Editorial: The Advances in Treatment for Coronary Artery Disease, Voices from Interventional Cardiologists at the Fortieth Year of Percutaneous Coronary Intervention

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The Advances in Treatment for Coronary Artery Disease Current Pharmaceutical Design, 2018, Vol. 24, No. 4 379
Editorial
The Advances in Treatment for Coronary Artery Disease, Voices from Interventional Cardiologists at the
Fortieth Year of Percutaneous Coronary Interv ention
In 1977, a 38-year-old patient with an advanced lesion of proximal left anterior descending coronary artery was treated with balloon dila-
tation by Dr. Andreas Grüntzig, which represented the first human case of percutaneous coronary intervention (PCI) [1]. This event was
marked as the birth of interventional cardiology. Dr. Andreas Grüntzig, considered as the father of PCI, demonstrated that doctors could per-
form cardiac “surgery” within coronary arteries in a patient who could be free of painful procedure while being completely awake. Of note,
the novel concept of percutaneous treatment of CAD was immediately recognized as a potential breakthrough in cardiovascular medicine, as
it not only avoided open thoracotomy, but also evolved into the preferred treatment in patients with acute myocardial infarction.
Over the past 40 years, the advancement of PCI has gone through four milestones [2]. Based on percutaneous trans-luminal coronary
angioplasty, next came the first generation of stents, bare-metal stents (BMS). Then, with the introduction of drug-eluting stents (DES) at the
beginning of this century, PCI has become one of the most frequently performed therapeutic treatment for patients with CAD [3].
During the last few years, drug-coated Balloons (DCB) has represented an emerging alternative to DES in specific clinical scenarios.
Without the basis of stent, this local drug system consists of four components: balloon platform, anti-proliferative drugs, excipient and bal-
loon coating process [10]. The primary goal of the system is to transfer the anti-proliferative drugs into coronary lesions to reduce the subse-
quent neo-intima hyperplasia and to restore normal morphology and function of vessels. Foin et al. analyzed the mech anisms of the action
and introduced current and upcoming DCB system along with their clinical applications [10]. Meanwhile, Rigatelli et al. focused on the high-
lights of DCB in certain clinical settings where DCB was demonstrated superior to DES [11].
Moving forward, once believed to be the fourth breakthrough for PCI, bioresorbable stent (BRS) has gained the most attention since in-
vented. In this thematic issue, a comprehensive introduction of BRS given by Mishra firstly retrospected the birth background and philoso-
phic definition of BRS, then focused on the manufacturing process of biodegradable polymers for BRS, including heat deflection temperature,
composition of a polymeric implant, polymer processing, and coating [12]. At last, suggestions were raised according to the limitations of
BRS of the current generation.
Overall, the primary aim of PCI fo r CAD is to restore the perfusion of affected coronary arteries, thereafter to co rrect the imbalance be-
tween oxygen supply and myocardial demand. This concept was primarily implemented in thrombolytic therapy, a method once considered as
the pioneer to kick-start the time of modern cardiology, but largely supplanted by primary PCI in the past few decades. In this special issue,
Leesar, Chatterhee and co-authors discussed the role of thrombolytic therapy in the era of primary PCI with a brief review on the history and
pharmacology of thrombolytics, as well as a summary of its current applications [13].
Notably, in addition to myocardial revascularization with thrombolytics, PCI or coronary artery bypass graft, current strategies for CAD
treatment are multi-dimensional, including but not limited to cardiac risk factor identification, secondary prevention via pharmacolo gic and
nonpharmacologic interventions, and management of symptoms [4]. Advances in second prevention have contributed to increasingly effective
treatmen t and reduced adverse cardiovascular events.
As the key elem ent of arterial atherosclerotic plaques, low density lipo-protein (LDL)-cholesterol has been giving rise to the cholesterol
hypothesis for the pathogenesis of atherosclerosis [5]. Moreover, lowering LDL-cholesterol is associated with reduced incidence of adverse
cardiovascular events, and of myocardial revascularization [6, 7]. Statin therapy has been used as a standard antilipemic treatment to control
serum LDL-cholesterol. In this issue, Vavlukis, Kedev and colleagues discussed the effects of high intensity statin therapy for diabetic dyslip-
idemia in CAD patients [14]. In spite of statin th erapy in high intensity , the result of LDL-cholesterol lowering seems not satisfying in certain
patients, particularly those who have an inadequate response or intolerance to statins. Proprotein convertase subtilisin/ kexin type 9 (PCSK9)
inhibitors have emerged as a novel therapeutic agent for reducing LDL-cholesterol treatment. Hoye and co-authors described the development
and the clinical usage of PCSK9 inhibitors [15]. In the review, they concluded that PCSK9 inhibitors represent an important improvement in
consistently reducing LDL cholesterol lev els, especially for patients insensitive to statins.
