Preprocedural C-reactive protein levels and cardiovascular events after coronary stent implantation.

OBJECTIVES: This study assessed the predictive value of preprocedural C-reactive protein (CRP) levels on six-month clinical and angiographic outcome in patients undergoing coronary stent implantation. BACKGROUND: Recent data indicate that low-grade inflammation as detected by elevated CRP serum levels predicts the risk of recurrent coronary events. METHODS: We prospectively investigated the predictive value of preprocedural CRP-levels on restenosis and six-month clinical outcome in 276 patients after coronary stent implantation. The primary combined end point was death due to cardiac causes, myocardial infarction related to the target vessel and repeat intervention of the stented vessel. RESULTS: Grouping patients into tertiles according to preprocedural CRP-levels revealed that, despite identical angiographic and clinical characteristics at baseline and after stent implantation, a primary end point event occurred in 24 (26%) patients of the lowest tertile, in 42 (45.6%) of the middle tertile and in 38 (41.3%) of the highest CRP tertile, p = 0.01. On multivariate analysis, tertiles of CRP levels were independently associated with a higher risk of adverse coronary events (relative risk = 2.0 [1.1 to 3.5], tertile I vs. II and III, p = 0.01) in addition to the minimal lumen diameter after stent (p = 0.04). In addition, restenosis rates were significantly higher in the two upper tertiles compared with CRP levels in the lowest tertile (45.5% vs. 38.3% vs. 18.5%, respectively, p = 0.002). CONCLUSIONS: Low-grade inflammation as evidenced by elevated preprocedural serum CRP-levels is an independent predictor of adverse outcome after coronary stent implantation, suggesting that a systemically detectable inflammatory activity is associated with proliferative responses within successfully implanted stents.     

Prognostic role of preprocedural glucose levels on short‐ and long‐term outcome in patients undergoing percutaneous coronary revascularization

Objectives : We investigated the prognostic role of preprocedural blood glucose levels (BGLs) on short‐ and long‐term outcome in patients undergoing elective percutaneous coronary intervention (PCI). Background : Hyperglycemia and hypoglycemia, with or without pre‐existing diabetes mellitus, are associated with adverse outcome in patients with coronary artery disease. Moreover, neointimal hyperplasia after coronary stent implantation is increased in presence of suboptimal glycemic control. Methods : Preprocedural BGLs were prospectively measured in 572 patients and predefined groups were considered: hypoglycemia ≤ 80 mg/dl; euglycemia 81–109 mg/dl; mild hyperglycemia 110–125 mg/dl; hyperglycemia ≥ 126 mg/dl. Primary end point was represented by the incidence of peri‐procedural myocardial infarction (MI) and secondary end point was the occurrence of major adverse cardiac events (MACE) at follow‐up. Results : Hypoglycemia was associated with an increased risk of peri‐procedural MI (51% vs 30%, 29%, and 37% in euglycemia, mild hyperglycemia and hyperglycemia groups, respectively; P for trend 0.025). After a mean follow‐up of 15 ± 8 months, the occurrence of MACE was 38% in the hypoglycemia group, 12% in the euglycemia group, 14% in the mild hyperglycemia and 22% in the hyperglycemia group (P < 0.001). The incidence of in‐stent restenosis and target vessel revascularization was also higher in patients with abnormal pre‐procedural BGLs (P for trend 0.007 and <0.001, respectively). Multivariate analysis confirmed hypoglycemia as a predictor of early and long‐term unfavorable cardiac prognosis (OR = 2.53, 95% CI 1.09‐5.81, P = 0.029 for peri‐procedural MI; OR = 2.91, 95% CI 1.26–6.69, P = 0.012 for MACE occurrence). Conclusions : We observed a significant association between preprocedural BGLs and adverse short‐and long‐term outcome in patients undergoing elective PCI. Thus, a careful glycemic monitoring should be recommended in all patients undergoing coronary stenting, irrespective of the diabetic status. © 2011 Wiley Periodicals, Inc.     

