizers, intermediate metabolizers, and poor metabolizers) and phenotype of platelet function (clopidogrel responders, semi-responders, and non-responders). The rates of major adverse cardiovascular events, combined cardiovascular events, and bleeding events were recorded during a at least 12 months follow-up period and compared among above defined groups. The association between genotype or phenotype and clinical outcome was assessed using multivariable Cox regression hazards model. Results: Three hundred and eighty patients received coronary stent implantation and met the inclusion criteria of the study, including 157(41.3%) clopidogrel extensive metabolizers, 176(46.3%) intermediate metabolizers, and 47(12.4%) poor metabolizers according to the genotype grouping; 98(25.8%) were responders to clopidogrel, 149(39.2%) were semi-responders, and 133 (35.0%) were non-responders according to the phenotype grouping. Three hundred and seventy-six patients accomplished follow-up. The highest combined cardiovascular events rate was observed in the poor metabolizers (34.0%(16/47)) as compared to the intermediate metabolizers (19.0%(33/174), P=0.026) and the extensive metabolizers (15.5%(24/155), P=0.005). The highest bleeding events rate was observed in the clopidogrel responders (33.7%(33/98)) as compared to the semi-responders (18.9%(28/149), P=0.008) and non-responders (17.7%(23/130), P=0.008). In multivariable Cox regression analysis, the adjusted risk of cardiovascular death, acute myocardial infarction, stent embolism, target lesion revascularization and angina onset was 2.305 times higher in clopidogrel poor metabolizers than in extensive and semi-metabolizers (95%CI=1.208-4.399, P=0.011). The adjusted HR for bleeding events was 0.540 (95%CI=0.321-0.909, P=0.021) among semi-responders vs. responders, was 0.52 (95%CI=0.301-0.905, P=0.021) among non-responders vs. responders during the 12 months follow-up period. Conclusions: Among CAD patients underwent stenting and clopidogrel treatment, poor CYP2C19 metabolizers group carries a significantly higher risk for combined cardiovascular events than in extensive metabolizers group, while clopidogrel responders patients are at significantly higher risk for bleeding as compared to the semi-responders and non-responders.

On-clopidogrel platelet reactivity as predictor for long-term clinical outcome in patients after planned discontinuation of clopidogrel.

It is unknown whether the known association of high on-treatment platelet reactivity (HTPR) with worse clinical outcome in patients on clopidogrel following coronary stent implantation persists after planned discontinuation of clopidogrel. This study investigated the association of HTPR with major ischaemic events after planned discontinuation of clopidogrel. Consecutive patients undergoing elective coronary stent implantation after loading with clopidogrel 600 mg were followed for up to seven years (n=765). Platelet reactivity was tested on day 1 after coronary intervention. Clopidogrel was continued for six months after implantation of drug-eluting stents and for one month if only bare-metal stents were used. The combined primary endpoint was death of any cause or non-fatal myocardial infarction (MACE). HTPR was found in 217 of 765 patients (28 %). During a median follow-up of 5.7 years, the primary endpoint occurred in 145 subjects after planned discontinuation of clopidogrel. Patients with HTPR showed a higher incidence of MACE after discontinuation of clopidogrel. There was a significant interaction of HTPR and time following discontinuation of clopidogrel beyond one year (p for interaction 0.08). Landmark analyses confirmed that the association of HTPR and MACE was only significant within the first year (HR: 2.93, 95 %-CI 1.13-7.60, p=0.03), but not beyond the first year following discontinuation of clopidogrel (HR: 1.19, 95 %-CI 0.82-1.72, p=0.37). In conclusion, patients with HTPR persist to be at high risk for death or myocardial infarction even following planned discontinuation of clopidogrel. However, this association was only significant for the first year following discontinuation of clopidogrel.

Effect of long-term adherence to clopidogrel on the VASP-PRI after elective coronary stent implantation: a randomized controlled study.

