- Email: [email protected]
Comparison of ischemia-modified albumin levels in patients undergoing percutaneous coronary intervention for unstable angina pectoris with versus without coronary collaterals
10. Higashi Y, Sanada M, Sasaki S, Nakagawa K, Goto C, Matsuura H, Ohama
K, Chayama K, Oshima T. Effect of estrogen replacement therapy on endothelial function in peripheral resistance arteries in normotensive and hypertensive postmenopausal women. Hypertension 2001;37:651–657. 11. Cortella A, Zambon S, Sartore G, Piarulli F, Calabro A, Manzato E, Crepaldi G. Calf and forearm blood flow in hypercholesterolemic patients. Angiology 2000;51:309 –318. 12. Mullen MJ, Kharbanda RK, Cross J, Donald AE, Taylor M, Vallance P, Deanfield JE, MacAllister RJ. Heterogenous nature of flow-mediated dilatation in
human conduit arteries in vivo. Relevance to endothelial dysfunction in hypercholesterolemia. Circ Res 2001;88:145–151. 13. Blake GJ, Ridker PM. Novel clinical markers of vascular wall inflammation. Circ Res 2001;89:763–771. 14. Ridker PM. Novel risk factors and markers for coronary disease. Adv Intern Med 2000;45:391–418. 15. Cai H, Harrison DG. Endothelial dysfunction in cardiovascular diseases: the role of oxidant stress. Circ Res 2000;87:840 –844.
Comparison of Ischemia-Modified Albumin Levels in Patients Undergoing Percutaneous Coronary Intervention for Unstable Angina Pectoris With Versus Without Coronary Collaterals Iris Paula Garrido, MD, Debashis Roy, MRCP, Ramon Calvin ˜o, MD, Jose Manuel Vazquez-Rodriguez, MD, Guillermo Aldama, MD, Juan Cosin-Sales, Juan Quiles, MD, David C. Gaze, BSC, and Juan Carlos Kaski, MD, DSC This study compared ischemia-modified albumin levels, a marker of ischemia in patients undergoing percutaneous coronary intervention. Ischemia-modified albumin levels were significantly lower in patients with collateral circulation compared with those without collateral circulation. 䊚2003 by Excerpta Medica, Inc. (Am J Cardiol 2004;93:88–90)
albumin levels (IMA), which are measured by the albumin– cobalt binding test, are a Inewschemia-modified marker of transient myocardial ischemia. Findings 1
from previous studies have shown that IMA levels are increased in patients with an acute coronary syndrome1–3 and also in patients after transient coronary occlusion occurring during percutaneous coronary intervention (PCI).4,5 It is not known whether IMA levels are affected by the presence of collateral circulation in patients undergoing PCI. We compared IMA levels in patients with unstable angina pectoris after elective PCI who had angiographically documented collateral circulation with patients not having collateral vessels. •••
We prospectively studied 90 patients (76 men) with unstable angina pectoris (age range 51 to 73 years, mean 63) from a series of 146 consecutive patients with an acute coronary syndrome6 who were considered candidates for elective PCI. To avoid the possible confounding effects of myocardial necrosis on IMA levels, we excluded patients with a history of ST-segment elevation myocardial infarction (n ⫽ 20) and patients who developed myocardial necrosis (cardiac troponin I ⬎0.6 ng/ml) during hospital admission From Unidad de Hemodina´ mica, Complejo Hospitalario Universitario Juan Canalejo, A Corun˜a, Spain; and the Departments of Cardiological Sciences and Chemical Pathology, St. George’s Hospital Medical School, London, United Kingdom. Dr. Kaski’s address is: St. George’s Hospital Medical School, Cranmer Terrace, London SW17 ORE. E-mail: [email protected]. Manuscript received June 27, 2003; revised manuscript received and accepted September 2, 2003.
