Ki-Bae Seung

Myosin-primed tolerogenic dendritic cells ameliorate experimental autoimmune myocarditis

AIMSnAutoimmunity plays an important role in the pathogenesis of viral myocarditis and giant cell myocarditis. Experimental autoimmune myocarditis (EAM) is a mouse model of myocarditis that is induced by cardiac myosin. Tolerogenic dendritic cells (tDCs) are used as anti-inflammatory and immunosuppressive targets in a number of autoimmune disease models, but their effect on EAM has not been addressed. The aim of this study was to investigate whether tDC therapy in an EAM mouse model can suppress inflammatory myocarditis, a potential precursor of dilated cardiomyopathy.nnnMETHODS AND RESULTSntDCs were generated by treating immature DCs (imDCs) with TNF-α and cardiac myosin. Mice with EAM were injected twice with tDCs (with a 1-week interval) at three doses (2 × 10(5), 1 × 10(6), or 2 × 10(6)). The severity of myocarditis was histopathologically assessed. The phenotypes of the DC and regulatory T (Treg) cell populations were determined by flow cytometry and the effect of tDCs on autoimmunity-inducing cytokines was examined by ELISA. Myosin-pulsed tDCs displayed lower levels of DC-related surface markers and expressed higher levels of indoleamine 2, 3-dioxygenase (IDO) than mature DCs (mDCs). Histopathological examination revealed that hearts from tDC-treated mice showed markedly reduced myocardial inflammation compared with those of untreated EAM mice. These therapeutic effects by tDCs were mediated at least by enhanced myosin-specific Treg cell induction and anti-inflammatory cytokine secretion.nnnCONCLUSIONnTaken together, these results show for the first time that myosin-pulsed tDCs ameliorate EAM, and that this occurs most likely via the induction of antigen-specific Treg cells.

Comparison of Antiplatelet Effect and Tolerability of Clopidogrel Resinate With Clopidogrel Bisulfate in Patients With Coronary Heart Disease (CHD) or CHD-Equivalent Risks: A Phase IV, Prospective, Double-Dummy, Parallel-Group, 4-Week Noninferiority Trial

BACKGROUNDnClopidogrel resinate is a resinate complex of (+)-clopidogrel optical isomer, wherein the (+)-clopidogrel isomer binds to a water-soluble cation exchange resin via sulfonic acid groups. It was approved by the Korean Food and Drug Administration on the basis of a Phase I study that demonstrated the bioequivalence of clopidogrel resinate and clopidogrel bisulfate. However, there are no available data regarding efficacy and tolerability in patients with vascular disease.nnnOBJECTIVEnThe goal of this study was to investigate the antiplatelet efficacy and tolerability of clopidogrel resinate in patients with coronary heart disease (CHD) or CHD-equivalent risks.nnnMETHODSnThis study was a Phase IV, randomized, double-blind, double-dummy, parallel-group, noninferiority trial. We prospectively recruited patients in 10 centers between March 2008 and July 2008. Patients who had documented CHD or CHD-equivalent risks were randomly assigned to 1 of 3 groups: group A, aspirin (100 mg) + clopidogrel bisulfate placebo + clopidogrel resinate placebo; group B, aspirin (100 mg) + clopidogrel bisulfate placebo + clopidogrel resinate (75 mg); or group C, aspirin (100 mg) + clopidogrel bisulfate (75 mg) + clopidogrel resinate placebo. The primary outcome was the percent P2Y(12) inhibition after medication, assessed by using a point-of-care assay. If the 1-sided 90% upper confidence limit for the difference was less than the prespecified delta value (-5.7), clopidogrel resinate would be considered noninferior to clopidogrel bisulfate. The secondary outcome, the prevalence of adverse events (AEs) associated with study medications, was assessed at each visit by direct interview.nnnRESULTSnA total of 314 patients (mean [SD] age, 62.2 [9.0] years; male 63.7%; weight, 67.3 [13.6] kg [range, 45-102 kg]; all Asian) were enrolled, and 287 patients finished the study (group A, n = 97; group B, n = 90; and group C, n = 100). Eight patients took no study medications and were excluded from the tolerability and efficacy analyses. Nineteen patients discontinued the study because of protocol violation (n = 15), adverse events (n = 3), or voluntary withdrawal (n = 1) and were excluded from the efficacy analysis. There were no significant differences in baseline clinical characteristics among the groups except for the frequency of a history of CHD (group A, 85.4%; group B, 73.0%; and group C, 88.3%; P = 0.01). Patients treated with either type of clopidogrel showed significant inhibition (mean [SD]) of P2Y(12) (group A, -5.9% [15.1%]; group B, 23.4% [21.9%]; and group C, 19.5% [23.8%]; P < 0.001). Differences between clopidogrel resinate and clopidogrel bisulfate in the inhibition of P2Y(12) did not exceed the predetermined value for inferiority (P for noninferiority, 0.02; 90% CI, -0.9 to 10.3). In the tolerability analysis, there was no mortality during the study period and no significant differences between groups in the frequency of AEs and serious AEs (AEs: group A, 33.0%; group B, 26.0%; and group C, 23.3% [P = 0.27]; serious AEs: group A, 1.0%; group B, 3.0%; and group C, 1.0% [P = 0.42]). One patient in group B underwent coronary stent implantation for treatment of stable angina.nnnCONCLUSIONSnIn this small, selected Asian patient population, differences in the platelet inhibition efficacies of clopidogrel resinate and clopidogrel bisulfate did not exceed the predetermined limits for noninferiority. The differences in tolerability between the 2 drugs did not reach statistical significance.

