Assessment of Angiographic Coronary Calcification and Plaque Composition in Virtual Histology Intravascular Ultrasound

Objectives

We assessed the relation between coronary plaque composition and angiographic calcification by using virtual histology intravascular ultrasound (VH‐IVUS).

Background

The plaque vulnerability according to angiographic calcification is unclear.

Methods

Subjects were 140 consecutive patients (145 lesions) undergoing VH‐IVUS before percutaneous coronary intervention. Subjects were divided into 4 groups: no calcification group (n = 27), spotty group (n = 65) that had calcium deposits under 90° in grayscale IVUS, intermediate group (n = 37) had calcium deposits with 90° or more and under 180°, and extensive group (n = 16) had calcium deposits with 180° or more.

Results

The number of VH thin‐cap fibroatheromas in spotty group was significantly larger than no calcification group, intermediate group, and extensive group (0.66 ± 0.71 vs 0.22 ± 0.42 [P < 0.01], 0.32 ± 0.48 [P < 0.05], 0.13 ± 0.34 [P < 0.01], respectively). Spotty group without angiographic calcification had significantly larger %necrotic core than with angiographic calcification (24.5 ± 6.7% vs 19.9 ± 7.2%, P < 0.05). Intermediate group without angiographic calcification had significantly larger necrotic core area than with angiographic calcification (2.5 ± 0.9 mm² vs 1.7 ± 0.9 mm², P < 0.05). Extensive group with angiographic calcification had significantly larger %dense calcium than without angiographic calcification (18.3 ± 4.0% vs 13.4 ± 4.4%, P < 0.05).

Conclusions

Lesions with spotty calcification was highly vulnerable in VH‐IVUS. Spotty or intermediate plaque calcification without angiographic calcification was more vulnerable than those with angiographic calcification. Extensive plaque calcification with angiographic calcification had more dense calcium than those without angiographic calcification.

     

A Randomized Study of Distal Filter Protection Versus Conventional Treatment During Percutaneous Coronary Intervention in Patients With Attenuated Plaque Identified by Intravascular Ultrasound

Objectives

The aim of this study was to evaluate the utility of distal protection during percutaneous coronary intervention (PCI) in patients with acute coronary syndromes at high risk for distal embolization.

红细胞膜胆固醇水平与非ST抬高型急性冠状动脉综合征患者PCI相关冠状动脉慢血流或无复流发生相关

目的探讨红细胞膜胆固醇水平是否与非ST抬高型急性冠状动脉综合征(ACS)患者经皮冠状动脉介入治疗(PCI)相关慢血流或无复流发生密切相关,或许是冠状动脉慢血流或无复流的预测因子。方法选取我院2012年3月至2014年3月收治的295例非ST抬高型ACS患者作为研究对象,年龄57.54±12.16岁,男168例,女127例。应用酶学方法检测红细胞膜胆固醇等生化因子。所有患者术前进行Gensini及Syntax评分后进行标准的冠状动脉造影并行罪犯血管PCI术,术后即刻应用TIMI血流计帧法评估冠状动脉血流速度,并分为血流正常组和慢血流或无复流组。结果与冠状动脉血流正常患者相比,发生PCI相关冠状动脉慢血流或无复流患者红细胞膜胆固醇水平明显升高(142.05±26.37比95.46±22.58,P0.001)。此外,发生慢血流或无复流患者的罪犯相关血管狭窄程度、Gensini积分、Syntax评分、支架长度及数量、中性粒细胞计数及高敏C反应蛋白(hs-CRP)均显著增加(P0.001)。同时发现吸烟和高龄与冠状动脉慢血流或无复流发生密切相关(P0.05)。而低密度脂蛋白胆固醇(LDLC)、高密度脂蛋白胆固醇(HDLC)及总胆固醇(TC)水平在两组间未见明显差异(P0.05)。多因素Logistic回归分析发现,红细胞膜胆固醇水平与罪犯血管狭窄程度、Gensini积分、Syntax积分、hs-CRP及长期吸烟史密切相关(OR分别为0.81、0.609、0.327、5.16及3.17,P0.01),而与总胆固醇水平、LDLC、HDLC无明显相关(OR分别为1.21、1.19及1.08,P0.05)。结论红细胞膜胆固醇水平与非ST抬高型ACS患者PCI相关冠状动脉慢血流或无复流发生密切相关,是非ST抬高型ACS患者PCI相关冠状动脉慢血流或无复流发生的预测因子,其机制与增加斑块内脂质核体积和PCI术中脂质核内含物释放及炎症激活有关。     