88
©2003 by Excerpta Medica, Inc. All rights reserved. The American Journal of Cardiology Vol. 93 January 1, 2004
MD,
and/or after PCI (n ⫽ 33). Patients with sustained ventricular arrhythmias requiring urgent electrical cardioversion during PCI (n ⫽ 3) were also excluded. The Local Research Ethics Committee approved the study protocol, and all subjects gave signed, written informed consent before being entered into the study. All patients were managed in accordance with routine hospital protocols7, and decisions regarding the need for PCI, number of balloon inflations, and use of stents were left to the discretion of the interventional cardiologist. Collateral vessels were assessed angiographically and graded according to Rentrop’s classification.8 Blood samples were drawn from the femoral artery sheath immediately before PCI and 10 minutes after the last balloon inflation. All samples were centrifuged and stored locally at ⫺70°C until shipped to the core laboratory (St. George’s Hospital, London, England). IMA levels were measured by the albumin– cobalt binding test (Ischemia Technologies, Denver, Colorado) using a Roche Cobas Mira Plus instrument (Boehringer Mannheim, Lewes, United Kingdom).1,3,9 Statistical analysis was performed with the SPSS 11.0 statistical software package (SPSS Inc., Chicago, Illinois). Quantitative variables that were normally distributed were presented as mean ⫾ SD, and those that were non-normally distributed were presented as medians (range). Qualitative variables were expressed as percentages. The Kolmogorov-Smirnov test was used to assess normal distribution. The chi-square test was used to compare categoric variables, the Mann-Whitney test for non-normally distributed variables, and the Student t test for normally distributed variables. Differences between preprocedural and postprocedural cardiac marker levels were assessed using the Student’s t test for paired samples. A p value ⬍0.05 was considered statistically significant. •••
The clinical and angiographic characteristics of the study patients are listed in Table 1. In the population as a whole, baseline IMA levels (101 ⫾ 14 U/ml) increased 0002-9149/04/$–see front matter doi:10.1016/j.amjcard.2003.09.019
TABLE 1 Clinical and Angiographic Characteristics of 90 Patients Undergoing Percutaneous Coronary Intervention (PCI) Clinical Characteristic Age (yrs) Men Systemic hypertension Hypercholesterolemia (total cholesterol ⬎5 mmol/L) Current smokers Diabetes mellitus PCI variables No. of coronary arteries narrowed ⬎70% 1 2 or 3 Affected coronary artery Left anterior descending Left circumflex Right coronary Patients with collateral circulation Rentrop’s grade 2 Rentrop’s grade 3 No. of balloon occlusions by median (range) Total balloon occlusion time in seconds per patient by median (range) Balloon pressure (atm) by median (range) Intracoronary stent inserted Chest pain during the procedure ST-segment deviation during the procedure
62 76 55 45
⫾ 11 (84%) (61%) (50%)
17 (19%) 12 (13%)
56 (62%) 34 (38%) 57 36 42 11 6 5 3 60
(63%) (40%) (47%) (12%) (7%) (5%) (1–12) (10–400)
14 85 33 7
(6–20) (94%) (38%) (8%)
FIGURE 1. Percent differences in mean IMA increment (95% confidence interval [CI]) after PCI balloon inflation in patients with and without collateral circulation.
significantly after PCI (113 ⫾ 15 U/ml, p ⬍0.0001). These patients differed from those without visible collateral circulation in the following ways: more extensive coronary artery disease (median 2 vessels [range 1 to 3] vs median 1 vessel [range 1 to 3], p ⬍0.005); required a larger number of balloon inflations during PCI (median 3 inflations [range 2 to 9] vs median 2 inflations [range 1 to 12], p ⫽ 0.049); and underwent longer balloon inflation times (median 120 seconds [range 24 to 100] vs median 60 seconds [range 10 to 360], p ⫽ 0.01). There were no significant differences in baseline IMA levels between patients with collateral circulation (102 ⫾ 10 U/ml) and those without (101 ⫾ 15 U/ml, p ⫽ 0.861).
FIGURE 2. Mean IMA levels (95% confidence interval [CI]) in units per milliliter at baseline and 10 minutes after PCI in patients with and those without collateral circulation.
