An Elevated Value of C-Reactive Protein is the Only Predictive Factor of Restenosis after Percutaneous Coronary Intervention

BACKGROUND: The current techniques for percutaneous coronary interventions (PCI) remain limited by restenosis. Recent studies have provided evidence of inflammation playing a role in the pathogenesis of cardiovascular disease. METHODS: Whether inflammatory markers are predictors of subsequent restenosis were prospectively tested in 272 consecutive patients with angiographically proven coronary artery disease. Patients having undergone PCI at Chonnam National University Hospital, between Sept. 1999 and Mar. 2001, were divided into two groups according to the occurrence of restenosis on a follow-up coronary angiogram: Group I were patients with restenosis (n=99, 59.5 +/- 10.8 years, M: F=77: 22) and Group II were those without restenosis (n=173, 58.8 +/- 10.2 years, M: F=131: 42). The IgG seropositivity, cytomegalovirus (CMV) titers, C. pneumoniae, H. pylori and levels of C-reactive protein (CRP) were compared between the two groups. RESULTS: There were no statistical differences in the seropositivity of the CMV IgG C. pneumoniae IgG and H. pylori IgG between the two groups (Groups I vs. II: 100 vs. 100%, 24.7 vs. 25.7% and 62.2 vs. 63.7%, respectively). Of the angiographic parameters, a low Thrombolysis In Myocardial Infarction (TIMI) flow (TIMI 0 or I) was more common in Group I than Group II (p=0.038). The patients with an elevated CRP (> 0.5 mg/dL) were more common in Group I than Group II (57.6 vs. 36.4%, p=0.001), with the CRP values being higher in Group I than Group II (3.3 +/- 5.8 vs. 1.3 +/- 2.6 mg/dL, p=0.001). According to a multiple logistic regression analysis, the CRP was the only predictor of restenosis, with an odds ratio of 2.1169 (95% C.I. 1.2062-3.7154, p=0.009). CONCLUSION: The CRP value is the most important predictor of restenosis after PCI.

The Effects of Radiation Using Ho-166 on Endothelial Function in a Porcine Coronary Model

BACKGROUND AND OBJECTIVES: It has been reported that intracoronary radiation therapy (ICRT) using a Ho-166 coated balloon inhibits restenosis of porcine coronary arteries. However, the consequences of ICRT on coronary artery endothelial function are unknown. The aim of this study is to investigate the effects of ICRT using a Ho-166 balloon on coronary artery endothelial function and vasomotor reactivity. MATERIALS AND METHODS: Female pigs (25-35 kg) were orally premedicated daily with aspirin (100 mg) and ticlopidine (250 mg) for the duration of the study. Under sterile conditions with local anesthesia of the skin provided by 2% lidocaine, an arteriotomy of the left carotid artery was performed, an 8 Fr sheath was inserted, and intraarterial heparin sodium (10,000 IU) was injected. Under fluoroscopic guidance, the coronary artery main branch was selected through an 8 Fr guiding catheter for coronary artery overdilation injury (balloon to artery ratio, 1.3:1) and ICRT. A Ho-166 coated balloon prepared to deliver 20 Gy at a depth of 2 mm from the balloon surface was used for ICRT. The coronary artery main branch in each pig was randomly assigned to either balloon injury (Group I) or balloon injury plus ICRT (Group II). Coronary artery segments were taken from the animals at 0 week (n=8), 4 weeks (n=6) and 8 weeks (n=8) after the intervention. Data in each group denote the relative ratio compared to non-injured coronary artery and are expressed as mean +/- standard error of mean. RESULTS: The degree of KCl-induced contractile response (g) was not different between the two groups at 0 and 4 weeks, but was significantly decreased in group II compared to group I at 8 weeks (I:1.04+/-0.06, II:0.79+/-0.07, p=0.014). In rings precontracted with prostaglandin F 2alpha (PGF 2alpha), the degree of NO-dependent relaxation (%) induced with substance P was significantly decreased in group II compared to group I at 0 week (I:0.93+/-0.33, II:0.47+/-0.31, p=0.03), but the difference between the two groups was not significant at 4 and 8 weeks. In rings precontracted with PGF 2alpha and LAME in the presence of indomethacin, the degree of EDHF-induced relaxation (%) using substance P was not different between the two groups at 0, 4 and 8 weeks; nor was the degree of sodium nitroprusside-induced endothelium independent relaxation (%) in depolarized conditions with PGF 2alpha. CONCLUSION: Endothelial function of the porcine coronary artery is only transiently impaired after ICRT using a Ho-166 coated balloon. Therefore this therapy can be used as an effective method to prevent restenosis after percutaneous coronary intervention.

