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The aim of this study was to determine the natural history of vascular remodeling of atherosclerotic plaques in patients with type 2 diabetes and the predictors of vessel shrinkage.
In this serial intracoronary ultrasound (IVUS) study, 237 coronary segments from 45 patients enrolled in the DIABETES I, II, and III trials were included. Quantitative...
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Background. Treatment of coronary intermediate lesions remains a controversy, and the role of arterial remodeling patterns determined by intravascular ultrasound in intermediate lesion is still not well known. The aim of this study was to investigate the impact of arterial remodeling of intermediate coronary lesions on long-term clinical outcomes....
Citations
... Although significant advancements in therapeutic techniques, it remains challenging to treat small vessel coronary artery lesions resulting from a higher risk of technical failure, restenosis, and need for repeated revascularization (2,3). Compared with non-diabetic patients, patients with diabetes mellitus suffered from worse clinical outcomes (e.g., binary restenosis and myocardial infarction) after PCI (4)(5)(6)(7) owing to more challenging coronary anatomies (8)(9)(10), such as diffuse atherosclerotic plaques and higher frequency of thin-cap fibroatheroma and fibrocalcific atheroma (11). ...
Purpose
This meta-analysis aimed to explore the comparative short-term efficacy and safety of drug-coated balloon (DCB) vs. drug-eluting stent (DES) for treating small-vessel coronary artery lesions in diabetic patients.
Methods
We searched PubMed, EMBASE, the Cochrane Library, and China National Knowledgement Infrastructure (CNKI) for retrieving relevant studies regarding the comparison of DCB with DES in treating small-vessel coronary artery lesions in diabetic patients until May 31, 2022. Two independent authors screened study, extracted data, and assessed methodological quality. Then, the meta-analysis was conducted using RevMan software, version 5.4.
Results
We included 6 studies with 847 patients in this meta-analysis. Pooled results showed that DCB was associated with fewer major adverse cardiac events (MACE) [RR, 0.60; 95% confidence interval (CI), 0.39–0.93; p = 0.02], myocardial infarction (MI) (RR, 0.42; 95% CI, 0.19–0.94; p = 0.03), target lesion revascularization (TLR) (RR, 0.24; 95% CI, 0.08–0.69; p < 0.001), target vessel revascularization (TVR) (RR, 0.33; 95% CI, 0.18–0.63; p < 0.001), binary restenosis (RR, 0.27; 95% CI, 0.11–0.68; p = 0.005), and late lumen loss (LLL) [mean difference (MD), −0.31; 95% CI, −0.36 to −0.27; p < 0.001], but was comparable technique success rate, death, minimal lumen diameter (MLD), and net lumen gain (NLG) to DES. There was no difference in long-term outcomes between these two techniques.
Conclusions
This meta-analysis shows that DCB is better than DES in the short-term therapeutic efficacy and safety of small-vessel coronary artery lesions in diabetic patients. However, more studies are required to validate our findings and investigate the long-term effects and safety of DCB.
... 50 51 Two different patterns of coronary remodelling have been described: a compensatory enlargement of the vessel in response to an increased burden of atherosclerotic plaque (positive remodelling) and a failure to enlarge or even vessel attenuation (negative remodelling). 52 The latter is a common finding in coronary stenosis of diabetic patients. In cross-sectional studies, negative remodelling has been associated with coronary risk factors, such as hypertension, tobacco use, the type of plaque (calcified, hard plaques) and metabolic control in diabetic patients. ...
Background
This study aimed to determine if there were any significant differences in coronary artery (CA) dimensions at prespecified segments during cardiac CT angiography (CCTA) compared with ethnicity at an academic tertiary medical centre in Trinidad and Tobago.
Methods
Patients (n=170) who underwent CCTA from July 2016 to June 2021 at the Eric Williams Medical Sciences Complex were selected based on predefined selection criteria. The size of the left main and proximal, mid and distal diameters of the left anterior descending, left circumflex and right coronary artery (RCA) were measured using quantitative coronary angiography, syngo.CT Coronary Analysis (Siemens Healthineers AG, Erlangen, Germany). Routine medical history, cardiovascular medications and anthropometric data were also recorded. Comparisons were performed using an independent sample t-test and analysis of variance for continuous variables.
Results
One hundred and seventy participants were enrolled in this study. There were no statistically significant associations between gender and CA dimensions; however, there were significant associations between South Asian and Caribbean black ethnicities for almost all CA dimensions except for the distal RCA segment. These findings were replicated when the analysis was adjusted for body surface area with the addition of the mid-RCA segment, which was bordering near-significance (p value 0.051).
