Profile of the Immune and Inflammatory Response in Individuals With Prediabetes and Type 2 Diabetes.

OBJECTIVE: The inflammatory and immune systems are altered in type 2 diabetes. Here, the aim was to profile the immune and inflammatory response in subjects with prediabetes and diabetes in a large population-representative sample. RESEARCH DESIGN AND METHODS: In total, 15,010 individuals were analyzed from the population-based Gutenberg Health Study. Glucose status was classified according to HbA1c concentration and history of diagnosis. All samples were analyzed for white blood cells (WBCs), granulocytes, lymphocytes, monocytes, platelets, C-reactive protein (CRP), albumin, fibrinogen, and hematocrit. Interleukin-18 (IL-18), IL-1 receptor antagonist (IL-1RA), and neopterin concentrations were determined in a subcohort. RESULTS: In total, 7,584 men and 7,426 women were analyzed (range 35-74 years), with 1,425 and 1,299 having prediabetes and diabetes, respectively. Biomarkers showed varying dynamics from normoglycemic via subjects with prediabetes to subjects with diabetes: 1) gradual increase (WBCs, granulocytes, monocytes, IL-1RA, IL-18, and fibrinogen), 2) increase with subclinical disease only (lymphocytes and CRP), 3) increase from prediabetes to diabetes only (neopterin), and 4) no variation with glucose status (hematocrit). The strongest relative differences were found for CRP, IL-1RA, and fibrinogen concentrations. Several inflammatory and immune markers were associated with the glucose status independent from cardiovascular risk factors and comorbidities, varied with disease severity and the presence of disease-specific complications in the diabetes subcohort. CONCLUSIONS: The inflammatory and immune biomarker profile varies with the development and progression of type 2 diabetes. Markers of inflammation and immunity enable differentiation between the early preclinical and clinical phases of the disease, disease complications, and progression.

Risk stratification following complex PCI: clinical versus anatomical risk stratification including "post PCI residual SYNTAX-score" as quantification of incomplete revascularization.

BACKGROUND: EuroSCORE and completeness of revascularization predicts long-term survival after multivessel PCI (MV-PCI). The SYNTAX-Score has also been proposed to predict clinical outcome. The prognostic impact of these scores to predict long-term survival after PCI has not yet been compared. METHODS AND RESULTS: Long-term survival was assessed in 740 patients undergoing MV-PCI. We calculated EuroSCORE, SYNTAX-Score, STS-Score, the clinical SYNTAX-Score (CSS), and the "post-PCI residual SYNTAX-Score." Mean follow-up time was 4.5 ± 2.5 years. 341 patients (46%) were treated for ACS (STEMI N = 191; NSTEMI N = 150). 113 patients (15%) underwent PCI of left main coronary artery. The EuroSCORE was significantly lower for stable patients compared to patients with ACS (stable 4.1 ± 4.5, NSTEMI 13.9 ± 13.3, STEMI 18.1 ± 18.7, p < 0.001). The differences in the SYNTAX-Score were less obvious but even significant (stable 14.9 ± 8.6, NSTEMI 17.8 ± 9.9, STEMI 18.3 ± 9.0; p < 0.001). Patients in the highest tertiles of each risk score experienced a dramatically elevated mortality rate compared to the extremely low mortality rate in the lower tertiles (p log-rank <0.001). This comparison remained significant for the EuroSCORE and STS-Score but not for the SYNTAX-Score, when analysis was restricted to stable patients. The multivariate Cox-regression-analysis confirmed the logistic EuroSCORE, EuroSCORE II, and the STS-Score as independent predictors of long-term mortality, whereas the SYNTAX-Score (including residual form) and the CSS had no predictive value. CONCLUSION: The EuroSCORE and the STS-Score outperforms the SYNTAX-Score and the CSS in predicting long-term survival following MV-PCI. In addition, the residual SYNTAX-Score predicts long-term survival not independently.

Prognostic impact of using drug-eluting-stents on outcome and strategy in multivessel PCI: data from the Frankfurt MV-PCI registry.

BACKGROUND: Drug-eluting-stents (DES) reduce clinical restenosis, but have mostly failed to demonstrate a reduction in death or myocardial infarction. The aim of this study was to evaluate the prognostic impact of the introduction of DES in patients undergoing multivessel percutaneous coronary intervention (MV-PCI). METHODS: Survival was assessed in 679 consecutive patients, who underwent PCI in at least two main vessels. Follow-up was available in 667 patients (98%) with a mean follow-up of 4.8 ± 2.5 years. We compared several scenarios: firstly, patients receiving at least one DES (≥ 1 DES group) vs. bare metal stent (BMS)-only patients (BMS only); secondly, the population was divided into a pre-DES-era (2000-2003; N=257) and a DES-era (2004-2006; N=422). RESULTS: 316 patients (47%) were treated for acute myocardial infarction (MI; N=176 ST-elevation MI; N=140 non-ST-elevation MI). On average, 2.2 ± 0.4 vessels were treated and 212 patients received at least one DES. The DES group showed a higher number of diseased (2.5 ± 0.6 vs. 2.4 ± 0.5; p=0.02) and treated vessels (2.2 ± 0.5 vs. 2.1 ± 0.3; p<0.01) and received more stents (3.3 ± 1.4 vs. 3.0 ± 1.1; p<0.01). The BMS group presented more frequently with acute MI (55% vs. 29%; p<0.01). The DES group showed more complex disease as evidenced by a higher SYNTAX-Score (17.4 ± 8.5 vs. 14.5 ± 8.3; p<0.01). Restricting the survival analysis to patients with stable coronary artery disease, a significant prognostic advantage was found for patients received at least one DES compared to the BMS group (hazard ratio 0.58, 95% confidence interval 0.34-0.99) in the multivariate cox-regression-analysis. CONCLUSION: The introduction of DES leads to extension of treatment to more complex patients. The use of DES is associated with improved survival in stable patients undergoing MV-PCI.

Impact of interventional strategy for unprotected left main coronary artery percutaneous coronary intervention on long-term survival.

BACKGROUND: Percutaneous coronary intervention (PCI) of unprotected left main coronary artery (ULMCA) is feasible. In cases involving the left anterior descending-left circumflex bifurcation, the optimal interventional strategy remains unclear. Randomized bifurcation trials in the past excluded ULMCA lesions. METHODS: A single-centre registry study with retrospective analysis of the interventional protocols and procedural angiograms of 102 patients who underwent stent PCI of ULMCA was performed in order to evaluate the impact of the interventional strategy on long-term survival. RESULTS: Isolated stenting of the ostium or mid ULMCA without bifurcation stenting was performed in 19 patients. Most interventions (n = 83) involved the left main bifurcation. Distal or bifurcation lesions were treated by provisional T-stenting in cases of single involved ostium (left anterior descending or right circumflex) or systematic T-stenting or V-stenting if both proximal coronary arteries were involved (n = 19). The majority (96%) of patients received drug-eluting stents. The long-term survival (mean follow-up = 3.4 ± 1.7 years) of patients was influenced by the interventional strategy. A single-stent strategy involving the bifurcation without side branch intervention was associated with less-favourable long-term survival (hazard ratio 4.08; 95% confidence interval, 1.91-8.69; multivariable Cox regression analysis). CONCLUSIONS: This prospective observational study suggests that single-stent PCI involving the bifurcation without side branch intervention of ULMCA is possibly associated with higher long-term mortality. ULMCA-PCI involving the bifurcation is possible with similar results compared with isolated PCI of ULMCA shaft or ostium. Large, randomized trials are warranted for comparison of optimal technical approach to LMCA interventions.