The biological response to clopidogrel is highly variable and a poor responsiveness is associated with major adverse cardiac events. Adherence to therapy is a major cause of poor responsiveness but its impact on long-term platelet inhibition is unknown. The objective of the present study was to evaluate the effect of different programmes monitoring adherence to clopidogrel on platelet reactivity. The study took the form of a monocentric, parallel group, randomized controlled trial. Adults treated with clopidogrel 75mg after elective coronary stenting were randomized into one of three groups: (i) a standard of care group; (ii) a standard of care+adherence electronic monitoring group, in which drug intake was recorded but kept blinded until the study end; or (iii) an integrated care group, with regular feedback on recorded adherence. Clopidogrel response was assessed with the vasodilator-stimulated phosphoprotein-platelet reactivity index (VASP-PRI) at randomization, 3months and 6months. A total of 123 adults were enrolled and randomized. Baseline VASP-PRI was highly variable, with a mean of 48±18.8%. No difference between groups in VASP-PRI was found at 6months (P = 0.761), despite better adherence to clopidogrel in the integrated care group. However, adherence (P = 0.035) and baseline VASP-PRI (P = 0.015) were associated with VASP-PRI at 3months and 6months. The association between adherence and VASP-PRI was lost in patients with baseline VASP-PRI > 50%. Diabetes, CYP2C19*2 carrier status and body mass index were significant predictors of VASP-PRI. The platelet response to clopidogrel during chronic therapy remained highly variable, despite high adherence. Different adherence monitoring programmes did not affect VASP-PRI at 6months. Poor adherence is associated with lower VASP-PRI only in initial good responders to clopidogrel.

Impact of Coronary Novolimus Bioresorbable Scaffold & Novolimus Eluting Stent Implantation on the Acute Inflammatory Response in Diabetic Patients with Coronary Artery Disease

Background: The most effective treatment for coronary arteries revascularization in patients suffering from coronary artery disease (CAD) is percutaneous coronary intervention (PCI). However, when a coronary stent implantation is applied to the affected coronary artery, a mechanical injury to the arterial wall may occur causing a local inflammatory response. As a result, immediately after a PCI, a rapid increase in circulatory inflammatory markers may occur. Objective: This study was undertaken to investigate the effect of Novolimus bioresorbable coronary scaffold and Novolimus eluting stent on the acute inflammatory response after implantation in patients with coronary artery disease. Patients and Methods: Between January and July 2015, 44 type II diabetic patients (29 male; 15 female ) with ischemic heart disease (unstable angina) were randomly assigned into two groups: Group1: Novolimus eluting Bioresorbable coronary scaffold implantation group (20 patients) and Group 2 :Novolimus eluting coronary stent implantation group (24 patients) .They were admitted to AL-Najaf center for cardiac surgery and trans catheter therapy and submitted to elective coronary stent implantation. Blood was drawn from peripheral vein directly before implantation, 12 hrs and 24 hrs after implantation and used to measure IL-8, hs-CRP, MMP-9, cTn-I and VCAM-1 levels by sandwich ELISA method. Results: Inflammatory markers in patients subjected to elective Novolimus eluting bioresorbable coronary scaffold were found to be significantly higher than those subjected to Novolimus eluting stent. Specifically (IL-8) levels were found to be elevated at (12, 24) hrs. Levels of hs-CRP, MMP-9, VCAM-1 were found to be elevated at 24 hrs (p 0.05) at (12, 24) hrs. Conclusions patients treated with BRS showed significantly higher increase in inflammatory mediators as compared to patients treated with Novolimus eluting stent.

A simple and rapid method for identification of lesions at high risk for the no-reflow phenomenon immediately before elective coronary stent implantation.

We aimed to design a rapid and reliable method to identify coronary lesions at high risk for the no-reflow phenomenon before elective coronary stent implantation using integrated backscatter intravascular ultrasound (IB-IVUS). The no-reflow phenomenon occurring during elective percutaneous coronary intervention (PCI) worsens patient prognosis, regardless of whether the phenomenon is transient or persistent. We retrospectively studied 353 coronary lesions to identify factors potentially promoting the no-reflow phenomenon, including lesion location and severity. We also performed component analysis by two- and three-dimensional IB-IVUS before elective stent implantation. The cutoff values of the true lipid volume and estimated lipid volume (lipid area at the minimal lumen diameter site×total stent length) for the no-reflow phenomenon were determined by receiver operating curve analysis. Type C lesions, regardless of location and a thrombolysis in myocardial flow grade of 0, were risk factors for the no-reflow phenomenon during PCI. The estimated lipid volume was significantly correlated with the true lipid volume (R 2=0.778, p<0.0001). The cutoff value of the estimated lipid volume for the no-reflow phenomenon was 132.6mm3 (area under the curve=0.719), and the predictive value was equivalent to that of the true lipid volume. Lesions with an estimated lipid volume of ≥132.6mm3 had a significantly higher risk of the no-reflow phenomenon during elective stent implantation (odds ratio, 4.35; 95% confidence interval, 1.67-12.7; p=0.0024). The simple and rapid measurement of the estimated lipid volume immediately before stenting during PCI constitutes a reliable predictor of lesions at high risk for the no-reflow phenomenon.