应用主动脉内球囊反搏对急性心肌梗死急诊经皮冠状动脉介入术后慢血流现象患者血浆脑钠肽水平及左室功能的影响

目的探讨应用主动脉内球囊反搏(IABP)对急性ST段抬高心肌梗死(STEMI)冠状动脉介入治疗术后慢血流(SCF)患者血浆脑钠肽(BNP)水平及左心室功能的影响。方法分析2008年1月—2010年12月因STEMI行PCI术后SCF现象患者28例资料,采用单双日分组方法将其中14例运用IABP治疗分为治疗组,其余14例为对照组,观察术后1h心电图梗死相关导联ST回落及术前、术后24h、术后1周BNP水平差异;治疗10d后应用彩色超声心动图测量患者左心房内径、左心室内径、左心室射血分数(LVEF);并随访3个月、6个月左心房内径、左心室内径、LVEF变化情况。结果术后1h心电图ST回落50%者对照组组占28.1%,治疗组占61%;术前两组BNP水平无明显差异,术后24h对照组为(365.1±121.6)ng/L,治疗组为(278.4±92.7)ng/L;术后1周对照组为(295.7±65.8)ng/L,治疗组为(203.8±64.7)ng/L,P<0.05。超声心动图测量两组患者恢复期LVEF值差别有明显统计学意义。结论急性STEMI患者直接PCI术后SCF现象患者应用IABP明显影响BNP水平,提高恢复期LVEF值,对心功能可能有一定的改善作用。     

Relationship Between the Urine Flow Rate and Risk of Contrast-Induced Nephropathy After Emergent Percutaneous Coronary Intervention

A low urine flow rate is a marker of acute kidney injury. However, it is unclear whether a high urine flow rate is associated with a reduced risk of contrast-induced nephropathy (CIN) in high-risk patients.We conducted this study to evaluate the predictive value of the urine flow rate for the risk of CIN following emergent percutaneous coronary intervention (PCI).We prospectively examined 308 patients undergoing emergent PCI who provided consent. The predictive value of the 24-hour postprocedural urine flow rate, adjusted by weight (UR/W, mL/kg/h) and divided into quartiles, for the risk of CIN was assessed using multivariate logistic regression analysis.The cumulative incidence of CIN was 24.4%. In particular, CIN was observed in 29.5%, 19.5%, 16.7%, and 32.0% of cases in the UR/W quartile (Q)-1 (≤0.94 mL/kg/h), Q2 (0.94–1.30 mL/kg/h), Q3 (1.30–1.71 mL/kg/h), and Q4 (≥1.71 mL/kg/h), respectively. Moreover, in-hospital death was noted in 7.7%, 3.9%, 5.1%, and 5.3% of patients in Q1, Q2, Q3, and Q4, respectively. After adjusting for potential confounding predictors, multivariate analysis indicated that compared with the moderate urine flow rate quartiles (Q2 + Q3), a high urine flow rate (Q4) (odds ratio [OR], 2.69; 95% confidence interval [CI], 1.27–5.68; P = 0.010) and low urine flow rate (Q1) (OR, 2.23; 95% CI, 1.03–4.82; P = 0.041) were significantly associated with an increased risk of CIN. Moreover, a moderate urine flow rate (0.94–1.71 mL/kg/h) was significantly associated with a decreased risk of mortality.Our data suggest that higher and lower urine flow rates were significantly associated with an increased risk of CIN after emergent PCI, and a moderate urine flow rate (0.94–1.71 mL/kg/h) may be associated with a decreased risk of CIN with a good long-term prognosis after emergent PCI.     

Plaque Characterization to Inform the Prediction and Prevention of Periprocedural Myocardial Infarction During Percutaneous Coronary Intervention: The CANARY Trial (Coronary Assessment by Near-infrared of Atherosclerotic Rupture-prone Yellow)

ObjectivesThis study sought to determine whether pre–percutaneous coronary intervention (PCI) plaque characterization using near-infrared spectroscopy identifies lipid-rich plaques at risk of periprocedural myonecrosis and whether these events may be prevented by the use of a distal protection filter during PCI.BackgroundLipid-rich plaques may be prone to distal embolization and periprocedural myocardial infarction (MI) in patients undergoing PCI.MethodsPatients undergoing stent implantation of a single native coronary lesion were enrolled in a multicenter, prospective trial. Near-infrared spectroscopy and intravascular ultrasound were performed at baseline, and lesions with a maximal lipid core burden index over any 4-mm length (maxLCBI_4mm) ≥600 were randomized to PCI with versus without a distal protection filter. The primary endpoint was periprocedural MI, defined as troponin or a creatine kinase-myocardial band increase to 3 or more times the upper limit of normal.ResultsEighty-five patients were enrolled at 9 U.S. sites. The median (interquartile range) maxLCBI_4mm was 448.4 (274.8 to 654.4) pre-PCI and decreased to 156.0 (75.6 to 312.6) post-PCI (p < 0.0001). Periprocedural MI developed in 21 patients (24.7%). The maxLCBI_4mm was higher in patients with versus without MI (481.5 [425.6 to 679.6] vs. 371.5 [228.9 to 611.6], p = 0.05). Among 31 randomized lesions with maxLCBI_4mm ≥600, there was no difference in the rates of periprocedural MI with versus without the use of a distal protection filter (35.7% vs. 23.5%, respectively; relative risk: 1.52; 95% confidence interval: 0.50 to 4.60, p = 0.69).ConclusionsPlaque characterization by near-infrared spectroscopy identifies lipid-rich lesions with an increased likelihood of periprocedural MI after stent implantation, presumably due to distal embolization. However, in this pilot randomized trial, the use of a distal protection filter did not prevent myonecrosis after PCI of lipid-rich plaques.