Predictors of Technical Failure in Transradial Coronary Angiography and Intervention.

Transradial access for coronary angiography and intervention is preferred over the femoral approach but can be technically challenging. Identification of predictors of transradial access failure is important, especially in the context of acute coronary syndromes. We therefore retrospectively analyzed 13,095 consecutive patients (66 ± 12 years, 64% male) in whom transradial access was attempted for coronary angiography or intervention to identify predictors of transradial access failure. Angiograms and patient files were systematically reviewed to analyze patient characteristics associated with failure. Transradial access failure rate was 6.8% (909 of 13,095). Patients with transradial access failure were more frequently female (9.5% vs 5.5%; p <0.001), significantly older (68 ± 12 vs 66 ± 12 years, p <0.001), and had a smaller body surface area (1.89 ± 0.21 vs 1.94 ± 0.2 m2; p <0.001). Transradial failure was not significantly more frequent in ST-elevation myocardial infarction versus other patients (8.1% vs 6.9%, p = 0.195). After multivariable adjustment, only female sex (odds ratio [OR] 1.44, p <0.001), higher patient age (OR 1.01/year, p = 0.002), and lower height (OR 0.98/cm, p = 0.004) independently predicted transradial access failure. In conclusion, female sex, higher age, and smaller height independently predict transradial access failure in coronary angiography and intervention. Failure rate in ST-elevation myocardial infarction is not significantly increased.

Plasma levels of sRANKL and OPG are associated with atherogenic cytokines in patients with intermediate cardiovascular risk.

Osteoprotegerin (OPG) and receptor activator of nuclear factor-κB ligand (RANKL) are regulators of bone remodeling, but are also considered to play important roles in coronary artery disease (CAD). This study evaluated potential associations of soluble (s) RANKL and OPG with atherosclerosis-relevant cytokines. Blood was collected from 414 individuals who presented to our hospital with intermediate likelihood for CAD for further examination. Plasma concentrations of total sRANKL, OPG, and 20 cytokines were measured using sandwich-type enzyme-linked immunoassays (ELISAs; OPG and sRANKL) and Luminex laser-based fluorescence analysis and correlated with each other. The plasma levels of interferon-γ (IFN-γ) and the T-helper cell 2 cytokines interleukin-4 (IL-4) and IL-13 showed a positive correlation with sRANKL. The association with sRANKL levels was negative for IFN-γ-induced protein-10 (IP-10) and monocyte chemotactic protein-1 (MCP-1). The strongest independent association with sRANKL in multivariable analyses was found for IFN-γ (positive) and IP-10 (negative), while IL-13 showed a positive and independent association with OPG plasma levels. OPG and sRANKL plasma levels correlate strongly and independently with specific circulating atherosclerosis-related cytokines in patients with intermediate cardiovascular risk.

Influence of Cardiovascular Risk Factors on the Prevalence of Coronary Atherosclerosis in Patients with Angiographically Normal Coronary Arteries.

RATIONALE AND OBJECTIVES: Cardiovascular (CV) disease is predominately influenced by CV risk factors and coronary computed tomography angiography (CTA) is capable of detecting early-stage coronary artery disease. We sought to determine the influence of CV risk factors on the prevalence of nonobstructive atherosclerosis in patients with normal-appearing coronary arteries in invasive coronary angiography (ICA). MATERIALS AND METHODS: In this retrospective analysis, we included 60 consecutive symptomatic patients, having undergone ICA and coronary CTA. Coronary dual source CTA was performed using electrocardiogram-triggered retrospective gated image acquisition at 40%-70% of RR interval (tube voltage 100-120 kV, tube current time product 320-440 mAs, 60 mL contrast, and flow rate 6 mL/s). RESULTS: Out of 60 patients (32 men, mean age 61 ± 11 years) with a normal coronary artery appearance in ICA, 45 (75%) patients showed atherosclerotic plaque in CTA. Plaque was present in 14 of 60 (23%) left main, 41 of 60 (68%) left anterior descending, 21 of 60 (35%) circumflex coronary arteries, and 24 of 60 (40%) right coronary arteries. More than 15% of all coronary artery segments showed detectable plaques. Interobserver agreement ranged from good to very good on a per-patient, per-vessel, and per-segment level. Patients with presence of plaque were significantly older (P = 0.005) and showed higher incidence of arterial hypertension (P = 0.019) as compared to individuals without coronary plaque in dual source computed tomography. CONCLUSIONS: The prevalence of coronary atherosclerosis by CTA is substantial in symptomatic patients with normal invasive coronary angiogram. Hypertension and older age significantly influence the prevalence of atherosclerotic plaque and highlight the importance of risk-modifying therapy.