Preprocedural statin therapy, inflammation, and myocardial injury in low‐risk stable coronary artery disease patients submitted to coronary stent implantation

Evaluate if statin therapy prior to elective coronary stent implantation (CSI) reduces the plasma levels of markers of inflammation and of myocardial necrosis in low-risk stable coronary artery disease patients (CAD). The elevation of markers of inflammation and of myocardial necrosis after percutaneous coronary intervention may interfere with clinical outcome. Among acute coronary syndrome patients, statins improve clinical outcomes when used before CSI-mostly due to reduction of CSI-related myocardial infarction. However, little is known concerning preprocedural statin therapy on the reduction of these markers in stable patients at low-risk. In this prospective, observational study, 100 patients (n = 50 on statin therapy vs. n = 50 not on statin) with stable coronary artery disease underwent elective CSI. Inflammatory (C-reactive protein [CRP], interleukin [IL]-6, tumor necrosis factor-α and matrix metalloproteinase-9) and myocardial necrosis markers (troponin I and CK-MB) were determined before and 24 hr after CSI. All patients presented a significant increase of CRP and IL-6 after CSI. However, this increase was attenuated in patients on statin therapy prior to CSI than those without statin therapy: 75% vs. 150% (P < 0.001) and 192% vs. 300% (P < 0.01). The other pro-inflammatory markers were similar for both sets of patients. Troponin I and CK-MB did not change after CSI regardless of previous statin therapy or not. Pretreatment with statin attenuates procedural inflammation, denoted by markedly lower increases of CRP and IL-6 levels, in elective CSI within low-risk stable CAD patients. Periprocedural myocardial injury was irrelevant and was not affected by preprocedural statin therapy in this population.

The platelet-to-lymphocyte ratio as a predictor of all-cause mortality in patients with coronary artery disease undergoing elective percutaneous coronary intervention and stent implantation

BackgroundThere is no data regarding the association between the platelet-to-lymphocyte ratio (PLR) and long-term mortality in patients with stable coronary artery disease (SCAD). The aim of this study is to evaluate the utility of the pre-procedural PLR for predicting long-term, all-cause mortality in patients with SCAD undergoing percutaneous coronary intervention (PCI) and stent implantation. MethodsWe analyzed a total of 2959 consecutive patients with SCAD who underwent PCI (balloon angioplasty followed by stent implantation or direct stenting) between July 2006 and December 2011 at our institution. The patients were stratified into tertiles according to their admission PLR. The association between the PLR value and the outcomes was assessed using Cox proportional regression analysis after adjusting for clinical angiographic and laboratory data. ResultsDuring median follow-up of 1124days, mortality was highest in patients with PLR within the 3rd tertile as compared to the 2nd and the 1st tertile (11.0% vs 8.7% vs. 9.6%, respectively, p=0.03). PLR remained associated with mortality in multivariable analysis including clinical variables, ejection fraction and angiographic parameters HR (per 10 units increase)=1.02 [95%CI,1.01÷1.04, p=0.006]. After adjustment for the eGFR and hemoglobin levels, PLR was however no longer significantly associated with mortality. ConclusionPLR has potential predictive value in patients with SCAD, which has not been reported previously, but statistical significance disappears after adjusting for estimated glomerular filtration rate (eGFR) and hemoglobin levels as a potential confounding variable.