Percutaneous Coronary Intervention Using Crosswire NT in Total Occlusion of Coronary Artery

BACKGROUND AND OBJECTIVES: Despite marked advances in the design of percutaneous coronary intervention hardware, total occlusion remains associated with a low primary success rate. The most common cause of failure is the inability to cross the lesion with a guidewire. We report the results of a non-randomized single-center investigation using a hydrophilic coated guidewire (Crosswire NT). SUBJECTS AND METHODS: We analyzed the angiographic results of 92 patients (68 males, 24 females, age 58.8+/-9.7 years-old) who underwent angioplasty utilizing Crosswire NT for either total (TIMI flow 1) or subtotal occlusion at Chonnam National University Hospital between December 2000 and July 2001. RESULTS: Clinical diagnoses of the studied subjects revealed 40 cases of acute myocardial infarction, 15 of myocardial infarction, 29 of unstable angina and 8 of stable angina. The primary success rate was 79.3% (73/92), the success rate in total occlusion was 69.0% (40/58), and that of the chronic total occlusion cases among the total occlusion group was 64.3% (18/28). The success rates in the use of Crosswire NT as the first and second choice were 85.7% and 78.8%, respectively. The abrupt occlusive lesions, complex lesions more than type B 2, and presence of collateral circulation were all associated with a lower success rate. Coronary artery perforation occurred in one case. CONCLUSION: The new nitinol hydrophilic wire, Crosswire NT, is a safe and effective tool for the recanalization of total occlusive coronary lesion.

The Effects of Beta-Radiation Using a Holmium-166 Coated Balloon on Neointimal Hyperplasia in a Porcine Coronary Stent Restenosis Model

BACKGROUND AND OBJECTIVES: Brachytherapy is a promising method in the prevention and treatment of coronary stent restenosis. We sought to observe the therapeutic effects of a radioactive balloon loaded with Holmium-166 (166Ho) in a porcine coronary stent restenosis model. Materials and Methods: A radioisotope of (166Ho) was coated on the balloon surface using a polyurethane coating (20 Gy in 0.5 mm depth). Stent overdilation injuries were performed in two coronary arteries in 8 pigs. Four weeks after the stent overdilation injury, radiation therapies were performed using a control balloon dilation in one coronary artery (Group I:n = 8) and a 166Ho-coated balloon in the other coronary artery in each pig (Group II:n = 8). Follow-up coronary angiogram and histopathologic assessment were performed at 4 weeks after the therepy was administered. RESULTS: Laboratory findings did not differ significantly between the pre-treatment baseline and the measurements taken after radiation. On quantitative coronary angiogram, the coronary artery diameters were not significantly different between the two groups before stenting or at 4 and 8 weeks after stenting. On histopathologic analysis, injury score, internal elastic lamina area and lumen area did not differ significantly between the two groups. The neointimal area was 1.78 +/- 0.11 mm2 in group I and 1.36 +/- 0.12 mm2 in group II (p=0.017), and the histopathologic area of stenosis was 35.1 +/- 1.6% in Group I, 27.6 +/- 1.9% in Group II (p=0.005). CONCLUSION: A treatment of beta-radiation in a stented porcine coronary artery using radioactive Ho-166 coated balloon inhibits stent restenosis without any side effects.

An elevated value of C-reactive protein is the only predictive factor of restenosis after percutaneous coronary intervention / 대한내과학회지

BACKGROUND: Current techniques of percutaneous coronary interventions (PCI) remain limited by the restenosis. Recent studies provide evidence that inflammation plays a role in the pathogenesis of cardiovascular disease. METHODS: We prospectively tested whether inflammatory markers are predictors of subsequent restenosis in 272 consecutive patients with angiographically proved coronary artery disease. The patients who underwent PCI at Chonnam National University Hospital between Sep. 1999 and Mar. 2001 were divided into two groups according to the occurrence of restenosis on follow-up coronary angiogram: patients with restenosis (Group I : n=99, 59.5 10.8 years, M : F=77:22) and patients without restenosis (Group II : n=173, 58.8 10.2 years, M : F=131:42). IgG seropositivity and titer of CMV, C. pneumoniae, H. pylori, levels of C-reactive protein (CRP) were compared between two groups. RESULTS: There were no statistical differences in the seropositivity of CMV IgG, C. pneumoniae IgG, H. pylori IgG between two groups (Group I vs. II : 100% vs. 100%, 24.7% vs. 25.7%, 62.2% vs. 63.7% in group I vs. II respectively). Among angiographic parameters, low TIMI flow (TIMI 0 or I) was more common in Group I than in Group II (p=0.038). The patients with elevated CRP (>0.5 mg/dL) were more common in Group I than those in Group II (57.6% vs. 36.4%, p=0.001) and the value of CRP was higher in Group I than in Group II (3.3+/-5.8 mg/dL vs. 1.3+/-2.6 mg/dL, p=0.001). According to multiple logistic regression analysis, CRP was the only predictor of restenosis with odd ratio of 2.1169 (95% C.I. 1.2062-3.7154, p=0.009). CONCLUSION: The value of CRP is the most important predictor of restenosis after PCI.