Bioresorbable vascular scaffold thrombosis in a consecutive cohort of 550 patients.

OBJECTIVE: To determine the rate of bioresorbable vascular scaffold (BVS) thrombosis in a large, real-world population. BACKGROUND: There is some concern about device thrombosis after percutaneous coronary intervention (PCI) using BVS. No data have been published for PCI using both BVS and metal stents. METHODS: A cohort of 550 consecutive patients who underwent PCI for stable chest pain or acute coronary syndromes with implantation of at least one BVS (Absorb, Abbott Vascular) was systematically followed up by telephone interview and review of medical charts. Data on device thrombosis were retrospectively analyzed in relationship to clinical and angiographic characteristics. RESULTS: Follow-up was achieved in 533 patients (97%, median follow-up 233 days). A total of 964 BVS were implanted in 645 vessels. In addition, 234 metal stents were implanted in 149 patients, including "hybrid intervention" with the combined use of BVS and stents in the same artery in 122 patients. Documented were 15 definite, 1 probable, and 8 possible cases of device thrombosis (rate of definite/probable device thrombosis: 3.0%). Of these, 6 definite and 6 possible thromboses could be unambiguously attributed to BVS (1.1%), whereas a total of 11 definite, 1 probable, and 8 possible thromboses were potentially attributable to BVS (2.3%). Definite device thrombosis occurred in 7/122 patients with "hybrid intervention" (5.7%). CONCLUSIONS: In a large real-world cohort treated with BVS, the rate of scaffold thrombosis was higher than published for randomized trials. A high rate of thrombosis was observed after combined implantation of BVS and stents within one vessel. © 2016 Wiley Periodicals, Inc.

Platelet CD40 contributes to enhanced monocyte chemoattractant protein 1 levels in patients with resistant hypertension.

BACKGROUND: Growing evidence shows that inflammation plays a pivotal role in the pathophysiology of essential hypertension (EH). Although it is acknowledged that target organ damage involves an inflammatory response, most work has focused on the role of macrophages. However, recently, platelets were identified as inducing inflammation partly by releasing cytokines. The goal of our study was to evaluate the role of platelets as inflammatory cells in the pathogenesis of EH. METHODS: Thirty-nine patients with EH and 30 healthy normotensive controls have been examined. Expression of platelet CD40 was measured by flow cytometry. Serum levels of monocyte chemoattractant protein 1 (MCP-1) and sCD40L were measured via a multiplexing assay. In in vitro experiments, activated platelets were cocultured with human umbilical vein endothelial cells (HUVEC) in the presence and absence of anti-CD154 antibodies. MCP-1 in the supernatants was measured by EIA. RESULTS: Essential hypertension patients showed significantly enhanced MCP-1 levels with highest levels in EH patients with microalbuminuria. EH patients showed increased expression of platelet CD40. In the cell coculture model, activated platelets were able to significantly induce MCP-1 release from HUVEC in a CD40L-dependent manner. EH patients showed elevated sCD40L levels with a positive correlation with MCP-1 levels. CONCLUSIONS: Platelets can contribute to enhanced MCP-1 levels in EH. MCP-1 is markedly elevated in serum of EH patients with highest levels in patients with microalbuminuria, one early sign of renal target organ damage. Further studies are required to test whether MCP-1 blocking or antiplatelet strategies may represent new therapeutic options in preventing hypertensive target organ damage.

Contrast volume reduction using third generation dual source computed tomography for the evaluation of patients prior to transcatheter aortic valve implantation.