Intrinsic platelet reactivity before start with clopidogrel as predictor for on-clopidogrel platelet function and long-term clinical outcome

High on-clopidogrel platelet reactivity is associated with worse clinical outcome. Previous data suggest that intrinsic platelet reactivity before initiation of clopidogrel contributes significantly to on-clopidogrel platelet reactivity. It is unknown whether intrinsic reactivity can sufficiently predict on-clopidogrel reactivity and therefore identify patients with insufficient response to clopidogrel before initiation of treatment and at risk for worse clinical outcome. This analysis included 765 consecutive patients undergoing elective coronary stent implantation. Platelet reactivity was assessed by light transmission aggregometry (5 µM ADP) before administration of clopidogrel 600mg and after intake of first maintenance dose of clopidogrel on day 1 following coronary stenting. Patients were followed for up to seven years. The combined primary endpoint was death of any cause or non-fatal myocardial infarction. Intrinsic and on-clopidogrel platelet reactivity were significant correlated (r=0.31; p < 0.001). Among all tested clinical and genetic factors including the cytochrome P450 2C19*2 polymorphism, intrinsic platelet reactivity was the strongest predictor for on-clopidogrel platelet reactivity. However, intrinsic platelet reactivity could only explain 8 % of variability of on-clopidogrel platelet function. Only on-treatment platelet reactivity was predictive for long-term clinical outcome (HR 1.47, 95 % CI 1.05-2.05; p = 0.02) whereas intrinsic platelet reactivity was not (HR 1.03, 95 % CI 0.74-1.43; p = 0.86). In conclusion, intrinsic platelet reactivity before initiation of clopidogrel is the strongest predictor of early on-clopidogrel platelet reactivity but can only explain a minor proportion of its variability and is not significantly associated with clinical outcome. Thus, baseline testing cannot substitute on-clopidogrel platelet function testing.

Colocalization of thin-cap fibroatheroma and spotty calcification is a powerful predictor of procedure-related myocardial injury after elective coronary stent implantation

Percutaneous coronary intervention (PCI)-related cardiac enzyme elevation is an independent risk factor for adverse clinical outcomes, but preprocedural predictors of this complication have not been established. This study evaluated the morphological characteristics of culprit lesions by frequency-domain optical coherence tomography (FD-OCT), and examined their predictive value for procedure-related myocardial injury in patients undergoing elective PCI. Sixty-eight patients treated by FD-OCT-guided elective PCI were studied. On the basis of the presence or absence of postprocedural plasma cardiac troponin T (cTnT) elevation, patients were divided into elevation (cTnT-E, n=25) and nonelevation (cTnT-nonE, n=43) groups. FD-OCT examinations of culprit lesions were performed before and after stent implantation, and tissue characteristics were evaluated within a 10-mm-long segment of each lesion. Clinical parameters were similar between the two groups. Stent length was significantly longer in the cTnT-E group than in the cTnT-nonE group. On baseline OCT images, thin-cap fibroatheroma and calcium deposition were more frequently observed within culprit segments of the cTnT-E group compared with the cTnT-nonE group (32.0 vs. 11.6%, P=0.043, and 72.0 vs. 46.5%, P=0.039, respectively). In addition, colocalization of these two findings was a powerful predictor of PCI-related cTnT elevation (odds ratio 8.40, 95% confidence interval 1.65-52.78, P<0.01). Further, the predictive value of this colocalization was enhanced when the analysis included only spotty calcification (odds ratio 21.00, 95% confidence interval 2.65-454.22, P=0.003). FD-OCT examination showed that colocalization of thin-cap fibroatheroma and spotty calcification was a powerful predictor of PCI-related cTnT elevation. FD-OCT is useful for stratifying risk during PCI to avoid procedure-related complications.

Impact of Albuminuria on the Incidence of Periprocedural Myocardial Injury in Patients Undergoing Elective Coronary Stent Implantation

Albuminuria has traditionally been associated with an elevated risk of cardiovascular events. However, few studies have examined the potential relation between albuminuria and periprocedural risk in percutaneous coronary intervention (PCI). The aim of this study was to evaluate the impact of albuminuria on the incidence of periprocedural myocardial injury (PMI) in patients who underwent PCI. The study included 252 consecutive patients who underwent PCI. The incidence of PMI was significantly higher in patients with albuminuria than in those with normoalbuminuria (31.9% vs 43.3%, respectively, p= 0.014). Even after adjustment for confounders, the presence of albuminuria predicted PMI (odds ratio 2.07, 95% confidence interval 1.08 to 3.97, p= 0.029). Furthermore, patients with albuminuria and preserved estimated glomerular filtration rate had a 4.2-fold higher risk for PMI than did patients with normoalbuminuria and preserved estimated glomerular filtration rate. In conclusion, albuminuria was a strong predictor of PMI in patients who underwent PCI.