Clinical outcomes and predictors of unprotected left main stem culprit lesions in patients with acute ST segment elevation myocardial infarction

Objectives: We aimed at comparing the clinical outcomes of the patients who underwent percutaneous coronary intervention (PCI) for ST segment elevation myocardial infarction (STEMI) due to left main coronary arteries (LMCA) and non‐LMCA determining the predictors of mortality in the patients. Background: There are few data regarding the midterm prognosis of STEMI due to LMCA as compared with them due to non‐LMCA. Methods: A total of 4,697 patients with STEMI (61 patients with LMCA and 4,636 patients with non‐LMCA) were enrolled in a nationwide Korea Acute Myocardial Infarction (MI) Registry between November 2005 and September 2009. The primary endpoints was a composite of cardiac death, nonfatal MI, and target lesion and vessel revascularization (TLR/TVR) during a 12‐month clinical follow‐up. Results: The LMCA group had a higher incidence of total major adverse cardiac events (MACEs) (26.2% vs. 7.8%; P < 0.001) at 12 months, which was largely attributable to cardiac deaths at 1 month (21.3% vs. 3.8%; P < 0.001). Therefore, there was no statistical difference in cardiac deaths, nonfatal MI, TLR/TVR, and MACEs after 1 month between the two groups. Presenting in cardiogenic shock (HR, 4.25; 95% CI, 1.01–17.97; P = 0.049) and heart rate ≥100 bpm (HR, 4.97; 95% CI, 1.18–21.00; P = 0.029) were independent predictors of cardiac death due to LMCA. Conclusion: Patients with STEMI and a LMCA had poor clinical outcomes, which is attributable to hemodynamic deterioration during the periprocedural period. However, after that time, midterm MACEs of the survivors following the periprocedural period may not be different between STEMI due to LMCA and non‐LMCA.

Long-Term Clinical Outcomes of Transient and Persistent No Reflow Phenomena following Percutaneous Coronary Intervention in Patients with Acute Myocardial Infarction

Background and Objectives There is limited information on the transient or persistent no reflow phenomenon in patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI). Subjects and Methods The study analyzed 4329 patients with AMI from a Korean multicenter registry who underwent PCI using coronary stents (2668 ST-elevation and 1661 non-ST-elevation myocardial infarction [MI] patients): 4071 patients without any no reflow, 213 with transient no reflow (no reflow with final thrombolysis in myocardial infarction [TIMI] flow grade 3), and 45 with persistent no reflow (no reflow with final TIMI flow grade≤2). The primary endpoint was all-cause mortality during 3-year follow-up. We also analyzed the incidence of cardiac mortality, non-fatal MI, re-hospitalization due to heart failure, target vessel revascularization, and stent thrombosis. Results The persistent no reflow group was associated with higher all-cause mortality (hazard ratio [HR] 1.98, 95% confidence interval [CI] 1.08-3.65, p=0.028) and cardiac mortality (HR 3.28, 95% CI 1.54-6.95, p=0.002) compared with the normal reflow group. Transient no reflow increased all-cause mortality only when compared with normal reflow group (HR 1.58, 95% CI 1.11-2.24, p=0.010). When comparing transient and persistent no reflow, persistent no reflow was associated with increased all-cause mortality (46.7 vs. 24.4%, log rank p=0.033). Conclusion The persistent no reflow phenomenon was associated with a poor in-hospital outcome and increased long-term mortality mainly driven by increased cardiac mortality compared to the transient no reflow phenomenon or normal reflow.

5-YEARS CLINICAL OUTCOMES OF KNOWN DIABETES MELLITUS AND NEWLY DIAGNOSED DIABETES AND PREDIABETES AMONG PATIENTS WITH ACUTE MYOCARDIAL INFARCTION UNDERGOING PRIMARY PERCUTANEOUS CORONARY INTERVENTION

We examined the 5-years clinical outcomes of known diabetes mellitus, newly diagnosed diabetes mellitus and prediabetes among acute myocardial infarction undergoing primary percutaneous coronary intervention.nnWe retrospectively analyzed a total of 4,748 acute myocardial infarction patients who

Effect of moderate-intensity statin therapy on plaque inflammation in patients with acute coronary syndrome: A prospective interventional study evaluated by 18F-FDG PET/CT of the carotid artery

BACKGROUNDnAsian patients with acute coronary syndrome (ACS) are frequently prescribed moderate-intensity statin in real practice, even during the early stage of ACS. Under assessment herein was the effect of moderate-intensity statin therapy on the resolution of plaque inflammation during the first month after ACS, a period with highest recurrent ischemic events, using dual time point ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT).nnnMETHODSnThis prospective study included statin-naïve patients with ACS and non-calcified carotid plaques (³ 3 mm on ultrasound images). Baseline FDG PET/CT images of the carotid arteries of the patients were obtained. Then, all patients received atorvastatin (20 mg/day); follow-up FDG PET/CT images of the carotid arteries were then obtained after 1 month of therapy. The primary endpoint measurement was the change in the target-to-background ratio (TBR) of the carotid artery between the initial and follow-up FDG PET/CT scans.nnnRESULTSnThirteen ACS patients completed the initial and follow-up FDG PET/CT scans. Moderate-intensity statin therapy failed to reduce plaque inflammation at 1 month after ACS (TBR 1.60 ± 0.20 at baseline vs. 1.50 ± 0.40 after therapy; p = 0.422) but significantly reduced serum low-density lipoprotein cholesterol (LDL-C) levels (mean LDL-C 101.2 ± 21.1 mg/dL at baseline vs. 70.7 ± 12.4 mg/dL after therapy; p < 0.001). Changes in the TBR and serum LDL-C levels were not correlated (r = -0.27, p = 0.243).nnnCONCLUSIONSnDual time point FDG PET/CT imaging demonstrates that moderate-intensity statin therapy was insufficient in suppressed plaque inflammation within the first month after ACS in Asian patients, even though achieving target LDL levels.