OBJECTIVES: Chronic renal failure is common in patients referred for transcatheter aortic valve implantation (TAVI). CT angiography is recommended and provides crucial information prior to TAVI. We evaluated the feasibility of a reduced contrast volume protocol for pre-procedural CT imaging. METHODS: Forty consecutive patients were examined with prospectively ECG-triggered high-pitch spiral acquisition using a novel third-generation dual-source CT system; 38 ml contrast agent was used. Image quality was graded on a visual scale (1-4). Contrast attenuation was measured at the level of the aortic root and at the iliac bifurcation. RESULTS: Mean patient age was 82 ± 6 years (23 males; 58 %). Mean attenuation/average image quality was 285 ± 60 HU/1.5 at the aortic annulus compared to 289 ± 74 HU/1.8 at the iliac bifurcation (p = 0.77/p = 0.29). Mean estimated effective radiation dose was 2.9 ± 0.3 mSv. A repeat acquisition was necessary in one patient due to image quality. Out of the 35 patients who underwent TAVI, 31 (89 %) patients had no or mild aortic regurgitation. Thirty-two (91 %) patients were discharged successfully. CONCLUSION: Pre-procedural CTA with a total of 38 ml contrast volume is feasible and clinically useful, using third-generation dual-source CT, allowing comprehensive imaging for procedural success. KEY POINTS: • Reduction of contrast agent volume is crucial in patients with chronic renal failure. • Novel third-generation computed tomography helps to reduce contrast agent volume. • Pre-procedural CT allows comprehensive imaging for procedural success before heart valve implantation. • A low-contrast CT protocol is feasible for pre-procedural TAVI planning.

CT-based analysis of pericoronary adipose tissue density: Relation to cardiovascular risk factors and epicardial adipose tissue volume.

BACKGROUND: Pericoronary adipose tissue (PCAT) can promote atherosclerosis. Metabolically active and inactive PCAT may display different CT densities. However, CT density could be influenced by partial volume effects and image interpolation. OBJECTIVE: To investigate whether PCAT density values in CT displays differences that are larger than those attributable to interpolation and partial volume effects, which would manifest themselves through the relationship between PCAT density and distance from the contrast-enhanced coronary lumen. METHODS: PCAT density analysis was performed (417 non-atherosclerotic segments, 63 patients) using dual-source CT with a threshold-based measurement method. Changes in PCAT density values depending on distance from the contrast-enhanced coronary lumen and the influence of cardiovascular risk profile were analyzed. RESULTS: Mean PCAT density was -78.1 ± 5.6 HU. PCAT density decreased from proximal to distal segments in the LAD (-78.0 ± 7.3 vs. -82.4 ± 7.7 HU; p < 0.001). PCAT density was higher close to the lumen compared to more peripheral locations (-76.0 ± 6.7 vs. -78.5 ± 5.4 HU; p < 0.001). Decreasing PCAT density was significantly associated with higher epicardial adipose tissue (EAT) volume and body mass index. There was a trend of lower PCAT values with a family history of coronary artery disease. CONCLUSION: CT-measured attenuation of PCAT is influenced by EAT volume and body mass index. A decrease of PCAT attenuation with increasing distance from the vessel and from proximal to distal segments may suggest variations in CT density of PCAT due to partial volume effects and image interpolation rather than solely due to differences in tissue composition or metabolic activity.

Comparison of Exo-Seal(®) and Angio-Seal (®) for arterial puncture site closure: A randomized, multicenter, single-blind trial.

BACKGROUND: The use of extravascular femoral closure devices in patients undergoing coronary angiography/intervention has not been sufficiently evaluated. We sought to define the impact of an extravascular polyglycolic acid (PGA) plug for the closure of a femoral access site in patients undergoing coronary angiography and/or percutaneous coronary intervention. METHODS: In this prospective, single-blind, multicenter trial we randomly assigned 319 patients to vessel closure with Angio-Seal(®) or Exo-Seal(®). We hypothesized that the use of an extravascular closure device is not inferior to an anchor/plug-mediated device regarding the occurrence of the composite primary endpoint: hematoma > 5 cm, significant groin bleeding (TIMI major bleed), false aneurysm, and device failure. RESULTS: There was no significant difference in patient baseline characteristics or procedural results. After 24 h the primary endpoint occurred in nine patients (5.6 %) in the Angio-Seal(®) group and in 13 patients (8.2 %) inthe Exo-Seal(®) group (p = 0.38). Hematoma > 5 cm was noted in three patients (1.9 %) receiving Angio-Seal(®) vs. two patients (1.3 %) receiving Exo-Seal(®) (p = 0.99). In one patient (0.6 %) of the Exo-Seal(®) group, TIMI major bleeding occurred, requiring transfusion (p = 0.49). There were four (2.5 %) false aneurysms found in patients treated with Angio-Seal(®) and two (1.3 %) in patients treated with Exo-Seal(®) (p = 0.68). There was a trend for a higher incidence of device failure in the Exo-Seal(®) group (1.2 vs. 5.2 %, p = 0.06). At telephone interview after 30 days, there was no significant difference found regarding the events readmission with surgery of puncture site, infection, bleeding, hematoma, or pain. CONCLUSION: In the present study, there were no significant differences found regarding the occurrence of hematoma > 5 cm, major bleeding, false aneurysm, and device failure between Angio-Seal(®) and Exo-Seal(®) 24 h after device implantation.