Prognostic significance of high sensitivity C-reactive protein in patients with angina pectoris underwent percutaneous coronary intervention

C-reactive protein is an easily measurable acute phase reactant synthesized by hepatocytes in response to pro-inflammatory cytokines. Elevated CRP has been identified as a strong predictor of prognosis in healthy individuals, in patients with stable angina, in unstable angina and in patients after acute myocardial infarction. The prognostic significance of high sensitivity CRP level in percutaneous coronary intervention is unclear. We prospectively studied 41 patients with chronic stable angina (28 patients) and unstable angina (13 patients) who underwent elective coronary stenting. All patients had normal troponin level before the procedure. Blood samples for hs_CRP were obtained before the procedure, 24 h after the procedure. Patients followed up at 1 month and after 2 years. Mean hs_CRP before the procedure in all patients underwent PCI was 2.38 ± 2.21 μg/ml. The mean hs_CRP 24 h post procedure was 7.43 ± 10.6 μg/ml. There was significant difference between pre procedural hs-CRP and 24 h post procedural ( P = 0.007) At follow up period (1 month), No major adverse cardiac events (MACE) have occurred. However, 24 patients complain of chest pain. There was no significant correlation between either pre-procedural, or 24 h post procedure hs-CRP and chest pain ( r = 0.13, 0.2, respectively). At follow up period (2 years), 7 cases missed; MACE has occurred in 13 patients. Mechanical disruption of atherosclerotic plaque during elective coronary stent implantation causes a systemic inflammatory response. Measuring of hs-CRP either pre-procedural or post procedural in low risk patients is not useful for predicting of either early or late cardiovascular events.

Remote Ischemic Preconditioning Reduces Myocardial Injury in Patients Undergoing Coronary Stent Implantation

BackgroundMyocardial necrosis occurs frequently in elective percutaneous coronary intervention (PCI) and is associated with subsequent major adverse cardiovascular events (MACEs). This study assessed the protective effect of remote ischemic preconditioning (RIPC) in patients undergoing successful drug-eluting stent implantation with normal baseline troponin values. MethodsWe analyzed 205 participants with normal baseline troponin values undergoing successful coronary stent implantation. Subjects were randomized to 2 groups: The RIPC group (n = 101), whose members received RIPC (created by three 5-minute inflations of a pneumatic medical tourniquet cuff to 200 mm Hg around the upper arm, interspersed with 5-minute intervals of reperfusion) < 2 hours before the PCI procedure, and the control group (n = 104). ResultsThe primary outcomes were high sensitive cardiac troponin I (hscTnI) levels and incidence of myocardial infarction (MI 4a, defined as hscTnI > 0.20 ng/mL) at 16 hours after the PCI procedure. The median hscTnI at 16 hours after PCI was lower in the RIPC group compared with the unpreconditioned, control group (0.11 vs 0.21 ng/mL; P < 0.01). The incidence of MI 4a was lower in the RIPC group compared with the control group (39% vs 54%, P < 0.05). Index of renal function showed no difference between the 2 groups at 16 hours after PCI (P > 0.05). ConclusionRIPC reduced post-PCI TnI release and incidence of MI 4a in patients undergoing elective coronary stent implantation.