A Clinical Trial Comparing Primary Stenting of the Infarct-Related Artery With Optimal Primary Angioplasty for Acute Myocardial Infarction: Results From the Florence Randomized Elective Stenting in Acute Coronary Occlusions (FRESCO) Trial

Objectives. This study sought to compare stenting of the primary infarct-related artery (IRA) with optimal primary percutaneous transluminal coronary angioplasty (PTCA) with respect to clinical and angiographic outcomes of patients with an acute myocardial infarction.Background. Early and late restenosis or reocclusion of the IRA after successful primary PTCA significantly contributes to increased patient morbidity and mortality. Coronary stenting results in a lower rate of angiographic and clinical restenosis than standard PTCA in patients with angina and with previously untreated, noncomplex lesions.Methods. After successful primary PTCA, 150 patients were randomly assigned to elective stenting or no further intervention. The primary end point of the trial was a composite end point, defined as death, reinfarction or repeat target vessel revascularization as a consequence of recurrent ischemia within 6 months of randomization. The secondary end point was angiographic evidence of restenosis or reocclusion at 6 months after randomization.Results. Stenting of the IRA was successful in all patients randomized to stent treatment. At 6 months, the incidence of the primary end point was 9% in the stent group and 28% in the PTCA group (p = 0.003); the incidence of restenosis or reocclusion was 17% in the stent group and 43% in the PTCA group (p = 0.001).Conclusions. Primary stenting of the IRA, compared with optimal primary angioplasty, results in a lower rate of major adverse events related to recurrent ischemia and a lower rate of angiographically detected restenosis or reocclusion of the IRA.     

Iron status and clinical outcome in patients with coronary artery disease after coronary stenting

BACKGROUND AND AIM: So far, no studies have assessed whether there is an association between iron status and the incidence of major adverse cardiac events or restenosis after coronary stenting. We conducted this study to investigate whether there is an association between body iron status and clinical outcome in patients with coronary artery disease after coronary stenting. METHODS AND RESULTS: The study included 664 patients with coronary artery disease who underwent coronary stent implantation. The soluble transferring receptor/ferritin ratio (sTfR/ferritin ratio) was used as an index of iron status. Patients were divided into three groups according to the tertiles of sTfR/ferritin ratio: lower tertile (<11.9; n = 221), middle tertile (11.9-27.8; n = 221) and upper tertile (>27.8; n = 222). The combined incidence of major adverse cardiac events (death, myocardial infarction and target vessel revascularization) was the primary end point of the study. Patients in the lower tertile of the sTfR/ferritin ratio presented more often with unstable angina or acute myocardial infarction and had longer lesions and higher grade of stenosis than the patients in the middle or upper tertile of the sTfR/ferritin ratio. Angiographic restenosis at 6-month angiography was also evaluated. The cumulative event rate of composite end point of death, myocardial infarction or target vessel revascularization was 27.6% in patients in the lower tertile, 24.4% in patients in the middle tertile and 28.4% in patients in the upper tertile of the sTfR/ferritin ratio (p = 0.68). Restenosis was found in 27.8% (n = 45) in the lower tertile, 25.8% (n = 42) in the middle tertile and 27.5% (n = 38) in the upper tertile of the sTfR/ferritin ratio (p = 0.90). CONCLUSIONS: Our study showed no association between iron status and the incidence of major adverse cardiac events or angiographic coronary restenosis in patients with coronary artery disease after coronary stenting.     