The role of C-reactive protein on long-term clinical outcomes in patients with acute myocardial infarction / 대한내과학회지

BACKGROUND: The inflammation is an important feature of atherosclerotic lesions, and high level of C-reactive protein (CRP) is known to be associated with increased coronary events and poor prognosis in acute myocardial infarction (AMI). We examined the clinical and angiographic outcomes, success rate of the percutaneous coronary intervention (PCI), and long-term survival rate after PCI according to the level of CRP on admission. METHODS: Two hundred and eight patients with AMI who underwent primary or rescue PCI between 1997 and 1999 at Chonnam National University Hospital were divided into two groups: Group I (n=86, 59.9+/-9.3 years, male 74.4%) with normal CRP ( or = 1.0 mg/dL, mean value=3.50+/-0.93 mg/dL) on admission. RESULTS: There were no significant differences in baseline characteristics between two groups. The incidence of cardiogenic shock was higher in Group II than in Group I (Group I; 3/86, 3.5% vs Group II; 15/122, 12.3%, p=0.026). The coronary angiographic findings were not different between two groups. The ejection fraction and Thrombolysis In Myocardial Infarction flow were improved after PCI in both groups (Group I; 49.4+/-10.5 to 52.0+/-9.0%, 1.52+/-1.13 to 2.77+/-0.55, p<0.001 vs Group II; 50.1+/-11.2 to 52.7+/-9.7, 1.55+/-1.11 to 2.76+/-0.53, p<0.001). Primary success rate of PCI was 94.2% (81/86) in Group I and 95.1% (116/122) in Group II (p=0.776). The survival rates of Group I was 97.7%, 97.7% and 96.5%, and those of Group II was 91.8%, 91.0% and 86.9% at 1, 6 and 12 months, respectively (p=0.043 at 1 month, p=0.040 at 6 months, p=0.018 at 12 months). CONCLUSION: Higher incidence of cardiogenic shock and worse long-term survival after PCI are observed in AMI patients with elevated CRP.

The Role of Fibrinogen, Lipoprotein (a) and C-Reactive Protein in Acute Thrombotic Occlusion after Percutaneous Coronary Intervention

BACKGROUND: Acute thrombotic occlusion after percutaneous coronary intervention (PCI) is a serious complication that provokes acute myocardial infarction, cardiac death or emergent bypass surgery. The role of fibrinogen, C-reactive protein (CRP) and lipoprotein (a) [Lp(a)] in the patients who developed acute thrombotic occlusion after PCI was investigated. METHODS: The patients with acute coronary syndrome who underwent PCI at Chonnam National University Hospital between Jan. 1999 and Jun. 2000 were divided into two groups according to the occurrence of acute thrombotic occlusion: patients with thrombotic occlusion after PCI (Group I; 62.3+/-8.8 years, M:F=19:8) and patients without thrombotic occlusion after PCI (Group II; 59.6+/-10.6 years, M:F=271:95). Clinical and angiographic characteristics, levels of fibrinogen, CRP and Lp(a) were compared between two groups. RESULTS: There were no significant differences in the level of fibrinogen between two groups. The patients with elevated CRP (>0.5mg/dL) were more common in Group I than those in Group II (88.9% vs. 42.3%, p=0.0001) and the value of CRP was higher in Group I than in Group II (4.97+/-5.18 mg/dL vs. 2.27+/-4.23 mg/dL, p=0.002). The patients with high Lp(a) (>30mg/dL) were more prevalent in Group I than those in Group II (44.4% vs 18.6%, p=0.001). There were no significant differences in the risk factors for coronary artery disease, except for diabetes mellitus (Group I : Group II, 40.7% : 16.9%, p=0.002). Thrombolysis in Myocardial Infarction (TIMI) flow of Group I was lower than in Group II (p=0.0001). Multiple regression analysis after the adjustment for age, sex and other cardiovascular risk factors, diabetes mellitus, low TIMI flow, high CRP and Lp(a) were independently associated with the occurrence of acute thrombotic occlusion (p=0.008, 0.0001, 0.031, 0.035, respectively). CONCLUSION:The elevated values of CRP and Lp(a), diabetes mellitus, and low TIMI flow are significant predictive factors for the acute thrombotic occlusion in patients with acute coronary syndrome after PCI.