Comparison of intracoronary versus intravenous administration of adenosine for measurement of coronary fractional flow reserve.

BACKGROUND: Measurement of fractional flow reserve (FFR) constitutes the current gold standard to evaluate the hemodynamic significance of coronary stenoses. Limited data validate the intracoronary application of adenosine against standard intravenous infusion. We systematically compared FFR measurements during intracoronary and intravenous application of adenosine about agreement and reproducibility. METHODS AND RESULTS: We included 114 patients with an intermediate degree of stenosis in coronary angiography. Two FFR measurements were performed during intracoronary bolus injection (40 µg for the right and 80 µg for the left coronary artery, FFRic), and 2 FFR measurements during continuous intravenous infusion of adenosine (140 µg/kg per minute, FFRiv). FFR value, the time to reach FFR and patient discomfort (on a subjective scale from 0 for no symptoms to 5 for maximal discomfort) were recorded for each measurement. Mean time to FFR was 100 ± 27 s for continuous intravenous infusion versus 23 ± 14 s for intracoronary bolus administration of adenosine (P < 0.001). Reported discomfort after intracoronary application was significantly lower compared with intravenous adenosine (subjective scale > 0 in 35.1% versus 87.7% of the patients; P < 0.001). Correlation between FFRiv and FFRic was extremely close (r = 0.99; P < 0.001) with no systematic bias in Bland-Altman analysis (bias 0.002 [confidence interval, -0.001 to 0.005]) and low intermethod variability (1.56%). Intramethod variability was not different between intravenous and intracoronary administration (1.47% versus 1.33%; P=0.5). CONCLUSIONS: Intracoronary bolus injection of adenosine (40 µg for the right and 80 µg for the left coronary artery) yields identical FFR results compared with intravenous infusion (140 µg/kg per minute), while requiring less time and offering superior patient comfort.

Association of systemic inflammation with epicardial fat and coronary artery calcification.

BACKGROUND: Increased epicardial fat volume (EFV) has been shown to be associated with coronary atherosclerosis. While it is postulated to be an independent risk factor, a possible mechanism is local or systemic inflammation. We analyzed the relationship between coronary atherosclerosis, quantified by coronary calcium in CT, epicardial fat volume and systemic inflammation. METHODS: Using non-enhanced dual-source CT, we quantified epicardial fat volume (EFV) and coronary artery calcium (CAC) in 391 patients who underwent coronary computed tomography for suspected coronary artery disease. In addition to traditional risk factors, serum markers of systemic inflammation were measured (IL-1α, IL-2, IL-4, IL-6, IL-7, IL-8, IL-10,IL-12, IL-13, IL-15, IL-17, IFN-γ, TNF-α, hs-CRP, GM-CS, G-CSF, MCP-1, MIP-1, Eotaxin and IP-10). In 94 patients follow-up data were obtained after 1.9 ± 0.5 years. RESULTS: The 391 patients had a mean age of 60 ± 10 years, and 69 % were males. Mean EFV was 116 ± 50 mL. Median CAC was 12 (IQR 0; 152). CAC and EFV showed a significant correlation (ρ = 0.37; P < 0.001). EFV and CAC were significantly correlated with the traditional risk factors like age, male gender, diabetes, smoking and hypertension. With regard to biomarkers, CAC was significantly associated (negatively) to G-CSF and IL-13. EFV (median binned) was significantly associated (positively) with IP-10 (P = 0.002) and MCP-1 (ρ = 0.037). In follow-up, EFV showed a mean annualized progression of 6 mL (IQR 3; 9) (P < 0.001); CAC progressed by a mean of six Agatston Units (IQR 0; 30). The progression of CAC was significantly correlated with the extent of EFV (P < 0.001) while there was no significant correlation between progression of EFV or CAC with systemic inflammation markers. CONCLUSION: Epicardial fat volume and the baseline extent as well as progression of coronary atherosclerosis-measured by the calcium score-are significantly correlated. While both baseline EFV and CAC displayed significant correlations with systemic inflammation markers, biomarkers were not predictive of the progression of CAC or EFV.

Accuracy of prospectively ECG-triggered very low-dose coronary dual-source CT angiography using iterative reconstruction for the detection of coronary artery stenosis: comparison with invasive catheterization.