Hydrocortisone reduces restenosis after stenting of small coronary arteries

Stenting of small coronary arteries has been limited by high rates of restenosis, and restenosis after stenting has chiefly been attributed to inflammatory reactions resulting in cell proliferation and intimal hyperplasia. In order to suppress this inflammatory process, we examined the effects of hydrocortisone, an antiinflammatory agent, on restenosis after stenting in a nonrandomized retrospective registry. The study population consisted of 193 patients treated at two hospitals, who underwent stent implantations in coronary arteries of reference diameter <3 mm between February 1999 and September 2001. Target lesions included complex, restenotic, diabetic, or chronic total lesions and types of implanted stents were Multi-Link, S-series, and gfx stents. Effect of intravenous administration of hydrocortisone (200 mg) before stenting was compared to control patients who did not receive this treatment. There was no significant difference of early outcomes between the hydrocortisone group and the control group. On angiographic follow-up at 6 months after stenting, the rate of restenosis was significantly lower in patients treated with hydrocortisone as compared with control group (22.8% vs 37%, respectively; P < 0.05). The revascularization rate of target lesion at 6 months was also significantly lower in the treated group (16.5% vs 29%, respectively; P < 0.05). These results suggest that preprocedural intravenous administration of hydrocortisone reduces restenosis after stenting of small coronary arteries. Prospectively controlled trials will be necessary to confirm this preventive effect of hydrocortisone on coronary in-stent restenosis.     

The French Randomized Optimal Stenting Trial: a prospective evaluation of provisional stenting guided by coronary velocity reserve and quantitative coronary angiography. F.R.O.S.T. Study Group

OBJECTIVES: We sought to make a prospective comparison of systematic stenting with provisional stenting guided by Doppler measurements of coronary velocity reserve and quantitative coronary angiography. BACKGROUND: Despite the increasing use of stents during percutaneous transluminal coronary angioplasty, it is unclear whether systematic stenting is superior to a strategy of provisional stenting in which stents are placed only in patients with unsatisfactory results or as a bail-out procedure. METHODS: Two hundred fifty-one patients undergoing elective coronary angioplasty were randomly assigned either to provisional stenting (group 1, in which stenting was performed if postangioplasty coronary velocity reserve was <2.2 and/or residual stenosis > or =35% or as bail-out) or to systematic stenting (group 2). The primary end point was the six-month angiographic minimal lumen diameter (MLD). Major adverse cardiac events were secondary end points (death, acute myocardial infarction and target lesion revascularization). RESULTS: Stenting was performed in 48.4% of patients in group 1 and 100% of patients in group 2 (p<0.01). Six months after angioplasty, the MLD did not differ between groups (1.90+/-0.79 mm vs. 1.99+/-0.70 mm, p = 0.39), as was the rate of binary restenosis (27.1% vs. 21.4%, p = 0.37). Among patients with restenosis, 13/32 (40.6%) in group 1 but 100% (25/25) in group 2 had in-stent restenosis (p<0.01). Target lesion revascularization (15.1% vs. 14.4% in groups 1 and 2 respectively, p = 0.89) and major adverse cardiac events (15.1% vs. 16.0%, p = 0.85) were not significantly different. CONCLUSIONS: Systematic stenting does not provide superior angiographic results at six months as compared with provisional stenting.     

A successful stenting of the coarctation of aorta in a patient presented with acute pulmonary edema

We report C-reactive protein (CRP) measured 1 month after stenting was an independent predictor of angiographic restenosis, and patients with both elevated preprocedural CRP and CRP 1 month after stenting had the worst long-term clinical outcomes. Measurement of CRP during follow-up in addition to preprocedural CRP may improve risk stratification after coronary stenting.     

Thoracic radiotherapy in patients with lymphoma and restenosis after coronary stent placement.

OBJECTIVES: The aim of this study was to assess the incidence of restenosis after coronary stenting in patients with lymphoma treated with thoracic radiation. BACKGROUND: Patients with Hodgkin lymphoma treated with thoracic radiation have an increased incidence of coronary artery disease (CAD). The incidence of restenosis after percutaneous coronary interventions is completely unknown. METHODS: This study included 12,626 consecutive patients with CAD treated with coronary stenting during a 10-year period. Within this cohort, three subgroups of patients were assessed: patients with lymphoma and previous thoracic radiation (15 patients), patients with lymphoma without thoracic radiation (7 patients) and patients without lymphoma or previous thoracic radiation (control group; 12,604 patients). Coronary stenting was performed after a median [25th; 75th percentiles] of 8 years [4; 17] after thoracic radiation. The primary end point of the study was restenosis at 6-month coronary angiography. RESULTS: Six-month coronary angiography was performed in 14 patients (93%) in the group with lymphoma and radiation, 6 patients (86%) in the group with lymphoma without radiation and 10,032 patients (80%) in the control group (P = 0.38). Angiographic restenosis was found in 12 patients (85.7%) in the group with lymphoma and radiation, 1 patient (16.7%) in the group with lymphoma without radiation and 2,555 patients (25.5%) in the control group (P < 0.001). Multiple logistic regression identified thoracic radiation as an independent predictor of coronary restenosis (odds ratio 21.7, 95% confidence interval, 4.7-100.9, P < 0.001). CONCLUSIONS: Patients with lymphoma treated with thoracic radiation have an increased risk of restenosis after coronary artery stenting.     