Ten minutes after the last balloon inflation, IMA levels increased significantly less in patients with collateral circulation compared with those without collateral vessels (4.8 ⫾ 10.0% vs 14.0 ⫾ 14.4%, p ⫽ 0.046; Figures 1 and 2). The results of this investigation confirm that IMA levels increase after PCI, as reported previously by several investigators,4,10 but this increment in IMA levels occurred significantly less in patients with collateral circulation compared with those without collateral vessels. This was true even though patients with collateral circulation had more extensive coronary artery disease and underwent larger numbers of balloon inflations and longer inflation times. The lower increments in IMA levels observed in patients with collateral vessels after PCI likely reflect a protective effect of the visible collateral circulation against PCI-induced ischemia. IMA levels have been shown to be increased in patients with acute chest pain and evidence of myocardial ischemia.1,3 In our patients, IMA levels were increased at baseline, a finding that is in agreement with the patients in the study having unstable angina pectoris. Our results confirm and expand the previous reports showing that IMA is a marker of PCI-induced myocardial ischemia, but more importantly, they suggest that decreased IMA production in patients with collateral vessels is likely to reflect the protective effect of collateral circulation against PCI-induced myocardial ischemia. 1. Bar-Or D, Lau E, Winkler JV. A novel assay for cobalt-albumin binding and
its potential as a marker for myocardial ischemia—a preliminary report. J Emerg Med 2000;19:311–315. 2. Bhagavan NV, Lai EM, Rios PA, Yang J, Ortega-Lopez AM, Shinoda H, Honda SA, Rios CN, Sugiyama CE, Ha CE. Evaluation of human serum albumin cobalt binding assay for the assessment of myocardial ischemia and myocardial infarction. Clin Chem 2003;49:581–585. 3. Christenson RH, Duh SH, Sanhai WR, Wu AH, Holtman V, Painter P, Branham E, Apple FS, Murakami M, Morris DL. Characteristics of an albumin cobalt binding test for assessment of acute coronary syndrome patients: a multicenter study. Clin Chem 2001;47:464 –470. 4. Bar-Or D, Winkler JV, Vanbenthuysen K, Harris L, Lau E, Hetzel FW.
BRIEF REPORTS
89
Reduced albumin-cobalt binding with transient myocardial ischemia after elective percutaneous transluminal coronary angioplasty: a preliminary comparison to creatine kinase-MB, myoglobin, and troponin I. Am Heart J 2001;141:985–991. 5. Sinha MK, Gaze DC, Tippins JR, Collinson PO, Kaski JC. Ischemia modified albumin is a sensitive marker of myocardial ischemia after percutaneous coronary intervention. Circulation 2003;107:2403–2405. 6. Alpert JS, Thygesen K, Antman E, Bassand JP. Myocardial infarction redefined—a consensus document of The Joint European Society of Cardiology/ American College of Cardiology Committee for the Redefinition of Myocardial Infarction. J Am Coll Cardiol 2000;36:959 –969. 7. Salgado FJ, Calvino SR, Vazquez-Rodriguez JM, Vazquez GN, Vazquez RE, Perez FR, Bouzas ZB, Castro BA. Transradial approach to coronary angiography
and angioplasty: initial experience and learning curve. Rev Esp Cardiol 2003;56: 152–159. 8. Rentrop KP, Cohen M, Blanke H, Phillips RA. Changes in collateral channel filling immediately after controlled coronary artery occlusion by angioplasty balloon in human subjects. J Am Coll Cardiol 1985;5:587–592. 9. Wu AH, Morris DL, Fletcher DR, Apple FS, Christenson RH, Painter PC. Analysis of the albumin cobalt binding (ACB) test as an adjunct to cardiac troponin I for the early detection of acute myocardial infarction. Cardiovasc Toxicol 2001;1:147–151. 10. Quiles J, Roy D, Gaze D, Garrido I, Avanzas P, Sinha M K, Kaski J.C. Ischemia modified albumin (IMA) levels following elective angioplasty are related to duration of balloon induced myocardial ischemia. Am J Cardiol 2003;92:322–324.