Conclusions
Significantly smaller CA dimensions were observed in South Asian patients compared with Caribbean black patients undergoing CCTA. This pilot study could be clinically significant for Trinidadian patients at risk of developing coronary artery disease.
Trial registration number
NCT04774861 .
... Diminutive vessel data are limited [28]. In cardiology, diminutive vessels or postobstruction vessel shrinkage are more common in chronic progressive occlusive pathologies, such as atherosclerosis [29,30]. Some Asian registries showed that intracranial atherosclerosis may be associated with smaller vessel diameters [2]. ...
Purpose
Despite advancement in mechanical thrombectomy (MT) techniques, 10–30% of MT for large vessel occlusions (LVO) are unsuccessful. Current prediction models fail to address the association between patient-specific factors and reperfusion. We aimed to evaluate objective, easily reproducible, admission clinical and radiological biomarkers that predict unsuccessful MT.
Methods
We analyzed consecutive anterior LVO MT patients at two comprehensive stroke centers. The primary outcome was unsuccessful reperfusion defined by a modified thrombolysis in cerebral infarction (mTICI) score of 0–2a. We quantitatively assessed the hyperdense vessel sign by measuring Hounsfield units (HU) on admission computed tomography (CT). Receiver operating characteristic (ROC) curves were plotted to estimate the predictive value of quantitative hyperdense middle cerebral artery (MCA) measurements (delta and ratio) and of the final model for mTICI scores. We performed multivariable logistic regression to analyze associations with outcomes.
Results
Out of 348 patients 87 had unsuccessful MT. Smoking, difficult arch, vessel tortuosity, vessel calcification, diminutive vessels, truncal M1 occlusion, delta HU and HU ratio were significantly associated with unsuccessful MT in the univariate analysis. When we fitted two separate multivariate models including all significant variables and a HU measurement; delta HU <6 (odds ratio, OR = 2.07, 95% confidence intervals, CI 1.09–3.92) and HU ratio ≤1.1 (OR = 2.003, 95% CI 1.05–3.81) were independently associated with failed MT after adjustment for smoking, diminutive vessels, vessel tortuosity, and difficult arch. The area under the curve AUC<9 of the final model was 0.717.
Conclusion
Novel radiological biomarkers on CT, CT angiography (CTA) and digital subtraction angiography (DSA) may help identify patients refractory to standard MT and prepare interventionalists for using additional alternative methods. Quantitative assessment of HU (delta and ratio) may be important in developing objective prediction tools for unsuccessful MT.
... In contrast, positive remodeling has been seen in the culprit lesions of ACS and negative remodeling in the stable angina in non-DM patients [39][40][41][42]. The natural history of vessel-wall remodeling in DM patients was studied by means of serial IVUS analyses, which showed positive vessel remodeling in two-thirds of plaque segments, with vessel shrinkage seen in the remaining third [43]. Vessel shrinkage is mainly influenced by insulin requirements. ...
Introduction:
The progression and pattern of coronary atherosclerosis in diabetes mellitus (DM) is different from non-DM, leading to a higher rate of vascular complications in DM.
Objective:
This study aims to assess and compare the high-risk plaque characteristics in the culprit artery of DM and non-DM patients with acute coronary syndrome (ACS) using virtual histology intravascular ultrasound (VH-IVUS).
Methods:
A total of 158 ACS patients were included, 63 of whom were known to have DM. IVUS analysis was done in the de novo target vessel and culprit lesion for which percutaneous coronary intervention was planned. Culprit lesions with a visual-estimate angiographic stenosis of <70% were excluded.
Results:
The mean age of patients was 52.4 ± 11.6 years. The study group comprised 82% men, 31% with hypertension, and 39.87% with DM. No significant difference was observed between the DM and non-DM groups in relation to quantitative IVUS parameters like lesion length, minimal lumen area, and plaque area. However, there was a significant difference in VH-IVUS parameters like higher necrotic core and dense calcium in the DM patients than in the non-DM patients (p < 0.01). The occurrence of VH-derived thin-cap fibroatheroma (VH-TCFA) in the culprit vessel was significantly higher in the DM group than in the non-DM group (25.3 vs. 5.2%; p < 0.01). Positive vessel-wall remodeling was noted in both groups without any significant difference (p = 0.74).