Clinical Characteristics of Ventricular Tachycardia

BACKGROUND AND OBJECTIVES: There has been few study on the epidemiology and clinical characteristics of ventricular tachycardia (VT) in Korea, although their determination is crucial to the management of VT. The purpose of this study is to determine the clinical characteristics of VT. MATERIALS AND METHODS: Hospital medical records were reviewed on clinical characteristics including demographic feature, underlying disease, and clinical presentation in 66 patients who visited emergency room or out-patient clinic with VT as a primary medical problem from April 1996 to March 1999. The diagnosis of VT was made based on physical signs and ECG recording during the VT and confirmed with electrophysiology study in some cases. RESULTS: There were 42 men and 24 women (mean age: 50.218.9 years). The most common presenting symptom was palpitation (n=30), which was followed by dyspnea (n=18), syncope (n=11), sudden death (n=5). Five patients had no specific symptom. Underlying disease was coronary artery disease in 18 (27.3%) patients, dilated or hypertrophic cardiomyopathy in 11 (16.7%), valvular heart disease in 7 (10.6%), myocarditis in 3 (4.5%), but absent in 20 (30.3%). Idiopathic VT (n=16) usually originated from either right ventricular outflow tract (RVOT, 56.3%) or left ventricular septum (LVS, 31.3%). One-year cardiac mortality rate was 43.8% in coronary artery disease (n=16), 20.0% in cardiomyopathy (n=10), 33.3% in valvular heart disease (n=6), but zero in idiopathic VT (n=19). CONCLUSIONS: These findings suggest that idiopathic VT may be the most common type of VT in Korea and usually originates from either RVOT or LVS. The response to medical therapy is poor in VT with underlying heart disease but excellent in idiopathic VT.

Prediction of head-up tilt test result in patients with syncope of unknown origin / 대한내과학회지

BACKGROUND: Vasovagal syncope has been believed to account for the majority of syncope of unknown origin (SUO). Head-up tilt test (HUT) has been well recognized as a useful test in the evaluation of SUO. The purpose of this study was to determine the predictors of HUT to develop a less time-consuming test protocol and get an information on the pathophysiology of vasovagal syncope. METHODS: Eighty five patients (mean age, 43+/-18 years: 47 men, 38 women) underwent a 80 degree HUT without or with isoproterenol infusion (2 migcrogram/min and 5 migcrogram/min, each for 6 minutes) for unexplained syncope or pre-syncope. Positive HUT was defined as symptomatic hypotension (systolic blood pressure or = 10 seconds) or asystole > or = 3 seconds. The patients were divided into two groups according to the result of the HUT: Group I included 47 patients (M:F=25:22) with positive result, Group II, 38 patients (M:F=22:16) with negative result. RESULTS: Group I patients had more episodes of syncope than Group II (3.1+/-2.5/year vs. 2.0+/-2.1/year, p<0.05). There were no significant differences between the 2 groups in the heart rate (HR), systolic and diastolic blood pressure (BP) at the baseline supine position. BP after tilt was not significantly different between 2 groups except for systolic BP at 6 minutes after tilt, which was significantly lower in Group I than Group II (109.5+/-17.5 mm Hg vs. 118.1+/-18.2 mm Hg, p<0.05).However, HR after tilt was significantly faster in Group I than Group II (81.1+/-15.1/min vs. 74.2+/-14.9/min, p<0.05 at 2 minutes after tilt; 83.7+/-14.4/min vs. 74.6+/-14.7/min, p<0.01 at 4 minutes after tilt). The increase in HR was greater in Group I than Group II (19.9+/-12.6/min vs. 12.8+/-10.6/min, p<0.001). In the prediction of positive HUT with HR rise above 14/min during the early 6 minute of baseline head-up tilting, the specificity, sensitivity, and positive predictive value were 63.2%, 70.2%, and 70.2%, respectively. CONCLUSION: In patients with SUO, positive HUT can be predicted with the early HR response during head-up tilt. This result shows that vasovagal syncope is triggered by exaggerated HR response to the decreased venous return and allow us to develop a less time-consuming HUT protocol.