Effectiveness of Percutaneous Coronary Intervention in Cardiac Allograft Vasculopathy Amit A. Doshi,
MD,
Joseph Rogers,
MD,
Morton J. Kern,
Twenty-five heart transplant recipients underwent 45 coronary interventions at a mean of 7.8 ⴞ 2.2 years from time of transplant. Periprocedural success was high, and there was a trend toward better outcomes in the group that underwent stent deployment compared with conventional balloon angioplasty. 䊚2003 by Excerpta Medica, Inc. (Am J Cardiol 2004;93:90–92)
he development of cardiac allograft vasculopathy (CAV) is commonplace after heart transplantation; T the reported prevalence is as high as 42% at 5 years. 1
CAV remains a major cause of graft failure and death in patients surviving ⬎1 year after transplantation.2 Pharmacologic3–5 and nonpharmacologic6 approaches have been proposed to either prevent or slow the progression of disease, but multicenter, long-term data have been lacking. Although a pattern of diffuse concentric intimal thickening is characteristic of CAV, many lesions are discrete, located proximally in the major epicardial vessels,7,8 and may be amenable to percutaneous interventions. Unfortunately, the published restenosis rate with percutaneous transluminal coronary angioplasty (PTCA) is high (55% at a mean of 7 months).9 Intracoronary stent placement, which has been shown to be superior to balloon angioplasty in patients with native atherosclerosis,10 has been studied in small cohorts of patients after heart transplantation.11–13 The data from these groups have been limited by the sample size, short follow-up period, and single-center experience. Therefore, we reviewed the experience from 2 adult heart transplant centers (Saint Louis University and Washington University, St. Louis, Missouri) during a 12-year period and compared the outcome of patients who underwent PTCA From the Saint Louis University Hospital, Saint Louis University School of Medicine; and the Washington University School of Medicine, St. Louis, Missouri. Dr. Hauptman’s address is: Division of Cardiology, FDT-15, Saint Louis University Hospital, 3635 Vista Avenue, St. Louis, Missouri 63110. E-mail: [email protected]. Manuscript received June 24, 2003; revised manuscript received and accepted August 27, 2003.
90
©2003 by Excerpta Medica, Inc. All rights reserved. The American Journal of Cardiology Vol. 93 January 1, 2004
MD,
and Paul J. Hauptman,
MD
versus stent placement with or without the use of atherectomy. •••
We performed a retrospective chart review of angiographic findings and laboratory and clinical transplant records of all heart transplant recipients who underwent the procedure between January 1991 and February 2003. For patients undergoing intervention, the report from the most recent catheterization before the intervention and data from all subsequent catheterizations were reviewed. Periprocedural angiographic success was defined as a decrease in luminal obstruction to ⬍50%; restenosis was defined as ⬎50% diameter stenosis on a follow-up angiogram. The severity of stenosis was defined by visual assessment of the coronary angiograms. Follow-up was determined until the date of retransplantation, date of death, or date the patient was last known to be alive. Continuous variables were expressed as mean ⫾ SD. Differences in outcome between the angioplasty and stent groups were analyzed using Wilcoxon’s test for equality. Institutional review board approval was granted for the study. Twenty-five recipients (21 white and 4 African American) underwent 45 separate procedures. The indications for transplantation were end-stage ischemic cardiomyopathy in 18 patients (72%), idiopathic cardiomyopathy in 5 (20%), and valvular cardiomyopathy in 2 (8%). Donor age was 34.1 ⫾ 7.1 years. Six of the 25 donor hearts were subjected to angiography before the transplant procedure. Two of the donor hearts had nonobstructive (⬍50% luminal diameter stenosis) single-vessel disease at the time of transplantation. Mean