Peripheral CD34+ cells and the risk of in-stent restenosis in patients with coronary heart disease

In-stent restenosis represents the major limitation of percutaneous coronary revascularization. The underlying neointimal hyperplasia mainly consists of smooth muscle cells (SMCs), which can be derived from bone marrow cells. We hypothesized that changes in the peripheral progenitor cell counts after coronary stenting may predict the development of restenosis. We prospectively studied men with atherosclerotic coronary artery disease who had undergone successful elective stenting of solitary target lesions (n = 17). Peripheral blood samples were drawn at baseline (before stenting) and 1 day after stenting. The CD34+ cell count was determined by flow cytometry. Follow-up quantitative coronary angiography was performed after 8.1 +/- 2.6 months. Except for longer primary lesions in patients with angiographic restenosis, no significant differences in patient and lesion characteristics were seen. The rate of restenosis (75% vs 11%, p = 0.015) and the extent of diameter stenosis at follow-up (56.9 +/- 26.9% vs 26.5 +/- 16.5%, p = 0.012) were higher in patients with a postprocedural increase in CD34+ cells than in those with a decrease in CD34+ cells. Postprocedural CD34+ cell counts were increased in patients with restenosis but decreased in those without restenosis (p = 0.002). A robust correlation was seen between the change in CD34+ cells and late lumen loss (r = 0.65, p <0.005). In a multivariate regression model, the change in CD34+ cells, lesion length, and preprocedural minimal lumen diameter independently predicted for late lumen loss. In conclusion, an increase in circulating CD34+ cells after coronary stenting constitutes an independent risk factor predicting in-stent restenosis and may be suggestive of their involvement in neointimal hyperplasia.     

Association between C-reactive protein levels and subsequent cardiac events among patients with stable angina treated with coronary artery stenting

PURPOSE: To investigate the prognostic value of elevated C-reactive protein levels in patients with stable angina who underwent coronary stenting. METHODS: We followed a consecutive series of 1152 patients with stable angina who had undergone coronary stenting. We measured baseline C-reactive protein levels before stenting with a high-sensitivity assay; 651 patients (57%) had elevated C-reactive protein levels (>5 mg/L). The primary endpoint was either death or myocardial infarction within 1 year after the procedure. Angiographic restenosis was defined as a > or =50% diameter stenosis at follow-up angiography. RESULTS: During the 1-year follow-up, 62 (9.5%) of the 651 patients with an elevated C-reactive protein level and 24 (4.8%) of the 501 patients with normal levels died or had a myocardial infarction (P = 0.002). In a multivariate analysis, elevated baseline C-reactive protein levels were associated with almost a twofold increase in the rate of death or myocardial infarction after coronary stenting (hazard ratio = 1.8; 95% confidence interval: 1.1 to 2.9). Most of the difference in the event rates developed within the first 30 days. Baseline C-reactive protein levels did not correlate with restenosis. CONCLUSION: Elevated preprocedural C-reactive protein levels are associated with a less favorable prognosis in patients with stable angina who undergo coronary stenting. The measurement of C-reactive protein levels in these patients may help to identify those who may benefit from a treatment strategy aimed at the attenuation of inflammation.     