Long-Term Clinical Follow-up in A Case of Takayasu's Arteritis Involving the Ostium of Left Coronary Artery after Ostioplasty

A 25-year-old woman presented with effort-induced chest pain. Physical examination revealed different blood pressures, 180/100 mmHg in right arm and 100/60 mmHg in left arm. Resting electrocardiogram was normal, but down-slope depression of ST segment more than 3 mm in V3-6, II, III, aVF developed at the stage 1 of treadmill exercise test. Stress Thallium-201 scan showed severe ischemia in the anteroseptal and lateral wall of left ventricle. Diagnostic coronary angiogram showed critical stenosis in the ostium of left main coronary artery. The left subclavian artery was occluded totally with well-developed collateral circulation. The patient underwent ostioplasty of left coronary ostium using pericardial patch, and her symptom improved after surgery. Follow-up coronary angiogram one year after surgery showed patent coronary artery ostium with good flow and myocardial perfusion improved on follow-up Thallium-201 SPECT. She has no major cardiac events during 7-year clinical follow-up.

The Relationship of Infection and Inflammation with Coronary Restenosis after Percutaneous Coronary Interventions

BACKGROUND AND OBJECTIVES: Possible correlations between the serologic status concerning Cytomegalovirus(CMV), Chlamydia pneumoniae (CP), Helicobacter pylori(HP), their related markers of C-reactive protein(CRP), erythrocyte sedimentation rate(ESR), and the restenosis(RS) in patients underwent percutaneous coronary intervention(PCI) were analyzed. Materials and METHODS: The 142 patients(58.010.9 year-old, M;F=116:26) with 189 coronary lesions, who underwent follow-up angiography after PCI, were evaluated. RESULTS: The overall RS rate was 47.1%(89/189), and the RS rate according to clinical diagnosis was 50.6% in acute myocardial infarction(MI), 41.8% in unstable angina(UA), 6.3% in stable angina(SA), and 1.3% in old MI. The values of RS rate in acute MI and UA were higher than those of old MI and SA(p=0.02). Thrombolysis In Myocardial Infarction(TIMI) flow was significantly lower in group with RS than without RS(p=0.039). Seropositivities of CMV, CP, HP were not different between groups with and without RS. Titers of CMV and HP were not different between two groups. Positivity of CRP was 56.3% in group with RS and 30.2% in group without RS(p=0.005). Titers of ESR and CRP were higher in group with RS than without RS(20.322.4 mm/hr, 2.24.5 mg/dL vs. 11.811.6 mm/hr, 0.70.8 mg/dL, p=0.007, p=0.010 respectively). CONCLUSION: RS rate after PCI is higher in patients with acute coronary syndrome and low TIMI flow. Inflammatory markers, such as CRP and ESR, might be associated with the RS after PCI.

The Clinical Effects of Tranilast on Restenosis after Percutaneous Transluminal Coronary Angioplasty

BACKGROUND AND OBJECTIVES: Tranilast is an anti-allergic drug that suppresses the release of cytokines, such as platelet-derived growth factor, transforming growth factor-beta and interleukin-1beta. It has recently become known to be effective in the prevention of restenosis following PTCA (percutaneous transluminal coronary angioplasty). SUBJECTS AND METHODS: One hundred forty two consecutive patients with angina who underwent PTCA between Jan 1999 and Jul 2000 at Chonnam National University Hospital were analyzed prospectively. Thirty patients (Tranilast group:60.8+/-7.7 years, M:F=22:8, 41 lesions) out of 48 who received 300 mg tranilast for 3 months following PTCA and who underwent follow-up CAG (coronary angiogram), were compared with 61 patients (Control group:58.1+/-11.0 years, M:F=52:9, 82 lesions) out of 94, 94 who did not receive tranilast but did undergo follow-up CAG. RESULTS: The restenosis rate per lesion was significantly lower in the Tranilast group than in the Control group on the 6-month follow-up CAG (Tranilast vs. Control group:19.5% vs. 40.2%, p=0.021). The minimal luminal diameter was significantly larger in the Tranilast group as compared to the Control group (1.99+/-0.76 vs. 1.50+/-0.83 mm p=0.002). One patient of the Tranilast group suffered from liver dysfunction and stopped medication. CONCLUSION: The oral administration of tranilast is safe and effective in the prevention of restenosis following PTCA in patients with angina.