age of the recipients at time of transplant was 57.7 ⫾ 8.1 years; all recipients were men. Fortyeight percent of recipients experienced International Society For Heart And Lung Transplantation grade ⱖ3A rejection, but none did so within 5.3 ⫾ 1.1 years of the intervention. Most had hypertension, which was defined as systolic blood pressure ⬎140 mm Hg or use of antihypertensive therapy at the time of intervention, and dyslipidemia, which was defined as low-density lipoprotein⬎100 mg/dl or the use of a 3-hydroxy-3methylglutaryl coenzyme A reductase inhibitor (92% 0002-9149/04/$–see front matter doi:10.1016/j.amjcard.2003.08.075
K, Chayama K, Oshima T. Effect of estrogen replacement therapy on endothelial function in peripheral resistance arteries in normotensive and hypertensive postmenopausal women. Hypertension 2001;37:651–657. 11. Cortella A, Zambon S, Sartore G, Piarulli F, Calabro A, Manzato E, Crepaldi G. Calf and forearm blood flow in hypercholesterolemic patients. Angiology 2000;51:309 –318. 12. Mullen MJ, Kharbanda RK, Cross J, Donald AE, Taylor M, Vallance P, Deanfield JE, MacAllister RJ. Heterogenous nature of flow-mediated dilatation in
human conduit arteries in vivo. Relevance to endothelial dysfunction in hypercholesterolemia. Circ Res 2001;88:145–151. 13. Blake GJ, Ridker PM. Novel clinical markers of vascular wall inflammation. Circ Res 2001;89:763–771. 14. Ridker PM. Novel risk factors and markers for coronary disease. Adv Intern Med 2000;45:391–418. 15. Cai H, Harrison DG. Endothelial dysfunction in cardiovascular diseases: the role of oxidant stress. Circ Res 2000;87:840 –844.
Comparison of Ischemia-Modified Albumin Levels in Patients Undergoing Percutaneous Coronary Intervention for Unstable Angina Pectoris With Versus Without Coronary Collaterals Iris Paula Garrido, MD, Debashis Roy, MRCP, Ramon Calvin ˜o, MD, Jose Manuel Vazquez-Rodriguez, MD, Guillermo Aldama, MD, Juan Cosin-Sales, Juan Quiles, MD, David C. Gaze, BSC, and Juan Carlos Kaski, MD, DSC This study compared ischemia-modified albumin levels, a marker of ischemia in patients undergoing percutaneous coronary intervention. Ischemia-modified albumin levels were significantly lower in patients with collateral circulation compared with those without collateral circulation. 䊚2003 by Excerpta Medica, Inc. (Am J Cardiol 2004;93:88–90)
albumin levels (IMA), which are measured by the albumin– cobalt binding test, are a Inewschemia-modified marker of transient myocardial ischemia. Findings 1
from previous studies have shown that IMA levels are increased in patients with an acute coronary syndrome1–3 and also in patients after transient coronary occlusion occurring during percutaneous coronary intervention (PCI).4,5 It is not known whether IMA levels are affected by the presence of collateral circulation in patients undergoing PCI. We compared IMA levels in patients with unstable angina pectoris after elective PCI who had angiographically documented collateral circulation with patients not having collateral vessels. •••
We prospectively studied 90 patients (76 men) with unstable angina pectoris (age range 51 to 73 years, mean 63) from a series of 146 consecutive patients with an acute coronary syndrome6 who were considered candidates for elective PCI. To avoid the possible confounding effects of myocardial necrosis on IMA levels, we excluded patients with a history of ST-segment elevation myocardial infarction (n ⫽ 20) and patients who developed myocardial necrosis (cardiac troponin I ⬎0.6 ng/ml) during hospital admission From Unidad de Hemodina´ mica, Complejo Hospitalario Universitario Juan Canalejo, A Corun˜a, Spain; and the Departments of Cardiological Sciences and Chemical Pathology, St. George’s Hospital Medical School, London, United Kingdom. Dr. Kaski’s address is: St. George’s Hospital Medical School, Cranmer Terrace, London SW17 ORE. E-mail: [email protected]. Manuscript received June 27, 2003; revised manuscript received and accepted September 2, 2003.
