Wolfgang Auch-Schwelk

Preprocedural C-reactive protein levels and cardiovascular events after coronary stent implantation.

OBJECTIVESnThis study assessed the predictive value of preprocedural C-reactive protein (CRP) levels on six-month clinical and angiographic outcome in patients undergoing coronary stent implantation.nnnBACKGROUNDnRecent data indicate that low-grade inflammation as detected by elevated CRP serum levels predicts the risk of recurrent coronary events.nnnMETHODSnWe prospectively investigated the predictive value of preprocedural CRP-levels on restenosis and six-month clinical outcome in 276 patients after coronary stent implantation. The primary combined end point was death due to cardiac causes, myocardial infarction related to the target vessel and repeat intervention of the stented vessel.nnnRESULTSnGrouping patients into tertiles according to preprocedural CRP-levels revealed that, despite identical angiographic and clinical characteristics at baseline and after stent implantation, a primary end point event occurred in 24 (26%) patients of the lowest tertile, in 42 (45.6%) of the middle tertile and in 38 (41.3%) of the highest CRP tertile, p = 0.01. On multivariate analysis, tertiles of CRP levels were independently associated with a higher risk of adverse coronary events (relative risk = 2.0 [1.1 to 3.5], tertile I vs. II and III, p = 0.01) in addition to the minimal lumen diameter after stent (p = 0.04). In addition, restenosis rates were significantly higher in the two upper tertiles compared with CRP levels in the lowest tertile (45.5% vs. 38.3% vs. 18.5%, respectively, p = 0.002).nnnCONCLUSIONSnLow-grade inflammation as evidenced by elevated preprocedural serum CRP-levels is an independent predictor of adverse outcome after coronary stent implantation, suggesting that a systemically detectable inflammatory activity is associated with proliferative responses within successfully implanted stents.

Statin therapy, inflammation and recurrent coronary events in patients following coronary stent implantation

OBJECTIVESnWe sought to investigate whether statin therapy affects the association between preprocedural C-reactive protein (CRP) levels and the risk for recurrent coronary events in patients undergoing coronary stent implantation.nnnBACKGROUNDnLow-grade inflammation as detected by elevated CRP levels predicts the risk of recurrent coronary events. The effect of inflammation on coronary risk may be attenuated by statin therapy.nnnMETHODSnWe investigated a potential interrelation among statin therapy, serum evidence of inflammation, and the risk for recurrent coronary events in 388 consecutive patients undergoing coronary stent implantation. Patients were grouped according to the median CRP level (0.6 mg/dl) and to the presence of statin therapy.nnnRESULTSnA primary combined end point event occurred significantly more frequently in patients with elevated CRP levels without statin therapy (RR [relative risk] 2.37, 95% CI [confidence interval] [1.3 to 4.2]). Importantly, in the presence of statin therapy, the RR for recurrent events was significantly reduced in the patients with elevated CRP levels (RR 1.27 [0.7 to 2.1]) to about the same degree as in patients with CRP levels below 0.6 mg/dl and who did not receive statin therapy (RR 1.1 [0.8 to 1.3]).nnnCONCLUSIONSnStatin therapy significantly attenuates the increased risk for major adverse cardiac events in patients with elevated CRP levels undergoing coronary stent implantation, suggesting that statin therapy interferes with the detrimental effects of inflammation on accelerated atherosclerotic disease progression following coronary stenting.

Coronary stent grafts covered by a polytetrafluoroethylene membrane

In a prospective observational study, 40 patients were treated with coronary stent grafts covered by a polytetrafluoroethylene membrane. These devices may be regarded as therapy of choice for acute coronary rupture; treatment of conventional in-stent restenosis was not associated with a favorable outcome, whereas the promising results in degenerated vein grafts warrant a randomized, controlled trial.

Treatment of Aortocoronary Vein Graft Lesions With Membrane-Covered Stents: A Multicenter Surveillance Trial

BackgroundStent implantation in lesions of degenerated aortocoronary vein grafts is associated with a high risk of periprocedural thrombus embolization and in-stent restenosis. Methods and ResultsIn a multicenter study, we followed up 109 consecutive patients (mean age 66±8 years, 12% female) who received polytetrafluoroethylene (PTFE) membrane–covered stents for 125 de novo stenoses in vein grafts 11±5 years after bypass surgery. Stent deployment was successful in all but 1 patient; 1 patient suffered from subacute stent thrombosis. Six-month cardiac mortality was 7% (8 patients), 3 patients (3%) underwent repeat bypass surgery, and 9 patients (8%) required target-lesion PTCA. Repeat angiography revealed vessel occlusions in 9% and in-stent restenosis in 8% of patients by the end of follow-up. ConclusionsMembrane-covered stents appear to be a safe and efficient treatment strategy associated with a low incidence of restenosis and target-vessel revascularization. Compared with previous studies, the investigated device is not associated with an increase in mortality or late vessel occlusions.