Conclusion:
The DM patients had high-risk plaque composition features like a higher necrotic core, which is a marker of plaque vulnerability. Thus, aggressive medical therapy targeting vascular inflammation using high-dose statins would help in the stabilization of unstable plaque morphology and the reduction of major cardiovascular events.
... With the presence of endothelial dysfunction, atherogenicity is increased, boosting the incidence of macrovascular disease. [27][28][29][30]. ...
Background
Sex differences in coronary artery disease presentation and outcomes have been described. The aim of this study was to compare sex disparities in chronic total occlusion (CTO) management and long-term outcomes.
Methods
All consecutive patients with at least one CTO diagnosed in our center between 2010 and 2014 were included. Demographic and clinical data were registered. All-cause and cardiac mortality were assessed during a median follow-up of 4.03 years (IQR 2.6–4.8).
Results
A total of 1248 patients (67.3 ± 10.9 years; 16% female) were identified. Women were older, had a higher prevalence of type 2 DM and a lower ventricle ejection fraction compared to men (p < .05). Although women had major proportion of positive result for severe ischemia-viability test (86% vs. 74%; p = .01), they were more often treated with MT alone compared to male (57% vs 51%; p = .02). During follow-up, 386 patients (31%) died. Women presented a higher rate of all-cause and cardiac mortality, and hospitalizations for heart failure independently of treatment strategy, compared to men (p < .001). In multivariable analysis female sex was associated with higher cardiac mortality [HR 1.67, 95% CI 1.10–2.57; p < .001]. Among women, the independent predictors for all-cause and cardiac mortalities were age, MT of the CTO and ACEF (age, creatinin and ejection fraction) score.
Conclusions
A significant sex gap regarding CTO treatment was observed. Female sex was an independent predictor for cardiac mortality at long-term follow-up. More data are needed to support these findings.
... Hyperglycaemia can enhance the activity of advanced glycation end products, thereby accelerating vascular inflammation, promoting smooth muscle cell proliferation and extracellular matrix production, and ultimately lead to excessive intimal hyperplasia and restenosis [8]. In addition, due to diabetic atherosclerosis, which is often complicated by insufficient vascular compensatory remodelling, patients with DM often have blood vessels with small diameters [9 ] . Insufficient stent expansion is also a mechanism for the formation of diabetic ISR [10,11]. ...
Background
The incidence of in-stent restenosis (ISR) in patients with diabetes mellitus (DM) after percutaneous coronary intervention (PCI) is significantly higher than that in patients without DM, but the mechanism is not clear. We hypothesised that patients with and risk factors including dyslipidaemia, elevated inflammatory factors would be prone to induction of ISR, and that dynamic observation of the comprehensive risk factor changes before and after PCI would be helpful to identify ISR .
Methods
This prospective cohort study consecutively enrolled 360 patients who received coronary drug-eluting stent implantation. Patients who underwent coronary angiography (CAG) and received clinical follow-up were prospectively reviewed. The patients were assigned to a DM (262) or a non-DM (98) group. The patients were further assigned according to whether ISR was present to the non-DM + non-ISR, non-DM + ISR, DM + non-ISR, and DM + ISR groups. The patients were further assigned according to whether low-density lipoprotein (LDL-c) was decreased more than 50% compared with baseline, or was less than 1.80 mmol/L in the follow-up, to the LDL-c achieved or the LDL-c failure groups.
Results
DM patients were prone to develop ISR after PCI and the degree of coronary stenosis was more severe than in non-DM patients. This result was more striking in DM and LDL-c failure patients. The levels of total cholesterol (TC), triglyceride, high-density lipoprotein (HDL-c), LDL-c, apolipoprotein B100, apolipoprotein E, remnant lipoprotein, TC/HDL-c ratio and triglyceride/HDL-c ratio in the DM + non-ISR were similar to those in the DM + ISR group before PCI and CAG. .The DM + ISR group had the highest levels of haemoglobin A1c and the highest Gensini scores. The inflammatory index changes including leukocytes and neutrophils were the most striking in the DM + ISR group. In multivariate regression analysis, neutrophil changes and glycosylated haemoglobin were independent risk factors for ISR [△neutrophil, OR 1.929,95% CI 1.216–3.058; HbA1-c OR 1.559,95% CI 1.001–1.707].