88
©2003 by Excerpta Medica, Inc. All rights reserved. The American Journal of Cardiology Vol. 93 January 1, 2004
MD,
and/or after PCI (n ⫽ 33). Patients with sustained ventricular arrhythmias requiring urgent electrical cardioversion during PCI (n ⫽ 3) were also excluded. The Local Research Ethics Committee approved the study protocol, and all subjects gave signed, written informed consent before being entered into the study. All patients were managed in accordance with routine hospital protocols7, and decisions regarding the need for PCI, number of balloon inflations, and use of stents were left to the discretion of the interventional cardiologist. Collateral vessels were assessed angiographically and graded according to Rentrop’s classification.8 Blood samples were drawn from the femoral artery sheath immediately before PCI and 10 minutes after the last balloon inflation. All samples were centrifuged and stored locally at ⫺70°C until shipped to the core laboratory (St. George’s Hospital, London, England). IMA levels were measured by the albumin– cobalt binding test (Ischemia Technologies, Denver, Colorado) using a Roche Cobas Mira Plus instrument (Boehringer Mannheim, Lewes, United Kingdom).1,3,9 Statistical analysis was performed with the SPSS 11.0 statistical software package (SPSS Inc., Chicago, Illinois). Quantitative variables that were normally distributed were presented as mean ⫾ SD, and those that were non-normally distributed were presented as medians (range). Qualitative variables were expressed as percentages. The Kolmogorov-Smirnov test was used to assess normal distribution. The chi-square test was used to compare categoric variables, the Mann-Whitney test for non-normally distributed variables, and the Student t test for normally distributed variables. Differences between preprocedural and postprocedural cardiac marker levels were assessed using the Student’s t test for paired samples. A p value ⬍0.05 was considered statistically significant. •••
The clinical and angiographic characteristics of the study patients are listed in Table 1. In the population as a whole, baseline IMA levels (101 ⫾ 14 U/ml) increased 0002-9149/04/$–see front matter doi:10.1016/j.amjcard.2003.09.019
TABLE 1 Clinical and Angiographic Characteristics of 90 Patients Undergoing Percutaneous Coronary Intervention (PCI) Clinical Characteristic Age (yrs) Men Systemic hypertension Hypercholesterolemia (total cholesterol ⬎5 mmol/L) Current smokers Diabetes mellitus PCI variables No. of coronary arteries narrowed ⬎70% 1 2 or 3 Affected coronary artery Left anterior descending Left circumflex Right coronary Patients with collateral circulation Rentrop’s grade 2 Rentrop’s grade 3 No. of balloon occlusions by median (range) Total balloon occlusion time in seconds per patient by median (range) Balloon pressure (atm) by median (range) Intracoronary stent inserted Chest pain during the procedure ST-segment deviation during the procedure
62 76 55 45
⫾ 11 (84%) (61%) (50%)
17 (19%) 12 (13%)
56 (62%) 34 (38%) 57 36 42 11 6 5 3 60
(63%) (40%) (47%) (12%) (7%) (5%) (1–12) (10–400)
14 85 33 7
(6–20) (94%) (38%) (8%)
FIGURE 1. Percent differences in mean IMA increment (95% confidence interval [CI]) after PCI balloon inflation in patients with and without collateral circulation.
significantly after PCI (113 ⫾ 15 U/ml, p ⬍0.0001). These patients differed from those without visible collateral circulation in the following ways: more extensive coronary artery disease (median 2 vessels [range 1 to 3] vs median 1 vessel [range 1 to 3], p ⬍0.005); required a larger number of balloon inflations during PCI (median 3 inflations [range 2 to 9] vs median 2 inflations [range 1 to 12], p ⫽ 0.049); and underwent longer balloon inflation times (median 120 seconds [range 24 to 100] vs median 60 seconds [range 10 to 360], p ⫽ 0.01). There were no significant differences in baseline IMA levels between patients with collateral circulation (102 ⫾ 10 U/ml) and those without (101 ⫾ 15 U/ml, p ⫽ 0.861).
FIGURE 2. Mean IMA levels (95% confidence interval [CI]) in units per milliliter at baseline and 10 minutes after PCI in patients with and those without collateral circulation.