OBJECTIVE: To evaluate the image quality and diagnostic accuracy of very low-dose computed tomography (CT) angiography (CTA) for the evaluation of coronary artery stenosis. BACKGROUND: Iterative reconstruction (IR) has shown to substantially reduce image noise and hence permit the use of very low-dose data acquisition protocols in coronary CTA. METHODS: Fifty symptomatic patients with an intermediate likelihood for coronary artery disease underwent coronary CTA (heart rate: 59 ± 5 bpm, prospectively ECG-triggered axial acquisition, 100 kV, 160 mAs, 2 × 128 × 0.6 mm collimation, 60 mL contrast, 6 mL/s) prior to invasive coronary angiography. CTA images were reconstructed using both standard filtered back projection (FBP) and a raw data-based IR algorithm [Sinogram Affirmed Iterative Reconstruction (SAFIRE), Siemens Healthcare]. Subjective image quality (four-point Likert scale from 0 = non-diagnostic to 3 = excellent image quality), image noise, signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), as well as the presence of coronary stenosis >50% were independently determined by two observers. RESULTS: The mean dose-length product was 46.8 ± 3.5 mGy cm (estimated effective dose 0.66 ± 0.05 mSv). IR led to significantly improved objective image quality compared with FBP (image noise: 41 ± 12 vs. 49 ± 11 HU, P < 0.0001; CNR: 16 ± 8 vs. 12 ± 4, P < 0.0001; SNR: 13 ± 7 vs. 10 ± 3, P < 0.0001). Four coronary segments were not evaluable on FBP data, whereas all segments showed diagnostic image quality with IR. To detect significant coronary stenosis, sensitivity, specificity, positive predictive value, and negative predictive value were 69% (11/16), 97% (175/180), 69% (11/16), and 97% (175/180) per vessel with FBP data sets, respectively. With IR data sets, the corresponding values were 81% (13/16), 97% (178/184), 68% (13/19), and 98% (178/181). These differences were not statistically significant (P = 0.617). CONCLUSIONS: Raw data-based IR significantly improves image quality in very low-dose prospectively ECG-triggered coronary dual-source CTA when compared with standard reconstruction using FBP.

Epicardial fat and coronary artery calcification in patients on long-term hemodialysis.

INTRODUCTION: Recent studies have shown a significant correlation between increased epicardial fat volume (EFV) and mortality, coronary artery disease events, and measures of coronary atherosclerotic burden, for example, coronary calcium. Patients with chronic kidney disease on hemodialysis have an increased prevalence of coronary atherosclerosis and coronary calcium. The mechanisms underlying both may differ from patients with normal kidney function. Only limited data are available on the relationship between epicardial fat and coronary calcium in these patients. METHODS: Ninety-three consecutive patients (62 men and 31 women; mean age, 55 ± 11 years) with chronic kidney failure on regular hemodialysis underwent computed tomography for coronary calcium scoring as well as assessment of cardiovascular risk factors. Calcium scoring was performed using a low-dose, prospectively ECG-triggered high pitch spiral acquisition protocol (dual-source computed tomography, 280-millisecond (ms) rotation, 2 × 128 × 0.6-mm collimation, 120-kV tube voltage, 80-mA·s tube current). Cross-sectional images were reconstructed with 3.0-mm thickness, 1.5-mm increment, and a medium sharp reconstruction kernel (B35f). Agatston score and EVF were analyzed in a semiautomatic fashion using dedicated software. RESULTS: The mean duration of dialysis was 5.7 years. Of all patients, 93% had arterial hypertension, 66% had hyperlipidemia, 30% were diabetic, and 49.5% were current or prior smokers. The mean body mass index (BMI) was 27 ± 4 kg/m. The mean EFV was 162 ± 80 mL, and the mean coronary artery calcification (CAC) was 765 ± 1391 Agatston units (AU). In univariable and multivariable analysis, EFV was significantly correlated to BMI (P < 0.05) and age (P = 0.021), but not to CAC (P = 0.106). In subanalysis for values binned by median, we also found a significant correlation between EFV (binned) and smoking (P = 0.49) as well as a significant correlation between EFV (binned) and CAC for 46 patients younger than 55 years (median age). CONCLUSION: The epicardial fat volume in patients with chronic kidney disease and on hemodialysis is significantly correlated to BMI, age, and smoking but, with the exception of younger patients, not to the coronary calcium score. Our data suggest that in this special patient cohort, other mechanisms might influence the genesis of coronary calcification.

Relation of functional echocardiographic parameters to infarct scar transmurality by magnetic resonance imaging.

