Drug eluting stent implantation for the treatment of symptomatic myocardial bridging is associated with favorable peri-procedural results and short-term outcomes.

Myocardial bridging is the most common congenital coronary abnormality, and is frequently found on post-mortem cardiac examination. Although often asymptomatic, clinical presentation can vary from unstable angina to sudden cardiac death. Only isolated cases of using drug eluting stents (DES) for bridging segments have been described. Our objective was to retrospectively analyze a series of patients undergoing percutaneous coronary intervention (PCI) with DES for symptomatic myocardial bridging and follow post-procedure outcomes. Results revealed favorable peri-procedural angiographic and short-term clinical results with DES implantation. Although initial data regarding DES implantation for symptomatic myocardial bridging are promising, long-term follow up, particularly related to in-stent restenosis will be important.

Effect of platelet antigen polymorphism on platelet inhibition by aspirin, clopidogrel, or their combination.

OBJECTIVES: We studied the modifier effect of platelet antigen polymorphism (PlA2) on platelet inhibition by acetylsalicylic acid (ASA, i.e., aspirin), clopidogrel, or their combination in patients with coronary heart disease. BACKGROUND: Clopidogrel, when administered with ASA, was shown to significantly improve the outcome of patients with acute coronary syndromes compared with patients receiving only ASA. We have shown previously that the effect of ASA on platelets is modified by the glycoprotein IIIa single nucleotide polymorphism PlA2. Hence, an important pharmacogenetic question remains whether the antiplatelet effect of clopidogrel is uniform for all patients or, like acetylsalicylic acid, more selective. METHODS: Thirty PlA1/A1 and 30 PlA1/A2 patients were assigned randomly to ASA 325 mg/day, clopidogrel 75 mg/day, or both. After 10 days, platelet function was studied. RESULTS: Clopidogrel provided stronger platelet inhibition than ASA with adenosine diphosphate as the agonist, and combination therapy resulted in greater inhibition than either inhibitor used alone (p < 0.0001). The use of ASA resulted in greater inhibition compared with clopidogrel with epinephrine (p < 0.0001) and collagen as agonists (p < 0.0001). With collagen as the agonist, platelets from PlA1/A2 donors were markedly and significantly less inhibited by ASA (p = 0.005). In contrast, with clopidogrel, no significant difference could be detected between inhibition of Pl(A1/A1) and Pl(A1/A2) platelets. CONCLUSIONS: The combination of ASA and clopidogrel appears superior to either agent alone in inhibiting platelet function. Pl(A2) functions as an important modifier for platelet responsiveness to ASA but not to clopidogrel. These findings could have significant impact on the future design of pharmacogenetic antithrombotic strategies for patients with coronary heart disease.

Advancing immunosuppression therapy to counter the progression of cardiac allograft vasculopathy.

BACKGROUND: Cardiac allograft vasculopathy (CAV) is the major cause of late mortality in heart transplant recipients. Because immunosuppressive therapy has been convincingly shown to suppress cellular rejection and prolong cardiac allograft survival, we assessed the efficacy of advancing immunosuppressive therapy in reversing or delaying CAV by switching azathioprine to combination mycophenolate mofetil and prednisone (MMF-P). METHODS AND RESULTS: Seventeen adult posttransplant patients, whose CAV was prospectively approached with the MMF-P protocol, were studied. The development of significant CAV was declared on the index coronary angiogram and the MMF-P protocol was instituted. The degree of occlusion for all coronary lesions was quantitated for the index angiogram, and for the angiograms performed 1 year before (baseline) the index angiogram and annually for 2 years after the index angiogram (MMF-P years 1 and 2). There was a significant change in percent occlusion over time (P < .001). Percent occlusion increased significantly from the baseline year to the index CAV year, but then decreased significantly from the index CAV year to the MMF-P treatment years 1 and 2. CONCLUSION: Advancing immunosuppression with MMF-P can delay the progression of and partially reverse lumen narrowing of CAV in heart transplant recipients.

Statin therapy, LDL cholesterol, C-reactive protein, and coronary artery disease.

BACKGROUND: Recent trials have demonstrated better outcomes with intensive than with moderate statin treatment. Intensive treatment produced greater reductions in both low-density lipoprotein (LDL) cholesterol and C-reactive protein (CRP), suggesting a relationship between these two biomarkers and disease progression. METHODS: We performed intravascular ultrasonography in 502 patients with angiographically documented coronary disease. Patients were randomly assigned to receive moderate treatment (40 mg of pravastatin orally per day) or intensive treatment (80 mg of atorvastatin orally per day). Ultrasonography was repeated after 18 months to measure the progression of atherosclerosis. Lipoprotein and CRP levels were measured at baseline and follow-up. RESULTS: In the group as a whole, the mean LDL cholesterol level was reduced from 150.2 mg per deciliter (3.88 mmol per liter) at baseline to 94.5 mg per deciliter (2.44 mmol per liter) at 18 months (P<0.001), and the geometric mean CRP level decreased from 2.9 to 2.3 mg per liter (P<0.001). The correlation between the reduction in LDL cholesterol levels and that in CRP levels was weak but significant in the group as a whole (r=0.13, P=0.005), but not in either treatment group alone. In univariate analyses, the percent change in the levels of LDL cholesterol, CRP, apolipoprotein B-100, and non-high-density lipoprotein cholesterol were related to the rate of progression of atherosclerosis. After adjustment for the reduction in these lipid levels, the decrease in CRP levels was independently and significantly correlated with the rate of progression. Patients with reductions in both LDL cholesterol and CRP that were greater than the median had significantly slower rates of progression than patients with reductions in both biomarkers that were less than the median (P=0.001). CONCLUSIONS: For patients with coronary artery disease, the reduced rate of progression of atherosclerosis associated with intensive statin treatment, as compared with moderate statin treatment, is significantly related to greater reductions in the levels of both atherogenic lipoproteins and CRP.

Rotational X-ray coronary angiography.

We designed and implemented a digital flat-panel-based rotational X-ray coronary angiography technique hypothesizing that luminal disease could be identified with less radiation exposure and contrast usage compared to conventional angiography. Individuals scheduled for diagnostic coronary angiography were prospectively enrolled. In addition to conventional acquisitions in standard planes, subjects underwent one additional left coronary artery (LCA) or right coronary artery (RCA) rotational (spin) acquisition using a predefined trajectory. Radiation exposure and contrast volume were recorded for each run. Seventy-five subjects were enrolled. When compared with standard five-view cine acquisition, LCA spin angiography with one cranial and one caudal run resulted in 34.38% +/- 13.65% less radiation, 18.98% +/- 4.97% less contrast, and comparable assessment of stenosis severity. One spin acquisition compared with three standard cine acquisitions for RCA angiography resulted in 59.31% +/- 29.07% lower radiation, no significant change in contrast, and comparable assessment of stenosis severity. Rotational X-ray coronary angiography provides comparable visualization of coronary anatomy compared with traditional nonrotational coronary angiography with significantly less radiation exposure and contrast volume.