Yu Yang Liu

Impact of clopidogrel resistance on thrombotic events after percutaneous coronary intervention with drug-eluting stent

OBJECTIVES This study examines whether patient resistance to clopidogrel is associated with long-term thrombotic events after elective coronary drug-eluting stent (DES) implantation. METHODS We prospectively enrolled 386 patients with stable angina who received elective percutaneous coronary intervention (PCI) with DES. Before the procedure, platelet reactivity was measured by light transmittance aggregometry (LTA) at baseline and approximately 24 h after the 300 mg loading dose of clopidogrel. Clopidogrel resistance was conservatively defined as < or = 10% absolute difference between baseline and post-treatment platelet aggregation. All patients received chronic dual antiplatelet treatment (aspirin 300 mg and clopidogrel 75 mg daily) for 12 months. Patients were followed for 1 year after coronary stenting for the occurrence of composite thrombotic events, including cardiovascular death, non-fatal myocardial infarction (MI), stent thrombosis or cerebrovascular ischemic accident (CVA). RESULTS Clopidogrel resistance was present in 65 patients (16.8%). During follow-up, composite thrombotic events occurred in 16.9% of clopidogrel resistant patients, yet in only 6.2% of non-resistant patients (p = 0.010). The incidence of definite or probable stent thrombosis was 9.2% in clopidogrel resistant patients and 2.5% in non-resistant patients (p = 0.018). After adjustment for other factors that affect cardiovascular outcome, clopidogrel resistance, diabetes, and left ventricular (LV) dysfunction were independently associated with 1-year composite thrombotic events. The hazard ratio (HR) for clopidogrel resistance was 2.44 (95% CI = 1.09 to 5.45; p = 0.031). CONCLUSION This study demonstrates the natural history of clopidogrel resistance among patients with stable cardiovascular disease, and shows that this resistance is an independent predictor of thrombotic events in patients undergoing PCI with DES.

Obesity and cardiovascular thrombotic events in patients undergoing percutaneous coronary intervention with drug-eluting stents

Background: Previous studies have reported conflicting findings regarding the relation of body mass index (BMI) to outcomes following percutaneous coronary interventions (PCI). No study to date has directly examined the effect of obesity on cardiovascular thrombotic events after stent implantation. Objective: To evaluate the effect of obesity on cardiovascular thrombotic events in patients undergoing PCI with drug-eluting stents. Methods: We studied 4972 patients between January 2004 and December 2006. Patients were divided into three groups according to body mass index: normal (BMI <24.9 kg/m2, n = 1284), overweight (BMI 25–29.9 kg/m2, n = 2475) and obese (BMI ⩾30 kg/m2, n = 1213). Median follow-up was 26 (interquartile range 20–33) months. Results: Composite cardiovascular thrombotic events, including cardiac death and non-fatal myocardial infarction, were significantly higher in obese patients (5.9%) than in normal (3.2%) and overweight (3.8%) patients (p = 0.001). The incidence of definite or probable stent thrombosis steadily increased with increasing body mass index (0.9% vs 1.0% vs 1.9% in normal, overweight and obese patients, respectively; p = 0.029). Multivariate analyses showed that obesity was an independent predictor of 3-year composite thrombotic events (hazard ratio 1.86; 95% confidence interval 1.25 to 2.75; p = 0.003) and definite or probable stent thrombosis (2.17; 1.04 to 4.55; p = 0.040). Conclusions: Obese patients have a higher risk for long-term cardiovascular thrombotic events following PCI with drug-eluting stents than patients with normal weight.

Effect of Obesity on Repeat Revascularization in Patients Undergoing Percutaneous Coronary Intervention With Drug‐Eluting Stents

Obesity is a major risk factor for developing coronary artery disease. The impact of obesity on prognosis among those with established coronary disease is less clear. The objective of this study was to evaluate the effect of obesity on repeat revascularization in patients undergoing percutaneous coronary intervention (PCI) with drug‐eluting stents (DES). We examined 6,083 patients who were divided into three groups according to BMI: normal (BMI 18.5–24.9 kg/m2, n = 1,592); overweight (BMI 25–29.9 kg/m2, n = 3,026) and obese (BMI >30 kg/m2, n = 1,465). The follow‐up focused on clinical‐driven repeat revascularization, including target lesion revascularization (TLR) and nonTLR. Median follow‐up was 26 months (interquartile range 20–32). There was no significant difference in the incidence of TLR among normal, overweight, and obese patients (6.3% vs. 6.1% vs. 7.1%; P = 0.423). In contrast, the incidence of nonTLR was significantly higher in obese patients compared with normal and overweight (8.4% vs. 6.0% vs. 5.8%, P = 0.003). Multivariate analysis showed that obesity was an independent predictor of nonTLR during follow‐up (hazard ratio = 1.39; 95% confidence interval = 1.06–1.83; P = 0.019), along with diabetes and hypercholesterolemia. Concomitant use of statins was independently associated with decreased risk of nonTLR (hazard ratio = 0.75; 95% confidence interval = 0.62–0.92; P = 0.005). In conclusion, among patients undergoing PCI with DES, obesity was not associated with TLR, but was associated with a higher risk of nonTLR.