BACKGROUND: Identification of viable but dysfunctional myocardium after myocardial infarction is important for management, including the decision for revascularization. Assessment of infarct transmurality (TRM) by late contrast enhancement on magnetic resonance imaging (MRI) is frequently used for this task but has several limitations, particularly its availability. The goal of this study was to compare the value of several simple echocardiographic parameters measured at rest at the bedside for the identification of three degrees of infarct TRM, with contrast-enhanced MRI as the gold standard. METHODS: In a prospective, single-center study, 41 patients (33 men; mean age, 62 ± 10 years; 32 with ST-segment elevation infarctions) underwent resting echocardiography and contrast-enhanced MRI <5 days after infarction. Wall motion score, preejection velocity by tissue Doppler, and longitudinal, circumferential, and radial peak systolic strain by speckle-tracking-based strain imaging were assessed, and the findings were compared with infarct TRM stratified by contrast-enhanced MRI (no scar, 0% TRM; nontransmural scar, 1%-50% TRM; and transmural scar, 51%-100% TRM). RESULTS: Four hundred segments showed no scar, 125 showed nontransmural scar, and 213 showed transmural scar on contrast-enhanced MRI. The sensitivity and specificity of visual wall motion scoring to detect any scar versus no scar were 71% and 81%, respectively, similar to values for circumferential strain (sensitivity and specificity both 81% with a cutoff of -14.5%). Longitudinal and radial strain performed less well, and the presence of preejection velocity performed distinctly worse (45% and 90%, respectively). The sensitivity and specificity for identifying nontransmural versus transmural infarction was better for circumferential strain (78% and 75%, respectively, with a cutoff of -10.5%) than for the other strain types, preejection velocity (52% and 67%, respectively), or visual wall motion scoring (50% and 81%, respectively, for a score > 2). CONCLUSION: Visual wall motion analysis alone is able to detect infarcted myocardium but cannot differentiate sufficiently between transmural and nontransmural infarction. This is best achieved at the bedside using speckle-tracking-based circumferential strain.

The proinflammatory effect of C-reactive protein on human endothelial cells depends on the FcγRIIa genotype.

INTRODUCTION: The stimulatory effects of CRP (C-reactive protein) on endothelial cells are mainly mediated via FcγRIIa. This receptor exists in two different allotypes bearing either arginine (R131) or histidine (H131) at the extracellular amino acid position 131 of the mature protein, but only FcγRIIa-R131 displays high avidity for CRP. This study investigated the role of the FcγRIIa genotype in CRP-stimulated endothelial cells. MATERIALS AND METHODS: We tested the effects of CRP on expression of the adhesion molecules ICAM-1, VCAM-1, and E-selectin, as well as the endothelial release of pro-inflammatory molecules as a function of the FcγRIIa-genotype (FcγRIIa-H/H131, FcγRIIa-H/R131, FcγRIIa-R/R131) in HUVEC (Human Umbilical Vein Endothelial Cells). HUVEC were grouped according to their FcγRIIa status by genotyping with an allele specific nested-PCR. The expression of ICAM-1, VCAM-1, and E-selectin on HUVEC was detected by flow cytometry. The release of soluble markers (sCD40L, IL-6, IL-8, MCP-1, tPA, sP-selectin, and sVCAM-1) was measured using a multiplex assay for flow cytometry. RESULTS AND CONCLUSIONS: CRP-stimulated expression of ICAM-1 and E-selectin was dependent on the specific FcγRIIa-genotype, with most pronounced induction in HUVEC with the FcγRIIa-R/R genotype, followed by H/R and H/H. In accordance with this finding, the supernatants of stimulated HUVEC with the R/R genotype showed significantly higher levels of tPA, MCP-1, and IL-6. Our data show that CRP stimulates the expression of adhesion molecules and the release of soluble markers by HUVEC as a function of the FcγRIIa-genotype. These findings could be relevant in the context of risk stratification in patients with cardiovascular disease.

Mild therapeutic hypothermia after out-of-hospital cardiac arrest complicating ST-elevation myocardial infarction: long-term results in clinical practice.