Prognostic significance of high sensitivity C-reactive protein in patients with angina pectoris underwent percutaneous coronary intervention

Background C-reactive protein is an easily measurable acute phase reactant synthesized by hepatocytes in response to pro-inflammatory cytokines. Elevated CRP has been identified as a strong predictor of prognosis in healthy individuals, in patients with stable angina, in unstable angina and in patients after acute myocardial infarction. The prognostic significance of high sensitivity CRP level in percutaneous coronary intervention is unclear. Methods We prospectively studied 41 patients with chronic stable angina (28 patients) and unstable angina (13 patients) who underwent elective coronary stenting. All patients had normal troponin level before the procedure. Blood samples for hs-CRP were obtained before the procedure, 24h after the procedure. Patients followed up at 1 month and after 2 years. Results Mean hs_CRP before the procedure in all patients underwent PCI was 2.38±2.21μg/ml. The mean hs_CRP 24h post procedure was 7.43±10.6μg/ml .There was significant difference between pre procedural hs-CRP and 24h post procedural ( P =0.007). At follow up period (1 month), no major adverse cardiac events (MACE) have occurred. However, 24 patients complain of chest pain. There was no significant correlation between either pre-procedural, or 24h post procedure hs-CRP and chest pain ( r =0.13, 0.2, respectively). At follow up period (2 years), 7 cases missed; MACE has occurred in 13 patients. Conclusion Mechanical disruption of atherosclerotic plaque during elective coronary stent implantation causes a systemic inflammatory response. Measuring of hs-CRP either pre-procedural or post procedural in low risk patients is not useful for predicting of either early or late cardiovascular events.

Relation of Nickel Allergy with in-Stent Restenosis in Patients Treated with Cobalt Chromium Stents

BackgroundIn-stent restenosis (ISR) is the major limitation of percutaneous coronary stenting procedure. The elements like nickel, chromate and molybdenum are known to cause contact allergy. Hypersensitivity reaction, against these metal ions, may be one of the reasons of ISR. Cobalt chromium coronary stents, which are increasingly being used in percutaneous coronary interventions, have more nickel amount than the stainless steel stents.ObjectiveWe aimed to investigate the association between nickel hypersensitivity reaction and ISR in patients treated with cobalt chromium coronary stents.MethodsEpicutaneous patch tests for nickel were applied to 31 patients who had undergone elective cobalt chromium coronary stent implantation and had ISR in control angiogram. Thirty patients, without ISR, were included as the control group. Patch test results and other clinical variables were compared.ResultsThere was no statistically significant difference of the mean age, sex, body mass index, rate of hypercholesterolemia, diabetes, hypertension and smoking between the patients with and without ISR. All other lesion characteristics were similar in the 2 groups. According to the patch test results, 7 patients had nickel contact allergy. All of these patients were in the ISR group, which was statistically significant (p<0.006).ConclusionPatients treated with cobalt chromium coronary stents and had ISR were found to have significantly more nickel allergy than the control group. Nickel allergy may play role in restenosis pathophysiology.

The relevance of P2Y12-receptor gene variation for the outcome of clopidogrel-treated patients undergoing elective coronary stent implantation: A clinical follow-up

The relevance of P2Y12-receptor gene variation for the outcome of clopidogrel-treated patients undergoing elective coronary stent implantation: A clinical follow-up -

Female platelets are hard to control.

Female platelets are hard to control.

Effect of gender difference on platelet reactivity

BackgroundPrevious studies have suggested that women do not accrue equal therapeutic benefit from antiplatelet medication as compared with men. The physiological mechanism and clinical implications behind this gender disparity have yet to be established.MethodsOn-treatment platelet reactivity was determined in 717 men and 234 women on dual antiplatelet therapy, undergoing elective coronary stent implantation. Platelet function testing was performed using arachidonic acid and adenosine diphosphate-induced light transmittance aggregometry (LTA) and the VerifyNow P2Y12 and Aspirin assays. Also the incidence of all-cause death, non-fatal acute myocardial infarction, stent thrombosis and ischaemic stroke was evaluated.ResultsWomen had higher baseline platelet counts than men. Women exhibited a higher magnitude of on-aspirin platelet reactivity using LTA, but not using the VerifyNow Aspirin assay. The magnitude of on-clopidogrel platelet reactivity was significantly higher in women as compared with men with both tests used. The cut-off value to identify patients at risk as well as the incidence of clinical endpoints was similar between women and men (16/234[6.8%] vs. 62/717[8.6%], p = 0.38).ConclusionAlthough the magnitude of platelet reactivity was higher in women, the absolute difference between genders was small and both the cut-off value to identify patients at risk and the incidence of the composite endpoint were similar between genders. Thus, it is unlikely that the difference in platelet reactivity accounts for a worse prognosis in women.