The Effect of Intravenous Vitamin C Infusion on Periprocedural Myocardial Injury for Patients Undergoing Elective Percutaneous Coronary Intervention

BACKGROUND This small study has determined the effect of vitamin C on myocardial reperfusion in patients undergoing elective percutaneous coronary intervention (PCI). This study was to explore whether antioxidant vitamin C infusion before the procedure is able to affect the incidence of periprocedural myocardial injury (PMI) in patients undergoing PCI. METHODS In this prospective single-centre randomized study, 532 patients were randomized into 2 groups: the vitamin C group, which received a 3-g vitamin C infusion within 6 hours before PCI, and a control group, which received normal saline. The primary end point was the troponin I-defined PMI, and the second end point was the creatine kinase (CK)-MB-defined PMI. Separate analyses using both end points were performed. PMI was defined as an elevation of cardiac biomarker values (CK-MB or troponin I) > 5 times the upper limit of normal (ULN), alone or associated with chest pain or ST-segment or T-wave changes. RESULTS After PCI, the incidence of PMI was reduced, whether defined by troponin or by CK-MB, compared with the control group (troponin I, 10.9% vs 18.4%; P = 0.016; CK-MB, 4.2% vs 8.6%; P = 0.035). Logistic multivariate analysis showed that preprocedure use of vitamin C is an independent predictor of PMI either defined by troponin I (odds ratio [OR], 0.56; 95% confidence interval [CI], 0.33-0.97; P = 0.037) or by CK-MB (OR, 0.37; 95% CI, 0.14-0.99; P = 0.048). CONCLUSIONS In patients undergoing elective PCI, preprocedure intravenous treatment with vitamin C is associated with less myocardial injury.

Association of depression with adverse cardiovascular events after percutaneous coronary intervention.

ObjectiveThe aim of this study was to investigate the impact of depression on the clinical outcomes of patients with coronary artery disease undergoing percutaneous coronary intervention (PCI). MethodsA total of 400 patients treated with PCI were assessed using the Mini-International Neuropsychiatric Interview 1 day before and 2 weeks after the procedure. All patients were followed up for 3 years after the procedure. The primary endpoint was a major adverse cardiovascular event (MACE) including mortality, nonfatal myocardial infarction, or repeat revascularization. ResultsDepression was present in 38.5% (n=154) of patients after the procedure, which was significantly higher than that before the procedure (25.5%, P<0.001). Patients with postprocedure depression had a higher rate of MACE (27.3 vs. 13.0%, P<0.001), mortality (5.8 vs. 2.0%, P=0.044), and repeat revascularization (13.0 vs. 6.5%, P=0.027) compared with patients without depression during the 3 years of follow-up. After adjustment for other factors that affect cardiovascular outcomes, postprocedure depression was seen to be an independent predictor of 3-year MACE [hazard ratio: 2.51, 95% confidence interval (CI): 1.57–4.02, P<0.001], mortality (3.60, 95% CI: 1.16–11.22, P=0.027), and repeat revascularization (hazard ratio: 2.22, 95% CI: 1.09–4.51, P=0.029). ConclusionDepression is common among patients treated with PCI. Postprocedure depression is an independent predictor of 3-year MACE, mortality, and repeat revascularization.

Contemporary Management and Attainment of Cholesterol Targets for Patients with Dyslipidemia in China

Aims It is well-established that lipid disorder is an important cardiovascular risk factor, and failure to reach optimal lipid levels significantly contributes to the residual cardiovascular risks. However, limited information is available on the management and the attainment of recommended cholesterol targets in real-world practice in China. Methods and Results A nationally representative sample of 12,040 patients with dyslipidemia from 19 provinces and 84 hospitals across China were consecutively enrolled in this survey. Risk stratification and individual cholesterol target was established for all participants. This survey identified a high-risk cohort, with over 50% of patients had hypertension, 37.5% had coronary artery disease, and more than 30% had peripheral artery disease. Thirty-nine percent of all participants received lipid lowering medications. And the majority of them (94.5%) had statins (42.5% with atorvastatin, 29.0% with simvastatin, and 15.2% with rosuvastatin). However, the overall attainment for low-density lipoprotein cholesterol (LDL-C) target is low (25.8%), especially, in female (22.2%), and in patients with increased body mass index (BMI) (38.3% for BMI<18.5, 28.1% for BMI 18.5–24.9, 26.0% for BMI 25.0–29.9, and 17.4% for BMI≥30, P<0.0001). Subgroup analysis also showed the attainment is significantly lower in patients who were stratified into high (19.9%) and very high (21.1%) risk category. In logistic regression analysis, eight factors (BMI, gender, coronary artery disease, systolic and diastolic blood pressure, hypertension, family history of premature coronary artery disease and current smoking) were identified as independent predictors of LDL-C attainment. Conclusions Despite the proven benefits of lipid-lowering therapies, current management of dyslipidemia continues to be unsatisfied. A considerable proportion of patients failed to achieve guideline-recommended targets in China, and this apparent treatment gap was more pronounced among patients with increased BMI, higher risk stratification and women.