Transient bilateral cortical blindness after coronary angiography.

breakdown of the blood-brain barrier selective for the occipital cortex with subsequent direct neurotoxicity of the contrast media. To our knowledge there have not been any reports showing the widespread effect on brain tissue, as in our case, weakening the hypothesis of selective disruption of the blood-brain barrier. The mechanism remains unknown, although neurotoxicity may be related to certain critical groups on the contrast media molecules. Rama and colleagues could show that re-exposure to contrast media during coronary angiography in three patients who developed transient cortical blindness at a previous angiography did not cause recurrent episodes of cortical blindness. Patient outcome seems to be favourable with return of vision within 24-48 hours and probably no increased risk at re-exposure.

Benefits of immediate initiation of statin therapy following successful coronary stent implantation in patients with stable and unstable angina pectoris and Q-wave acute myocardial infarction

Statin therapy reduces clinical events in patients with stable coronary artery disease. Recent data indicate that the beneficial effects of statin therapy may also extend to patients experiencing an acute ischemic coronary event. However, the potential role of statins to further modify clinical outcome in patients undergoing coronary stent implantation has not been addressed. Therefore, we investigated whether the initiation of statin therapy immediately after successful coronary stent implantation improves short-term clinical outcome in 704 patients (335 patients with stable angina pectoris [AP], 224 patients with unstable AP, and 145 patients with Q-wave acute myocardial infarction [AMI]). Compared with the lowest risk group (patients with stable AP receiving statin therapy), patients with unstable AP (RR 6.9, 95% confidence interval [CI] 1.5 to 31, p = 0.004) and patients with Q-wave AMI (RR 7.6, 95% CI 1.5 to 37, p = 0.004) experienced an increased risk for the occurrence of the primary combined end point of cardiac death and AMI. Importantly, initiation of statin therapy abrogated the increased risk in patients with unstable AP to the level of patients with stable AP receiving statin therapy (RR 1.5, 95% CI 0.2 to 11, p = 0.7). In contrast, statin therapy did not affect the RR in patients with Q-wave AMI during 6-month follow-up (RR 7.9, 95% CI 1.6 to 39 vs RR 7.6, 95% CI 1.5 to 37, p = NS). The beneficial effects of statin therapy after successful coronary stent implantation in unstable AP were most prominent during the first 4 weeks after the ischemic episode. Statins appear to contribute to the rapid transformation of unstable coronary artery disease into a stable condition with a very low event rate over the forthcoming 6 months in patients with unstable AP undergoing successful coronary stent implantation.

Cobalt–chrome MULTI-LINK VISION™-stent implantation in diabetics and complex lesions: results from the DaVinci-Registry

AimsRestenosis in bare-metal stents is in part related to stent design and material. Optimized strut design of cobalt–chrome (CoCr) stents may yield nearly comparable results to drug-eluting stents (DES) in selected lesions. The prospective multicenter DaVinci registry investigates the clinical outcome of a CoCr coronary stent (MULTI-LINK VISION™), particularly in terms of patients with diabetes and complex lesions (B1, B2, C).Methods and resultsThe prospective internet-based registry included 1,344 patients (76% males, aged 66xa0±xa010xa0years) undergoing stent implantation (nxa0=xa01,642) in 32 centres from July 2003 to June 2004. Follow-up data (median 9xa0±xa01xa0months) of this cohort were available for 1,289 patients (98.1%). Of these patients 327 (26.2%) were diabetics. In total, 1,429 de-novo lesions (A 11.9%, B1 47.7%, B2 31.6%, C 8.8%) were treated with the CoCr stent. The predefined primary endpoint was defined as a composite of death, Q-wave myocardial infarction (STEMI), non-STEMI (NSTEMI), target vessel revascularization (TVR) by coronary bypass graft (CABG) or PCI at 270xa0days (target vessel failure, TVF). Secondary endpoints include death, time to the first myocardial infarction, TVR and CABG. The cumulative incidence of major adverse cardiac events (MACE) was 12.4% with 0.8% deaths, 1.5% non-fatal MI, and 9.7% TVR. TVF in the overall cohort was documented in 137 (10.8%) patients. For diabetics and complex lesions TVF was 13.8% (95% CI 4.2–18) and 11.4% (95% CI 2.0–13.3), respectively.ConclusionThis large registry confirms good acute and long-term success of CoCr stents making this strategy valuable, particularly in a special cohort (diabetics and complex lesions) as long as late stent thrombosis with DES plays a role and short-term antiplatelet therapy is favoured.