BACKGROUND: Recently, mild therapeutic hypothermia (MTH) has been integrated into the European resuscitation guidelines to improve outcomes after out-of-hospital cardiac arrest (OHCA). Data on long-term results are limited, especially in patients with acute ST-elevation myocardial infarction (STEMI). HYPOTHESIS: Invasive MTH influences long-term prognosis after OHCA due to STEMI. METHODS: We analyzed 48 patients who underwent emergency coronary angiography for STEMI after witnessed OHCA. In 24 consecutive patients, MTH was performed via intravascular cooling (CoolGard System, 34°C maintained for 24 hours) after initialization by rapid infusion of cold saline. Clinical, procedural, and mortality data were compared to 24 historical controls. Neurological recovery was assessed using the Cerebral Performance Category score (CPC) at 30-day and 1-year follow-up. RESULTS: Median time delay until arrival of emergency medical service was 6 minutes (MTH group) vs 6.5 minutes (controls) (P = 0.16). Initial rhythm was ventricular fibrillation in 75% vs 66.7% (P = 0.75). There were no differences regarding baseline characteristics, angiographic findings, and success of cardiac catheterization procedures. MTH was not associated with a higher frequency of bleeding complications or of pneumonia. Thirty-day mortality was 33.3% in both groups. One-year mortality was 37.5% (MTH group) vs 50% (controls) (P = 0.56). At 1 year, favorable neurological outcome (CPC ≤2) was significantly more frequent in the MTH group (58.3% vs 20.8%, P = 0.017). Multivariate analysis identified MTH as independent predictor of favorable neurological outcome (P < 0.02, odds ratio: 12.73). CONCLUSIONS: MTH via intravascular cooling improves neurological long-term prognosis after OHCA due to STEMI and is safe in clinical practice.

Impact of telmisartan on the inflammatory state in patients with coronary atherosclerosis--influence on IP-10, TNF-α and MCP-1.

BACKGROUND: Hypertension is one of the most prominent risk factors for coronary artery disease (CAD). Treatment of hypertension is therefore important for reducing cardiovascular events and the progression of atherosclerosis. Several treatment strategies are common in clinical practice for example the use of ACE-blockers or angiotensin receptor II blockers (ARBs), so called sartans. Telmisartan, belonging to the class of ARBs, was shown to exert anti-inflammatory effects besides the blood pressure lowering. METHODS: In this work, two separate substudy groups of hypertensives were compared. 16 patients with arterial hypertension have been treated with telmisartan (initial 40 mg Kinzalmono®) for 7.3 ± 4.4 months. The telmisartan group was compared to a matched control group including 31 hypertensive patients without telmisartan treatment with a follow up period of 1.9 ± 0.5 years. Serum samples from the beginning and the end of follow up were analyzed with Luminex® technology for 26 cytokines and chemokines. The baseline scores of coronary artery calcification (CAC) were gathered by multislice detector computer tomography. RESULTS: After 7 months of telmisartan treatment and 2 years in control patients most of the measured analytes did not change significantly. MCP-1 (P=0.001; P<0.001) was increased significantly in both telmisartan and control group. The relative decrease in IP-10 and TNF-α levels was observed in telmisartan group, as opposed to the increase in control (telmisartan vs. control P=0.048; P=0.01). No linear rank-correlation between measured analytes and the initial CAC was found. CONCLUSION: Telmisartan reduced blood pressure in patients with atherosclerosis and arterial hypertension within a short time period, whereas the inflammatory status of these patients remained largely unchanged. An involvement of telmisartan in the regulation of inflammatory and anti-inflammatory mediators in the context of CAD and CAC is possible, but cannot clearly be assumed based on the present findings.

Low-dose dual-source CT angiography with iterative reconstruction for coronary artery stent evaluation.