Direct stenting compared to conventional stenting in Diabetic Patients Undergoing Elective Angioplasty for Coronary Artery Disease (DECIDE): a multicenter, open label, randomized, controlled efficacy study

Background

Direct stenting (DS) has been shown to be associated with reduced radiation exposure and procedural costs but has a restenosis rate and clinical outcomes similar to conventional stenting (CS) with balloon predilatation. Whether DS confers benefit in diabetic patients, who have been shown to have high restenosis risk after stent implantation, remains unknown.

Methods

In a multicenter randomized trial, diabetic patients undergoing elective coronary stent implantation for a de novo lesion in a native coronary artery between April 2001 and October 2002 were randomized into DS or CS treatment groups. All patients received NirElite stents (SciMed, Boston Scientific, Maple Grove, Minn). They were scheduled to undergo a 6-month angiographic follow-up with quantitative coronary analysis evaluation. The primary end point was a 6-month binary restenosis rate and the secondary end point involved 6-month all-cause mortality, nonfatal acute myocardial infarction, or target vessel revascularization rates.

Results

A total of 128 diabetic patients were randomized into DS or CS treatment groups (n = 64, both groups). The 2 groups were well matched in baseline and lesion characteristics. The procedural success rate was similar (DC vs CS; 98.4% vs 96.9%). Nineteen patients (29.7%) crossed over from DS to CS. Six-month angiographic follow-up showed similar restenosis rates, minimum luminal diameter and late lumen loss. The binary restenosis rate was 43% in DS and 52% in CS groups (P = NS). The 6-month all-cause mortality, nonfatal acute myocardial infarction, or target vessel revascularization rates were also similar in both groups.

Conclusions

Among diabetic patients undergoing elective coronary stent implantation, DS is safe and feasible. However, it is not associated with reduction in restenosis rate or improvement in clinical outcomes when compared with CS.     

Preprocedural serum levels of C-reactive protein predict early complications and late restenosis after coronary angioplasty.

OBJECTIVES: We sought to investigate whether early and late outcome after percutaneous transluminal coronary angioplasty (PTCA) could be predicted by baseline levels of acute-phase reactants. BACKGROUND: Although some risk factors for acute complications and restenosis have been identified, an accurate preprocedural risk stratification of patients undergoing PTCA is still lacking. METHODS: Levels of C-reactive protein (CRP), serum amyloid A protein (SAA) and fibrinogen were measured in 52 stable angina and 69 unstable angina patients undergoing single vessel PTCA. RESULTS: Tertiles of CRP levels (relative risk [RR] = 12.2, p < 0.001), systemic hypertension (RR = 4.3, p = 0.046) and female gender (RR = 4.1, p = 0.033) were the only independent predictors of early adverse events. Intraprocedural and in-hospital complications were observed in 22% of 69 patients with high serum levels (>0.3 mg/dl) of CRP and in none of 52 patients with normal CRP levels (p < 0.001). Tertiles of CRP levels (RR = 6.2, p = 0.001), SAA levels (RR = 6.0, p = 0.011), residual stenosis (RR = 3.2, p = 0.007) and acute gain (RR = 0.3, p = 0.01) were the only independent predictors of clinical restenosis. At one-year follow-up, clinical restenosis developed in 63% of patients with high CRP levels and in 27% of those with normal CRP levels (p < 0.001). CONCLUSIONS: Preprocedural CRP level, an easily measurable marker of acute phase response, is a powerful predictor of both early and late outcome in patients undergoing single vessel PTCA, suggesting that early complications and clinical restenosis are markedly influenced by the preprocedural degree of inflammatory cell activation.     