Koronarer Spasmus — Ein klinisch relevantes Problem?

ZusammenfassungKoronarspasmen sind reversible Koronarstenosen, die zu einer kritischen Einschränkung des koronaren Blutflusses unter Ruhebedingungen führen. Die vasospastische Angina kann durch den Nachweis der erhöhten Kontraktilität der Koronararterien entweder durch spontane Spasmen oder durch geeignete Provokationstests diagnostiziert werden. Obwohl verschiedene Stimuli Koronarspasmen auslösen können, ist mit Ergonovin die höchste Spezifität und Sensitivität im Vergleich zur klinischen Symptomatik belegt. Charakteristischerweise manifestieren sich Koronarspasmen als Angina pectoris in Ruhe, von besonderer klinischer Bedeutung sind Myokardinfarkte oder Synkopen. Die Prävalenz der Erkrankung ist mangels systematisch durchgeführter Provokationstests nicht bekannt, die Häufigkeit positiver Provokationstests hängt stark von der Symptomatik des untersuchten Patientenkollektivs ab (0 bis 54%). Spasmen treten fast immer in zumindest gering arteriosklerotisch veränderten Koronarsegmenten auf. Abweichend von der koronaren Herzkrankheit prädisponiert nur Zigarettenrauchen, nicht aber die anderen Risikofaktoren zum Auftreten von Koronarspasmen. Der endogene Mediator und die zellulären Mechanismen bei der Erkrankung sind unbekannt. Die Prognose quoad vitam ist günstig. Die Therapie der Wahl ist die Behandlung mit Calciumantagonisten und Nitraten, während β-Blocker bei diesen Patienten nicht angewandt werden sollten. Die Symptomatik persistiert oder rekurriert jedoch häufig trotz medikamentöser Therapie.SummaryCoronary spasms are defined as reversible coronary stenosis, which limits coronary blood flow under resting conditions. The demonstration of either spontaneous or provoked coronary spasm proves coronary hypercontractility and thus the diagnosis of variant angina. Several stimuli can provoke coronary vasospasm, but the highest sensitivity and specificity has been shown with ergonovine. Alternatively acetylcholine or, with less sensitivity, but high specificity, hyperventilation may be employed. Typically coronary vasospasm presents with angina pectoris at rest; the manifestation with myocardial infarction or syncope are of great clinical importance. The prevalence of the disease is unknown due to the rarely performed provocation tests in Western countries. The incidence of positive test results strongly depends on the symptoms of the patients; from 0% in patients without any evidence for myocardial ischemia up to 54% in patients with typical angina at rest have been observed. Coronary vasospasm is closely related to atherosclerotic coronary artery disease, since intravascular ultrasound studies reveal atherosclerotic plaques in almost any spastic segment. Risk factors for coronary artery disease and coronary vasospasm, however, differ profoundly. For the latter cigarette smoking is the only established risk factor. Although several candidates and predisposing factors (serotonin, histamine, thromboxane, endothelin) have been described, the mediators and the pathogenesis of the disease remains unknown. Endothelial dysfunction alone is not sufficient to explain the features of variant angina. Some evidence supports the hypothesis of local inflammation. The mortality in variant angina depends on the extent of the coronary artery disease. Pure coronary vasospasm does not lead to increased mortality; patients with highly active disease presenting with syncope may have an increased risk. Medical treatment should include long-acting calcium antagonists or nitrates, β-blockers may even favor the occurrence of ischemic attacks. Although the benefit has not been proven, the use of aspirin® may considered in highly active disease.Coronary spasms are defined as reversible coronary stenosis, which limits coronary blood flow under resting conditions. The demonstration of either spontaneous or provoked coronary spasm proves coronary hypercontractility and thus the diagnosis of variant angina. Several stimuli can provoke coronary vasospasm, but the highest sensitivity and specificity has been shown with ergonovine. Alternatively acetylcholine or with less sensitivity, but high specificity, hyperventilation may be employed. Typically coronary vasospasm presents with angina pectoris at rest; the manifestation with myocardial infarction or syncope are of great clinical importance. The prevalence of the disease is unknown due to the rarely performed provocation tests in Western countries. The incidence of positive test results strongly depends on the symptoms of the patients; from 0% in patients without any evidence for myocardial ischemia up to 54% in patients with typical angina at rest have been observed. Coronary vasospasm is closely related to atherosclerotic coronary artery disease, since intravascular ultrasound studies reveal atherosclerotic plaques in almost any spastic segment. Risk factors for coronary artery disease and coronary vasospasm, however, differ profoundly. For the latter cigarette smoking is the only established risk factor. Although several candidates and predisposing factors (serotonin, histamine, thromboxane, endothelin) have been described, the mediators and the pathogenesis of the disease remains unknown. Endothelial dysfunction alone is not sufficient to explain the features of variant angina. Some evidence supports the hypothesis of local inflammation. The mortality in variant angina depends on the extent of the coronary artery disease. Pure coronary vasospasm does not lead to increased mortality; patients with highly active disease presenting with syncope may have an increased risk. Medical treatment should include long-acting calcium antagonists or nitrates, beta-blockers may even favor the occurrence of ischemic attacks. Although the benefit has not been proven, the use of aspirin may considered in highly active disease.