OBJECTIVES: The purpose of this study was to evaluate the image quality and diagnostic accuracy of very low-dose, dual-source computed tomography (DSCT) angiography for the evaluation of coronary stents. BACKGROUND: Iterative reconstruction (IR) leads to substantial reduction of image noise and hence permits the use of very low-dose data acquisition protocols in coronary computed tomography angiography. METHODS: Fifty symptomatic patients with 87 coronary stents (diameter 3.0 ± 0.4 mm) underwent coronary DSCT angiography (heart rate, 60 ± 6 beats/min; prospectively electrocardiography-triggered axial acquisition; 80 kV, 165 mA, 2 × 128 × 0.6-mm collimation; 60 ml of contrast at 6 ml/s) before invasive coronary angiography. DSCT images were reconstructed using both standard filtered back projection and a raw data-based IR algorithm (SAFIRE, Siemens Healthcare, Forchheim, Germany). Subjective image quality (4-point scale from 0 [nondiagnostic] to 3 [excellent image quality]), image noise, contrast-to-noise ratio as well as the presence of in-stent stenosis >50% were independently determined by 2 observers. RESULTS: The median dose-length product was 23.0 (22.0; 23.0) mGy · cm (median estimated effective dose of 0.32 [0.31; 0.32] mSv). IR led to significantly improved image quality compared with filtered back projection (image quality score, 1.8 ± 0.6 vs. 1.5 ± 0.5, p < 0.05; image noise, 70 Hounsfield units [62; 80 Hounsfield units] vs. 96 Hounsfield units [82; 113 Hounsfield units], p < 0.001; contrast-to-noise ratio, 11.0 [9.6; 12.4] vs. 8.0 [6.2; 9.3], p < 0.001). To detect significant coronary stenosis in filtered back projection reconstructions, the sensitivity, specificity, positive predictive value, and negative predictive value were 97% (32 of 33), 53% (9 of 17), 80% (32 of 40), and 90% (9 of 10) per patient, respectively; 89% (43 of 48), 79% (120 of 152), 57% (42 of 74), and 96% (121 of 126) per vessel, respectively; and 85% (12 of 14), 69% (51 of 73), 32% (11 of 34), and 96% (51 of 53) per stent, respectively. In reconstructions obtained by IR, the corresponding values were 100% (33 of 33), 65% (11 of 17), 85% (33 of 39), and 100% (11 of 11) per patient, respectively; 96% (46 of 48), 84% (129 of 152), 66% (47 of 71), and 98% (127 of 129) per vessel, respectively; and 100% (14 of 14), 75% (55 of 73), 44% (14 of 32), and 100% (55 of 55) per stent, respectively. These differences were not significant. CONCLUSIONS: In selected patients, prospectively electrocardiography-triggered image acquisition with 80-kV tube voltage and low current in combination with IR permits the evaluation of patients with implanted coronary artery stents with reasonable diagnostic accuracy at very low radiation exposure.

Invasive hemodynamic characteristics of low gradient severe aortic stenosis despite preserved ejection fraction.

OBJECTIVES: The study sought to compare echocardiographic with invasive hemodynamic data in patients with "paradoxic" aortic stenosis and in patients with conventionally defined severe aortic stenosis. BACKGROUND: Controversy exists whether low gradient severe aortic stenosis despite preserved ejection fraction ("paradoxic" aortic stenosis; aortic valve area <1 cm(2), mean gradient <40 mm Hg, ejection fraction >50%), which has been mainly diagnosed by echocardiography (echo), may be largely due to mistakes in echocardiographic measurements. METHODS: We compared echocardiographic and invasive hemodynamic data from 58 patients (43% male, mean age 77 ± 5 years) with "paradoxic" aortic stenosis. Data of 22 patients (45% male, mean age 73 ± 7 years) with conventionally defined severe aortic stenosis area (aortic valve area ≤1 cm(2), mean gradient >40 mm Hg, ejection fraction ≥50%) were also analyzed. RESULTS: In patients with "paradoxic" aortic stenosis, orifice area by echo (0.80 ± 0.15 cm(2)) and catheterization showed modest agreement, whether stroke volume was measured by oxymetry (0.69 ± 0.16 cm(2), bias 0.14 ± 0.17 cm(2)), or by thermodilution (0.85 ± 0.19 cm(2), bias -0.03 ± 0.19 cm(2)). Mean systolic gradients were very similar (32 ± 7 mm Hg vs. 31 ± 6 mm Hg; bias -0.08 ± 7.8 mm Hg). In comparison, in patients with conventionally defined severe aortic stenosis, orifice area by echo was 0.72 ± 0.17 cm(2) and by catheterization 0.51 ± 0.15 cm(2) (oxymetry) and 0.68 ± 0.21 cm(2) (thermodilution), respectively, and mean systolic gradient 51 ± 10 mm Hg and 55 ± 8 mm Hg, respectively. Ejection fractions did not differ significantly in both groups. Ascending aortic diameter was significantly smaller in the "paradoxic" aortic stenosis group than in patients with conventionally defined severe aortic stenosis (28 ± 5 mm vs. 31 ± 5 mm), and energy loss index was significantly larger (0.51 ± 0.12 cm(2)/m(2) vs. 0.42 ± 0.09 cm(2)/m(2), respectively). Heart rate and mean blood pressure during echo and catheterization were not significantly different. CONCLUSIONS: Occurrence of low gradient severe aortic stenosis despite preserved ejection fraction was confirmed by invasive hemodynamics and was not the result of a systematic bias in the echo calculation of aortic orifice area.