The main goal of lipid lowering therapy is to block plaque progression, to promote plaque stabilization, to prevent plaque rupture or ero-
sion, and to subsequently reduce adverse cardiovascular events. In terms of plaque stabilization, in our special issue, Wu et a l. examined the
pathophysiologic and experimental basis for therapeutic targeting of the plaque micro-vessels and presented a framework for future preclini-
cal investigation [16].
Apart from stabilizing vulnerable plaques, retarding thrombus propagation with antiplatelet and anticoagulant agents is crucial for reduc-
ing the risk of adverse events. In patients with acute coronary syndrome and receiving PCI, cautions should be stressed in selecting the best
regimen of antiplatelet drugs for optimal efficacy of preventing ischemic events, and minimum risk of bleeding events. In a review by Ro-
dríguez et al., safety and efficacy of three platelet ADP-receptor antagonists (P2Y12 inhibitor), known as clopidogrel, ticagrelor and prasu-
grel, were compared with each other on the pharmacological characteristics and the clinical performance in patients with acute coronary syn-
dromes after PCI [17]. Antiplatelet and anticoagulant therapy is always accompanied by increased risks of bleeding, especially in patients
with other comorbidities. Munawar et al. discussed the antiplatelet therapy for CAD in specific conditions such as diabetic mellitus, renal
dysfunction and atrial fibrillation (AF) [18]. In his rev iew, platelet changes and current clinical evidences of antiplatelet treatment in patients
with CAD as well as these comorbidities were reviewed. In another review on the topic of antithrombotics, Pan et al. provided an overview of
the available risk stratification schemes for stroke and bleeding risk, focused on the optimal regimens of oral antiplatelet and anticoagulation
therapy, and sum marized evidence and recommendations related to long-term an tithrombotic therapy for AF patients receiving stent implan-
tations [19].
Although the introduction of PCI remains a milestone for CAD treatment, up to 30% of patients are unsuitable for this procedure, such as
ones with poor heart function or microvascular malfunction [8]. In the scenario of coexistence with CAD and heart failure (HF), left ventricu-
lar dysfunction could diminish the coronary blood flow, further leading to myocardium ischemia [9]. Nguyen and his colleagues presented the
therapeutic mechanisms of angiotensin converting enzyme inhibitors or beta-blockers in fluid mobilization, followed by clarifying the crucial
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380 Current Pharmaceutical Design, 2018, Vol. 24, No. 4 The Advances in Treatment for Coronary Artery Disease
questions of wh en and how these agents are u sed in patients with CAD and HF [20]. On the other h and, coronary microcirculation dysfunc-
tion or coronary vasospasm was considered as one of the causes of myocardial infarction with non-obstructive coronary arteries (MINOCA).
In a review by Bil and Gil, advances in mechanisms and treatment options for MINOCA were overviewed [21]. Additionally, for C AD pa-
tients with contraindications of PCI, therapeutic angiogenesis therapy could be another promising option. In the review by Wu et al, recent
progress on various strategies developed for therapeutic angiogenesis was discussed, including direct administration of potent angiogenic
growth factors, promoting expression of angiogenic genes, or delivery of stem cells or exosomes [16].
At last, Pawlak et al. presented us with an interesting review about the pharmacological therapy for CAD coexisting with viral heart dis-
ease [22]. With guidance of proper diagnosis in this population, antiviral therapy is recommended as its effect of inhibiting plaque inflamma-
tion and promoting plaque stabilization.
Overall, 13 outstanding international experts were invited in this thematic issue to share their magnificent opinions, with perspectives of
interventional cardiologists, for the advance in therapy for CAD. And we sincerely hope hot topics discussed in the theme issue will promote
further discussion among pharmaceutical industry and interventional cardiologists.
As the executive guest editor, I firstly would like to express my appreciation for all the invited authors and co-authors for their marvelous
work. Meanwhile, I would like to thank and acknowledge the experts who made their substantial reviewing efforts and comments advices. In
addition, I would like to express my gratitude to the Bentham Science Publishers for offering me such a wonderful opportunity for participat-
ing in the work of this thematic issue. Last but not least, I must say it is of great pleasure working with the Director Kazim Baig and Editorial
Assistant Aamer M. Khan. And I acknowledge the contributions of others who were responsible for editing and processing the manuscripts to
obtain the best final quality for our thematic issue.
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Dr. Wen Wu
Department of Cardiology,
Nanjing First Hospital,
Nanjing Medical University,
No. 68 Changle road, Nanjing City,
Jiangsu Province,
China
Tel: +86 15195967050
E-mail: timwu1988@126.com