Drug-Eluting Stents Versus Bare-Metal Stents in Patients With Decreased GFR: A Meta-analysis

BACKGROUND Decreased estimated glomerular filtration rate (eGFR) is a strong predictor of both mortality and subsequent cardiac events after percutaneous coronary intervention. The safety and efficacy of drug-eluting (DESs) versus bare-metal stents (BMSs) in this population have not been evaluated adequately. STUDY DESIGN A systematic review and meta-analysis. SETTING & POPULATION Studies involving the comparison of clinical outcomes between DESs and BMSs in patients with eGFR <60 mL/min/1.73 m(2). Studies exclusively involving patients with ST-segment elevation myocardial infarction were excluded. SELECTION CRITERIA FOR STUDIES MEDLINE (on Ovid), EMBASE, and the Cochrane Library databases from 2002-2013 were searched for studies comparing DESs with BMSs in patients with eGFR <60 mL/min/1.73 m(2). INTERVENTION DES versus BMS implantation. OUTCOMES Mortality, repeat revascularization, myocardial infarction, and stent thrombosis. RESULTS Data from 26 comparative studies with 66,840 patients were included. Compared with BMSs, DESs were associated with significant reductions in repeat revascularization (OR, 0.61; 95% CI, 0.50-0.74; P < 0.001) and myocardial infarction (OR, 0.85; 95% CI, 0.79-0.92; P < 0.001), with no detectable difference in stent thrombosis (OR, 0.72; 95% CI, 0.46-1.12; P = 0.1). The superiority of DESs over BMSs in decreasing mortality also was documented (OR, 0.77; 95% CI, 0.65-0.90; P = 0.01). This survival benefit of DESs over BMSs was attenuated in randomized controlled trials or adjusted observational studies versus unadjusted observational studies. LIMITATIONS Most studies were observational studies. Meta-analysis was not performed on individual patient data. CONCLUSIONS DES use in patients with eGFR <60 mL/min/1.73 m(2) is associated with a reduced rate of repeat revascularization and myocardial infarction without increased risk of stent thrombosis. The true effect of DESs versus BMSs on mortality needs to be confirmed by randomized controlled trials.

Sex difference in the effect of obesity on prognosis for patients undergoing percutaneous coronary intervention.

ObjectivesTo examine whether obesity has a similar effect on long-term prognosis between men and women undergoing a percutaneous coronary intervention (PCI). MethodsWe separately examined 3926 men and 2157 women undergoing PCI with drug-eluting stents between January 2004 and December 2006. All the patients were categorized according to BMI: normal weight (<25 kg/m2), overweight (25–29.9 kg/m2), and obese (≥30 kg/m2). The primary endpoint was major adverse cardiovascular events (MACE), defined as a composite of cardiac death and nonfatal myocardial infarction. The median follow-up was 26 months. ResultsThe MACE rate was significantly higher in obese than in normal-weight and overweight patients among men (6.8 vs. 3.5 vs. 4.2%; P=0.001) but not among women (5.1 vs. 4.4 vs. 4.1%; P=0.684). Further categorization of BMI showed a linear association between the risk of MACE and BMI in men, with a graded increase in obesity grade I (30–34.9 kg/m2) and grade II/III (≥35 kg/m2) groups compared with normal-weight individuals [hazard ratio (HR) 1.94; 95% confidence interval (CI) 1.22–3.06; P=0.005 for obesity grade I and HR 2.62; 95% CI 1.50–4.56; P=0.001 for obesity grade II/III]. In women, the risk of MACE showed no difference in obesity grade I group, whereas there was a significant increase in the obesity grade II/III group compared with normal-weight patients (HR 2.15; 95% CI 1.10–4.18; P=0.025). ConclusionIn patients undergoing PCI, BMI is associated with a risk of MACE in both men and women. However, BMI exerts relatively less effect on women than on men.