[Coronary stent implantation in elderly patients: acute and long-term results].

The number of elderly patients with coronary heart disease is rapidly growing. Morbidity, related with PTCA is increased in elderly patients, presumably because of the more complex adverse baseline characteristics. However, it has not been firmly elucidated whether routine use of coronary stents is associated with a more favourable outcome in this population. Therefore, we investigated the influence of age on acute procedural success, rate of restenosis (quantitative coronary angiography) and major cardiovascular events (death/myocardial infarction [MI]) 6 months after intracoronary stent implantation in 1306 patients. Patients were categorised into < 65 years (n = 709), 65–75 years (n = 443) and > 75 years (n = 154). Older patients had a higher amount of multivessel disease (p < 0.001) and a lower left ventricular ejection fraction (p < 0.001). Nevertheless, the rate of acute success and restenosis were comparable between the different age groups. In contrast, older patients had significantly more adverse clinical events during long-term followup. (Death/MI < 65 years 3.0%, 65–75 years 3.9%, > 75 years 7.8%, p = 0.02). However, by multivariate analysis age was no longer an independent predictor of adverse clinical events (p = 0.26), which were predominantly determined by coexisting impaired left ventricular function (p < 0.001). After proper judgement of the clinical situation, coronary stent implantation should be considered in selected elderly patients. Thus, advanced age as a solely factor should not be regarded as a contraindication for coronary stent implantation. Aufgrund der demographischen Entwicklung nimmt der Anteil älterer Patienten mit koronarer Herzerkrankung ständig zu. Eine stärkere Verkalkung der Gefäße im Alter wirkt sich ungünstig auf die Ergebnisse einer Ballondilatation aus; ein Nachteil, der durch die Verwendung von koronaren Stents ausgeglichen werden könnte. Wir untersuchten daher den Einfluss von Alter auf Akutergebnis und Restenoserate (quantitative Koronarangiographie) sowie auf das Auftreten von kardiovaskulären Ereignissen (Tod/Myokardinfarkt) bei 1306 konsekutiven Patienten nach intrakoronarer Stentimplantation. Die Patienten wurden kategorisiert in < 65 (n = 706), 65–75 (n = 443) und > 75 (n = 154) Jahre. Alte Patienten weisen häufiger Mehrgefäßerkrankungen (p < 0,001) und eine schlechtere linksventrikuläre Funktion (p < 0,001) auf als jüngere Patienten. Trotzdem waren die akute Erfolgsrate sowie die Restenoserate zwischen allen Altersgruppen vergleichbar. Allerdings weisen ältere Patienten eine signifikant höhere Ereignisrate (Tod/Myokardinfarkt) innerhalb von 6 Monaten auf (3,0% bei < 65 Jahre, 3,9% bei 65–75 Jahre und 7,8% bei > 75 Jahre, p = 0,02). Die multivariate Cox-Regressionsanalyse demonstriert aber, dass hohes Alter an sich keinen unabhängigen Risikofaktor darstellt (p = 0,26), sondern dass vielmehr die bei alten Patienten häufiger eingeschränkte linksventrikuläre Pumpfunktion als unabhängiger Prädiktor für das Auftreten von Tod oder Myokardinfarkt innerhalb von 6 Monaten anzusehen ist (p < 0,001). Nach sorgfältiger Abwägung der Gesamtsituation des Patienten kann bei ausgewählten Patienten auch im hohen Alter eine perkutane Revaskularisation mit Stentimplantation mit gutem Langzeitergebnis durchgeführt werden. Ein hohes Alter per se ist demnach keine Kontraindikation für eine koronare Stentimplantation.