Conclusion
Coronary artery disease patients with DM had a high risk for ISR if they had preoperative risk factors including dyslipidaemia, elevated inflammatory factors, and a high Gensini score. Dynamic observation of the changes of the preoperative and postoperative comprehensive risk factors was helpful to identify ISR in patients with DM.
... Patients with diabetes are prone to have an early and accelerated course of coronary atherosclerosis [5] and exhibit a markedly increased incidence of adverse cardiovascular events and less favorable outcomes after myocardial infarction or percutaneous coronary intervention (PCI) [6][7][8][9]. Intravascular ultrasound (IVUS) studies have shown that apart from lesion progression, coronary arteries in diabetics, compared with those in non-diabetics, are typically described as smaller and more likely to be diffuse and undergo negative remodeling (when the vascular area decreased as plaque develops) [10]. However, the exact mechanisms of negative coronary artery remodeling in diabetic patients remain not fully elucidated. ...
... In a pooled analysis of five IVUS trials, diabetic patients demonstrated a greater atheroma volume and exhibited a smaller lumen with no differences in EEM compared with non-diabetic counterparts [30]. Likewise, negative coronary artery remodeling occurs in about 72% of lesions in the DIABETES trial [10]. In this study, we observed that almost two-thirds of patients with type 2 diabetes developed negative coronary artery remodeling, which substantiated the concept that compensatory positive remodeling was impaired in diabetic patients, and constrictive remodeling might itself be attributed to an inability for adaptive remodeling. ...
... It is possible that increasing deposition of fibrous and calcific tissue in the arterial wall, in addition to impaired endothelial-dependent relaxation [42,43], may limit vessel wall expansion with plaque accumulation. Previous studies including ours showed that serum LDL level was independently related to negative coronary artery remodeling in diabetic patients [10]. In this study, we found that serum GA levels were elevated but serum esRAGE levels were decreased in diabetic patients with RI < 0.95. ...
Background
Negative coronary artery remodeling is frequent in patients with diabetes, but its mechanism remains unclear. We here evaluated the association of serum levels of glycated albumin (GA) and endogenous secretory receptor for advanced glycation end products (esRAGE) with coronary artery remodeling in type 2 diabetic patients.
Methods
Serum levels of GA and esRAGE were measured and intravascular ultrasound was performed in 136 consecutive diabetic patients with 143 coronary intermediate lesions. The remodeling index (RI) was calculated as the ratio between external elastic membrane (EEM) area at the lesion site and EEM area at the reference segment. Negative remodeling (NR) was defined as an RI < 0.95 and intermediate or positive remodeling as an RI ≥ 0.95.
Results
Mean plaque burden at the lesion site was 70.96 ± 9.98%, and RI was 0.96 ± 0.18. Negative coronary arterial remodeling existed in 81 (56.6%) lesions. RI correlated closely with serum esRAGE level (r = 0.236, P = 0.005) and was inversely related to serum GA level (r = − 0.240, P = 0.004) and plasma low-density lipoprotein cholesterol (LDL-C) (r = − 0.206, P = 0.014) and total cholesterol levels (r = − 0.183, P = 0.028). Generalized estimating equations logistic regression analysis identified esRAGE (OR 0.037; 95% CI 0.012–0.564, P = 0.021), GA (OR 1.093; 95% CI 1.013–1.179, P = 0.018) and LDL-C (OR 1.479; 95% CI 1.072–2.835, P = 0.023) as independent predictors for negative remodeling.
Conclusions
In diabetic patients, negative coronary artery remodeling is associated with increased GA and decreased esRAGE levels in serum.
... The underlying mechanisms are far from understood, however, CVD risk in diabetic patients is independent of hyperlipidemia and hypertension [2] suggesting a direct effect of hyperglycemia and/or insulin resistance within macrovascular tissue. This idea is supported by studies showing that diabetic patients have altered remodeling capacity [3,4] as well as an augmented prevalence of artery calcification [5] and -stiffening [6]. A paradoxical protection against aneurysms among diabetic individuals is likewise compatible with the notion that specific arterial alterations form the background for cardiovascular consequences of diabetes [7]. ...
Background:
Type 2 diabetes mellitus (T2DM) is an independent risk factor of cardiovascular disease (CVD), however, the underlying mechanisms are largely unknown. Using non-atherosclerotic internal thoracic arteries (ITAs) obtained from coronary artery bypass grafting, we previously identified a distinct elevation in the level of proteins comprising the arterial basement membrane in T2DM patients not treated with metformin. Altered transcription of genes encoding these proteins has not been observed, indicating alternative mechanisms of dysregulation.