Ten minutes after the last balloon inflation, IMA levels increased significantly less in patients with collateral circulation compared with those without collateral vessels (4.8 ⫾ 10.0% vs 14.0 ⫾ 14.4%, p ⫽ 0.046; Figures 1 and 2). The results of this investigation confirm that IMA levels increase after PCI, as reported previously by several investigators,4,10 but this increment in IMA levels occurred significantly less in patients with collateral circulation compared with those without collateral vessels. This was true even though patients with collateral circulation had more extensive coronary artery disease and underwent larger numbers of balloon inflations and longer inflation times. The lower increments in IMA levels observed in patients with collateral vessels after PCI likely reflect a protective effect of the visible collateral circulation against PCI-induced ischemia. IMA levels have been shown to be increased in patients with acute chest pain and evidence of myocardial ischemia.1,3 In our patients, IMA levels were increased at baseline, a finding that is in agreement with the patients in the study having unstable angina pectoris. Our results confirm and expand the previous reports showing that IMA is a marker of PCI-induced myocardial ischemia, but more importantly, they suggest that decreased IMA production in patients with collateral vessels is likely to reflect the protective effect of collateral circulation against PCI-induced myocardial ischemia. 1. Bar-Or D, Lau E, Winkler JV. A novel assay for cobalt-albumin binding and
its potential as a marker for myocardial ischemia—a preliminary report. J Emerg Med 2000;19:311–315. 2. Bhagavan NV, Lai EM, Rios PA, Yang J, Ortega-Lopez AM, Shinoda H, Honda SA, Rios CN, Sugiyama CE, Ha CE. Evaluation of human serum albumin cobalt binding assay for the assessment of myocardial ischemia and myocardial infarction. Clin Chem 2003;49:581–585. 3. Christenson RH, Duh SH, Sanhai WR, Wu AH, Holtman V, Painter P, Branham E, Apple FS, Murakami M, Morris DL. Characteristics of an albumin cobalt binding test for assessment of acute coronary syndrome patients: a multicenter study. Clin Chem 2001;47:464 –470. 4. Bar-Or D, Winkler JV, Vanbenthuysen K, Harris L, Lau E, Hetzel FW.
BRIEF REPORTS
89
Reduced albumin-cobalt binding with transient myocardial ischemia after elective percutaneous transluminal coronary angioplasty: a preliminary comparison to creatine kinase-MB, myoglobin, and troponin I. Am Heart J 2001;141:985–991. 5. Sinha MK, Gaze DC, Tippins JR, Collinson PO, Kaski JC. Ischemia modified albumin is a sensitive marker of myocardial ischemia after percutaneous coronary intervention. Circulation 2003;107:2403–2405. 6. Alpert JS, Thygesen K, Antman E, Bassand JP. Myocardial infarction redefined—a consensus document of The Joint European Society of Cardiology/ American College of Cardiology Committee for the Redefinition of Myocardial Infarction. J Am Coll Cardiol 2000;36:959 –969. 7. Salgado FJ, Calvino SR, Vazquez-Rodriguez JM, Vazquez GN, Vazquez RE, Perez FR, Bouzas ZB, Castro BA. Transradial approach to coronary angiography
and angioplasty: initial experience and learning curve. Rev Esp Cardiol 2003;56: 152–159. 8. Rentrop KP, Cohen M, Blanke H, Phillips RA. Changes in collateral channel filling immediately after controlled coronary artery occlusion by angioplasty balloon in human subjects. J Am Coll Cardiol 1985;5:587–592. 9. Wu AH, Morris DL, Fletcher DR, Apple FS, Christenson RH, Painter PC. Analysis of the albumin cobalt binding (ACB) test as an adjunct to cardiac troponin I for the early detection of acute myocardial infarction. Cardiovasc Toxicol 2001;1:147–151. 10. Quiles J, Roy D, Gaze D, Garrido I, Avanzas P, Sinha M K, Kaski J.C. Ischemia modified albumin (IMA) levels following elective angioplasty are related to duration of balloon induced myocardial ischemia. Am J Cardiol 2003;92:322–324.