Effect of abciximab on clinical and angiographic restenosis in patients with non-ST-segment elevation acute coronary syndromes

The ISAR-REACT 2 trial was designed to assess the effect of abciximab in patients with acute coronary syndromes undergoing percutaneous coronary intervention after a 600-mg loading dose of clopidogrel. The aim of the present study was to investigate the impact of abciximab on clinical and angiographic restenosis after coronary stenting in patients with acute coronary syndromes. The angiographic substudy included 1,544 patients from the ISAR-REACT 2 trial randomly assigned to abciximab (771 patients) or placebo (773 patients). All patients were scheduled for routine angiographic follow-up at 6 to 8 months after intervention. The primary end point was incidence of angiographic in-segment binary restenosis. The secondary end point was 1-year incidence of target-lesion revascularization. Binary restenosis was observed in 21.9% of patients in the abciximab group and 24.5% of patients in the placebo group (p=0.29). Percentages of in-stent (29+/-22% vs 33+/-24%; p=0.02) and in-segment (35+/-20% vs 38+/-21%; p=0.04) diameter stenoses were significantly lower in the abciximab group than the placebo group. There was a strong trend toward lower 1-year incidence of target-lesion revascularization in patients treated with abciximab than in patients treated with placebo (13.6% vs 16.8%; p=0.08). In conclusion, in patients with non-ST-segment elevation acute coronary syndromes undergoing early percutaneous coronary intervention with stenting after a 600-mg loading dose of clopidogrel, abciximab therapy may have a slight positive impact on the prevention of restenosis.     

Usefulness of preprocedural soluble CD40 ligand for predicting restenosis after percutaneous coronary intervention in patients with stable coronary artery disease

CD40-CD40 ligand interaction is involved in the inflammatory pathogenesis of atherosclerosis but clinical data about its role in stent restenosis are still limited. We investigated the effect of preprocedural CD40 ligand (sCD40L) on stent restenosis. We enrolled 36 patients (mean age 61.4 +/- 8.5 years) with stable angina who underwent successful stent implantation. Control angiograms were performed in all patients after 6 months. Plasma sCD40L and high-sensitive C-reactive protein levels were measured before stent implantation and at 1 and 6 months after the procedure. Angiographically proven restenosis rate was 27.8%. Plasma sCD40L levels were significantly higher (preprocedural 0.74 +/- 0.79) and more prolonged in patients with stent restenosis compared with patients without stent restenosis (0.02 +/- 0.22 ng/ml, p < 0.001). According to receiver-operator characteristic analysis, sCD40L > 0.41 ng/ml was the best distinguished parameter between patients with and without restenosis. At the multivariate logistic regression analysis, preprocedural sCD40L was an independent predictor (RR 39.4, 95% confidence interval 4.05 to 383.8, p = 0.002) of stent restenosis after adjusting for confounding variables, including diabetes, reference vessel diameter, lesion length, stent diameter, stent length, and baseline high-sensitive C-reactive protein. Sensitivity, specificity, and positive and negative predictive values and likelihood ratio of preprocedural sCD40L levels in stent restenosis were 78%, 92%, 78%, 92%, and 9.37%, respectively. In conclusion, enhanced inflammation of plaque (increased sCD40L) before percutaneous coronary intervention may increase the rate of stent restenosis. Increased preprocedural sCD40L level is an independent predictor of stent restenosis. We can use this marker for the assessment of risk stratification before planning stent implantation.     

A randomized comparison of repeat stenting with balloon angioplasty in patients with in-stent restenosis

OBJECTIVES: This randomized trial compared repeat stenting with balloon angioplasty (BA) in patients with in-stent restenosis (ISR). BACKGROUND: Stent restenosis constitutes a therapeutic challenge. Repeat coronary interventions are currently used in this setting, but the recurrence risk remains high. METHODS: We randomly assigned 450 patients with ISR to elective stent implantation (224 patients) or conventional BA (226 patients). Primary end point was recurrent restenosis rate at six months. Secondary end points included minimal lumen diameter (MLD), prespecified subgroup analyses, and a composite of major adverse events. RESULTS: Procedural success was similar in both groups, but in-hospital complications were more frequent in the balloon group. After the procedure MLD was larger in the stent group (2.77 +/- 0.4 vs. 2.25 +/- 0.5 mm, p < 0.001). At follow-up, MLD was larger after stenting when the in-lesion site was considered (1.69 +/- 0.8 vs. 1.54 +/- 0.7 mm, p = 0.046). However, the binary restenosis rate (38% stent group, 39% balloon group) was similar with the two strategies. One-year event-free survival (follow-up 100%) was also similar in both groups (77% stent vs. 71% balloon, p = 0.19). Nevertheless, in the prespecified subgroup of patients with large vessels (> or =3 mm) the restenosis rate (27% vs. 49%, p = 0.007) and the event-free survival (84% vs. 62%, p = 0.002) were better after repeat stenting. CONCLUSIONS: In patients with ISR, repeat coronary stenting provided better initial angiographic results but failed to improve restenosis rate and clinical outcome when compared with BA. However, in patients with large vessels coronary stenting improved the long-term clinical and angiographic outcome.     