Koronare Stentimplantation bei alten Patienten

The number of elderly patients with coronary heart disease is rapidly growing. Morbidity, related with PTCA is increased in elderly patients, presumably because of the more complex adverse baseline characteristics. However, it has not been firmly elucidated whether routine use of coronary stents is associated with a more favourable outcome in this population. Therefore, we investigated the influence of age on acute procedural success, rate of restenosis (quantitative coronary angiography) and major cardiovascular events (death/myocardial infarction [MI]) 6 months after intracoronary stent implantation in 1306 patients. Patients were categorised into < 65 years (n = 709), 65–75 years (n = 443) and > 75 years (n = 154). Older patients had a higher amount of multivessel disease (p < 0.001) and a lower left ventricular ejection fraction (p < 0.001). Nevertheless, the rate of acute success and restenosis were comparable between the different age groups. In contrast, older patients had significantly more adverse clinical events during long-term followup. (Death/MI < 65 years 3.0%, 65–75 years 3.9%, > 75 years 7.8%, p = 0.02). However, by multivariate analysis age was no longer an independent predictor of adverse clinical events (p = 0.26), which were predominantly determined by coexisting impaired left ventricular function (p < 0.001). After proper judgement of the clinical situation, coronary stent implantation should be considered in selected elderly patients. Thus, advanced age as a solely factor should not be regarded as a contraindication for coronary stent implantation. Aufgrund der demographischen Entwicklung nimmt der Anteil älterer Patienten mit koronarer Herzerkrankung ständig zu. Eine stärkere Verkalkung der Gefäße im Alter wirkt sich ungünstig auf die Ergebnisse einer Ballondilatation aus; ein Nachteil, der durch die Verwendung von koronaren Stents ausgeglichen werden könnte. Wir untersuchten daher den Einfluss von Alter auf Akutergebnis und Restenoserate (quantitative Koronarangiographie) sowie auf das Auftreten von kardiovaskulären Ereignissen (Tod/Myokardinfarkt) bei 1306 konsekutiven Patienten nach intrakoronarer Stentimplantation. Die Patienten wurden kategorisiert in < 65 (n = 706), 65–75 (n = 443) und > 75 (n = 154) Jahre. Alte Patienten weisen häufiger Mehrgefäßerkrankungen (p < 0,001) und eine schlechtere linksventrikuläre Funktion (p < 0,001) auf als jüngere Patienten. Trotzdem waren die akute Erfolgsrate sowie die Restenoserate zwischen allen Altersgruppen vergleichbar. Allerdings weisen ältere Patienten eine signifikant höhere Ereignisrate (Tod/Myokardinfarkt) innerhalb von 6 Monaten auf (3,0% bei < 65 Jahre, 3,9% bei 65–75 Jahre und 7,8% bei > 75 Jahre, p = 0,02). Die multivariate Cox-Regressionsanalyse demonstriert aber, dass hohes Alter an sich keinen unabhängigen Risikofaktor darstellt (p = 0,26), sondern dass vielmehr die bei alten Patienten häufiger eingeschränkte linksventrikuläre Pumpfunktion als unabhängiger Prädiktor für das Auftreten von Tod oder Myokardinfarkt innerhalb von 6 Monaten anzusehen ist (p < 0,001). Nach sorgfältiger Abwägung der Gesamtsituation des Patienten kann bei ausgewählten Patienten auch im hohen Alter eine perkutane Revaskularisation mit Stentimplantation mit gutem Langzeitergebnis durchgeführt werden. Ein hohes Alter per se ist demnach keine Kontraindikation für eine koronare Stentimplantation.