Effectiveness of Percutaneous Coronary Intervention in Cardiac Allograft Vasculopathy Amit A. Doshi,
MD,
Joseph Rogers,
MD,
Morton J. Kern,
Twenty-five heart transplant recipients underwent 45 coronary interventions at a mean of 7.8 ⴞ 2.2 years from time of transplant. Periprocedural success was high, and there was a trend toward better outcomes in the group that underwent stent deployment compared with conventional balloon angioplasty. 䊚2003 by Excerpta Medica, Inc. (Am J Cardiol 2004;93:90–92)
he development of cardiac allograft vasculopathy (CAV) is commonplace after heart transplantation; T the reported prevalence is as high as 42% at 5 years. 1
CAV remains a major cause of graft failure and death in patients surviving ⬎1 year after transplantation.2 Pharmacologic3–5 and nonpharmacologic6 approaches have been proposed to either prevent or slow the progression of disease, but multicenter, long-term data have been lacking. Although a pattern of diffuse concentric intimal thickening is characteristic of CAV, many lesions are discrete, located proximally in the major epicardial vessels,7,8 and may be amenable to percutaneous interventions. Unfortunately, the published restenosis rate with percutaneous transluminal coronary angioplasty (PTCA) is high (55% at a mean of 7 months).9 Intracoronary stent placement, which has been shown to be superior to balloon angioplasty in patients with native atherosclerosis,10 has been studied in small cohorts of patients after heart transplantation.11–13 The data from these groups have been limited by the sample size, short follow-up period, and single-center experience. Therefore, we reviewed the experience from 2 adult heart transplant centers (Saint Louis University and Washington University, St. Louis, Missouri) during a 12-year period and compared the outcome of patients who underwent PTCA From the Saint Louis University Hospital, Saint Louis University School of Medicine; and the Washington University School of Medicine, St. Louis, Missouri. Dr. Hauptman’s address is: Division of Cardiology, FDT-15, Saint Louis University Hospital, 3635 Vista Avenue, St. Louis, Missouri 63110. E-mail: [email protected]. Manuscript received June 24, 2003; revised manuscript received and accepted August 27, 2003.
90
©2003 by Excerpta Medica, Inc. All rights reserved. The American Journal of Cardiology Vol. 93 January 1, 2004
MD,
and Paul J. Hauptman,
MD
versus stent placement with or without the use of atherectomy. •••
We performed a retrospective chart review of angiographic findings and laboratory and clinical transplant records of all heart transplant recipients who underwent the procedure between January 1991 and February 2003. For patients undergoing intervention, the report from the most recent catheterization before the intervention and data from all subsequent catheterizations were reviewed. Periprocedural angiographic success was defined as a decrease in luminal obstruction to ⬍50%; restenosis was defined as ⬎50% diameter stenosis on a follow-up angiogram. The severity of stenosis was defined by visual assessment of the coronary angiograms. Follow-up was determined until the date of retransplantation, date of death, or date the patient was last known to be alive. Continuous variables were expressed as mean ⫾ SD. Differences in outcome between the angioplasty and stent groups were analyzed using Wilcoxon’s test for equality. Institutional review board approval was granted for the study. Twenty-five recipients (21 white and 4 African American) underwent 45 separate procedures. The indications for transplantation were end-stage ischemic cardiomyopathy in 18 patients (72%), idiopathic cardiomyopathy in 5 (20%), and valvular cardiomyopathy in 2 (8%). Donor age was 34.1 ⫾ 7.1 years. Six of the 25 donor hearts were subjected to angiography before the transplant procedure. Two of the donor hearts had nonobstructive (⬍50% luminal diameter stenosis) single-vessel disease at the time of transplantation. Mean age of the recipients at time of transplant was 57.7 ⫾ 8.1 years; all recipients were men. Fortyeight percent of recipients experienced International Society For Heart And Lung Transplantation grade ⱖ3A rejection, but none did so within 5.3 ⫾ 1.1 years of the intervention. Most had hypertension, which was defined as systolic blood pressure ⬎140 mm Hg or use of antihypertensive therapy at the time of intervention, and dyslipidemia, which was defined as low-density lipoprotein⬎100 mg/dl or the use of a 3-hydroxy-3methylglutaryl coenzyme A reductase inhibitor (92% 0002-9149/04/$–see front matter doi:10.1016/j.amjcard.2003.08.075