Predictive value of preintervention C-reactive protein on clinical outcome after directional coronary atherectomy followed by stent implantation.

BACKGROUND: Preprocedural C-reactive protein (CRP) serum levels have been shown to predict the recurrence of angina or major adverse cardiac events after percutaneous coronary intervention. Directional coronary atherectomy (DCA), by reducing residual plaque burden and restenosis, has been shown to improve clinical outcome after coronary stenting. Thus, we assessed the influence of preprocedural CRP serum levels on the recurrence of cardiac events after DCA followed by bare metal stent implantation. METHODS: We enrolled 40 consecutive patients (34 males; 61+/-10 years old) with single-vessel disease who were undergoing DCA. In all patients, preprocedural CRP serum levels were measured by an ultrasensitive nephelometric method. The endpoint of the study was defined as the composite incidence of death, myocardial infarction, and recurrence of angina requiring repeat revascularization at 6-month follow-up. RESULTS: CRP serum levels were a significant independent predictor of the composite endpoint at multiple regression analysis [odds ratio=1.69; 95% confidence interval (95% CI)=1.04-2.75; P=.033]. Patients with recurrence of cardiac events had CRP serum levels higher than those of patients not having events on follow-up [3.95 (2.2-5.7) vs. 2 (1.3-3.3); P=.05]. CONCLUSION: In conclusion, our study shows that baseline CRP serum levels predict cardiac events after coronary bare metal stenting despite plaque debulking with directional atherectomy.     

Predictive value of the adipocyte-derived plasma protein adiponectin for restenosis after elective coronary stenting

The purpose of this study was to test the hypothesis that plasma levels of adiponectin can predict angiographic in-stent restenosis after coronary stenting. We prospectively examined adiponectin levels in 127 consecutive patients undergoing elective coronary stenting. Restenosis was defined as more than 50% stenosis at follow-up study by quantitative coronary angiography. There were no significant differences in the clinical characteristics or angiographical findings between the groups with restenosis and no restenosis. The levels of adiponectin did not differ between the restenosis group and the no restenosis group (5.7 +/- 2.8 vs 5.9 +/- 3.6 microg/mL, p = 0.72). The plasma levels of adiponectin were not related with the late loss index after coronary stenting (r = 0.01, p = 0.89). The levels of adiponectin were significantly lower in men than in women (5.5 +/- 3.2 vs 8.8 +/- 3.7 microg/ mL, p < 0.001), and negatively correlated with body mass index (r = -0.21, p = 0.01). We analyzed adiponectin levels in male, female, obese, non-obese, diabetes, and non-diabetes patients, however, there were no significant differences between the restenosis group and no restenosis group. This study has demonstrated that the measurement of adiponectin could not predict angiographic restenosis after elective coronary stenting, whereas the plasma levels of adiponectin were associated with some coronary risk factors in patients with coronary artery disease.     