Methods:
In this study we screened for differential expression of arterial microRNAs (miRNAs) in T2DM patients to test the hypothesis that the arterial protein signature of diabetic patients is associated with dysregulation at the miRNA level, and further to lay the foundation for novel hypotheses addressing the increased CVD risk of T2DM patients. MiRNA isolated from fresh frozen ITAs [from 18 T2DM- (10 of which were subject to metformin treatment) and 30 non-diabetes mellitus (non-DM) patients] were analyzed by microarray, and miRNAs isolated from formalin-fixated paraffin-embedded (FFPE) ITAs were analyzed by quantitative PCR (qPCR) in an independent study group [26 T2DM- (15 of which were subject to metformin treatment) and 26 non-DM patients] to determine expression levels of miRNAs in a pre-defined panel of 12 miRNAs.
Results:
Unexpectedly, no miRNAs were found to be affected by T2DM status in either of the two study groups.
Conclusions:
Our data suggest that alternatives to microRNA dysregulation underlie T2DM-associated protein changes in non-atherosclerotic arteries.
... Nevertheless, diabetes plays also a central role in the progression of atherosclerotic disease and it has been recognized as a negative prognostic factor for non-TV events. An intravascular coronary ultrasound analysis which included 237 coronary segments from 45 patients enrolled in the DIABETES I, II and III trials [19,20,21] showed that insulin-dependent diabetes was associated with vessel shrinkage and disease progression, both in treated and not previously treated lesions [22]. In the PROSPECT trial, patients with insulin-requiring diabetes had a three-fold increased risk of non-culprit-lesion-related major adverse cardiovascular events at 3-year follow-up [3]. ...
Aims:
to determine the 5-year correlates of non-TV related adverse events (AE) in STEMI patients included in the EXAMINATION trial.
Methods and results:
the EXAMINATION trial randomized 1498 STEMI patients to bare-metal or everolimus-eluting stent. In this sub-study, patients were analyzed according to non-TV related AE, defined as the composite of either non-TV revascularization (non-TVR) or non-TV related myocardial infarction (MI). At 5-year follow-up, 125 patients (8.3%) exhibited 136 non-TV related AE [124 (8.3%) non-TVR, 12 (0.8%) non-TV related MI], accounting for 47.1% of overall 289 non-fatal cardiac events. These patients had a higher incidence of diabetes mellitus (p<0.001), arterial hypertension (p=0.032), previous MI (p=0.073), multivessel disease (p<0.001), incomplete revascularization (p=0.049) and a lower rate of ST segment resolution > 70% (p=0.042) as compared to the rest. At Cox analysis, previous MI (HR 1.872, 95%CI 1.004 - 3.489; p= 0.048), incomplete revascularization (HR 1.746, 95%CI 1.029 - 2.963; p=0.039) and diabetes (HR 1.942, 95%CI 1.292 - 2.919; p= 0.001) were independent correlates of non-TV related AE.
Conclusions:
In STEMI patients undergoing primary percutaneous coronary intervention, previous MI, incomplete revascularization and diabetes resulted as independent correlates of 5-year non-TV related AE.
... P < 0.001), and prior revascularization (17.5 [6.50-46.90]; P < 0.001)[39]. ...
Purpose of Review
Intravascular ultrasound (IVUS) is an essential tool in the cardiac cath lab, providing tomographic slices series of intra-luminal and vascular wall images with high quality and spatial resolution, that complement angiographic luminal information. It has been successfully used in research for the understanding of atherosclerotic process, and it was the first clinical method that delineated diverse patterns of atherosclerosis. IVUS also contributed to the advancement in the knowledge of restenosis after percutaneous coronary interventions (PCI).
Recent Findings
Routine clinical of IVUS is hindered in most Latin American countries due to lack of reimbursement. In comparison with the rate of IVUS utilization around 5 % in the USA and of 5 % in Europe, the rate is less than 1 % in Latin America. These low rates occur despite the fact that the European, American, and Brazilian guidelines agreed regarding IVUS utilization in specific clinical settings: assessment of non-left main intermediate lesions as evaluated by angiography, assessment of angiographically uncertain severity of left main coronary artery disease, and as a guidance to optimization of coronary stent implantation.
Summary
In this review, we emphasize the importance of IVUS as a research tool in selected patients with coronary heart disease, especially those treated with PCI, particularly in diabetic patients, and also discuss some data that support its routine clinical use.