High P-selectin expression and low CD36 occupancy on circulating platelets are strong predictors of restenosis after coronary stenting in patients with coronary artery disease

Recent studies have shown that circulating platelets play an important role in the development of restenosis early after coronary stent implantation. We investigated P-selectin expression and CD36 blockade on platelets by flow cytometry in 48 consecutive patients who underwent coronary stenting. P-selectin expression was significantly higher 1 day after stenting in patients who had restenosis (n = 15) than in those who had no restenosis (n = 28), and the odds ratio for restenosis in patients with high P-selectin levels (MFI > 6.5) was 11.67 (P < 0.001) as compared with patients who had intermediate and low P-selectin levels. CD36 blockade was assessed with the use of two anti-CD36 antibodies, OKM5 and GS95 (our new anti-CD36 antibody), the binding of which indicates total CD36 amount and free CD36 unoccupied by lipid-related ligands, respectively. Binding of OKM5 to platelets was similar before and after stenting in both groups. CD36 blockade on platelets was seen 1 day after stenting in the non-restenosis group, and the odds ratio for restenosis in patients without CD36 blockade [GS95 binding ratio >0.8 as compared with binding before stenting] on day 1 was 28.60 (P < 0.001). P-selectin expression and unoccupied CD36 on platelets shortly after stenting may be strong predictors of post-stent restenosis.     

Increased circulating platelet-derived microparticles are associated with stent-induced vascular inflammation

Inflammation as well as platelet activation at the site of local vessel-wall injury plays an essential role in the mechanism of restenosis after Percutaneous coronary intervention (PCI). Platelet-derived microparticles (PDMPs) released from activated platelets are thought to play a role in the inflammatory process, possibly interacting with leukocyte integrin Mac-1. We serially measured circulating PDMPs, high-sensitive C-reactive protein (hs-CRP) and activated Mac-1 on the surface of neutrophils in 61 patients undergoing coronary stenting. PDMPs, hs-CRP and Mac-1 increased after coronary stenting in a time-dependent manner with the maximum response at 48 h in coronary sinus blood (PDMPs: 10.3+/-8.9-32.8+/-13.8 U/ml; P<0.001, hs-CRP: 0.27+/-0.23-1.46+/-0.99 mg/dl; P<0.001, activated Mac-1, 134+/-19% relative increase, P<0.001). PDMPs were correlated with hs-CRP (R=0.58, P<0.001) and the relative increase in Mac-1 (R=0.69, P<0.001) 48 h after coronary stenting. Multiple regression analysis showed that each of PDMPs (R=0.40, P<0.05), hs-CRP (R=0.33, P<0.05) and Mac-1 (R=0.48, P<0.01) was an independent predictor of the late lumen loss. Coronary stenting enhanced circulating PDMPs in association with an inflammatory response in the injured vessel wall. PDMPs may be a useful marker for evaluation of stent-induced inflammatory status and a powerful predictor of restenosis equivalent to activated Mac-1.     

Serologic markers of persistent Chlamydia pneumonia infection and long-term prognosis after successful coronary stenting

Background

Previous studies have shown an incremental role of inflammation in late prognosis following coronary stenting (CS). In particular, high preprocedural levels of plasma C-reactive protein (CRP) have been related to increased hazard of late ischemic complications. Persistent Chlamydia pneumoniae (Cp) infection, detected by positive IgA anti-Cp titers, may be associated with this inflammatory process and portend a high risk of late adverse prognosis after CS.

Methods

A total of 483 consecutive patients with either stable or unstable coronary syndromes were followed-up for 1 year after successful CS. The composite of cardiac death, myocardial infarction, rehospitalization for rest-unstable angina, and exertional angina, whichever occurred first, was the clinical end point. Additionally, the rate of in-stent restenosis and progression of coronary artery disease during this period were evaluated. Anti-Cp titers and plasma CRP levels were measured before the procedure.

Results

Positive immunoglobulin A (IgA), but not positive immunoglobulin G (IgG), titers were significantly associated with high plasma CRP levels in patients with unstable coronary syndromes (P = .005), but not in those with stable angina (P = .7). Moreover, positive IgA titers were significantly related to increased risk of both the composite clinical end point (P = .04) and progression of coronary artery disease (P < .001) in patients with unstable coronary syndromes but not in those with stable angina. Neither positive IgA nor positive IgG titers were associated with the rate of in-stent restenosis.

Conclusions

Persistent Cp infection may drive an inflammatory response in the coronary vasculature and portends an adverse late outcome after CS in patients with unstable coronary syndromes.